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138 Cards in this Set
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30 year old woman with diarrhea and fatigue and 3kg weight loss over 6 months. Afebrile, mild muscle wasting, motor strength normal. No occult blood, ova, or parasites in the stool. Patient is placed on diet with no wheat or rye grain products. What will a biopsy specimen of the jejunum look like
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Villous blunting and flattening. This patient has malabsorption that responded to dietary treatment. She probably has celiac disease (gluten sensitivity). The histologic features of celiac disease are flattening of the mucosa, diffuse and severe atrophy of the villi, and chronic inflammation of the lamina propria. There is an increase in intraepithelial lymphocytes.
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In what gastrointestinal disease does lymphatic obstruction occur. There is macrophage accumulation in the lamina propria. They contain PAS-positive granules
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Whipple disease. The PAS positive granules, under EM, show an actinomycete called Tropheryma whippelii
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Noncaseating granulomas are found in the intestinal wall in what disease
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Crohn disease
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Two days after eating a chicken salad sandwich, a 35 year old man experiences cramping abdominal pain with fever and watery diarrhea. Mild diffuse abdominal pain on palpation, but there are no masses. Bowel sounds present. Stool sample negative for occult blood. Recovers completely within a few days without therapy. What infectious organism most likely produced these findings
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Salmonella enteritidis. Infection by one of several Salmonella species causes a self limited diarrhea. This is a form of food poisoning, typically from contaminated poultry products
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What infectious agent is most often found in contaminated milk or pork products and may disseminate to produce lymphadenitis and further extraintestinal infection
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Yersinia enterocolitica
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What infectious agent causes an acute onset of abdominal pain, bloating, and diarrhea not by directly infecting the gastrointestinal tract but by producing an exotoxin while growing on food that is subsequently digested
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Staphylococcus aureus
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38 year old woman has had nausea for the past 6 months. No vomiting or diarrhea. Diffuse gastric mucosal erythema with focal mucosal erosions but no ulcerations. Esophageal and duodenal mucosal surfaces appear normal. Gastric biopsy shows increased numbers of neutrophils, lymphocytes, and plasma cells in the mucosa, as well as edema, focal mucosal hemorrhage, and loss of the surface epithelium. No H pylori present. Normal serum gastrin levels. What pharmacologic agent is most likely producing these findings
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Acetylsalicylic acid (aspirin). These finding are consistent with an acute gastritis. Heavy consumption of alcohol is probably the most common cause, but aspirin and NSAIDs, smoking, and chemotherapy agents can produce the same findings.
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One year after having an acute myocardial infarction, a 55 year old man saw his physician because of severe abdominal pain and bloody diarrhea. Abdomen was diffusely tender, and bowel sounds were present. Xray no free air. Normal CBC and normal levels of serum amylase, lipase, and bilirubin. Condition deteriorates to irreversible shock. What lesion will likely be found at autopsy
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Intestinal infarction. The patient's history of myocardial infarction suggests that he had severe coronary atherosclerosis. Atheromatous disease most likely involved the mesenteric vessels as well, giving rise to thrombosis of the blood vessels that perfuse the bowel. The symptoms and signs suggest infarction of the gut
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Pseudomembranous colitis develops in patients receiving what
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Antibiotic therapy
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Vacuolating cytotoxin (VacA). Helicobacter pylori organisms reside in the gastric mucus and are associated with a variety of gastric disorders, from chronic gastritis with erythema and thickened rugal folds as in this case, to peptic ulcers and to adenocarcinoma. H pylori organisms elaborate several toxic substances that injure the epithelium. Vacuolating cytotoxin causes cell injury characterized by vacuolization, and its expression is controlled by another gene encoding cytotoxin-associated antigen (CagA). More than 80% of patients with duodenal ulcers are infected by CagA positive H. pylori strains also expressing VacA
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59 year old man has had nausea and vomiting for several months. No hematemesis. No ab tenderness, and bowel sounds are present. Erythematous areas of mucosa with thickening of the rugal folds in the gastric antrum. What toxin will likely be present
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What does vacuolating cytotoxin (VacA) cause
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Cell injury characterized by vacuolization, and its expression is controlled by another gene encoding cytotoxin-associated antigen (CagA). More than 80% of patients with duodenal ulcers are infected by CagA positive H. pylori strains also expressing VacA
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What organism produces cysteine proteinases that aid in tissue invasion
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Entamoeba histolytica
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What toxin, which is produced by some strains of E. coli, is associated with the hemolytic-uremic syndrome mediated by endothelial injury
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Verocytotoxin
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A 62 year old man sees his physician because he has had fever and back pain for the past 2 days. Tenderness of the right costovertebral angle. Leukocytosis and pyuria with WBC casts. Has been receiving cefotaxime, clindamycin, and nafcillin for the past 16 days. Now develops lower ab pain and severe diarrhea. Clostridium difficile toxin is identified in a stool specimen. What condition has he most likely now developed
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Pseudomembranous colitis. This is caused by overgrowth of Clostridium difficile, which occurs when the normal gut flora is altered by broad-spectrum antibiotic therapy. In this case, the patient was treated for acute pyelonephritis. Organisms other than C. difficile, such as Candida, may overgrow, but C. difficile is the most common organism identified with pseudomembranous colitis
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What gastrointestinal disease is not common, and most often leads to watery diarrhea in middle aged women
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Collagenous colitis
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What is a rare condition with cecal inflammation that occurs in immunocompromised persons
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Typhlitis
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70 year old man with stool sample positive for occult blood. 5cm sessile mass in the upper portion of the descending colon at 50cm from the anal verge. Histology shown above. Patient refused further treatment. 5 years later sees physician because of constipation, microcytic anemia, and 5kg weight loss over the past 6 months. 7cm mass encircling the descending colon. What neoplasm does he now most likely have
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Adenocarcinoma. This patient had a large villous adenoma, as shown in the figure. There is a high probability(>40%) that large (>4cm) villous adenomas will progress to invasive adenocarcinoma. When they occur in the descending colon, these lesions are annular and cause obstruction.
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What type of gastrointestinal tumor is typically small and yellowish, and grows slowly
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Carcinoid tumor
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70 year old man with a lengthy history of chronic alcoholism has had increasing difficulty swallowing and has noticed a 6kg weight loss over the past 2 months. 3cm ulcerative mass in the midesophagus that partially occludes the esophageal lumen. Esophagectomy shown above. Most likely diagnosis?
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Squamous cell carcinoma. This large, ulcerated lesion with heaped up margins is a malignant tumor of the esophageal mucosa. There are two main histologic types of esophageal carcinomas--squamous cell carcinoma and adenocarcinoma--with distinct risk factors. Smoking and alcoholism are the most frequent risk factors for esophageal squamous cell carcinoma in the Western world. Adenocarcinoma is most likely to arise in the lower third of the esophagus and to be associated with Barrett esophagus.
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Thrombosed vascular channels in the esophagus suggest what
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They occur in sclerotherapy for esophageal varices; they do not produce an ulcerated mass
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When might a dense, collagenous scar of the midesophagus occur
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After injury from ingestion of a caustic liquid
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Multinucleated cells with intranuclear inclusions suggests what
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Infection with herpes simplex virus or cytomegalovirus, both of which are likely to produce ulceration without a mass; both occur in immunocompromised patients
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33 year old man bothered by low-volume, mostly watery diarrhea associated with flatulence. Symptoms occur episodically, but they have been persistent for the past year. Has experienced 5kg weight loss. No fever, nausea, vomiting, or ab pain. Stool negative for bugs. Biopsy of upper small bowel shows severe diffuse blunting of villi and a chronic inflammatory infiltrate in the lamina propria. What serological test will be positive in this patient
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Antigliadin antibody. The clinical and histologic features are most suggestive of celiac sprue. This rare chronic disease may manifest in childhood or young adulthood. Celiac sprue results from gluten sensitivity. Exposure to the gliadin protein in wheat, oats, barley, and rye results in intestinal inflammation. A trial of a glutten-free diet is the most logical therapeutic option. Patients usually become symptom free. Almost 100% of patients with active celiac disease have IgA antibodies. These antibodies generally decrease or disappear in patients on gluten-free diets. Serum tests for IgA-class endomysial antibodies in conjunction with tests for antibodies to reticulin or gliadin enable the serologic detection of virtually all cases of celiac disease
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Anticentromeric antibody is most specific for what
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Limited scleroderma (CREST syndrome) with esophageal dysmotility
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Anti-DNA topoisomerase I antibody is most specific for what
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Diffuse scleroderma, in which gastrointestinal tract involvement by submucosal fibrosis may be more extensive, and malabsorption may be present
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Antimitochondrial antibody is more specific for what
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Primary biliary cirrhosis
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Antinuclear antibody is present when
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In a wide variety of autoimmune diseases, but is not characteristic of celiac sprue
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A potluck lunch party is held at the office at noon on Thursday. A variety of meats, salads, breads, and desserts that were brought in earlier that morning are served. By mid-afternoon, many people have an acute, explosive diarrhea accompanied by ab cramping. What likely caused this
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Staphylococcus aureus. The clinical features suggest food poisoning caused by the ingestion of a preformed enterotoxin. S. aureus grows in food and elaborates an enterotoxin that, when ingested, produces diarrhea within hours.
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When does diarrheal illness develop after infection with Salmonella enteritidis
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Within 2 days
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During a dairy celebration, a 40 year old man suffers from episodic ab bloating, flatulence, and explosive diarrhea. No bugs present. Doesn't eat milk products the rest of the year. Diagnosis
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Disaccharidase deficiency. This is an uncommon congenital condition in which the lactose in milk products is not broken down into glucose and galactose, resulting in an osmotic diarrhea and gass production from gut flora
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An autoimmune gastritis is most likely to result in malabsorption of what
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Vitamin B12
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What can cause biliary tract obstruction with malabsorption of fats and right upper quadrant abdominal pain.
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Cholelithiasis
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For the past year, a 20 year old man has had increasingly voluminous, bulky, foul-smelling stools and a 10kg weight loss. No history of hematemesis or melena. Some bloating but no ab pain. No ab masses; bowel sounds present. What will likely be found on examination of his stool
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Increased stool fat. This patient is most likely to have fat malabsorption. Smelly, bulky stools containing increased amounts of fat (steatorrhea) are characteristic. Pancreatic or biliary tract diseases are important causes of fat malabsorption
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Giardiasis produces what type of diarrhea
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Watery
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68 year old woman has had substernal pain after meals for many years. For the past year, increased difficulty swallowing both liquids and solids. Lower esophageal mass that nearly occludes the lumen of the esophagus. Diagnosis?
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Adenocarcinoma of the esophagus, which is typically located in the lower esophagus, where Barrett esophagus develops at the site of long-standing gastroesophageal reflux disease. Barrett esophagus is associated with a greatly increased risk of developing adenocarcinoma.
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Where do carcinoid tumors often occur
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In different parts of the gut, including the appendix, ileum, rectum, stomach, and colon
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6 week infant began feeding poorly after 1 week, and his mother noticed that much of the milk he ingested was forcefully vomited within 1 hour. Midbdominal mass present. Bowel sounds active. Mother and sibling had similar illness during infancy. Diagnosis
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Pyloric stenosis. The infant's condition occurred several weeks after birth because of hypertrophy of pyloric smooth muscle. Pyloric stenosis manifests the genetic phenomenon of a "threshold of liability," above which the disease is manifested--more genetic risks are present
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A 53 year old woman has had nausea, vomiting, and midepigastric pain for 5 months. Findings include gastric outlet obstruction. Ulcerated mass that is 2x4cm at the pylorus. What is the most likely neoplasm here
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Adenocarcinoma. The most likely cause of a large mass lesion in the stomach is a gastric carcinoma, and this lesion is an adenocarcinoma
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What are two neoplasms that tend to form bulky masses in the fundus
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Malignant lymphomas and leiomyosarcomas
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60 year old man has had increasing fatigue for the past 8 months. Appears pale. No masses palpable on digital rectal exam, but stool sample positive for occult blood. Active bowel sounds with no masses or areas of tenderness. Hgb 8.4, hct 24.6, MCV 73, platelets 226,000, WBC 7640. Colonoscopy finds no source of bleeding. Angiography shows a 1cm focus of dilated and tortuous vascular channels in the mucosa and submucosa of the cecum. Diagnosis?
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Angiodysplasia of the colon. Angiodysplasia refers to tortuous dilations of mucosal and submucosal vessels, seen most often in the cecum in patients older than 50 years of age. These lesions, although not common, account for 20% of significant lower intestinal bleeding. Bleeding is usually not massive, but can occur intermittently over months to years. This lesion is very difficult to diagnose and is often found radiographically. The focus (or foci) of abnormal vessels can be excised
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What is a rare thrombosis that may result in bowel infarction with severe abdominal pain
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Mesenteric venous thrombosis
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43 year old woman has become increasingly tired and listless over the past 5 months. She has had menometrorrhagia for the past 3 months. Positive result on stool guaiac testing. Hgb 9.2, hct 27.3%, MCV 75. Enlarged uterus. Pap smear shows abnormal cells of probably endometrial origin. Partial colectomy results shown above. What molecular abnormality most likely led to these findings
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Mutation in a DNA mismatch repair gene. The figure shows a large, fungating mass that is typical of adenocarcinoma of the right colon. Such cancers are unlikely to obstruct, but they can bleed a small amount over months to years, causing iron deficiency anemia. This relatively young woman has evidence for an additional cancer, an endometrial cancer, and this combination is most likely due to an inherited mutation in one of the DNA mismatch repair genes such as hMSH2 and hMLH1. Homozygous loss of these genes can give rise to right-sided colon cancer and endometrial cancer. Such a mutation is typically associated with microsatellite instability, in contrast to the APC-Beta-catenin pathway associated with familial adenomatous polyposis syndrome. This latter pathway is also known as the "adenoma-carcinoma sequence" since the carcinomas develop through an identifiable series of molecular and morphologic steps
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What mutation occurs in gastointestinal stromal tumors and responds well to treatment with imatinib mesylate, a tyrosine kinase inhibitor also used to treat chronic myelogenous leukemia
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Mutation with activation of c-KIT tyrosine kinase activity
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Loss of what is seen in endometrial carcinomas not associated with colon carcinoma, and with some hamartomatous polyps of the colon
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Loss of the PTEN tumor suppressor gene
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Infection with what leads to Rb protein inactivation and development of cervical carcinoma
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Some strains of human papillomavirus (HPV)
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23 year old woman has had a bloody, mucoid, low-volume diarrhea for the past 5 weeks. Five stools per day. Afebrile, no ab tenderness or pain. Bowel sounds present. No ova or parasites in stool, only mucus and blood with few leukocytes. Friable, erythematous mucosa extending from the rectum to the middle of the descending colon. Rectal biopsy specimen shows acute mucosal inflammation with crypt abscesses and epithelial cell necrosis. Diagnosis?
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Ulcerative colitis. The continuous mucosal involvement to a demarcated end point is more typical of ulcerative colitis than of Crohn disease, both of which are idiopathic inflammatory bowel diseases. Because the colon absorbs mainly water and concentrates stool, inflammatory conditions involving the colon tend to produce low-volume diarrhea, whereas conditions that affect the small bowel and lead to malabsorption result in high-volume diarrhea
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What causes dysentery with many fecal leukocytes
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Shigellosis
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52 year old man has had a 6kg weight loss and nausea for the past 6 months. No vomiting or diarrhea. 6cm area of irregular pale fundic mucosa and loss of the rugal folds. Monomorphous infiltrate of lymphoid cells. H pylori organisms are identified in mucus overlying adjacent mucosa. Antibiotics cause a resolution of the infiltrate. Diagnosis?
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Mucosa-associated lymphoid tissue tumor. Certain gastrointestinal lymphomas that arise from MALT are called MALT lymphomas. Gastric lymphomas that occur in association with H. pylori infection are composed of monoclonal B cells, whose growth and proliferation remains dependent on cytokines derived from T cells that are sensitized to H. pylori antigens. Treatment with antibiotics eliminates H. pylori and therefore the stimulus for B-cell growth. MALT lesions can occur anywhere in the gastrointestinal tract, although they are rare in the esophagus and appendix.
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In what H. pylori-associated disease, which may precede lymphoma development, are there lymphoplasmacytic mucosal infiltrates
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Chronic gastritis caused by H. pylori
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Autoimmune gastritis is a risk for developing what
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Gastric adenocarcinoma
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70 year old man takes large quantities of NSAIDs because of arthritis. Recently, he has had epigastric pain with nausea and vomiting and an episode of hematemesis. Gastric biopsy will likely reveal what pathology
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Acute gastritis. Prolonged uses of NSAIDs is an important cause of acute gastritis. Excessive alcohol consumption and smoking are also possible causes. Acute gastritis tends to be diffuse and, when severe, can lead to significant hemorrhage that is difficult to control
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Gastric epithelial dysplasia may occur at the site of what
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Chronic gastritis. It is a forerunner of gastric cancer.
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Hyperplastic polyps of the stomach may arise in association with what
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Chronic gastritis
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A 44 year old woman has had increasing difficulty swallowing liquids and solids for the past 6 months. Fingers have reduce mobility because of taut, nondeforming skin. Barium swallow reveals marked dilation of the esophagus with "beaking" in the distal portion, where there is marked luminal narrowing. Prominent submucosal fibrosis with little inflammation. Diagnosis?
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CREST syndrome. Esophageal dysmotility is the "E" in CREST syndrome, the limited form of systemic sclerosis (scleroderma). Although the disease is autoimmune, little inflammation is seen by the time the patient seeks clinical attention. There is increased collagen deposition in submucosa and muscularis. Fibrosis may affect any part of the gastrointestinal tract, but the esophagus is the site most often involved
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A diagnosis of what disease must have columnar metaplasia in the esophagus, and there is often a history of reflux disease
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Barrett esophagus
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Iron deficiency anemia may cause what pathology in the esophagus
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An upper esophageal web
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A 35 year old man has had epigastric pain for over 1 year. Pain tends to occur 2-3 hours after a meal and is relieved if he takes antacids or eats more food. Has noticed 4kg weight gain in the past year. Does not smoke, but drinks alcohol. Urea breath test positive, gastric biopsy specimen contains urease. Improves with antibiotics, but stops before the course is complete. Without further treatment, what complication will most likely develop
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Hematemesis. The clinical symptoms in this case suggest peptic ulcer disease. In most cases, peptic ulcers are associated with H. pylori infection. These bacteria secrete urease, which can be detected by oral administration of radioactive urea. If not properly treated, peptic ulcers can produce many complications, including massive bleeding that can be fatal
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Is there a risk of metastases as a complication of peptic ulcer disease?
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No. Peptic ulcers rarely progress to gastric carcinoma
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Autoimmune atrophic gastritis can lead to deficiency of what
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Vitamin B12, because intrinsic factor, which is required for B12 absorption, is produced by gastric parietal cells
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27 year old man has sudden onset of marked abdominal pain. Ab diffusely tender and distended, bowel sounds absent. 27cm segment of terminal ileum removed. Biopsy shown above. What additional complication is the patient most likely to develop
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Enterocutaneous fistula. The ileum shows chronic inflammation with lymphoid aggregates. The inflammation is transmural, affecting the mucosa, submucosa, and muscularis. A deep fissure extending into the muscularis is also seen. These histologic features are highly suggestive of Crohn disease. Extension of fissures into the overlying skin can produce enterocutaneous fistulas, although enteroenteric fistulas between loops of bowel are more common. Although the risk of adenocarcinoma is increased in Crohn disease, this complication is less common than sequelae of inflammation.
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What may occur when there is a congential or acquired obstruction in the bowel
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Intussusception
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What liver pathology may follow amoebic colitis
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Hepatic abscess
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8 month old previously healthy infant develops a watery diarrhea that lasts for 1 week. Mild fever during the illness but no abdominal pain or swelling. 37.7C. Stool negative for bugs. Parents are told to give her plenty of fluids, and she recovers fully. What is the most likely organisms affecting her
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Rotavirus, which is the most common cause of viral gastroenteritis in children. It is a self-limited disease that affects mostly infants and young children, who can lose a significant amount of fluid relative to their size and they can quickly become dehydrated
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59 year old man has had increasing difficulty swallowing during the past 6 months. Upper GI Endoscopy shows areas of erythematous mucosa above the Z line. Biopsy shown above. What complication is likely to occur in this patient
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Adenocarcinoma. The biopsy specimen shows columnar metaplasia, typical of Barrett esophagus. Patients with a focus of Barrett esophagus larger than 2cm are at 30-40 fold higher risk of developing adenocarcinoma than is the general population
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What refers to failure of relaxation of the lower esophageal sphincter that gives rise to dilation of the proximal portion of esophagus
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Achalasia
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What is associated with vertical lacerations in the esophagus that may occur with severe vomiting and retching
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Mallory-Weiss syndrome
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One day after a meal of raw oysters, a healthy 21 year old woman develops profuse, watery diarrhea. 37.5C. Stool negative for occult blood. No ab distention or tenderness, bowel sounds present. Diarrhea subsides over the next three days. What organism is responsible
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Vibrio parahemolyticus. Raw or poorly cooked shellfish can be the source of Vibrio parahaemolyticus, which tends to produce a milder diarrhea than Vibrio cholerae
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57 year old woman has had burning epigastric pain after meals for more than 1 year. Upper GI shows erythematous patch in the lower esophageal mucosa. Basal squamous epithelial hyperplasia, elongation of lamina propria papillae, and scattered intraepithelial neutrophils with some eosinophils. Diagnosis?
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Reflux esophagitis. These findings indicate an ongoing inflammatory process resulting from reflux of acid gastric contents into the lower esophagus. GERD is a common problem that stems from a variety of causes, including sliding hiatal hernia, decreased tone of the lower esophageal sphincter, and delayed gastric emptying. Patients may have a history of heartburn after eating
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What is a complication of GERD that is characterized by columnar metaplasia of squamous epithelium that normally lines the esophagus
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Barrett esophagus
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Progressive fibrosis with stenosis in the esophagus is found with what
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Scleroderma
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49 year old woman with ab cramps and diarrhea, and six stools per day for the past month. History of similar episodes of self-limited pain and diarrhea over the past 20 years. Each episode lasts 2 weeks and resolves without treatment. Stool sample positive for occult blood. No bugs in stool. Diffuse and uninterrupted mucosal inflammation and superficial ulceration extending from the rectum to the ascending colon. Diffuse, predominantly mononuclear, infiltrate in the lamina propria. The patient is at high risk for developing what complication
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Adenocarcinoma of the colon. This patient has clinical and histologic features of ulcerative colitis. Particulary important are relapsing and remitting episodes of diarrhea containing blood and mucus and diffuse inflammation and ulceration of the rectal and colonic mucosa. One of the most dreaded complications of ulcerative colitis is the development of colonic adenocarcinoma. There is a 20-30 fold higher risk in patients who have had ulcerative colitis for 10 or more years compared with control populations
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Why does fat malabsorption usually not occur in ulcerative colitis
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The ileum often is not involved
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Sclerosing cholangitis is an extraintestinal manifestation of what disease
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Ulcerative colitis
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A 41 year old man has been HIV+ for the past 8 years and has been receiving HAART for the past year. For the past 2 weeks he has experienced pain when swallowing. No episodes of hematemesis and no nausea or vomiting. No remarkable findings on exam. CD4+ count 285. What condition is most likely to produce these findings?
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Herpes simplex esophagitis. A patient who is infected with HIV and has low CD4+ cell counts is at great risk of developing infections. Herpes simplex and Candida are the most likely upper gastrointestinal infections involving the esophagus
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Fibrosis with stenosis of the esophagus is a feature of what two gastrointestinal pathologies
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GERD and scleroderma
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67 year old woman has experienced severe nausea, vomiting, early satiety, and 9kg weight loss over the past 4 months. Mild muscle wasting. The entire gastric mucosa is eroded and has an erythematous, cobblestone appearance. Stomach small and shrunken. What will be seen on a histologic exam
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Signet-ring cell adenocarcinoma. The endoscopy findings describe the linitis plastica (leather bottle) appearance of diffuse gastric carcinoma. Histologically, these carcinomas are composed of gastric-type mucus cells that infiltrate the stomach wall diffusely. The individual tumor cells have a signet-ring appearance, because the cytoplasmic mucin pushes the nucleus to one side
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What type of gastric carcinoma is confined to the mucosa and submucosa
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Early gastric carcinoma
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In what gastric disease are the rugal folds lost, but there is no significant scarring or shrinkage
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Chronic atrophic gastritis
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What type of gastrointestinal tumors tend to be bulky masses
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Gastrointestinal stromal tumors
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51 year old man has sudden onset of massive emesis of bright red blood. 36.9C, pulse 103, resp 19, BP 85/50, Hct 21%. Serologic test result for HBsAg is positive. No prior episodes of hematemesis. The hematemesis is most likely to be a consequence of what
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Esophageal varices. Variceal bleeding is a common complication of hepatic cirrhosis, which can be an outcome of chronic hepatitis B infection. The resultant portal hypertension leads to dilated submucosal esophageal veins that can erode and bleed profusely
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What pathology is located in the upper esophagus and results from cricopharyngeal motor dysfunction; it presents a risk for aspiration but not for hematemesis
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Zenker diverticulum
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16 year old boy who is receiving chemotherapy for ALL now has pain for 1 week when he swallows food. 0.5-0.8cm mucosal ulcers in the region of the middle to lower esophagus. Shallow ulcers are round, sharply demarcated, and have an erythematous base. What caused this
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Herpes simplex esophagitis. The "punched-out" ulcers described result from rupture of the herpetic vesicles
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Infection with what will cause esophageal ulcers with the gross appearance of tan-to-yellow plaques
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Candida, causing esophagitis
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11 month old previously health infant has not produced a stool for 1 day. Abdomen is distended. Ab very tender and bowel sounds are nearly absent. Xray no free air, but there are distended loops of small bowel with air-fluid levels. What would cause this
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Intussusception. The infant has signs and symptoms of acute bowel obstruction. Intussusception occurs when one small segment of small bowel becomes telescoped into the immediately distal segment. This disorder can have sudden onset in infants and may occur in the abscence of any anatomic abnormality
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What gastrointestinal pathology, which typically occurs with other anomalies such as trisomy 21, usually manifests soon after birth
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Duodenal atresia
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22 year old woman has had several episodes of aspiration of food associated with difficulty swallowing during the past year. Crackles are heard at the base of the right lung. Marked esophageal dilation above the level of the lower esophageal sphincter. Absence of the myenteric ganglia in the lower esophagus. Diagnosis?
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Achalasia. In achalasia, there is incomplete relaxation of the lower esophageal sphincter. Most cases are primary or of unknown origin. They are believed to be caused by degenerative changes in neural innervation; hence, the myenteric ganglia are usually absent from the body of the esophagus. There is a long-term risk of development of squamous cell carcinoma
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53 year old woman comes to her physician for routine exam. Occult blood found in stool. 1.5cm solitary, rounded, erythematous polyp on a 0.5cm stalk at the splenic flexure. Polyp appears above. What should the physician tell this patient
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A detailed workup to detect metastases from this lesion is not warranted. The figure shows a solitary pedunculated adenoma of the colon with no evidence of malignancy. High magnification shows a small focus of dysplastic, non-mucin-secreting epithelial cells lining a colonic crypt, giving rise to "tubular" architecture. Such a small (<2cm), solitary, tubular adenoma is unlikely to harbor a focus of malignancy; hence, a search for metastases is unwarranted
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What could cause a young patient to develop hundreds of colonic polyps
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Mutated APC gene
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Patients with what pathology have an increased risk of endometrial cancer and develop colon cancer at a young age
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Hereditary nonpolyposis colorectal cancer
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A 20 year old woman 9 months pregnant has increasing pain on defecation and notices bright red blood on the toilet paper. No previous gastrointestinal problems. After she gives birth, the rectal pain subsides, and there is no more bleeding. Diagnosis?
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Hemorrhoids. This is a common problem that can stem from any condition that increases venous pressure and causes dilation of internal or external hemorrhoidal veins above and below the anorectal junction
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Angiodysplasia of the colon leads to what
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Intermittent hemorrhage, typically in older persons
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Severe atherosclerotic disease involving mesenteric vessels, and occuring in older patients, is an underlying cause of what
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Ischemic colitis
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Neonate born at 32 weeks gestation was in stable condition and feeding well 3 days after birth. On day 4 the infant's abdomen was tender and appeared distended. A stool sample was positive for occult blood. Leukocytosis and E.coli present. The infant died of septic shock. What will most likely be found at autopsy
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Dark red necrotic ileum and cecum. This infant has neonatal necrotizing enterocolitis, a complication of prematurity. Necrotizing enterocolitis is believed to result from immaturity of the immune system of the gut and is often precipitated by oral feeding. The necrotic bowel can perforate
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26 year old man undergoes surgery after a gunshot wound. Surgeon noticed a 2cm mass near the site of bowel perforation. Yellow-tan-colored submucosal ileal mass is removed. EM shown above. What is the most likely cell of origin of this legion
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Neuroendocrine cell. The figure shows a carcinoid tumor. The cytoplasm of the tumor cell contains small, dark, round granules with a dense core (neurosecretory granules), which are characteristic of neuroendocrine cells. The gross appearance of this tumor and its location are also characteristic of carcinoid tumors. Many small carcinoids and other small, benign bowel tumors are discovered incidentally; most are 2cm or smaller
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20 year old woman has had nausea and vague lower abdominal pain for the past 24 hours, but now the pain has become more severe. Pain is worse in the right lower quadrant, and there is rebound tenderness. Stool sample negative for blood. Xray no free air. Not pregnant. What lab finding will be most useful for diagnosis of this patient
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Leukocytosis. These findings indicate acute appendicitis. The elevated WBC count with neutrophilia is helpful but not decisive, and the decision to operate must be based on clinical judgment.
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Hyperamylasemia occurs in what pathology
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Acute pancreatitis
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Diarrhea with fluid loss and dehydration can lead to what abnormal lab value
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Hypernatremia
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The carcinoembryonic antigen level may be increased in patients with what
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Colonic cancers; however, this test is not specific for colon cancer
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The alkaline phosphatase level may be increased with what disease
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Biliary tract obstruction
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Over the past 3 months, a 45 year-old woman has noticed that her skin has become progressively more yellow. Afebrile and has scleral icterus and generalized jaundice. Serum bili 8.9, direct bili 6.8, serum ALT 125, AST 108. Liver biopsy shows sclerosing cholangitis. What disease of the gastrointestinal tract is most likely to coexist with this liver disease
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Ulcerative colitis. Sclerosing cholangitis is a serious extraintestinal manifestation of idiopathic inflammatory bowel disease, most often ulcerative colitis or, less often, Crohn disease.
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Pancreatitis and cholangitis may be complications of what
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Biliary tract lithiasis
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One week after a trip to Central America, a 31 year old woman had an increasingly severe diarrhea. Stools show mucus and streaks of blood. Diarrheal illness subsided within a couple of weeks, but now the patient has become febrile and has pain in the right upper quadrant of the abdomen. Ultrasound showed 10cm irregular, partly cystic mass in the right hepatic lobe. What infectious organism is most likely to produce these findings
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Entamoeba histolytica. Diarrhea with mucus and blood in the stools can be caused by several enteroinvasive microorganisms, including Shigella dysenteriae and E. histolytica. In most cases, the diarrhea is self-limited. The inital episode of diarrhea could have been caused by one of several organisms; however, the occurence of a liver abscess after an episode of diarrhea most likely results from infection with E. histolytica. Colonic mucosal and submucosal invasion by E. histolytica allows the organisms to gain access to submucosal veins draining to the portal system and to the liver
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51 year old woman has been feeling increasingly tired for the past 7 months. Hgb 9.5, hct 29.1%, MCV 124, platelets 268,000, WBC 8350. Reticulocyte index low. Hypersegmented polymorphonuclear leukocytes are found on a peripheral blood smear. Antibodies to what are likely to be found in this patient
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Gastric H+,K+ -ATPase. This patient has megaloblastic anemia with a high MCV. Delayed maturation of the myeloid cells leads to hypersegmentation of PMN leukocytes. She most likely has pernicious anemia, resulting from autoimmune atrophic gastritis. Loss of parietal cells from autoimmune injury causes a deficiency of intrinsic factor. In the abscence of this factor, vitamin B12 cannot be absorbed in the distal ileum. Among the various "antiparietal cell" antibodies are those directed against the acid-producing "proton pump" enzyme hydrogen, potassium ATPase. In pernicious anemia, no antibodies are directed against intrinsic factor receptor on ileal mucosal cells
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24 year old woman gives birth to healthy infant. Three days after birth, the infant vomits all oral feedings. Afebrile, abdomen distended and tender and bowel sounds are reduced. Ultrasound marked colonic dilation above a narrow segment in the sigmoid region. Biopsy specimen shows absence of ganglion cells in the muscle wall and submucosa. Diagnosis?
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Hirschsprung disease. The aganglionic segment of the bowel wall produces a functional obstruction with proximal distension.
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24 year old man with ab pain and increasing fatigue that has developed over the past 6 months. Afebrile and appears pale. Mild pain in the right lower quadrant of the abdomen. No masses, and bowel sounds are active. Hgb 8.9, Hct 26.7%, MCV 74, platelets 255000, WBC 7780. No lesions in the gut. One month later, the patient continues to experience the same ab pain. Diagnosis?
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Meckel diverticulum. About 2% of persons have Meckel diverticulum, an embryologic remnant of the omphalomesenteric duct, but only a subset of these persons have ectopic gastric mucosa within it, which causes intestinal ulceration. The symptoms may mimic acute appendicitis, but appendicitis should not last for 1 month or cause significant blood loss.
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What is a gastrointestinal disease that may be difficult to detect, is almost always seen in patients older than 70, and can cause significant blood loss
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Angiodysplasia
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Where are diverticula almost always located
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The colon
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30 year old man with stool sample positive for occult blood. Ulcerative lesion is seen projecting into the cecum. Histology appears above. What biologic mutation most likely lead to development of this lesion
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A defective DNA mismatch-repair gene. The lesion is an adenocarcinoma, showing irregular glands infiltrating the muscle layer. Such a lesion in a 30 year old man strongly indicates a hereditary predisposition. One form of hereditary carcinoma of the colon results from inheritance of a defective copy of the DNA mismatch-repair genes. A second mutation at the same locus inactivates both copies of such genes and cripples the ability to repair certain forms of DNA damage. The resultant genomic instability predisposes to early onset of colon carcinoma. This type of cancer is called hereditary nonpolyposis colorectal carcinoma (HNPCC). Unlike familial adenomatous polyposis syndrome HNPCC does not lead to the development of hundreds of polyps in the colon.
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Will E-cadherin levels be increased or decreased in carcinoma cells
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E-cadherin is required for intercellular adhesion; its levels are reduced in carcinoma cells
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Detection of ERBB2 expression is important in what type of cancer
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Breast cancers
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Translocation of the retinoic acid receptor alpha gene is characteristic of what
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Acute promyelocytic leukemia
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19 year old man with genetic disease. Stool positive for occult blood. Colectomy performed and shown above. Molecular analysis of this patient's normal fibroblasts is most likely to show a mutation in what gene
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APC. The young patient's colon shows hundreds of polyps. This is most likely a case of familial adenomatous polyposis syndrome (FAP), which results from inheritance of one copy of the APC tumor suppressor gene. Every somatic cell of this patient will most likely have one defective copy of the APC gene. Polyps are formed when the second copy of the APC gene is lost in many colon epithelial cells. Without treatment, colon cancers arise in 100% of these patients because of accumulation of additional mutations in one or more polyps, typically before 30 years of age
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NOD2 mutations are linked to what disease
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Crohn disease
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38 year old man who has been HIV positive for 10 years has had severe nausea and vomiting for the past 2 weeks. Afebrile. Stool sample is positive for occult blood. Abdomen is not distended, there are no palpable masses or organomegaly, and bowel sounds are present. The patient has oral thrush. There are several reddish-purple, 0.5-1cm nodules on the skin of the trunk. CD4+ count 118. Upper GI endoscopy shows 12 reddish-purple, 0.6-1.8cm gastric mucosal nodules. A biopsy of the nodules will likely show what neoplasm
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Kaposi Sarcoma. This, along with non-Hodgkin lymphoma and anorectal squamous carcinoma are neoplasms that define AIDS in patients with HIV infection. Kaposi sarcoma most often involves the skin, but it can be found anywhere in the body, including the gastrointestinal tract. Kaposi sarcoma is a vascular lesion; hence the color. Non-Hodgkin lymphomas and squamous carcinomas have a white cut surface and rarely are large enough to cause obstruction.
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Carcinoid tumors are most common where
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In the small and large bowel or appendix. They have a yellowish appearance
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What type of polyps are associated with mucocutaneous pigmentation
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Peutz-Jeghers polyps
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59 year old man with a lengthy history of chronic alcoholism has noticed increasing abdominal girth for the past 6 months. Increasing abdominal pain for the past 2 days. 38.2C. Exam of abdomen shows a fluid wave and prominent caput medusae over the skin of the abdomen. There is diffuse abdominal tenderness. An abdominal plain film radiograph shows no free air. Paracentesis yields 500mL of cloudy yellow fluid. A gram stain of the fluid shows gram negative rods. Diagnosis?
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Spontaneous bacterial peritonitis, an uncommon complication found in about 10% of adult patients with cirrhosis of the liver and ascites. The ascitic fluid provides an excellent culture medium for bacteria, which can invade the bowel wall or spread hematogenously to the serosa. Spontaneous bacterial peritonitis can also appear in children, particularly those with nephrotic syndrome and ascites. The most common organism cultured is Escherichia coli.
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What does collagenous colitis most often lead to
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Watery diarrhea in middle-aged women. It is not common
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In an alcoholic patient with ascites and abdominal pain, should ischemic colitis be suspected
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Ischemic colitis may produce infarction with rupture and peritonitis, but ascites are usually lacking, and persons with chronic alcoholism are unlikely to have marked atherosclerosis
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In an alcoholic patient with abdominal tenderness and ascites, should diverticulitis be suspected
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Diverticulitis with rupture could produce peritonitis, but there is typically no ascites, and diverticulitis is not related to alcoholism
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35 year old woman has had increasing lower back pain for 5 years. Has also had arthritic pain involving the knees, hips, and wrists. A stool sample is positive for occult blood. Pelvic radiograph shows changes consistent with sacroiliitis. A colonoscopy is performed, and she undergoes a total colectomy. The gross appearance of the colectomy specimen is shown. What caused the presentation of these symptoms
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Dysregulated CD4+ T-cell responses. The segment of colon shows the diffuse and severe ulceration characteristic of ulcerative colitis. The inflammation shown is so severe that areas of mucosal ulceration have produced pseudopolyps or islands of residual mucosa. Ulcerative colitis is a systemic disease; in some patients, it is associated with migratory polyarthritis, ankylosing spondylitis, and primary sclerosing cholangitis. The pathogenesis of UC is unclear, but is most likely mediated by a Tcell response to an unknown antigen (but not a gut infection), leading to an imbalance between Tcell activation and regulation. The CD4+ T cells present in the lesions secrete damaging substances. Autoantibodies against tropomyosin are present but do not play a pathogenic role in UC
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35 year old woman has had increasing lower back pain for 5 years. Has also had arthritic pain involving the knees, hips, and wrists. A stool sample is positive for occult blood. Pelvic radiograph shows changes consistent with sacroiliitis. A colonoscopy is performed, and she undergoes a total colectomy. The gross appearance of the colectomy specimen is shown. What caused the presentation of these symptoms
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Dysregulated CD4+ T-cell responses. The segment of colon shows the diffuse and severe ulceration characteristic of ulcerative colitis. The inflammation shown is so severe that areas of mucosal ulceration have produced pseudopolyps or islands of residual mucosa. Ulcerative colitis is a systemic disease; in some patients, it is associated with migratory polyarthritis, ankylosing spondylitis, and primary sclerosing cholangitis. The pathogeneis of UC is unclear, but is most likely mediated by a Tcell response to an unknown antigen (but not a gut infection), leading to an imbalance between Tcell activation and regulation. The CD4+ T cells present in the lesions secrete damaging substances. Autoantibodies against tropomyosin are present but do not play a pathogenic role in UC
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45 year old woman is being treated in the hospital for pneumonia complicated by septicemia. She has required multiple antibiotics and was intubated and mechanically ventilated earlier in the course. On day 20 of hospitalization, she had abdominal distention. Bowel sounds are absent, and an abdominal radiograph shows dilated loops of small bowel suggestive of ileus. She has a low volume of blood stool that is positive for Clostridium difficile toxin. At laparotomy, a portion of distal ileum and cecum is resected. Diagnosis?
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Pseudomembranous enterocolitis. An open colon would show fibrinopurulent debris attached to the mucosa. These patches are called pseudomembranes. Pseudomembranous enterocolitis is a complication of broad-spectrum antibiotic therapy, which alters gut flora to allow overgrowth of C. difficile or other organisms that are capable of inflicting mucosal injury. This type of grow pattern can also appear from ischemic injury that is vascular or mechanical, but this patient's history and the time course support an iatrogenic cause
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A dilated, thinned, toxic megacolon is an uncommon complication of what
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Ulcerative colitis
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52 year old man sustained extensive thermal burn injury over 70% of his body. Three weeks later he had melanotic stools. BP 80/40, Hct 18%. Soon after, he died of cardiac arrest. What was most likely found in the GI tract at autopsy
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Multiple 2-5mm ulcers throughout the gastric mucosa that are confined to the mucosa. The patient has so-called stress ulcers, also known as Curling ulcers when they occur in patients with burn injuries. The ulcers are small (<1cm) and shallow, never penetrating the muscularis propria, but they can bleed profusely. Similar lesions can occur after traumatic or surgical injury to the central nervous system (Cushing ulcers).
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68 year old woman with a history of rheumatic heart disease is hospitalized with severe congestive heart failure. Several days after admission, she develops abdominal distention. On physical examination, she is afebrile. The abdomen is tympanitic, without a fluid wave, and bowel sounds are absent. A stool sample is positive for occult blood. An abdominal xray shows no free air. Colonoscopy shows patchy areas of mucosal erythema with some overlying tan exudate in the ascending and descending colon. No polyps or masses found. Diagnosis?
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Ischemic colitis. Hypotension with hypoperfusion from heart failure is a common cause of ischemic bowel in hospitalized patients. The ischemic changes begin in scattered areas of the mucosa and become confluent and transmural over time. This can give rise to paralytic ileus and bleeding from the affected regions of the bowel mucosa
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What usually produces marked mucosal inflammation with necrosis, usually in a continuous distribution from the rectum upward
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Ulcerative colitis
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27 year old man has had intermittent cramping abdominal pain and low-volume diarrhea for several weeks. Afebrile; mild lower abdominal tenderness but no masses, and bowel sounds are present. Stool sample positive for occult blood. Symptoms subside within 1 week. Six months later, the abdominal pain recurs with perianal pain. There is now a perirectal fistula. Colonoscopy shows many areas of mucosal edema and ulceration and some areas that appear normal. Microscope from ulcerated area shows a patchy acute and chronic inflammatory infiltrate, crypt abscesses, and several noncaseating granulomas. Diagnosis?
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Crohn disease. The clinical and histological features are consistent with Crohn disease, one of the idiopathic inflammatory bowel diseases. It is marked by segmental bowel involvement and transmural inflammation that leads to strictures, adhesions, and fistulae. Fissures and fistulas may be seen. In general, crypt abscesses are more typical of ulcerative colitis, and granulomas are more typical of Crohn disease, but these features are not present in most biopsy specimens from patients with either condition
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49 year old man has complained of heartburn for decades. Endoscopy shows an erythematous area of velvety mucosa just above the gastroesophageal junction. The mucosa shows columnar metaplasia with goblet cells. What produced these findings
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Gastroesophageal reflux disease. Columnar metaplasia of the lower esophageal mucosa, also called Barrett esophagus, is a consequence of chronic gastroesophageal reflux disease. The metaplasia may be accompanied by inflammation.
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65 year old woman with stool sample positive for occult blood. CT shows 1cm outpouchings of the sigmoid and descending colon. What complication is most likely in this patient
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Pericolic abscess. This patient has colonic diverticulosis, which may be accompanied by intermittent minimal bleeding and, rarely, by severe bleeding. One or more diverticula may become inflammed (diverticulitis) or, less commonly, may perforate to produce an abscess, peritonitis, or both. Diverticular disease is not a premalignant condition. The diverticula project outward, and even with inflammation, luminal obstruction is unlikely
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45 year old woman has had increasing abdominal distention for the past 6 weeks. Abdominal fluid wave and bowel sounds are present. Paracentesis yields 1000ml of slightly cloudy serous fluid. Cytology show adenocarcinoma. No major medical illnesses and no surgical procedures. What condition most likely preceded the development of the adenocarcinoma
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Hereditary nonpolyposis colon carcinoma, which is likely to lead to adenocarcinoma in someone of this age
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32 year old man has experienced nausea and vomiting for the past week. Appears cachectic and has noticed 15kg weight loss over the past 2 months. 10cm nontender mass is palpable in the midabdominal region. CT show the mass involves the small intestine. The patient is HIV positive. Biopsy of the mass will show infiltrates of what
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Infiltrates of large monoclonal B lymphocytes. The patient has a non-Hodgkin lymphoma associated with AIDS. These lymphomas are high-grade B-cell neoplasms that have a poor prognosis. Kaposi sarcoma, non-Hodgkin lymphoma, and anorectal squamous cell carcinoma are malignancies found in the gastrointestinal tract in association with HIV infection.
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What gastrointestinal tract pathology is characterized by blunting and flattening of villi containing increased numbers of lymphocytes and plasma cells
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Lymphomas of the gastrointestinal tract may be found in patients with Celiac sprue
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What type of tumors are associated with Helicobacter pylori infection
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Sporadic MALT lymphomas
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Densely packed tubular glands are characteristic of what pathology that is common in the colon
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Tubular adenomas (adenomatous polyps)
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In AIDS, ulceration with cytomegalovirus is most likely to occur where in the GI tract
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The esophagus or colon. A mass effect is unlikely
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Patients are identified who had abdominal pain and diarrhea during week 1 of their illness. By week 2, these patients had splenomegaly and elevations in serum AST and ALT levels. By week three, they were septic and had leukopenia. At autopsy, those who died were found to have ulceration of Peyer's patches. What infectious agent would do such a thing?
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Salmonella typhi. Typhoid fever begins as an intestinal infection, but it becomes a systemic illness. A chronic carrier state can occur in some infected persons, with colonization of the gallbladder
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57 year old man has increasing abdominal pain with distension that developed over the past 24 hours. Diffuse ab tenderness. Ab tympanic, without a fluid wave, and bowel sounds are nearly absent. Well-healed, 5cm transverse scar in the right lower quadrant of the abdomen. No caput medusae. Stool sample negative for occult blood. Dilated loops of small bowel with air-fluid levels, but no free air. Surgeon notices a 20cm portion of reddish-black ileum that changes abruptly to pink-appearing bowel on distal and proximal margins. Patient had appendectomy 32 years ago. What caused these findings?
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Adhesions. The patient had acute bowel obstruction, and the findings at surgery show bowel infarction. The most common causes in developed nations are adhesion, hernias, and metastases. Adhesions are most often the result of prior surgery, as in this case, and produce "internal" hernias, where a loop of bowel becomes trapped (incarcerated) and the blood supply is compromised. Loops of bowel that become trapped in direct or indirect inguinal hernias can also infarct.
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