Bikman: GI Path

Question 1

Conditions associated with mouth path

Answer 1

• Bulemia
• Gardner’s Syndrome
• Plummer-Vinson

Question 2

Bulemia

Answer 2

Patient consumes large volumes and vomits (or uses laxatives)

• 2x/week for >3mo
• Signs
  
  • Parotid enlargement b/c of nutritional deficiency
  • Cardinal sign: severe erosion of enamel along lingual surface of maxillary teeth

Question 3

Gardner’s Syndrome

Answer 3

• Intestinal polyps, premalignant variant (adenomatous)
• Osteomas
• Usually have prophylactic colectomy
  
  • ​Colon cancer by 40yo
• Supernumerary teeth
• Unerupted/impacted teeth
• Radiography of jaws with family history can provide early detection

Question 4

Plummer-Vinson Syndrome

Answer 4

• 4th to 5th decades in women
• Dysphagia (difficulty swallowing) is hallmark of disease from esophageal stricture (narrowing of esophagus) or webs
• Iron deficiency anemia
• Atrophic glossitis, thinning of vermillion borders and leukoplakia
• Oral squamous cell carcinoma reported in around 10% of patients

Question 5

Conditions associated with saliva gland path

Answer 5

• Sjogren syndrome
• Mucoepidermoid carcinoma

Question 6

Sjogren syndrome

Answer 6

Sicca Syndrome

• Autoimmune destruction of exocrine glands (salivary and lacrimal glands)
  
  • Genetic predisposition
  • T cells react against Ag in gland and form immune complexes = destroyed gland
    
    • Dry eyes and mouth
    • Women > Men
      
      • Middle-aged women
• Increased risk of lymphoma - 40x greater risk
• Systemic disease
  
  • Warthin’s tumor - “papillary cystadenoma lymphomatosum” (also increased risk from smoking)
  • Fatigue
  • Arthralgia/Myalgia (muscle and joint pain)
  • Gland enlargement
  • Raynaud phenomenon
  • Vasculitis
  • Peripheral neuropathy
  • Oral changes - atrophic papillae, deeply fissured epithelium, angular chelitis, missing teeth, caries, xerostomia, altered taste, mucosal ulcers

Question 7

How does the facial swelling associated with Sjorgen Syndrome due to autoimmune destruction of glands differ from lymphoma?

Answer 7

Lymphoma doesn’t progress up towards the ears like it does with Sjogren syndrome

Question 8

What is Raynaud phenomenon? Of the pathological conditions covered in this lecture, which one is this phenomenon associated with?

Answer 8

Spontaneous vasoconstriction on the digits and/or nose

Question 9

Sjogren Syndrome Tx

Answer 9

Treatment

• Supportive and symptom based
• Oral
  
  • Adequate hydration
  • Scrupulous dental hygiene
  • Cholinergic agents (stimulate saliva) - stimulate parasympathetic
• Eye
  
  • Lubricating solutions
• Systemic
  
  • Steroids

Question 10

Mucoepidermoid Carcinoma

Answer 10

• One of the most common malignant salivary gland tumors
• Commonly in parotid glands
• Prognosis depends on stage

Question 11

Esophageal pathological conditions

Answer 11

• Hiatal hernia
• Mallory-Weiss syndrome
• Barrett esophagus
• Carcinoma

All can cause dysphpagia

Question 12

Hiatal hernia

Answer 12

• Dilated portion of stomach protrudes above the diaphragm
  
  • Diaphragm creates functional sphincter separating esophagus and stomach
• Common; asymptomatic
• Danger: ulceration, bleeding
• Can cause esophageal stricture
• Manifestations:
  
  • Heartburn, regurgitation of chyme, and upper abdominal pain within minutes of eating
  • GERD progressing to reflux esophagitis

Question 13

What are the different types of hiatal hernia?

Answer 13

• Sliding hiatal hernia
  
  • Most common - ~90%
• Paraesophageal (rolling) hiatal hernia

Question 14

Mallory-Weiss Syndrome

Answer 14

• GE junction tears
• Tx: cauterization
• Prognosis: usually heals but sometimes fatal
• Manifestations:
  
  • Bleeding, pain, infections
• Cause
  
  • Severe vomiting

Question 15

Barrett Esophageus

Answer 15

• Replacement of squamous epithelium by columnar epithlium with goblet cells
  
  • ​Adaptation if you have reflux or GERD, the acid damages the esophagus and the esophageal tissue starts to adapt to produce mucus to protect itself
• Danger: 30-100x risk of adenocarcinoma
• Tx: Screen for high-grade dysplasia
• Cause: Chronic reflux esophagitis

Question 16

Esophagus Carcinoma

Adenocarcinoma vs. Squamous cell carcinoma

Answer 16

• Adenocarcinoma
  
  • Most common in US
  • Risk factor: Barrett esophagus
  • Distal 1/3 of esophagus
  • Symptoms: Insidious onset; late obstruction
• Squamous cell carcinoma
  
  • Most common worldwide
  • Risk factors: Esophagitis, smoking, alcohol, genetics
  • Middle 1/3 of esophagus
  • Sypmtoms: Insidious onset; late obstruction

Question 17

Stomach pathological conditions

Answer 17

• Gastritis
• Ulcers
• Carcinoma

Question 18

Gastritis

Acute gastritis

Answer 18

• Inflammatory disorder of gastric mucosa
• Acute gastritis - superficial erosion of mucosa due to bacteria (H. pylori) or others
• Other causes
  
  • NSAIDS
  • Alcohol
  • Smoking
• Erode mucosal lining and/or increase HCl secretion*

Question 19

Chronic gastritis

Answer 19

• Chronic fundal gastritis - autoimmune; more rare
• Chronic antral gastritis - more common

Danger: Intestinal Metaplasia

Question 20

Histiological markers of gastritis

Answer 20

Marked accrual of subepithelial plasma cells

Question 21

What are the two types of stomach ulcers?

Answer 21

• Deep - Once it has gotten to the submucosal layer (VERY vascular), you’ll start to get some bleeding
• Superficial

Question 22

What is a stomach ulcer? Manifestations, causes, symptoms?

Answer 22

• Erosion of mucosa into submucosa
• Manifestations:
  
  • GI bleeding
  • Perforation
• Cause:
  
  • H. pylori
  • NSAIDs
• Symptoms:
  
  • Epigastric pain

Question 23

GI Bleeding

Answer 23

• Hematamesis = from stomach or esophagus = bright red blood coming up (spitting up blood)
• Melena = stomach or duodenum = dark tarry stool
• Hematochezia = jejunum and down = bright red blood coming down and out

Question 24

How may timing of pain be diagnostic with stomach ulcers?

Answer 24

Gastric: Almost immediately after eating

Duodenal: 2-3 hours eating

Question 25

What is peptic ulcer disease?

Answer 25

Ulcers in lower esophagus, stomach, duodenum

Question 26

What pathological condition is associated with Zollinger-Ellison Syndrome?

Answer 26

Ulcers You have an increased risk of ulcers because of **gastrinoma** present with *Z**ES*

Question 27

Polyps

Answer 27

Stomach - Carcinoma * •Nodules that project above the level of surrounding mucosa * •Usually accompanying chronic gastritis * •Size matters: \> 1.5 cm is considered “precancerous”

Question 28

Two types of stomach carcinoma

Answer 28

Intestinal Diffuse

Question 29

Stomach Carcinoma Intestinal type vs. Diffuse type

Answer 29

* **Intestinal Type** * Arises in intestinal epithelium * Tend to be bulky * Risk factors: Chronic gastritis, poor diet * Glandular morphology * Generally asymptomatic * **Diffuse Type** * Arises from gastric glands * Results in thick GI wall * **Linitis plastica**?? Hard to the touch like plastic * Risk factors undefined * **Signet ring morphology** * Rugal flattening and rigid appearance * Generally asymptomatic

Question 30

Intestine Pathology Conditions

Answer 30

* •Diverticulosis * •Inflammatory Bowel Disease * –Crohn’s * –Ulcerative colitis * •Large Bowel Disorders * –Hirschsprung disease * –(Ulcerative colitis) * •Small Bowel Disorders * –Malabsorption syndromes * •Celiac Sprue * –(Crohn’s) * –Peutz-Jeghers syndrome * •Carcinoma

Question 31

Diverticulosis

Answer 31

**•Mucosa/submucosa herniates through muscle wall** * **Older** patients * Occur in **sigmoid colon** * **Asymptomatic unless infected (“diverticulitis”)**

Question 32

Crohn Disease vs. Ulcerative Colitis

Answer 32

* **Crohn Disease** * •Anywhere * •Patchy (“skip lesions”) * •Transmural * •Poor response to surgery * •Increased risk of cancer * •Likely caused by a combination of genetics and environment (some evidence of autoimmune) * **Ulcerative Colitis** * •Colon only * •Continuous lesions * •Superficial * •Good response to surgery * •Increased risk of cancer * •Autoimmune

Question 33

CD & UC Tx

Answer 33

* Anti-inflammatory drugs (e.g., corticosteroids) * Immune suppressors * Antibiotics **Ileoanal pull through = manipulating small intestine to act as a resevoir to have more control over your pooping**

Question 34

Hirchsprung Disease

Answer 34

* Congenital disorder * Caused by a section of **_aganglionic_** colon - not innervated, so it traps the bolus? before it gets out of the colon * No peristalsis; leads to obstructions ## Footnote ***Often associated with Down Syndrome***

Question 35

Small Bowel Disorders: Malabsorption syndrome symptoms

Answer 35

* Steatorrhea – loose, fatty stool * Malnutrition – not absorbing nutrients

Question 36

Celiac Sprue

Answer 36

AKA Celiac Disease * An **_autoimmune_** disorder of the small intestine * Caused by a reaction to **gliadin** (a gluten protein) * Manifestations * **Diarrhea** (pale, voluminous, malodorous) * **Atrophy of villi** * Abdominal pain * **Mouth ulcers** * **Thinning hair** * Etc. * Treatment * Avoid wheat (and a few others)

Question 37

Peutz-Jeghers Syndrome

Answer 37

* **_Genetic mutation_** causing **GI polyps and mucosal hyperpigmentation** * Various manifestations - **dark pigmentation on the lips** * **Autosomal dominant**

Question 38

Colorectal Carcinoma

Answer 38

* **Almost always arises from adenoma (polyp)** * May be **diet related** * Symptoms * Usually **silent until advanced stages** * **Fatigue, iron-deficiency anemia** * **Occult bleeding** – bleeding in the intestines * 5 year prognosis: 4% (stage 4) – 90% (stage 1)