lymph pathology

Question 1

What is Lymphangitis & Lymphadenitis ?

Answer 1

lymphadenitis - infection of one or more lymph nodes

SYMPTOMS

• lymph node -swollen, red (skin over node), tender, hard - does have to be all of them
• Rubbery , soft, smooth node if abscess formation present.
• Pain
• Enlargement
• tenderness
• pain and tenderness distinguish it from lymphadenopathy.
• contained within lymph nodes

Lymphangitis - infection of vessels connecting lymph nodes (lymph vessels ) - inflammation is spreading past lymph node.
0 usually an acute bacterial infection - Streptococcal

• in some patients you will see red streaks on skin showing inflammation. (red , irregular , warm , tender streaks form on extremity from lesion - where bacteria entered - to regional lymph node.

throbbing pain

• fever
  0 malaise , headache , loss appetite
• Treatment - Antibiotics.

Question 2

What is Lymphadenopathy ?

Answer 2

Palpable enlargement (by more than 1cm) of one or more lymph nodes.

local - in one area

generalized - in 2 or more areas.

CAUSES

0 infection
0 cancer
0 idiopathic -self limiting.

Question 3

differing symptoms btw acute appendicitis vs mesenteric lymphadenitis ?

Answer 3

shifting tenderness -pain upon palpation - mesenteric lymph nodes move with movement of the patient / change in posture.

Question 4

complications of lymphadenopathy

Answer 4

lymphandenopthy - used to describe both lymphangitis and lymphadenitis .

Question 5

Mangement of lymphadenopathy ?

Answer 5

suspected upper airway obstruction - arrange emergency hospital admission :
0 Lymphadenopathy associated with :
- stridor
- dysphagia upon aspiration
- signs of superior vena cava obstruction

Question 6

Mangement of lymphadenopathy ?

Answer 6

suspected upper airway obstruction - arrange emergency hospital admission :
0 Lymphadenopathy associated with :
- stridor
- dysphagia upon aspiration
- signs of superior vena cava obstruction

Lymphadenopathy -suspected infected cause
- Arrange review :
0 suspected upper viral respiratory tract infection.

0 becomes systematically unwell

0 lymphadenopathy grows progressively over 7 days - may indicate non -infective swelling of abscess.

0 suspected bacterial infection - assess need for antibiotic

• if lymphadenopathy not reserved within 2 -4 weeks urgently refer to ears , nose , throat surgeon for further investigation.

clinical feature f malignant primary tumour e.g

• asymptomatic nodule/ mass e.g in glandular tissue e.g. parathyroid , salivary . thyroid glands
  0 urgently refer to head and neck - 2 week suspected cancer pathway.
• if lymphanepathy unexplained and generalized
  0 arrange urgent full blood count - within 48hrs to check for leukaemia

0 consider referral - 2 week suspected cancer pathway - to exclude lymphoma - unexplained lymphadenopathy or splenomegaly for 25 and over
48 hrs for those below 25.

Question 7

What are Diverticula ?

Answer 7

small buldges or pockets that can develop in the lining of the intestines as you get older.

formation - linked to fibre deficiency

Diverticulosis - diverticula with no symptoms

Diverticular disease - diverticula with symptoms
o left lower pain - get worse during eating or just after / relived by pooing / farting
o occasional blood in poo
o Constipation
o Diarrhoea

Diverticulitis - diverticula become inflamed and infected.

• Hight temp
• Pain in lower left stomach becomes more painful
• ## mucus/ poo in faeces / rectal bleeding

Question 8

Treatment of Diverticular disease , Diverticulitis ?

Answer 8

Diverticular disease - high fibre diet
- beans , starchy foods, cereals , fruit and veg , pulses

paracetamol
(ibuprofen , aspirin - may make stomach pain worse - ask GP or pharmacist first )

DIVERTICULITIS

Antibiotics

• low fibre diet - to rest digestive system while recovering - can return to high fibre diet after recovery.
• paracetamol.
• no ibuprofen or aspirin.

If serious complications

o abcess formation - (most common complication ) percanteous drainage

o Colectomy - removal of the affected part of in bowel.

(Symptoms of Diverticular D & Diverticulitis - similar to Coeliac D , IBS, Bowel cancer.

Question 9

Diagnosis of Diverticula (and the different subtypes )

Answer 9

Colonoscopy - most common
- laxative given to clear out bowel before.

CT scan ( can be with / without colonoscopy )

Question 10

When can Crohns’s disease be suspected ?

Answer 10

0 Persistent diarrhoea (including nocturnal diarrhoea) with possible blood or mucus in the stool.

0 Abdominal pain or discomfort.

0 Weight loss, faltering growth or delayed puberty (in children).

0 Non-specific symptoms

• fatigue
• malaise
• anorexia
• fever.

OE-
Abdominal tenderness or mass, for example in the right lower quadrant.
Perianal pain or tenderness, anal or perianal skin tags, fissure, fistula, or abscess.
Signs of malnutrition and malabsorption.
Abnormalities of the joints, eyes, liver, and skin.

if systemically unwell - emergency admission to hospital

if well - urgent referral to
gastroenterologi st

Question 11

Differential diagnosis Crohn’s disease ?

Answer 11

Ulcerative colitis

Infective colitis - infection of the colon

Pseudomembranous colitis - (C difficile) bacteria infection .
o caused by overgrowth of C. Difficile
o linked to antibiotic usage - reduce population of gut flora which compete with C.diff.

Diarrhoea - common side effect of antibiotic treatment.
( if C.diff infection suspected - stool sample taken
- if not suspected or negative C.diff test - antibiotic stopped - if apporiate )
- if positive - antibiotics to treat specificallt C.diff infection
- risk of C.diff outbreak assessed,

0 Microscopic Colitis - (IBD)
that affects the large bowel (colon and rectum).
-typically presents with chronic watery diarrhoea in older people, and may be associated with the use of drugs, such as lansoprazole, aspirin, sertraline, ranitidine, and simvastatin.

0 Intestinal ischemia

0 Acute appendicitis

0 Diverticulitis

0 Coeliac disease

0 IBS

0 Anal fissure

0 malignancy (Colorectal / anal / 
- lower gastrointestinal cancers - symptoms 
    o appetite loss
    o unexplained weight loss
    o Rectal bleeding
    o Occult bleeding in faeces (blood you cant see with naked eye )
    o unexplained change in bowel habit 
    o unexplained abdominal pain
    o Abdominal mass or rectal mass
   o Anaemia
   o Deep vein thrombosis.  

O Endometriosis

0 Laxative misuse

Question 12

Treatment of Crohns’s disease ?

Answer 12

To induce remission of symptoms

o Corticosteriods (short term - dose gradually tapered )

o Immunosuppression
Azathiopine , mercaptopurine - 1st line

Methotrexate - 2nd line

Added to corticosteriod therapy if 2 or more exacebations in a year of if corticosteriod therapy cannot be tolerated.

Anti- tumour necrosis factor alpha monoclonal antibody
o Infliximab
o Adalimumab

used if conventional therapy not working .

Sulfaslazine , mesalzine - aminosalicylates - can be used if corticosteriods contrainsicated , not tolerated.

Question 13

What is ulcerative colitis ?

Answer 13

chronic, relapsing-remitting, non-infectious inflammatory disease of the gastrointestinal tract

Effects the large intestine & rectum.

Symptoms

• Recurring diarrhoea - may contain blood , mucus or pus
• Stomach pain
• Frequent need to empty bowels.

May experience
- extreme tiredness , loss of appetite , weight loss.

extra -intestinal manifestation.
o uveitis

o inflammatory arthritis,

o erythema nodosum

o pyoderma gangrenosum.

Question 14

When should you expect Ulcerative Colitis ?

Answer 14

A history of bloody diarrhoea for more than 6 weeks,

o rectal bleeding

o faecal urgency and/or incontinence

o nocturnal defecation

o tenesmus
o abdominal pain

o weight loss

o non-specific symptoms such as :

• Fatigue
• malaise,
• anorexia
• fever.

Examination findings of pallor, clubbing; abdominal distension, tenderness, or mass.

Question 15

Diagnosis of UC ?

Answer 15

• FBC
• inflammatory markers,
• U &E,
• LFTs
• TFT
• ferritin,
• vitamin B12
• folate
• vitamin D levels
• coeliac serology.

Stool microscopy and culture including Clostridium difficile toxin, and faecal calprotectin.

Question 16

Treatment of UC ?

Answer 16

Aminosalicylates - Sulfaslazine , mesalazine - 1 st line - mild to moderate presentation.
(Topical (suppository , enema) or oral if remission tnot acieved within 4 weeks

• Corticosterioid - monotherapy

(Corticosteroid dependency - PL with UC who are unable to stop corticosteroids within 3 months without recurrent active disease / who have a relapse requiring corticosteroids within 3 months of stopping them.)

Calcneurin inhibitors - e.g Tarcolimus , Ciclosproin may be added to steriod with inadequate response to C within 2 -4 weeks.

• IV Ciclosporin - may be used if C contraindicated , not tolerated or not effective )

0 o Immunosuppression
Azathioprine , mercaptopurine - 1st line

Methotrexate - 2nd line

Added to corticosteroid therapy if 2 or more exacerbations in a year of if corticosteroid therapy cannot be tolerated, or not achieving remission with aminosalicycates.

Anti- tumour necrosis factor alpha monoclonal antibody 
    o Infliximab 
    o Adalimumab 
    o golimumab 
(Also good at maintaining remission )

Question 17

What is IBS ?

Answer 17

Chronic condition - affects Large bowel

CAUSES

• linked to food passing throught the gut too quickly or slowly or oversentitive nerves in the gut.

SYMPTOMS

o Stomach pain 
o changes in bowel habit 
(can include Constipation , Diarrhoea )
o Bloating
o Flatulence 
o mucus in poo
o nausea
o frequent urination 
o cannot fully empty bladder
o faecal incontinence

Question 18

When should IBS be suspected ?

Answer 18

following symptoms for at least 6 months:
o Abdominal
pain

o Bloating

o Change in 
   bowel 
   habit.

Question 19

Diagnosis of IBS ?

Answer 19

A diagnosis of IBS should be made if a person has abdominal pain which is either related to defecation, and/or associated with altered stool frequency (increased or decreased), and/or associated with altered stool form or appearance (hard, lumpy, loose, or watery); and there are at least two of the following:
Alternative conditions with similar symptoms have been excluded.
Passage of rectal mucus, and
Symptoms worsened by eating.
Abdominal bloating (more common in women than men), distension, or hardness.
Altered stool passage (straining, urgency, or incomplete evacuation).

Question 20

What is Coeliac’s disease ?

Answer 20

IAutoimmune condition

mmune system attacks self tissue when gluten is eaten———————> damages gut ————————————-> unable to take in nutrients.
(Adverse reaction to gluten - wheat , barley , rye (any food that contain these )

SYMPTOMS

o Diarrhoea 
o pain
o Bloating 
o Constipation 
o Indigestion

• in children - failure to thrive

More general symptoms (some of them dont have to present )

• fatigue
• malnutrition
• unintentional weight loss
• itchy rash - dermatitis herpetiformis (not common )
• nerve damage
• ataxia ( problems with co-ordination , balance , speech)
• infertility

Diagnosis

• Iron deficiency anaemia - common presentation

be aware of asociation of auto immune thyroid disease - unexplained need for increasing levothyroxine ) - coeliac testing.

Question 21

Treatment of Coeliac disease ?

Answer 21

Gluten- free diet

o Vitamin & mineral supplementation

o if not working refferal to gastroenterologist or dietician

Question 22

What is Coeliac Crisis ?

Answer 22

acute onset or rapid progression of gastrointestinal symptoms that could be attributed to celiac disease and required hospitalization and/or parenteral nutrition, along with signs or symptoms of dehydration or malnutrition.

Present with :
o severe watery diarrhoea
o acidosis 
o hypocalcemia 
o hypoalbuminemia 
o nutritional deficiencies 
o dehydrated

Treatment

0 Rehydration + correction of electrolyte abnormalities

0 Corticosteriod - adjunct - for some patients,

Question 23

Pancreas and Diabetes ?

Answer 23

Patholgies of the pancreas can cause development of diabetes .
(secondary diabetes )

Damage to insulin producing cells

o Chronic Pancreatitis ( cystic fibrosis - most common cause in children )
o Pancreatic cancer
o

Question 24

Chronic Pancreatitis ?

Answer 24

Chronic inflammation of the pancreas

Can be triggered by recurring bouts of Acute pancreatitis cause by :

Alcohol
Cystic Fibrosis
Trauma
Tumour

Normal tissue is replaced by :
Mishaped ducts 
Fibrosis 
Atrophy of acinar cells
Calcification (calcium deposits )
Pseudocysts - (fluid accumulates in fibrosis tissue )

Diagnosis / Symptoms

0 Intermittent epigastric pain - sometimes radiates to the back.
- pain often intense for hours

0 Weight loss
(Pancreatic insufficiency - acinar cells trouble producing digestive enzymes - so cant digest food )

0 Fat soluble Vitamin Deficiency - Vitamin A, D, K , E )

0 steatorrhoea - fat greasy stools
(fat not being digested so ends up in poo )

0 Abominal XR or CT scan - show calcifications.

0 MRCP -( Magentic resosonance cholangopancreaticography )

non-invasive and could give additional information about the pancreas and ducts.

(ERCP (Endoscopic retrograde - cholangopancreatography - endoscope camera passed through mouth into duodenum )
o should not be used as a purely diagnostic tool due to its significant complication rate. It is mostly a therapeutic procedure to retrieve retained common bile duct stones

NOTE

Acute pancreatitis - is different as damage is caused by auto digestion - digestive enzymes breaks down pancreas.

Question 25

Treatment of Chronic Pancreatitis ?

Answer 25

If drinking excessively or smoking - advise to stop. Alcohol abuse - most common cause smoking - worsens it treat complications e.g Diabetes , Pancreatic insufficiency - replace digestive agents - nutritional supplements

Question 26

``` Autoimmune Hepatitis alcoholic hepatitis. Primary biliary cholangitis (Cirrhosis ) haemochromatosis. hepatitis C ``` Suggestive factors for these pathologies ?

Answer 26

0 Anti-smooth muscle antibodies - autoimmune hepatitis 0 High serum transferrin - reflects the iron overload in haemochromatosis. 0 Although not specific or always present, the combination of steatosis and Mallory’s hyaline on liver biopsy is suggestive of alcoholic hepatitis. 0 Injecting drug use points to hepatitis C virus infection (injecting drug users are also at risk of hepatitis B) 0 Anti - mitochondrial antibodies - Primary biliary cholangitis (Cirrhosis )

Question 27

What is Idiosyncratic drug induced liver injury ?

Answer 27

Rare but severe adverse reaction to a potentially hepatoxic drug. Painkillers and medicines containing paracetamol NSAIDS 0 Amiodarone 0 Anabolic steroids 0 Atorvastatin 0 Birth control pills 0 Chlorpromazine 0 Erythromycin 0 Halothane (a type of anesthesia) 0 Methyldopa 0 Isoniazid 0 Methotrexate 0 Statins - LFTs monitoring fr first year of use e.g. Pravastatin Atorvastatin 0 Sulfa drugs 0 Tetracyclines 0 Amoxicillin-clavulanate 0 Some anti-seizure medicines