Gastrointestinal - Pathology Part 2

eesohbel's version from 2015-06-30 01:15


Question Answer
Effects of liver cell failurecoma, scleral icterus, fetor hepaticus (breath smells musty), spider nevi, gynecomastia, jaundice, testicular atrophy, liver "flap" = asterixis (coarse hand tremor), bleeding tendency (↓ clotting factors, ↑ prothrombin time), anemia, ankle edema
Shunts that alleviate portal hypertensionesophageal varices, caput medusae
Aminotransferases (AST, ALT)Viral hepatitis (ALT>AST)
Alcoholic hepatitis (AST>ALT)
Alkaline phosphatase (ALP)Obstructive liver disease (hepatocellular carcinoma)
bone disease
bile duct disease
γ-glutamyl transpeptidase (GGT)↑ in various liver/biliary diseases like ALP
NOT ↑ in bone disease
AmylaseAcute pancreatitis
LipaseAcute pancreatitis
Ceruloplasmin↓ in Wilson's disease
Reye's syndromeRare, fatal childhood hepatoencephalopathy
Viral infxn (VZV, influenza B) that has been treated with aspirin
Reye's syndrome findingsMitochondrial abnormalities
fatty liver (microvesicular fatty change)
Reye's syndrome mechanismAspirin metabolites ↓ β-oxidation by reversible inhibition of mitochondrial enzyme.
Avoid aspirin in children, except in those with Kawasaki's disease
Hepatic steatosisShort-term change with moderate alcohol intake - hepatocytes filled with fat droplets
Macrovesicular fatty change that may be reversible with alcohol cessation
Alcoholic hepatitisAfter sustained, long-term consumption
Swollen and necrotic hepatocytes with neutrophilic infiltration
Mallory bodies - intracytoplasmic eosinophilic inclusions
AST > ALT (ration > 1.5)
Alcoholic cirrhosisFinal and irreversible form
Micronodular, irregularly shrunken liver with "hobnail" appearance
Sclerosis around central vein (zone 3)
Hepatocellular carcinoma/hepatoma associationsAssoc w hep B/c, Wilson's disease, hemochromatosis, α1-antitrypsin deficiency, alcoholic cirrhosis, carcinogens (aflatoxin from Aspergillus)
Hepatocellular carcinoma/hepatoma findingsjaundice, tender hepatomegaly, ascites, polycythemia, hypoglycemia, ↑ α-fetoprotein
May lead to Budd-Chiari syndrome
Cavernous hemangiomaCommon, benign liver tumor
age 30-50 yyears
Don't biopsy - risk of hemorrhage
Hepatic adenomaBenign liver tumor related to oral contraceptive or steroid use
can regress spontaneously
Angiosarcomaarsenic, polyvinyl chloride
malignant tumor of endothelial origin
Nutmeg liverd/t backup of blood into liver
Caused by rt-sided heart failure and budd-chiari syndrome
Progresses to centrilobular congestion and necrosis → cardiac cirrhosis
Budd-Chiari syndromeOcclusion of IVC or hepatic veins with centrilobular congestion and necrosis → congestive liver disease
hepatomegaly, ascites, abdominal pain, eventual liver failure
May see abdominal and back veins due to varices
Absence of JVD
Budd-Chiari associationsHypercoagulable state, polycythemia vera, pregnancy, hepatocellular carcinoma
α1-antitrypsin deficiencyMisfolded protein aggregates in hepatocellular ER → cirrhosis with PAS-positive globules in liver
Lungs: lack of fn'ing enzyme → ↓ elastic tissue → panacinar emphysema
Codominant trait
Hyperbilirubinemia in hepatocellular jaundiceDirect/indirect
Hyperbilirubinemia in obstructive jaundiceDirect
Hyperbilirubinemia in hemolytic jaundiceIndirect
Urine bilirubin in hepatocellular jaundiceIncreased
Urine bilirubin in obstructive jaundiceIncreased
Urine bilirubin in hemolytic jaundiceAbsent (acholuria)
Physiologic neonatal jaundiceImmature UDP-glucuronyl transferase → unconjugated hyperbilirubinemia → jaundice/kernicterus
Tx: phototherapy (converts UCB to water-soluble form)
Gilbert's syndromeHereditary hyperbilirubinemia
mild ↓ UDP-glucuronyl transferase or ↓ bilirubin uptake
Elevated unconjugated bilirubin w/o overt hemolysis
Bilirubin increases with fasting and stress
Crigler-Najjar syndrome, type 1Hereditary hyperbilirubinemia
Absent UDP-glucuronyl transferase
Presents early and kids die within a few years
Findings: jaundice, kernicterus (bilirubin deposition in brain), ↑ unconjugated bilirubin
TX: plasmapheresis and phototherapy
Typ2 - less severe and responds to phenobarbital
Dubin-Johnson syndromeConjugated hyperbilirubinemia d/t defective liver excretion
a grossly black liver
Wilson's diseaseInadequate hepatic copper excretion and failure of copper to enter circulation as ceruloplasmin (↓ ceruloplasmin)
Copper accumulation in liver, brain, cornea, kidneys, joints
Tx with penicillamine
AR problem with ATP7B gene on chromosome 13 - normally allows for excretion of copper into bile by hepatocyte
Wilson's disease Findings↓ Ceruloplasmin, cirrhosis, corneal deposits (Kayser-Fleischer rings), HC carcinoma
Hemolytic anemia
Basal ganglia degeneration (Parkinsonian symptoms)
Asterixis (hand flapping d/t hepatic encephalopathy)
Dementia, dyskinesia, dysarthria
Primary Hemochromatosisdeposition of hemosierin (iron)
AR C282Y or H63D mutation on HFE gene
Associated with HLA-A3
2° hemochromatosischronic transusion therapy (β-thalassemia major)
Hemochromatosis findingsTriad: Cirrhosis, diabetes mellitus, skin pigmentation → "Bronze diabetes"
Results in CHF, testicular atrophy in males, ↑ risk of HC carcinoma
Hemochromatosis txrepeated phlebotomy, deferasirox, deferoxamine

Biliary tract disease

Question Answer
Presentation of biliary tract diseasePruritus
dark urin
light stools
Labs of biliary tract disease↑ conjugated bilirubin
↑ cholesterol
↑ alkaline phosphatase
Secondary biliary cirrhosisExtrahepatic biliary obstruction → ↑ pressure in intrahepatic ducts → injury/fibrosis and bile stasis
Primary biliary cirrhosisAutoimmune reaction → lymphocytic infiltrate + granulomas
↑ serum mitochondrial antibodies, including IgM
Assoc w. CREST, RA, celiac disease
Primary sclerosing cholangitisOnion-skinning bile duct fibrosis → alternating strictures and dilation with "beading" of intra- and extrahepatic bile ducts on ERCP
Hypergammaglobulinemia (IgM)
Assoc w ulcerative colitis
Can lead to 2° biliary cirrhosis
Cholesterol cholelithiasisradiolucent with some opacification due to calcifications
Assoc w obesity, Crohn's, CF, advanced age, clofibrate, estrogens, multiparity, rapid weight loss, Native Americans
Pigment cholelithiasisRadiopaque
Chronic hemolysis, alcoholic cirrhosis, advanced age, biliary infxn.
Black - hemolysis
brown - infection
Biliary colicCCK after fatty meal → contraction of gallbladder → forcing stone into cystic duct
Painless in diabetics
Air in biliary treeCholelithiasis caused fistula between gallbladder and small intestine
If gallstone obstructs ileocecal valve → air in biliary tree
Charcot's triad of cholangitisJaundice, fever, RUQ pain
Murphy's signpositive if inspiratory arrest on deep RUQ palpation due to pain
Cholecystitisinflammation of gallbladder
Usually from stones - could be from CMV
↑ alk phos if bile duct becomes involved (ascending cholangitis)


Question Answer
Causes of acute pancreatitisGET SMASHED
Scorpion sting
Hypercalcemia/Hypertriglyceridemia (>1000)
ERCP - Endoscopic retrograde cholangiopancreatography
Drugs (sulfa drugs)
Acute pancreatitis can lead to...DIC
Diffuse fat necrosis
pseudocyst formation (lined by granulation tissue, not epithelium)
multiorgan failure
Acute pancreatitis and labsEpigastric abdominal pain radiating to back
Labs: ↑ amylase, lipase (higher specificity)
Difference between interstitial and necrotizing pancreatitisInterstitial: grossly edematous, interstitial edema
Necrotizing: chalky-white, fat necrosis, hemorrhage
Both have Ca deposits
Chronic pancreatitisInflammation, atrophy, and calcification of the pancreas
Caused by alcohol abuse and idiopathic
Pancreatic insufficiency → steatorrhea, ADEK vitamin deficiency, diabetes mellitus, ↑ risk of pancreatic adenocarcinoma
Amylase & lipase are less elevated than in acute pancreatitis
Pancreatic adenocarcinoma findingsCA-19-9 and CEA, obstructive jaundice (tumor is usually in pancreatic head)
Pancreatic adenocarcinoma risk factorsTobacco use, chronic pancreatitis (esp > 20 yrs), age>50, Jewish and AA males
Pancreatic adenocarcinoma presentationAbdominal pain raidiation to back
weight loss
migratory thrombophlebitis - redness/tenderness on palpation of extremities (Trousseau's syndrome)
Obstructive jaundice with palpable,non-tender gallbladder (Courvoisier's sign)
Pancreatic adenocarcinoma txWhipple procedure, chemo, radiation