Path and CS GI 2

• F>M. sx beginning before they were aged 35. Mostly start during childhood. Rarely after 40
• Rome criteria: recurrent ab pain for at least 3 day/mo, assoc w/ 2 or more of the following
• Improvement w/ defecation
• Onset assoc w/ change in frequency of stool
• Onset assoc w/ change in form of stool

• IBS-D (diarrhea predominant)
• IBS-C (constipation predominant)
• IBS-M (mixed diarrhea and constipation)
• IBS-A (alternating diarrhea and constipation)

altered stool passage, altered GI motility, visceral hyperalgesia (widened dermatomal distributions of referred pain. Sensitization of GI afferent nociceptive pathways). psycho disturbances (can be cause or outcome--axis I disorders like anxiety, panic, depression), Small bowel bacterial overgrowth and fecal microflora

postprandially

postinfectious IBS. Enteroendocrine cells secrete high serotonin levels. lymphocytic infiltration. Increased numbers of colonic mucosal lymphocytes and enteroendocrine cells

• pain mostly in LLQ, Acute episodes of sharp pain are often superimposed on a more constant dull ache
• Meals may precipitate pain. Defecation may or may not improve pain, Pain from presumed gas pockets in the splenic flexure, sigmoid tenderness or a palpable sigmoid cord

• Lactose intolerance. Fructose intolerance
• Celiac Disease (1/200, more of Irish descendent) or Gluten intolerance

onset middle age or older. ･Nocturnal symptoms. Anorexia or weight loss. Fever. ･Rectal bleeding. Painless diarrhea. Steatorrhea

ulcerative colitis and crohn dz. highest incidence in developed countries, highest in Jewish populations, appear in late adolescent to 3rd decade

pseudopolyps, erythema nodosum, uveitis, sacroiletis, ankylosis spondylitis

• Ileitis: Infection – Neoplasm – NSAIDs – Vascular…
• Proctitis : HIV & STD
• Colitis. Behcet’s Syndrome. Ischemic Colitis. Microscopic Colitis
• Colitis and Diverticulosis. Diversion Colitis

duodenal sprue. celiac dz

osteomalacia. malabsorption

zinc deficiency. malabsorption

bloody diarrhea, limited to mucosa/submucosa, begin at rectum, spread to sigmoid and rest of colon. NO skip lesions. no newly formed granulomas, mural thickening does not occur, high risk of carcinoma developmt, more common than Crohn, more common in whites, colicky lower ab pain, RELAPSES

Pseudopolyps, ASCA - / p ANCA+, Neutrophilic Infiltrate, Crypt Abcesses, Crypt Distorsion, toxic megacolon (colon swells & becomes gangrenous), progressive mucosal atrophy leads to a flattened and attenuated mucosal surface, diffuse mononuclear infiltrate in lamina

migratory polyarthritis, sacroiliitis, ankylosing spondylitis, uveitis, erythema nodosum, and hepatic involvemt (pericholangitis and primary sclerosing cholangitis)

ulcerative colitis than w/ crohn dz

pain in lower ab or RLQ, pt fatique and anemic, ASCA + / p ANCA-, ileum frequently involved, rectum spared, formation of granulomas, frequent fistulae, frequent perineal dz, SKIP lesions, Prevalent in US, Great Britain, and Scandinavia. Occurs at any age, F>M. More often among Jews than among non-Jews

often mesenteric fat wraps around bowel surface ("creeping fat"). Intestinal wall is rubbery and thick, result of edema, inflammation, fibrosis, and hypertrophy of the muscularis propria. Lumen is narrowed; in small intestine this is seen on x-ray as "string sign." Sharp demarcation of diseased bowel segments. TRANSMURAL

Dysplastic changes appearing in mucosal epithelial cells, after long standing Crohn dz --> carcinoma. Fistula formation, abscess, intestinal strictures, Massive intestinal bleeding, toxic dilation of colon, or carcinoma of colon (less than cancer risk of ulcerative colitis) or small intestine

uveitis, sacroiliitis, migratory polyarthritis, erythema nodosum, bile duct inflammatory disorders, and obstructive uropathy with attendant nephrolithiasis

Type I & II in perihilar region. Type III is perihilar and intrahepatic. Type IV can be perihilar and intrahepatic or can spread to distal extrahepatic.

over 50 yrs (like average risk)

40 yrs

age 40 or 10 yrs younger than earliest dx in family. repeat every 5 yrs

women, overweight, antibodies to mitochondria

most common anomaly. Failure of involution of omphalomesenteric duct, leaving a blind-ended tubular protrusion. Usually in ileum, asymptomatic, except when they permit bacterial overgrowth that depletes vitamin B12 --> pernicious anemia. Peptic ulceration, intestinal bleeding

tumor, cystic fibrosis, gallstone in common bile duct

alcohol, viruses (mumps), drugs (thiazides, diuretics), trauma, hypercalcemia, obesity, hyperlipidemia

old age (may rupture), and neutrophilia left shift

mucinous cystadenoma. (glistening look) – can be benign or having malignant potentials

serous cystadenoma. usually benign.

acute hemorrhagic pancreatitis

chronic pancreatitis. can present w/ diabetes

• Occlusion of biliary and pancreatic ducts via migrating gallstones
• Biliary colic, Acute cholecysitis, Ascending cholangitis
• Acute pancreatitis

gallstones: bile concentrated in gallbladder --> supersaturated --> microscopic crystals --> trapped in gallbladder mucus --> gallbladder sludge --> crystals grow, aggregate, and fuse to form macroscopic stones ---> occlusion of ducts

Tenderness to palpation rebound tenderness, guarding over the gallbladder +/- rigidity pericholecystic inflammation. Murphy sign – push posteriorly at border of costal margin, midclavicular line. Fever, tachycardia and hypotensive. jaundice.

RUQ tenderness, fever, jaundice. characteristic of ascending cholangitis

OBESITY, insulin resistance, type II diabetes mellitus, hypertension, and hyperlipidemia. pregnancy (progesterone), gallbladder stasis (prolonged fasting with total parenteral nutrition), rapid wt loss, gastric bypass

stone in common bile duct. Elevated wbc, transaminases, followed by elevated alkaline phosphatase & bilirubin. If obstruction is at level of ampulla of Vater, may obstruct pancreatic duct & see elevation of lipase and amylase

hepatic angiosarcoma

• cholesterol stones most common.
• calcium, bilirubin, and pigmented gallstones.
• mixed stones

• Due to oxidation the stones turn black: High heme turnover. Disorders of Hemolysis
• Sickle cell anemia, Hereditary spherocytosis, Beta-thalassemia
• Splenomegaly due to cirrhosis, Red cell sequestration

colonized w/ bacteria. Biliary strictures (post surgical). Choledochal cyst. Liver flukes infestation causing intra and extrahepatic bile duct strictures

cholesterol gallstones become colonized by bacteria (Lytic enzymes from the bacteria and leukocytes hydrolyze the bilrubin and fatty acids). calcifies thru time. calcium ring forms around stone.

pseudocysts. Cysts that lack an epithelial lining. Just a sac filled w/ edema fluid or digestive enzymes. Complication of chronic pancreatitis.

pseudocyst. Cysts that lack an epithelial lining. Just a sac filled w/ edema fluid or digestive enzymes. complication of chronic pancreatitis

calcfications in old necrotic regions. complication of chronic pancreatitis

• acute pancreatitis and cancer.
• Acute cholecystitis, Chronic cholecystitis
• Gallbladder adenocarcinoma, Cholecystoenteric fistula

• Stone retention in the cystic duct: Mirizzi Syndrome
• Stone retention in the ampula of vater: Obstructs the pancreatic duct and cause acute pancreatitis
• Ascending cholangitis: Infection due to the obstruction

gallbladder edema and pericholecystic fluid

CT

MRI

HIDA: Technetium-99m

ERCP: Endoscopic retrograde cholangiopancreatography

episodes of biliary colic,

etiology linked to carcinoma of pancreatic head, gallstones, strictures, and biliary atresia

apthous ulcer or canker sores

herpetic stomatitis. cold sores. hsv1

adenocarcinoma of esophagus

celiac sprue. blunted vili.

whipple dz. PAS stain. Distended macs?

signet ring cells (mucinous cells). gastric diffuse adenocarcinoma. Gross apperance will be linitus plastica (like leather bottle)

female, fat, forty, fertile

Crohn dz. Cobblestone. skip lesions

ulcerative colitis

diverticulosis. older pts

colon cancer

C diff colitis

tubular adenoma in colon polyps. most common type of colon polyp

tubular adenoma in colon polyps. most common type of colon polyp

villous adenoma of colon polyps

villous adenoma of colon polyps

acute pancreatitis w/ fat necrosis

cholestasis

steatosis of liver

mallory bodies in hepatic failure

acute sterile peritonitis because pseudocysts contain enzymes, no bacteria

head

anti mitochondrial Abs in primary biliary cirrhosis.

primary biliary cirrhosis. infiltrate of lymphocytes and plasma cells. granulomatous destruction of bile duct. Elevated alkaline phosphatase

primary sclerosis cholangitis. Beading and strictured biliary tree on radiography. Assoc w/ ulcerative colitis.Ankylosis spondylysis, polyarthritis

hepatic hemangioma. most common tumor of liver. benign

females, oral contraceptives