Zanki GI Pathology
Zanki GI Pathology
Zanki GI Pathology
2. Aphthous ulcers ("canker sores") are painful, superficial ulcerations of the oral mucosa
3. Aphthous ulcers arise in relation to stress and resolve spontaneously however they often recur
8. Oral herpes ("cold sores") is characterized by painful, shallow, red ulcers involving the oral mucosa
10. The HSV-1 virus that causes oral herpes remains dormant in the ganglia of the trigeminal nerve
11. Dormant HSV-1 virus may be reactivated by stress and sunlight leading to an episode of oral herpes
12. The major risk factors for squamous cell carcinoma of the oral mucosa are alcohol and tobacco
13. What is the most common location for oral squamous cell carcinoma? Floor of the mouth
15. Oral leukoplakia is a white deposit on the tongue that cannot be easily scraped away
16. Oral candidiasis is a white deposit on the tongue that can be easily scraped away
18. Hairy leukoplakia is a squamous cell hyperplasia (not dysplasia) induced by EBV infection
20. Oral candidiasis and hairy leukoplakia are usually seen in immunocompromised individuals
23. Which lesion leukoplakia or erythroplakia is more suggestive of squamous cell dysplasia? Erythroplakia
24. What virus is associated with bilateral inflammation of the parotid glands? Mumps virus
25. In addition to parotitis mumps may also present with orchitis pancreatitis and aseptic meningitis
26. What enzyme is elevated in mumps patients due to involvement of the pancreatic or salivary glands? α-amylase
29. Sialadenitis most commonly occurs due to sialolithiasis which often leads to Staphylococcus aureus mediated sialadenitis / parotitis
33. If a salivary gland tumor involves a non-parotid gland it is more likely to be malignant (benign or malignant)
34. Salivary gland tumors typically present as a mobile painless mass/swelling (painful or painless) at the angle of the jaw
39. Which salivary gland tumor is associated with a high rate of recurrence following resection? Pleomorphic adenoma
40. Warthrin tumor is a cystic salivary gland tumor with abundant lymphocytes and germinal centers
43. What is the most common malignant salivary gland tumor? Mucoepidermoid carcinoma
44. Malignant salivary gland tumors present with signs of facial nerve damage
45. Esophageal web is a thin protrusion of esophageal mucosa most often in the upper esophagus
47. Plummer-Vinson syndrome is characterized by a triad of iron deficiency anemia esophageal web and a beefy-red tongue (atrophic glossitis)
48. Zenker diverticulum is an outpouching of pharyngeal mucosa through an acquired defect in the muscular wall (false diverticulum) caused
by cricopharyngeal motor dysfunction
49. Is Zenker diverticulum a true or false diverticulum? False (only involves mucosa and submucosa)
50. Zenker diverticulum classically arises at Killian's triangle between the thyropharyngeal and cricopharyngeal parts of the inferior pharyngeal
constrictor
51. Zenker diverticulum often presents with oropharyngeal dysphagia obstruction and halitosis (bad breath)
54. The tears in Mallory-Weiss syndrome are caused by a rapid increase in intraabdominal pressure (ex. retching vomiting)
57. Is the hematemesis seen with Mallory-Weiss syndrome typically painful or painless? Painful
59. Boerhaave syndrome presents as esophageal rupture with pneumomediastinum (air in the mediastinum) and subcutaneous emphysema
61. Esophageal varices are dilated submucosal veins in the lower 1/3rd of the esophagus
63. In portal hypertension the left gastric vein backs up into the esophageal vein resulting in varices
65. Is the hematemesis seen with esophageal varices typically painful or painless? Painless
67. Achalasia is characterized by disordered esophageal motility due to inability to relax the lower esophageal sphincter
68. Primary achalasia is due to an autoimmune destruction of ganglion cells in the myenteric (Auerbach) plexus
69. Achalasia may be idiopathic or secondary to a known insult such as Chagas disease and extraesophageal malignancies
70. Does achalasia present with dysphagia for solids or liquids? Both solids and liquids :)
75. What type of hernia increases risk of developing GERD? Sliding hiatal hernia
76. Gastroesophageal reflux disease (GERD) often presents with heartburn which can mimic cardiac chest pain
77. Gastroesophageal reflux disease (GERD) may present with chronic cough and adult-onset asthma
82. Barrett esophagus is characterized by specialized intestinal metaplasia of the lower esophageal mucosa
83. In Barrett esophagus non-keratinized stratified squamous epithelium is replaced with non-ciliated columnar epithelium with goblet
cells(metaplasia)
85. Which type of esophageal cancer (SCC or adenocarcinoma) is associated with obesity GERD and Barrett esophagus? Adenocarcinoma
88. Adenocarcinoma of the esophagus is the most common type of esophageal carcinoma in America (location)
89. Adenocarcinoma of the esophagus most commonly arises from pre-existing Barrett esophagus
91. Squamous cell carcinoma of the esophagus is a malignant proliferation of squamous cells
92. Squamous cell carcinoma of the esophagus is the most common type of esophageal carcinoma worldwide (location)
93. The most common causes of squamous cell carcinoma of the esophagus are alcohol and tobacco
94. Which type of esophageal cancer (SCC or adenocarcinoma) is associated with esophageal web (e.g. Plummer-Vinson syndrome)? Squamous
cell carcinoma
95. Which type of esophageal cancer (SCC or adenocarcinoma) is associated with achalasia? Both :)
96. Which type of esophageal cancer (SCC or adenocarcinoma) is associated with very hot tea? Squamous cell carcinoma
97. Which type of esophageal cancer (SCC or adenocarcinoma) is associated with esophageal injury (e.g. lye/caustic ingestion)? Squamous cell
carcinoma
98. Which part of the esophagus is typically affected by squamous cell carcinoma? Upper 2/3rds
100. Symptoms of esophageal carcinoma include progressive dysphagia (solids to liquids) weight loss pain and hematemesis
101. Squamous cell carcinoma of the esophagus may present with hoarseness due to involvement of the recurrent laryngeal nerve
102. Squamous cell carcinoma of the esophagus may present with cough due to tracheal involvement
103. Esophageal carcinoma in the upper third of the esophagus spreads to cervical lymph nodes
104. Esophageal carcinoma in the middle third of the esophagus spreads to mediastinal tracheobronchial or paratracheal lymph nodes
105. Esophageal carcinoma in the lower third of the esophagus spreads to celiac or gastric lymph nodes
106. Barrett esophagus is characterized by extension of the squamocolumnar junction (Z-line) into the esophageal mucosa
107. Eosinophilic esophagitis is characterized by eosinophilic infiltration of the esophagus often in atopic patients
108. Eosinophilic esophagitis presents with esophageal rings and linear furrows often seen on endoscopy
109. Eosinophilic esophagitis classically presents with dysphagia and food impaction in response to food allergens
110. Does eosinophilic esophagitis respond to GERD therapy (e.g. PPIs)? No
117. The low LES pressure in scleroderma predisposes to acid reflux and dysphagia
119. Acute gastritis arises due to imbalance between mucosal defenses and acidic environment
121. Mucosal defenses include normal blood supply which provides nutrients and picks up leaked acids
122. Acute gastritis may arise with severe burns due to hypovolemia which causes mucosal ischemia
125. Acute gastritis may arise with increased ICP due to increased vagal stimulation which increases H+ production
126. What type of gastric ulcer is caused by increased intracranial pressure? Cushing ulcer
127. Acute gastritis may arise with shock which presents as multiple stress ulcers secondary to ischemia
128. Acute gastritis is especially common among alcoholics and patients taking daily NSAIDs (e.g. rheumatoid arthritis patients)
132. Chronic gastritis is associated with atrophy of the gastric mucosa (hypertrophy or atrophy)
134. What is the effect of chronic gastritis on gastric HCl secretion? Decreased (achlorhydria or hypochlorhydria)
140. Which areas of the stomach are affected in chronic autoimmune gastritis? body and fundus
141. Chronic autoimmune gastritis is associated with antibodies against parietal cells and/or intrinsic factor
142. What type of hypersensitivity reaction is chronic autoimmune gastritis? Type IV (T-cell mediated)
144. What is the most common (90%) form of chronic gastritis? Chronic H. pylori gastritis
145. Which area of the stomach is initially affected by chronic H. pylori gastritis? antrum
146. Does H. pylori invade the stomach mucosa? No (sits on top of mucosa)
149. What cytotoxin released by H. pylori breaks down the protective mucus barrier? CagA toxin
150. H. pylori produces urease which alkalinizes the local environment enabling bacterial survival
152. Is the intestinal metaplasia seen with H. pylori gastritis reversible? Yes (resolves with treatment of infection)
153. Peptic ulcer disease is a solitary mucosal ulcer involving the proximal duodenum (90%) or distal stomach (10%)
154. Duodenal ulcers are almost always due to H. pylori (~ 90%)
157. Duodenal ulcers are diagnosed via endoscopic biopsy which shows an ulcer with hypertrophy of Brunner glands
159. Duodenal ulcers located in the posterior duodenum may rupture leading to bleeding from the gastroduodenal artery
163. What is the most common location for a gastric ulcer? Lesser curvature of stomach
164. Gastric ulcers on the lesser curvature of the stomach may rupture leading to bleeding from the left gastric artery
166. Benign gastric ulcers are usually small (< 3 cm), sharply demarcated ("punched-out"), and surrounded by radiating folds of mucosa
167. Malignant gastric ulcers are usually large and irregular with heaped up margins
168. Gastric ulcers (gastric or duodenal) should be biopsied at the margins to rule out malignancy
169. What is the most common ulcer complication (both gastric and duodenal)? Hemorrhage
170. Which type of duodenal ulcer (anterior or posterior) is more commonly associated with hemorrhage? Posterior
171. One possible ulcer complication is obstruction of the pyloric channel or duodenum
172. Which type of duodenal ulcer (anterior or posterior) is more commonly associated with perforation? Anterior
173. Perforation of an anterior duodenal ulcer is characterized by free air under the diaphragm (pneumoperitoneum)
174. Perforation of an anterior duodenal ulcer may present with referred pain to the shoulder via the phrenic nerve
175. What is the most common classification of gastric carcinoma (e.g. SCC lymphoma adenocarcinoma etc.)? Adenocarcinoma
177. Which type of gastric carcinoma (intestinal or diffuse) is more common? Intestinal type
178. The intestinal type of gastric carcinoma most commonly arises on the lesser curvature of the antrum
179. Which type of gastric carcinoma (intestinal or diffuse) is associated with H. pylori infection? Intestinal
180. Which type of gastric carcinoma (diffuse or intestinal) is associated with chronic gastritis? Intestinal
181. The intestinal type of gastric carcinoma is associated with nitrosamines which are found in smoked foods (common in Japan)
183. The diffuse type of gastric carcinoma is characterized by signet ring cells that infiltrate the gastric wall
184. The diffuse type of gastric carcinoma may cause linitis plastica which is a grossly thickened and leathery stomach wall
185. Gastric carcinoma typically presents late (timing) with weight loss early satiety abdominal pain and anemia
186. Gastric adenocarcinoma rarely may present with acanthosis nigricans which is hyperpigmented velvety plaques in the axilla and neck
187. Gastric adenocarcinoma rarely may present with the Leser-Trelat sign which is sudden onset of multiple seborrheic keratoses
188. Gastric carcinoma may spread and involve the left supraclavicular node also known as Virchow's node
190. Gastric carcinoma may spread and involve the periumbilical region also known as a Sister Mary Joseph nodule
191. Which type of gastric carcinoma (diffuse or intestinal) is associated with a Sister Mary Joseph nodule? Intestinal
192. Gastric carcinoma may spread and involve the bilateral ovaries also known as a Kruckenberg tumor
193. Which type of gastric carcinoma (diffuse or intestinal) is associated with Kruckenberg tumor? Diffuse
194. Menetrier disease is characterized by hyperplasia of the gastric mucosa and atrophy of the parietal / chief cells
195. Menetrier disease is characterized by hypertrophied gastric rugae that resemble brain gyri
197. Menetrier disease is characterized by parietal cell atrophy with decreased acid production
198. Does menetrier disease increase risk for gastric cancer? Yes (pre-cancerous lesion)
199. Meckel diverticulum is an outpouching of all three layers of the bowel wall (true diverticulum)
202. What is the most common congenital anomaly of the GI tract? Meckel diverticulum
206. Meckel diverticulum is typically located in the small bowel two feet from the ileocecal valve
207. Meckel diverticulum typically presents during the first two years of life
209. Meckel diverticulum is diagnosed using a 99mTc-pertechnetate study for uptake by heterotopic gastric mucosa
210. Meckel diverticulum is typically asymptomatic but may present with volvulus intussusception melena RLQ pain or obstruction
213. What congenital anomaly is caused by complete failure of the vitelline duct to close? Vitelline fistula
214. What congenital anomaly is caused by only partial closure of the vitelline duct? Meckel diverticulum
215. What congenital anomaly is caused by cystic dilation of the vitelline duct? Vitelline cyst (enterocyst)
216. What congenital anomaly presents with meconium discharge from the umbilicus? Vitelline fistula
219. Volvulus of the sigmoid colon is more commonly seen in the elderly (age group)
223. In children the most common cause of intussusception is lymphoid hyperplasia (e.g. due to rotavirus or adenovirus)
224. What is the most common pathologic lead point for intussusception in children over 2? Meckel diverticulum
225. What is the most common lead point for intussusception in adults? Intraluminal mass or tumor
226. Where in the GI tract does intussusception most commonly occur? Ileocecal junction
227. Intussusception results in compromised blood supply, which causes intermittent abdominal pain (frequency) with "currant jelly" stool
229. Acute mesenteric ischemia may occur due to a thrombotic or embolic occlusion of the superior mesenteric artery
232. Acute mesenteric ischemia is associated with small bowel necrosis and abdominal pain out of proportion to physical findings
233. Acute mesenteric ischemia may present with "currant jelly" stool
234. Chronic mesenteric ischemia may occur due to severe hypotension or atherosclerosis of the celiac artery SMA or IMA
236. Chronic mesenteric ischemia is typically caused by intestinal hypoperfusion as a result of narrowed vasculature
237. Chronic mesenteric ischemia presents with epigastric pain that occurs after eating (before or after)
239. Boerhaave syndrome may present with subcutaneous emphysema which is characterized by crepitus felt in the neck region or chest wall
240. Esophagitis may occur with medications such as bisphosphonates tetracyclines NSAIDs iron and potassium chloride
241. Loss of which hormones/neurotransmitters (2) are implicated in the pathogenesis of achalasia? NO and VIP
244. Lactose intolerance is caused by decreased function of the lactase enzyme found in brush border enterocytes
245. Lactose intolerance presents with abdominal distention and diarrhea upon consumption of milk products
247. Temporary lactase deficiency may be seen after small bowel infection (e.g. viral enteritis)
250. The lactose hydrogen breath test is positive for lactose malabsorption if the post-lactose breath hydrogen rises > 20 ppm compared with baseline
253. What malabsorption disorder is associated with HLA-DQ2 and HLA-DQ8? Celiac disease
257. Which immune cell mediates the tissue damage in Celiac disease? Helper T cells
258. Celiac disease in children (age group) classically presents as abdominal distention steatorrhea and failure to thrive
259. Celiac disease in adults (age group) classically presents with chronic steatorrhea and bloating
261. Celiac disease is associated with dermatitis herpetiformis which are small herpes-like vesicles on the skin
262. The dermatitis herpetiformis that arises with celiac disease is due to IgA deposition at the tips of the dermal papillae
263. Celiac disease is classically associated with IgA antibodies against endomysium tissue transglutaminase (tTG) and/or deamidated gliadin
264. In patients with IgA deficiency and celiac disease IgG antibodies against endomysium tTG or gliadin are useful for diagnosis
270. Which type of sprue (celiac or tropical) primarily affects the proximal small bowel? Celiac sprue
271. Celiac disease is associated with increased risk for small bowel carcinoma and T-cell lymphoma
274. Is celiac disease associated with normal or decreased urinary excretion of D-xylose (D-xylose test)? Decreased
275. Tropical sprue is characterized by damage to small bowel villi due to an unknown organism resulting in malabsorption
278. Which type of sprue (celiac or tropical) can affect any part of the small bowel? Tropical sprue
281. Is tropical sprue associated with normal or decreased urinary excretion of D-xylose (D-xylose test)? Decreased
282. Whipple disease is characterized by systemic tissue damage with macrophages loaded with Tropheryma whipplei organisms
284. The granules in macrophages in Whipple disease stain positive for PAS and are diastase resistant
285. Which malabsorption syndrome is associated with PAS positive foamy macrophages? Whipple disease
286. Whipple disease classically involves the lamina propria (mucosal layer) of the small bowel
287. Whipple disease may present with fat malabsorption and steatorrhea due to compression of lacteals by macrophages
288. What lymph nodes are commonly affected in Whipple disease? Mesenteric nodes
289. The symptoms of Whipple disease may be remembered with the mnemonic "Foamy Whipped cream in a CAN": C: cardiac
symptoms A: arthralgias N: neurologic symptoms
291. Pancreatic insufficiency causes malabsorption of fat fat-soluble vitamins and vitamin B12
295. Is pancreatic insufficiency associated with normal or decreased urinary excretion of D-xylose (D-xylose test)? Normal
299. Abetalipoproteinemia is associated with malabsorption due to defective chylomicron formation which requires apoB-48
300. Abetalipoproteinemia is associated with absent plasma VLDL and LDL which require apoB-100
302. The tumor cells in carcinoid tumors contain secretory granules that stain positive for chromogranin A synaptophysin as well as other
neuroendocrine markers
303. Carcinoid tumors may arise anywhere in the gut however they most commonly arise in the small bowel
304. What is the most common malignancy in the small intestine? Carcinoid tumor
306. The serotonin released from carcinoid tumors in the small bowel is metabolized in the liver by monoamine oxidase (MAO) producing 5-HIAA
307. Carcinoid tumors are characterized by increased excretion of 5-HIAA in the urine
308. Metastasis of carcinoid tumor to the liver allows serotonin to bypass first-pass metabolism and enter systemic circulation
309. The symptoms of carcinoid syndrome may be remembered with the mnemonic "Be FDR":
Be: bronchospasm F: flushing D: diarrhea R: right-sided heart disease
310. The symptoms of carcinoid syndrome may be triggered by alcohol or emotional stress which stimulate serotonin release from the tumor
311. Carcinoid syndrome may cause right-sided valvular heart lesions such as tricuspid regurgitation and pulmonic stenosis
312. Why are left-sided heart valve lesions NOT seen with Carcinoid syndrome? Lung contains MAO which metabolizes serotonin
313. Does carcinoid syndrome occur with carcinoid tumors that are limited to the GI tract? No
314. What vitamin deficiency may be caused by malignant carcinoid syndrome? Niacin (B3) deficiency
315. Carcinoid syndrome may be treated with surgical resection or with a somatostatin analog
320. Appendicitis presents with diffuse periumbilical pain that eventually localizes to McBurney's point
321. Appendicitis may lead to rupture resulting in peritonitis with guarding and rebound tenderness on physical exam
322. One sign of appendicitis is the obturator sign which is pain on passive flexion and internal rotation of the right hip
323. One sensitive sign of appendicitis and psoas abscess is the psoas sign which is pain on passive extension of the right hip
324. One sign of appendicitis is the Rovsing sign which is pain over the right iliac fossa with palpation of the left iliac fossa
326. What other pathologies should be on a differential when considering appendicitis? diverticulitis (elderly) and ectopic pregnancy
327. Inflammatory bowel disease classically presents in young women (gender) with recurrent bloody diarrhea and abdominal pain
328. Inflammatory bowel disease is more prevalent in the West particularly in caucasians and Eastern European Jews
330. Which form of IBD involves only mucosal and submucosal ulcers? Ulcerative colitis
331. Which form of IBD involves transmural inflammation with "knife-like" fissures? Crohn disease
332. Ulcerative colitis (IBD) is characterized by continuous colonic lesions that always involve the rectum
333. Ulcerative colitis always involves the rectum and can extend proximally up to the cecum
334. Crohn disease (IBD) is characterized by skip lesions which can occur anywhere from the mouth to the anus
336. Crohn disease usually does NOT affect the rectum (rectal sparing)
338. Which form of IBD may cause bloody or non-bloody diarrhea? Crohn disease
339. Ulcerative colitis is typically characterized by left lower quadrant pain (left or right)
340. Crohn disease is typically characterized by right lower quadrant pain (left or right)
341. Ulcerative colitis (IBD) is characterized histologically by crypt abscesses with neutrophils ulcers and bleeding
347. Crohn disease appears grossly with strictures (lumen size) and bowel wall thickening
348. Crohn disease (IBD) is associated with the "string" sign on imaging, secondary to strictures
350. Ulcerative colitis (IBD) is associated with the "lead pipe" sign on imaging, secondary to loss of haustra
351. Complications of both ulcerative colitis and Crohn disease include malabsorption and colorectal cancer
352. Risk for colorectal cancer development from IBD is based on extent of colonic involvement and duration of disease
353. Complications of ulcerative colitis include toxic megacolon which may perforate and fulminant colitis
356. One complication of Crohn disease is enterovesical fistula which can cause UTI and pneumaturia
357. Which form of IBD is associated with perianal disease phlegmon/abscess formation and strictures? Crohn disease
358. Extraintestinal manifestations of IBD include arthritis such as ankylosing spondylitis sacroiliitis migratory polyarthritis and peripheral joints
359. Extraintestinal manifestations of IBD include rash such as erythema nodosum and pyoderma gangrenosum
363. What biliary tract disease is associated with ulcerative colitis? Primary sclerosing cholangitis
365. Crohn disease (IBD) may be associated with positive serum anti-Saccharomyces cervisiae antibodies (ASCA)
367. What 5-aminosalicylic preparations (2) are useful in the management of ulcerative colitis and Crohn disease? mesalamine and sulfasalazine
368. Treatment of IBD (Crohn's UC) may involve TNF-α inhibitors such as infliximab and adalimumab
369. Treatment of IBD (Crohn's UC) may involve immunosuppressors such as azathioprine and 6-mercaptopurine
373. Hirschsprung disease is characterized by defective relaxation and peristalsis of the rectum and distal sigmoid colon
375. Hirschsprung disease occurs due to a congenital failure of ganglion cells to descend into the myenteric and submucosal plexus
376. The ganglion cells that fail to descend in Hirschsprung disease are derived from neural crest
378. Hirschsprung disease is characterized by failure to pass meconium within 48 hours and chronic constipation
379. Hirschsprung disease may present with abdominal distention and bilious vomiting (bilious or nonbilious)
380. Hirschsprung disease is characterized by explosive expulsion of feces ("squirt sign") and an empty rectal vault on digital rectal exam
381. Hirschsprung disease is characterized by massive dilation of the bowel proximal to the aganglionic segment (proximal or distal), resulting in a
"transition zone"
384. Colonic diverticula are "blind pouches" that communicate with the lumen of the gut
385. Are colonic diverticula typically true or false diverticula? False (only involves mucosa and submucosa)
386. Which gut wall layers are involved in a false diverticulum (psuedodiverticulum)? Mucosa and submucosa
387. Which gut wall layers are involved in a true diverticulum? All three (mucosa submucosa muscularis externa)
388. GI tract diverticula classically arise where the vasa recta perforates the muscularis propria (weak point in colonic wall)
391. Diverticulosis is related to wall stress (pulsion diverticulosis) (e.g. constipation straining low fiber diet) and obesity
393. What demographic (age group) is commonly associated with diverticulosis? Older adults (risk increases with age)
398. What GI tract pathology presents with appendicitis-like symptoms in the LLQ? Diverticulitis
399. Diverticulitis may lead to a colovesical fistula which presents with pneumaturia (e.g. air or stool in the urine)
402. Angio-dysplasia is an acquired malformation resulting in tortuous dilation of vessels of the GI tract
403. Angiodysplasia usually arises in the cecum and right colon (right or left) due to high wall tension
406. Hereditary hemorrhagic telangiectasia is an autosomal dominant (inheritance) disorder resulting in thin-walled blood vessels especially in
the mouth and GI tract
410. Ischemic colitis usually occurs at the splenic flexure (griffith's point) which is the watershed area of the SMA and the IMA
413. Ischemic colitis may present with the "thumbprint" sign on imaging due to mucosal edema/hemorrhage
414. Irritable bowel syndrome is recurrent abdominal pain with > 2 of the following: - Pain improves with defecation - Change in stool frequency -
Change in stool consistency
415. What demographic is most commonly associated with irritable bowel syndrome? Middle-aged women
416. The chronic symptoms of irritable bowel syndrome may be diarrhea-predominant constipation-predominant or mixed
418. The first line treatment for Irritable bowel syndrome is lifestyle modification and increased dietary fiber
426. Hamartomatous colonic polyps are growths of normal colonic tissue with distorted architecture
428. What type of colonic polyp is small (< 5 mm) and resembles normal mucosa? Mucosal polyps (clinically insignificant)
429. What type of colonic polyp is a result of mucosal erosion from inflammatory bowel disease? Inflammatory pseudopolyp
430. What type of colonic polyp may include lesions such as lipomas leiomyomas fibromas and others? Submucosal polyps
435. Which adenoma-carcinoma sequence mutation results in increased risk for polyp formation? APC mutation
436. Following APC mutation (adenoma-carcinoma sequence) KRAS mutations lead to polyp formation (adenoma)
438. Progression of colonic adenoma to carcinoma occurs with mutations in the p53 or loss of heterozygosity in the region that encodes
for SMAD 2 / 4
440. What drug class may be used to impede progression of colonic adenoma to carcinoma? NSAIDs (e.g. aspirin)
441. Sessile serrated colonic polyps have a "saw-tooth" pattern similar to hyperplastic polyps, but extend to the crypts and involve lateral crypt
growth
444. Screening for colorectal polyps/carcinoma is performed by colonoscopy and testing for fecal occult blood (stool guiaic test)
445. Can an adenomatous polyp be distinguished from a hyperplastic polyp on gross examination (e.g. colonoscopy)? No (thus remove all polyps)
446. Which type of polyp has greater malignant potential sessile or pedunculated? Sessile
447. Colonic polyps have a greater risk of progression to carcinoma if they are > 2 cm in size
448. Adenomatous polyps with a tubular histology have less malignant potential than villous histology (tubular or villous)
449. Familial adenomatous polyposis (FAP) is an autosomal dominant (inheritance) disorder characterized by 100s to 1000s of adenomatous
colonic poylps
450. Familial adenomatous polyposis (FAP) is due to an inherited mutation in the APC gene on chromosome 5q
451. Colorectal cancer arises in patients with familial adenomatous polyposis via the "2-hit hypothesis"
453. Familial adenomatous polyposis is treated with prophylactic colectomy or else 100% of patients progress to CRC
455. Turcot syndrome is a combination of familial adenomatous polyposis with malignant CNS tumors (e.g. medulloblastoma glioma)
456. Juvenile polyps usually present in childhood as a solitary rectal polyp that prolapses and bleeds
458. What demographic (age group) is associated with juvenile polyposis syndrome? Children < 5 years old
459. Juvenile polyposis syndrome is characterized by many juvenile polyps in the stomach colon and small bowel
461. Peutz-Jeghers syndrome is characterized by numerous harmatomatous polyps WITH hyperpigmentation of the lips mouth hands and genital
skin
462. Peutz-Jeghers syndrome is associated with increased risk of breast GI and gynecologic cancers
465. FAP and most sporadic colorectal carcinomas arise via the chromosomal instability pathway
466. Lynch syndrome and some sporadic colorectal carcinomas arise via the microsatellite instability pathway
468. The microsatellite instability pathway of colorectal cancer is characterized by mutations or methylation of mismatch repair genes
469. Lynch syndrome is due to an inherited defect in DNA mismatch repair enzymes resulting in microsatellite instability
470. Lynch syndrome was previously known as hereditary nonpolyposis colorectal cancer (HNPCC)
473. Lynch syndrome is usually right-sided and always involves the proximal colon (proximal or distal)
474. Lynch syndrome is associated with increased risk for colorectal endometrial ovarian and skin cancers
475. Screening for colorectal carcinoma in low-risk patients begins at 50 years of age (e.g. colonoscopy fecal occult blood (stool guiaic test))
476. 25% of colorectal cancers arise in patients with a positive family history
477. Patients with a first-degree relative with colon cancer should be screened via colonoscopy starting at age 40 or starting 10 years prior to their
relative's presentation
480. Risk factors for colorectal carcinoma include diets with processed meat and low fiber
481. Which part of the colon does colorectal carcioma most commonly arise? Rectosigmoid region
483. Left-sided colorectal carcinoma presents with decreased stool caliber due to partial obstruction
484. Left-sided colorectal carcinoma presents with colicky pain and hematochezia (stool)
485. Left-sided colorectal carcinoma usually arises as a result of the adenoma-carcinoma sequence
487. Right-sided colorectal carcinoma presents with vague pain weight loss and iron deficiency anemia
488. Right-sided colorectal carcinoma usually arises as a result of the microsatellite instability pathway
489. Iron deficiency anemia in males (especially > 50) and postmenopausal females raises suspicion of colorectal carcinoma
491. Colorectal carcinoma may be visualized as an "apple core" lesion seen on barium enema X-ray
492. The T of TNM staging for colorectal carcinoma represents the depth of invasion
493. The N of TNM staging for colorectal carcinoma represents regional lymph node involvement
496. What tumor marker is useful for assessing treatment response and recurrence of colorectal carcinoma? CEA
497. Is the CEA tumor marker useful for screening for colorectal carcinoma? No
498. Is the CEA tumor marker useful for monitoring recurrence of colorectal carcinoma? Yes
499. Adhesions are fibrous bands of scar tissue that commonly form after GI surgery
501. Ileus is an intestinal hypomotility without obstruction that results in constipation and decreased flatus
503. Treatment of ileus includes bowel rest electrolyte correction and cholinergic drugs (stimulate intestinal motility)
504. Meconium ileus is characterized by a meconium plug that obstructs the intestine preventing stool passage at birth
505. Necrotizing enterocolitis is a GI pathology seen in premature formula-fed infants with immature immune systems
506. Necrotizing enterocolitis (NEC) is characterized by necrosis of intestinal mucosa with possible perforation which can lead to: - free air in the
bowel wall (pneumatosis intestinalis) - free air in the abdomen (pneumoperitoneum) - portal venous gas on imaging
508. In acute pancreatitis trypsin is prematurely activated which leads to activation of other pancreatic enzymes
512. The causes of acute pancreatitis may be remembered with the mnemonic "I GET PP SMASHED":
I: Idiopathic G: Gallstones E: Ethanol T: Trauma (e.g. automobile accident in children - seatbelt injury) P: Posterior duodenal ulcer
rupture P: Pancreas Divisum S: Steroids M: Mumps A: Autoimmune disease S: {{c8::Scorpion sting
H: HYPERcalcemia or Hypertriglyceridemia/Hyperchylomicronemia E: ERCP (endoscopic retrograde
cholangiopancreatography) D: Drugs (e.g. sulfa drugs, NRTIs, protease inhibitors)
513. Acute pancreatitis is diagnosed by 2 of 3 criteria: - Acute epigastric pain that radiates to the back - Increased serum amylase or lipase to 3x
upper limit of normal - Characteristic imaging findings
514. One criteria for diagnosis of acute pancreatitis is acute epigastric abdominal pain that radiates to the back
516. Which pancreatic enzyme (amylase or lipase) is more specific for acute pancreatitis? Lipase
518. Acute pancreatitis may progress to shock due to pancreatic hemorrhage and fluid sequestration
519. Acute pancreatitis may be complicated by pancreatic pseudocysts which are formed by fibrous tissue surrounding liquefactive necrosis and
pancreatic enzymes
520. Pancreatic pseudocyst presents as an abdominal mass with persistently elevated serum amylase
521. Pancreatic pseudocysts may rupture causing hemorrhage and release of enzymes into the abdominal cavity
522. Pancreatic abscess presents with abdominal pain high fever and persistently elevated serum amylase
525. Complications of acute pancreatitis include ARDS due to damage to the alveolar capillary interface
528. What are the major causes of chronic pancreatitis in adults? alcohol and genetic predisposition (ex. Cystic Fibrosis)
529. What is the most common cause of chronic pancreatitis in children? cystic fibrosis
530. Pancreatitis (acute and chronic) may present with epigastric abdominal pain that radiates to the back
531. Chronic pancreatitis may present with pancreatic insufficiency which results in malabsorption with steatorrhea and fat-soluble vitamin
deficiences
532. Are serum amylase and lipase useful serum markers for chronic pancreatitis? No (may or may not be elevated)
534. Contrast studies of chronic pancreatitis reveal a "chain of lakes" pattern due to dilatation of pancreatic ducts
535. What endocrine pathology may arise secondary to chronic pancreatitis? Diabetes mellitus
537. What type of cancer (e.g. SCC adenocarcinoma etc.) is pancreatic carcinoma? Adenocarcinoma
538. Pancreatic adenocarcinoma is a very aggressive tumor arising from the pancreatic ducts (ducts or acini)
540. The major risk factors for pancreatic adenocarcinoma are - smoking - chronic pancreatitis (especially > 20 years)
542. What endocrine pathology is a risk factor for pancreatic adenocarcinoma? Diabetes mellitus
543. Pancreatic adenocarcinoma often presents with epigastric abdominal pain that radiates to the back
544. Pancreatic adenocarcinoma often presents with weight loss secondary to malabsorption and anorexia
548. Pancreatic adenocarcinoma in the body or tail may present with secondary diabetes mellitus
549. Pancreatic adenocarcinoma may present with migratory thrombophlebitis which is redness and tenderness in the extremities
551. Pancreatic adenocarcinoma is associated with the serum tumor markers CA 19-9 and CEA (less specific)
553. What surgical procedure involves the en bloc removal of the head/neck of the pancreas proximal duodenum and gallbladder? Whipple
procedure
554. What is the prognosis of pancreatic adenocarcinoma? Very poor (1-year survival < 10%)
560. Which type of gallstone is the most common especially in the West? Cholesterol stone (80%)
563. Risk factors for cholesterol gallstones may be remembered with the "4 F's": 1. Fat 2. Female (estrogen increases activity of HMG-CoA
reductase) 3. Fertile (pregnant) 4. Forty
564. What classes (2) of lipid lowering drugs are associated with cholesterol gallstone formation? fibrates and bile acid resins
566. Which type of gallstone (cholesterol or pigment) is associated with rapid weight loss? Cholesterol gallstone
567. Which form of IBD has increased risk for gallstones (both cholesterol and pigment)? Crohn disease
569. Brown pigment gallstones (color) are radio-lucent and arise with biliary tract infection
570. Biliary tract infections may cause pigment gallstones by deconjugating bilirubin which increases risk of precipitation
571. Which type of gallstone is associated with extravascular hemolysis? Bilirubin (pigment) stones
572. Ascaris lumbricoides is a common roundworm that infects the biliary tract increasing the risk for gallstones
573. Clonorchis sinensis is a liver fluke that infects the biliary tract increasing the risk for gallstones cholangitis and cholangiocarcinoma
575. Which type of gallstone is associated with total parenteral nutrition (TPN)? Cholesterol stones
579. Biliary colic is a waxing and waning right upper quadrant pain associated with gallstones; may also have nausea and vomiting
581. Cholecystitis is an acute or chronic inflammation of the gallbladder with gallbladder wall thickening
583. Calculous cholecystitis results from an impacted stone in the cystic duct resulting in dilatation with inflammation and bacterial overgrowth
584. What bacteria is a common cause of secondary infection in calculous cholecystitis? E. coli
585. Acalculous cholecystitis is due to gallbladder stasis hypoperfusion or infection (no obstruction); seen in critically ill patients
587. Acute cholecystitis presents with RUQ pain that often radiates to the right scapula
588. Cholecystitis may present with elevated serum alkaline phosphatase if the bile duct is involved
589. Cholecystitis is associated with a positive Murphy's sign which is inspiratory arrest on RUQ palpation due to pain
590. Rokitansky-Aschoff sinus is a herniation of gallbladder mucosa into the muscular wall associated with chronic cholecystitis
591. Chronic cholecystitis presents with vague RUQ pain especially after eating
594. Porcelain gallbladder is a shrunken hard gallbladder due to chronic inflammation fibrosis and dystrophic calcification
595. Porcelain gallbladder is treated with prophylactic cholecystectomy due to high rates of gallbladder cancer (mostly adenocarcinoma)
597. Ascending cholangitis is usually due to ascending infection with enteric gram-negative bacteria
598. Ascending cholangitis classically presents with the Charcot triad of jaundice fever and RUQ pain
599. In addition to the Charcot triad Ascending cholangitis may also present with altered mental status and shock (Reynolds pentad)
600. There is an increased incidence of ascending cholangitis with choledocholithiasis (stones in the biliary ducts)
601. Choledocholithiasis is the presence of gallstones in the common bile duct often leading to elevated ALP GGT direct bilirubin and/or AST/ALT
603. Gallstone ileus occurs secondary to cholecystitis with fistula formation between the gallbladder and small bowel
604. Cholecystitis can cause fistula formation with the GI tract resulting in air in the biliary tree (pneumobilia)
605. What type of cancer (e.g. SCC adenocarcinoma etc.) is gallbladder carcinoma? Adenocarcinoma
606. The major risk factor for gallbladder carcinoma is gallstones especially when complicated by porcelain gallbladder
616. Physiological neonatal jaundice occurs due to transiently low UDP-glucuronyl transferase activity at birth
618. In physiological neonatal jaundice unconjugated bilirubin deposits in the brain especially in the basal ganglia
619. Kernicterus is the deposition of bilirubin in the brain especially basal ganglia causing neurologic deficits and possibly death
621. How does phototherapy treat neonatal jaundice? Isomerize UCB to water-soluble form
622. What is the mode of inheritance of hereditary hyperbilirubinemias (e.g. Gilbert Crigler-Najjar Dubin-Johnson)? Autosomal recessive
623. Gilbert syndrome is due to mildly low UDP-glucuronyl transferase activity
628. Crigler-Najjar syndrome causes jaundice and kernicterus early in life; patients often die within a few years
630. What are the treatments (2) for Crigler-Najjar syndrome type I? plasmapheresis and phototherapy
631. Crigler-Najjar syndrome type II is less severe and responds to phenobarbital which increases liver enzyme synthesis
634. Dubin-Johnson syndrome presents with a grossly black liver but is otherwise not clinically significant
635. Rotor syndrome is similar to Dubin-Johnson syndrome but milder and WITHOUT black liver
637. What type of jaundice is associated with gallstones parasites and liver fluke? Obstructive jaundice
638. What type of jaundice is associated with cholangiocarcinoma and pancreatic carcinoma? Obstructive jaundice
639. Does biliary tract obstruction (obstructive jaundice) result in unconjugated or conjugated hyperbilirubinemia? Conjugated
640. Obstructive jaundice is associated with dark urine due to increased urine conjugated bilirubin
643. Obstructive jaundice is associated with increased serum bile acids which may cause pruritus
647. Viral hepatitis is associated with dark urine due to increased urine conjugated bilirubin
649. In addition to hepatitis virus viral hepatitis may also be caused by EBV and CMV
651. Acute hepatitis is associated with inflammation that involves the lobules of the liver and portal tracts; characterized by apoptosis of hepatocytes
652. Chronic hepatitis is associated with inflammation that primarily involves the portal tracts
653. Cirrhosis is characterized by disruption of normal hepatic parenchyma by bands of fibrosis and regenerative nodules of hepatocytes
655. Alcoholic cirrhosis may be associated with sclerosis around central veins in early disease
658. What is the most common cause of portal hypertension in Western countries? Cirrhosis
659. Portal hypertension may be caused by vascular obstruction such as portal vein thrombosis and Budd-Chiari syndrome
662. Portal hypertension may lead to portosystemic shunts which can result in esophageal varices gastric varices anorectal varices and caput
medusae
664. Hepatorenal syndrome is a complication of portal hypertension characterized by rapidly developing renal failure secondary to cirrhosis
665. Cirrhosis may present with neuropsychiatric symptoms due to increased serum ammonia (NH3)
668. Hepatic encephalopathy may be triggered by increased NH3 production or absorption such as increased dietary protein
669. Hepatic encephalopathy may be triggered by decreased NH3 removal such as renal failure
670. What antibiotics (2) are used to treat hepatic encephalopathy? rifaximin and neomycin
672. Dermatologic symptoms of cirrhosis include jaundice spider angiomas palmar erythema and petechiae/purpura
675. Increased estrogen in cirrhosis may lead to gynecomastia testicular atrophy and amenorrhea (reproductive symptoms)
680. What is the most common cause of liver disease in the West? Alcohol consumption
681. Which alcoholic liver disease is characterized by macrovesicular fatty change with a heavy greasy liver? Hepatic steatosis
683. Which form of alcoholic liver disease may be reversible with abstinence? Hepatic steatosis
684. Alcoholic hepatitis is characterized by swelling of hepatocytes with necrosis and neutrophilic infiltration
685. Alcoholic hepatitis is characterized histologically by mallory bodies which are intracytoplasmic eosinophilic inclusions of damaged keratin
(intermediate) filaments
689. Non-alcoholic fatty liver disease is associated with obesity and metabolic syndrome
690. Nonalcoholic fatty liver disease is characterized by fatty infiltration of hepatocytes with cellular "ballooning" and eventual necrosis
691. Nonalcoholic fatty liver disease is characterized by elevated liver enzymes with ALT > AST
693. The tissue damage in hemochromatosis is mediated by the generation of free radicals
694. Hemochromatosis may be primary; due to autosomal recessive (inheritance) mutations in iron absorption
695. Hemochromatosis typically presents after age 40 when total body iron > 20g
699. Primary hemochromatosis is due to mutations in the HFE gene on chromosome 6 leading to increased expression of DMT1 and decreased
synthesis of Hepcidin
701. What point mutations in the HFE gene are typically seen with primary hemochromatosis? C282Y (more common) and H63D
712. Liver biopsy of a patient with hemochromatosis reveals accumulation of brown pigment (color) in hepatocytes
713. The coarse yellowish-brown pigment in hepatocytes / kupffer cells from hemochromatosis may be distinguished from lipofuscin by staining
with Prussian blue
714. Lipofuscin is a yellow-brown "wear and tear" pigment associated with normal aging
717. What type of drug are deferasirox deferoxamine and deferiprone (oral)? Iron chelators
718. What GI disorder may be treated with deferasirox deferoxamine and oral deferiprone? Hemochromatosis
721. Wilson disease results in lack of copper transport into bile and lack of incorporation into ceruloplasmin
723. Wilson disease is characterized by accumulation of copper especially in the liver brain cornea and kidneys
725. Wilson disease often presents with cirrhosis due to copper accumulation in the liver
726. Wilson disease often presents with neuropsychiatric manifestations due to copper deposition and resultant cystic degeneration in
the putamenand other adjacent structures
727. Wilson disease presents with Kayser-Fleisher rings due to copper deposits in Descemet's membrane of the cornea
728. Wilson disease may present with renal disease such as Fanconi syndrome
732. Wilson disease may be treated with oral zinc or chelating agents (e.g. penicillamine trientine)
733. Biliary tract diseases (e.g. PSC PBC) present with features of obstructive jaundice
734. Does biliary tract disease (e.g. PBC PSC) result in unconjugated or conjugated hyperbilirubinemia? Conjugated
735. Biliary tract diseases (e.g. PBC PSC) are associated with increased serum cholesterol
737. Does primary biliary cholangitis (PBC) effect intra- or extrahepatic bile ducts? Intrahepatic
739. What demographic is classically affected by primary biliary cholangitis (PBC)? Middle-aged women (~ 40 y.o)
740. Which biliary tract disease is classically seen in middle-aged women and presents with generalized pruritis and fatigue? Primary biliary
cholangitis (PBC)
743. Which biliary tract disease is caused by extrahepatic biliary obstruction? Secondary biliary cholangitis
744. Secondary biliary cholangitis occurs in patients with known obstructive lesions (e.g. gallstones biliary strictures pancreatic carcinoma)
746. Primary sclerosing cholangitis is characterized by inflammation and fibrosis of both intra- and extrahepatic bile ducts
747. Does primary sclerosing cholangitis (PSC) effect intra- or extrahepatic bile ducts? Both :)
749. Primary sclerosing cholangitis is characterized by a "beading" appearance of intra- and extrahepatic bile ducts on ERCP and MRCP
750. What demographic is classically affected by primary sclerosing cholangitis (PSC)? Middle-aged men (classically with IBD)
752. Primary sclerosing cholangitis and primary biliary cholangitis are associated with increased serum IgM
753. Primary sclerosing cholangitis is associated with increased risk for cholangiocarcinoma and gallbladder cancer
754. What is a late complication associated with biliary tract disease (e.g. PBC PSC)? Cirrhosis
755. Reye syndrome is fulminant liver failure and encephalopathy in children with viral illness who take aspirin
756. Reye syndrome may occur due to decreased β-oxidation secondary to reversible inhibition of mitochondrial enzymes in hepatocytes by
aspirin metabolites
757. Reye syndrome presents with micro-vesicular fatty change in the liver hypoglycemia vomiting hepatomegaly and eventually coma/death
758. What viruses classically cause Reye syndrome when treated with aspirin? Influenza B and VZV
759. Hepatic adenomas are rare benign tumors associated with OCP and anabolic steroid use; regress upon cessation of drug
760. Hepatic adenomas may rupture causing intraperitoneal bleeding especially during pregnancy
761. Hepatic adenomas are subcapsular tumors and grow with exposure to estrogen
762. Hepatic angiosarcoma is a malignant tumor associated with exposure to arsenic and vinyl chloride
763. Cavernous hemangiomas are common benign tumors involving the deeper tissues of the body (ex. liver brain) that typically occur from age 30
- 50 years
765. Hepatocellular carcinoma (hepatoma) is the most common primary malignant liver tumor in adults
766. Risk factors for hepatocellular carcinoma include chronic hepatitis (e.g. HBV HCV)
767. Risk factors for hepatocellular carcinoma include causes of cirrhosis (e.g. alcohol NAFLD hemochromatosis Wilson disease A1AT deficiency)
770. In addition to HCC Budd-Chiari syndrome may also be seen with hypercoaguable and post-partum states
773. Budd-Chiari syndrome presents with painful hepatomegaly (painful or painless) ascites varices and liver failure
774. Budd-Chiari syndrome results in congestion and necrosis of the centrilobular zone of the liver
775. Does Budd-Chiari syndrome present with jugular venous distention (JVD)? No
779. Which is more common primary liver tumors or metastasis to the liver? Metastasis
780. Does metastasis to the liver typically present as a single or multiple nodules? Multiple
781. Metastasis to the liver may be detected clinically as hepatomegaly with a nodular free edge of the liver
782. Spontaneous (primary) bacterial peritonitis is a common potentially fatal bacterial infection in patients with cirrhosis and ascites
783. Spontaneous bacterial peritonitis is commonly caused by aerobic gram negative organisms especially E. coli and Klebsiella
784. Spontaneous bacterial peritonitis is diagnosed by paracentesis with ascitic fluid absolute neutrophil count > 250 cells/mm3
785. AST > ALT in nonalcoholic liver disease suggests progression to advanced fibrosis or cirrhosis
786. Which liver enzyme is increased in cholestasis (e.g. biliary obstruction) infiltrative disorders and bone disease? Alkaline phosphatase
787. Which liver enzyme is increased in various liver/biliary diseases but NOT in bone disease? γ-glutamyl transpeptidase (GGT)
789. How does prothrombin time (PT) change with advanced liver disease? Increased
792. The best way to visualize Kayser-Fleisher rings in Wilson disease is via slit-lamp examination
798. Sialolithiasis is typically treated conservatively with NSAIDs gland massage warm compresses and sialogogues
799. Behcet syndrome has a high incidence in those of Turkish / East Mediterranean descent
802. Patients who are experiencing intussusception may draw legs to their chest to ease the pain