minarcik robbins 2013_ch17-gi
TRANSCRIPT
![Page 1: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/1.jpg)
GI
![Page 2: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/2.jpg)
GI• ESOPHAGUS• STOMACH• SMALL/LARGE BOWEL•APPENDIX, PERITONEUM
![Page 3: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/3.jpg)
ESOPHAGUS• Congenital Anomalies• Achalasia• Hiatal Hernia• Diverticula• Laceration• Varices• Reflux• Barretts• Esophagitis• Neoplasm: Benign, Sq. Cell Ca., Adenoca.
![Page 4: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/4.jpg)
ANATOMY• 25 cm.• UES/LES• Mucosa/Submucosa/Muscularis/Adventitia*
![Page 5: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/5.jpg)
Inf. Thyroid Arts.
R. Bronch. Art.
Thoracic. Aor.
Left Gastric Art.
Variations:
Inf, Phrenic
Celiac
Splenic
Short Gast.
![Page 6: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/6.jpg)
![Page 7: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/7.jpg)
DEFINITIONS• Heartburn (GERD/Reflux)• Dysphagia• Hematemesis• Esophagospasm (Achalasia)
![Page 8: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/8.jpg)
CONGENITAL ANOMALIES• ECTOPIC TISSUE (gastric, sebaceous, pancreatic)• Atresia/Fistula/Stenosis/”Webs”• Schiatzki “Ring” in lower esophagus
MOST COMMON
![Page 9: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/9.jpg)
MOTOR DISORDERS• Achalasia• Hiatal Hernia (sliding [95%],
paraesophageal)• “ZENKER” diverticulum• Esophagophrenic diverticulum• Mallory-Weiss tear
![Page 10: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/10.jpg)
![Page 11: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/11.jpg)
ACHALASIA• “Failure to relax”–Aperistalsis– Incomplete relaxation of the LES– Increased LES tone• INCREASE: Gastrin, serotonin, acetylcholine,
Prostaglandin F2α, motulin, Substance P, histamine, pancreatic polypeptide• DECREASE: N.O., VIP
–Progressive dysphagia starting in teens–Mostly UNCERTAIN etiology
![Page 12: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/12.jpg)
HIATAL HERNIA• Diaphragmatic muscular defect• WIDENING of the space which the lower
esophagus passes through• IN ALL cases, STOMACH above
diaphragm• Usually associated with reflux• Very common Increases with age• Ulceration, bleeding, perforation,
strangulation
![Page 13: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/13.jpg)
![Page 14: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/14.jpg)
![Page 15: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/15.jpg)
DIVERTICULA•ZENKER (HIGH)•TRACTION (MID)•EPIPHRENIC (LOW)•TRUE vs. FALSE?
![Page 16: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/16.jpg)
DIVERTICULUM
![Page 17: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/17.jpg)
LACERATION• Tears are LONGITUDINAL (lower esophagus)
• Usually secondary to severe VOMITING• Usually in ALCOHOLICS• Usually MUCOSAL tears
• By convention, they are all called:
MALLORY-WEISS
![Page 18: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/18.jpg)
![Page 19: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/19.jpg)
VARICES• THREE common areas of portal/caval anastomoses
–Esophageal– Umbilical– Hemorrhoidal
• 100% related to portal hypertension• Found in 90% of cirrhotics• MASSIVE, SUDDEN, FATAL hemorrhage is the most
feared consequence
![Page 20: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/20.jpg)
VARICES
![Page 21: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/21.jpg)
VARICES
![Page 22: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/22.jpg)
ESOPHAGITIS•GERD/Reflux Barrett’s•Barrett’s•Chemical• Infectious
![Page 23: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/23.jpg)
REFLUX/GERD• DECREASED LES tone• Hiatal Hernia• Slowed reflux clearing• Delayed gastric emptying• REDUCED reparative ability of gastric
mucosa
![Page 24: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/24.jpg)
REFLUX/GERD• Inflammatory Cells–Eosinophils–Neutrophils–Lymphocytes
• Basal zone hyperplasia• Lamina Propria papillae elongated
and congested, due to regeneration
![Page 25: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/25.jpg)
REFLUX/GERD
![Page 26: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/26.jpg)
BARRETT’S ESOPHAGUS
• Can be defined as intestinal metaplasia of a normally SQUAMOUS esophageal mucosa. The presence of GOBLET CELLS in the esophageal mucosa is DIAGNOSTIC.
• SINGLE most common RISK FACTOR for esophageal adenocarcinoma
• 10% of GERD patients get it• “BREACHED” G-E junction
![Page 27: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/27.jpg)
BARRETT’S ESOPHAGUS
![Page 28: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/28.jpg)
![Page 29: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/29.jpg)
BARRETT’S ESOPHAGUS
• INTESTINALIZED (GASTRICIZED) mucosa is AT RISK for glandular dysplasia.
• Searching for dysplasia when BARRETT’s is present is of utmost importance
• MOST/ALL adenocarcinomas arising in the esophagus arise from previously existing BARRETT’s
![Page 30: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/30.jpg)
![Page 31: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/31.jpg)
ESOPHAGITIS• CHEMICAL– LYE (suicide attempts) with strictures–Alcohol–Extremely HOT drinks–CHEMO (often harmful to ALL high turnover
mucosas)
• INFECTIOUS–HSV, CMV, Fungal (especially CANDIDA)
![Page 32: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/32.jpg)
ESOPHAGITIS
![Page 33: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/33.jpg)
ESOPHAGITIS
![Page 34: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/34.jpg)
TUMORS•BENIGN•MALIGNANT–Squamous cell carcinoma–Adenocarcinoma
![Page 35: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/35.jpg)
BENIGN TUMORS• LEIOMYOMAS• FIBROVASCULAR
POLYPS• CONDYLOMAS (HPV)• LIPOMAS• “GRANULATION”
TISSUE (PSEUDOTUMOR)
![Page 36: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/36.jpg)
SQUAMOUS CARCINOMA
• Nitrites/Nitrosamines• Betel• Fungi in food (nitrosamines)• Tobacco• Alcohol• Esophagitis?
![Page 37: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/37.jpg)
SQUAMOUS CARCINOMA
• DYSPLASIAIN-SITUINFILTRATION
![Page 38: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/38.jpg)
![Page 39: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/39.jpg)
![Page 40: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/40.jpg)
![Page 41: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/41.jpg)
ADENOCARCINOMA• BARRETT’s• BARRETT’s• BARRETT’s• BARRETT’s• BARRETT’s• BARRETT’s• BARRETT’s• (heterotopic gastric or submucosal glands)
![Page 42: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/42.jpg)
ADENOCARCINOMA
![Page 43: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/43.jpg)
![Page 44: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/44.jpg)
STOMACHSTOMACHNORMAL: Anat., Histo, Physio.PATHOLOGY
CONGENITALGASTRITISPEPTIC ULCER“HYPERTROPHIC” GASTRITISVARICESTUMORS
BENIGNADENOCARCINOMAOTHERS
![Page 45: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/45.jpg)
ANATOMYANATOMYCardia (esoph), Fundus (diaph), Body (acid), Antrum, PylorusGreater/Lesser Curvatures1500-3000 mlRugaeINNERVATION: VAGUS, SympatheticVEINS: PortalBlood Supply: RG, LG, RGE(O), LGE(O), SG, ALL 3 branches of the celiac, no matter what the variations may be.
![Page 46: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/46.jpg)
![Page 47: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/47.jpg)
![Page 48: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/48.jpg)
![Page 49: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/49.jpg)
![Page 50: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/50.jpg)
![Page 51: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/51.jpg)
CELLS
MUCOUS: MUCUS, PEPSINOGEN IICHIEF: PEPSINOGEN I, IIPARIETAL: ACIDENTEROENDOCRINE: HISTAMINE, SOMATOSTATIN, ENDOTHELIN
![Page 52: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/52.jpg)
PHYSIOLOGY PHASES(HCl Secretion)
CEPHALIC (VAGAL)
GASTRIC (STRETCH)
INTESTINAL (DUOD)
![Page 53: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/53.jpg)
ACID PROTECTIONMUCUSHCO3-EPITHELIAL BARRIERSBLOOD FLOWPROSTAGLANDIN E, I
![Page 54: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/54.jpg)
CONGENITAL• ECTOPIC PANCREAS (ectopic pancreas tissue
stomach), very common• ECTOPIC GASTRIC (ectopic gastric tissue
pancreas), not rare• Diaphragmatic HERNIA Failure of diaphragm to
close, not rare• PULMONARY SEQUESTER (rare) (foregut anomaly)• …..and the #1 congenital gastric disease ?????
![Page 55: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/55.jpg)
PYLORIC STENOSIS• CONGENITAL: (1/500), Neonatal
obstruction symptoms, pyloric splitting curative• ACQUIRED: Secondary to extensive
scarring such as advanced peptic ulcer disease
![Page 56: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/56.jpg)
GASTRITIS• ACUTE• CHRONIC• AUTOIMMUNE• OTHER–EOSINOPHILIC–ALLERGIC– LYMPHOCYTIC–GRANULOMATOUS–GVH
![Page 57: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/57.jpg)
GASTRITIS• ACUTE, HEMORRHAGIC• (NSAIDs), particularly aspirin
• Excessive alcohol consumption
• Heavy smoking
• CHEMO
• Uremia
• Salmonella, CMV
• Severe stress (e.g., trauma, burns, surgery)
• Ischemia and shock
• Suicidal attempts, as with acids and alkali
• Gastric irradiation or freezing
• Mechanical (e.g., nasogastric intubation)
• Distal gastrectomy
![Page 58: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/58.jpg)
GASTRITIS• ACUTE, HEMORRHAGIC• HISTOLOGY: Erosion, Hemorrage,
NEUTROPHILS
![Page 59: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/59.jpg)
GASTRITIS• CHRONIC, NO EROSIONS, NO HEMORRHAGE
•Chronic infection by H. pylori
• Immunologic (autoimmune), e.g., PA• Toxic, as with alcohol and cigarette smoking • Postsurgical, reflux of bile• Motor and mechanical, including obstruction, bezoars (luminal
concretions), and gastric atony • Radiation • Granulomatous conditions (e.g., Crohn disease) • GVH, uremia
![Page 60: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/60.jpg)
GASTRITIS• CHRONIC, NO EROSIONS, NO HEMORRHAGE• Perhaps some neutrophils• Lymphocytes, lymphoid follicles• REGENERATIVE CHANGES
– METAPLASIA, intestinal– ATROPHY, mucosal hypoplasia, “thinning”– DYS-PLASIA
![Page 61: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/61.jpg)
![Page 62: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/62.jpg)
GASTRITIS•AUTOIMMUNE (10%)• ANTIBODIES AGAINST–acid producing enzyme H+ –K+ -ATPase–gastrin receptor–and intrinsic factor
![Page 63: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/63.jpg)
GASTRITIS• OTHER–EOSINOPHILIC, middle aged women–ALLERGIC, children (also eosinophils)– LYMPHOCYTIC, T-Cells, body, DIFFUSE–GRANULOMATOUS, Crohn’s, other granulomas–GVH, in bone marrow transplants
![Page 64: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/64.jpg)
![Page 65: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/65.jpg)
“PEPTIC” ULCERS• “PEPTIC” implies acid cause/aggravation• ULCER vs. EROSION (muscularis mucosa intact)• MUCSUBMUCMUSCULARISSEROSA• Chronic, solitary (usually), adults• 80% caused by H. pylori• 100% caused by H. pylori in duodenum• NSAIDS “STRESS”
![Page 66: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/66.jpg)
Helicobacter pylori• Causes 80% of gastric peptic ulcers• Causes 100% of duodenal peptic ulcers• Causes chronic gastritis• Causes gastric carcinomas• Causes MALT lymphomas
![Page 67: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/67.jpg)
“PEPTIC” ULCERS• Gnawing, burning, aching pain, epigastric• Fe deficiency anemia• Acute hemorrhage• Penetration, perforation:–Pain in BACK–Pain in CHEST–Pain in LUQ
•NOT felt to develop into malignancy
![Page 68: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/68.jpg)
“PEPTIC” ULCERS• Bleeding– Occurs in 15% to 20% of patients
– Most frequent complication
– May be life-threatening
– Accounts for 25% of ulcer deaths
– May be the first indication of an ulcer
• Perforation– Occurs in about 5% of patients
– Accounts for two thirds of ulcer deaths
– Rarely, is the first indication of an ulcer
• Obstruction from edema or scarring– Occurs in about 2% of patients
– Most often due to pyloric channel ulcers
– May also occur with duodenal ulcers
– Causes incapacitating, crampy abdominal pain
– Rarely, may lead to total obstruction with intractable vomiting
![Page 69: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/69.jpg)
“ACUTE” ULCERS• NSAIDS• “STRESS” ULCERS–ENDOGENOUS STEROIDS• SHOCK• BURNS• MASSIVE TRAUMA• Intracranial trauma, Intracranial surgery• SEPSIS
–EXOGENOUS STEROIDS• CUSHING ULCER
![Page 70: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/70.jpg)
“ACUTE” ULCERS• Usually small (<1cm), superficial, MULTIPLE
![Page 71: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/71.jpg)
GASTRIC DILATATION• PYLORIC STENOSIS• PERITONITIS ( pyloric stenosis)• 1.5-3.0 liters NORMAL• 10 liters can be present• ACUTE RUPTURE is associated with
a HIGH immediate mortality rate
![Page 72: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/72.jpg)
BEZOARS• PHYTO-bezoar (plant material)• TRICHO-bezoar (hairball)• NON-food material in PSYCH patients– pins– nails– razor blades– coins– gloves– leather wallets
![Page 73: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/73.jpg)
![Page 74: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/74.jpg)
“HYPERTROPHIC”* GASTROPATHY
RUGAL PROMINENCE (cerebriform)NO INFLAMMATIONHYPERPLASIA of MUCOSA
![Page 75: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/75.jpg)
“HYPERTROPHIC” GASTROPATHY• Inaccurate name “hypertrophic gastritis”• Ménétrier disease, resulting from profound hyperplasia
of the surface mucous cells with accompanying glandular atrophy, ass. w. CMV, H. Pylori, ↑TGF-α
• Hypertrophic-hypersecretory gastropathy, associated with hyperplasia of the parietal and chief cells within
gastric glands (normal gastrin)
• Gastric gland hyperplasia secondary to excessive gastrin secretion, in the setting of a gastrinoma (Zollinger-Ellison syndrome)
![Page 76: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/76.jpg)
![Page 77: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/77.jpg)
GASTRIC “VARICES”• SAME SETTING AND ETIOLOGY AS
ESOPHAGEAL VARICES, i.e., PORTAL HYPERTENSION• NOT AS COMMON AS ESOPHAGEAL VARICES• MAY LOOK LIKE PROMINENT RUGAE• IF A PATIENT HAS GASTRIC VARICES, HE ALSO
PROBABLY HAS ESOPHAGEAL, (but probably not vice versa)
![Page 78: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/78.jpg)
GASTRIC TUMORS• BENIGN:
– “POLYPS*” (HYPERPLASTIC vs. ADENOMATOUS)
– LEIOMYOMAS (Same gross and micro as smooth muscle)– LIPOMAS (Same gross and micro as adipose tissue)
• MALIGNANT– (ADENO)-Carcinoma– LYMPHOMA
• POTENTIALLY MALIGNANT– G.I.S.T. (Gastro-Intestinal “Stromal” Tumor)– CARCINOID (NEUROENDOCRINE)
![Page 79: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/79.jpg)
BEBNIBGNB
BENIGN TUMORS
MUCOSA(POLYPS)---HYPERPLASTIC---Fundic---Peutz-Jaeger---Juvenile
---ADENOMATOUS
MUSCLEFAT
![Page 80: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/80.jpg)
BEBNIBGNBMALIG. TUMORS
MUCOSALYMPHS
(MUSCLE)(FAT)
![Page 81: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/81.jpg)
WHO GASTRIC NEOPLASMS• Epithelial Tumors: Adenomatous polyps,
Adenocarcinoma (papillary, tubular, mucinous, signet ring, adenosquamous, unclassified), Small cell, Carcinoid (neuroendocrine)• Nonepithelial Tumors: Leiomyo(sarc)oma,
Schwannoma, GIST, Granular Cell Tumor, Kaposi sarcoma• Malignant Lymphomas:
![Page 82: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/82.jpg)
ADENOCARCINOMA• H. pylori associated, MASSIVELY!!!• Japan, Chile, Costa Rica, Colombia,
China, Portugal, Russia, and Bulgaria• M>>F• Socioeconomically related*
![Page 83: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/83.jpg)
ADENOCARCINOMARISK FACTORS
• H. pylori• H. pylori• H. Pylori• Nitrites, smoked meats, pickled, salted, chili
peppers, socioeconomic, tobacco• Chronic gastritis, Barrett’s, adenomas• Family history
![Page 84: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/84.jpg)
ADENOCARCINOMAGROWTH PATTERNS
![Page 85: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/85.jpg)
ADENOCARCINOMAGROWTH PATTERNS
![Page 86: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/86.jpg)
PAPILLARY
![Page 87: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/87.jpg)
TUBULAR
![Page 88: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/88.jpg)
MUCINOUS
![Page 89: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/89.jpg)
SIGNET RING
![Page 90: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/90.jpg)
ADENOSQUAMOUS
![Page 91: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/91.jpg)
G.I.S.T. TUMORS• Can behave and/or look benign or malignant• Usually look like smooth muscle, i.e., “stroma”, “spindly”• Are usually POSITIVE for
c-KIT (CD117), i.e., express this antigen on immunochemical staining, the tumor cells are derived from the interstitial cells of Cajal, a “neural” type of cell, similar to the neural plexi found in the intestines.
![Page 92: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/92.jpg)
SMALL/LARGE INTESTINE• NORMAL: Anat., Vasc., Mucosa, Endocr., Immune,
Neuromuscular.• PATHOLOGY:
– CONGENITAL– ENTEROCOLITIS: DIARRHEA, INFECTIOUS, OTHER– MALABSORPTION: INTRALUMINAL, CELL SURFACE, INTRACELL.– (I)IBD: CROHN DISEASE and ULCERATIVE COLITIS– VASCULAR: ISCHEMIC, ANGIODYSPLASIA, HEMORRHAGIC– DIVERTICULOSIS/-ITIS– OBSTRUCTION: MECHANICAL, PARALYTIC (ILEUS) (PSEUDO)– TUMORS: BENIGN, MALIGNANT, EPITHELIAL, STROMAL
![Page 93: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/93.jpg)
ANATOMY• SI = 6 meters (100% intraP, except for duodenum), LI = 1.5 meters (50%
retroP)• Mucosa, submucosa, muscularis, serosa/adv.
2πr x L = ?
![Page 94: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/94.jpg)
BLOOD SUPPLY• SI: SMA Jejunal, Ileal• LI: SMA, IMA Ileocolic, R, M, L, colic, Sup. Rect• RECTUM: Superior, Middle, Inferior
• SMA has anastomoses with CELIAC (pancreatoduodenal), IMA (marginal)
![Page 95: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/95.jpg)
MUCOSA• SI: ABSORPTIVE, MUCUS, PANETH (apical granules)– VILLI
• LI: MUCUS, ABSORPTIVE, ENTEROENDOCRINE (basal granules)– CRYPTS (like stomach), NOT villi
![Page 96: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/96.jpg)
![Page 97: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/97.jpg)
ENTEROENDOCRINE• SECRETORY PEPTIDES• Endocrine, Paracrine, Neurocrine• Chemical messengers• Regulate digestive functions• Serotonin, somatostatin, motilin,
cholecystokinin, gastric inhibitory polypeptide, neurotensin, vasoactive inhibitory peptide (VIP), neuropeptides (generic), enteroglucagon
![Page 98: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/98.jpg)
IMMUNE SYSTEM• MALT
• PEYER PATCHES, mucosa, submucosa, 1˚, 2 ˚
• IgGAMDE
![Page 99: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/99.jpg)
NEUROMUSCULAR• AUTONOMIC (VAGUS, Symp.)-----extrinsic• INTRINSIC (gut has it’s own brain)
–Meissner (submucosa)– Auerbach (between circular and longitudinal)
![Page 100: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/100.jpg)
CONGENITAL• DUPLICATION• MALROTATION• OMPHALOCELE• GASTROSCHISIS• ATRESIA/STENOSIS SPECTRUM• MECKEL (terminal ileum, “vitelline” duct)• AGANGLIONIC MEGACOLON
(HIRSCHSPRUNG DISEASE)
![Page 101: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/101.jpg)
![Page 102: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/102.jpg)
ENTEROCOLITIS• DEFINITION of diarrhea: INCREASE in MASS,
FLUIDITY, and/or FREQUENCY• DIARRHEA is merely a SYMPTOM: 1) SECRETORY,
2) OSMOTIC, 3) EXUDATIVE, 4) MALABSORPTION, 5) MOTILITY– INFECTIOUS (Viral, Bacterial, Parasitic)– NECROTIZING
– COLLAGENOUS
– LYMPHOCYTIC
– AIDS
– After BMT
– DRUG INDUCED
– RADIATION
– “SOLITARY” RECTAL ULCER
![Page 103: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/103.jpg)
SECRETORY DIARRHEA• Viral damage to mucosal epithelium• Entero-toxins, bacterial• Tumors secreting GI hormones• Excessive laxatives
![Page 104: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/104.jpg)
OSMOTIC DIARRHEA• Disaccharidase deficiencies• Bowel preps• Antacids, e.g., MgSO4
![Page 105: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/105.jpg)
EXUDATIVE DIARRHEA• BACTERIAL DAMAGE to GI MUCOSA• IBD• TYPHLITIS (immunosuppression
colitis)
![Page 106: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/106.jpg)
MALABSORPTION DIARRHEA• INTRALUMINAL• MUCOSAL CELL SURFACE• MUCOSAL CELL FUNCTION• LYMPHATIC OBSTRUCTION• REDUCED FUNCTIONING BOWEL
SURFACE AREA
![Page 107: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/107.jpg)
MOTILITY DIARRHEA• DECREASED TRANSIT TIME–Reduced gut length–Neural, hyperthyroid, diabetic–Carcinoid syndrome
• INCREASED TRANSIT TIME–Diverticula–Blind loops–Bacterial overgrowth
![Page 108: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/108.jpg)
INFECTIOUS enterocolitis• VIRAL
–Rotavirus (69%), Calciviruses, Norwalk-like, Sapporo-like, Enteric adenoviruses, Astroviruses
• BACTERIAL– E. coli, Salmonella, Shigella, Campylobacter, Yersinia, Vibrio,
Clostridium difficile, Clostridium perfringens, TB– Bacterial “overgrowth”
• PARASITIC– Ascaris, Strongyloides, Necator, Enterobius, Tricuris– Diphyllobothrium, Taenia, Hymenolepsis– Amebiasis (Entamoeba histolytica)– Giardia
![Page 109: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/109.jpg)
VIRAL enterocolitis• Rotavirus most common, by far–Selectively infects and destroys
mature enterocytes in the small intestine–Crypts spared
• Most have a 3-5 day course• Person to person, food, water
![Page 110: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/110.jpg)
BACTERIAL enterocolitis• Ingestion of bacterial toxins– Staph– Vibrio– Clostridium
• Ingestion of bacteria which produce toxins–Montezuma’s revenge (traveller’s diarrhea), E.coli
• Infection by enteroinvasive bacteria– Enteroinvasive E. coli (EIEC)– Shigella– Clostridium difficile
![Page 111: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/111.jpg)
E. coli• Toxin, invasion, many subtypes• Food, water, person-to-person• Usually watery, some hemorrhagic• INFANTS often, in epidemics
![Page 112: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/112.jpg)
SALMONELLAFood, not hemorrhagic
SHIGELLA(person-to-person, invasive,
i.e., often hemorrhagic)
![Page 113: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/113.jpg)
CAMPLYOBACTER• Toxins, Invasion• Food spread
![Page 114: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/114.jpg)
YERSINIA (enterocolitica)• Food• Invasion• LYMPHOID REACTION
![Page 115: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/115.jpg)
VIBRIO cholerae• Water, fish, person-to-person• Cholera epidemics• NO invasion (watery)• ENTEROTOXIN
![Page 116: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/116.jpg)
CLOSTRIDIUM DIFFICILE• CYTOTOXIN (lab test readily available)• NOSOCOMIAL• PSEUDOMEMBRANOUS (ANTIBIOTIC
ASSOCIATED) COLITIS
![Page 117: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/117.jpg)
BACTERIAL OVERGROWTH SYNDROME
• One of the main reasons why “normal” gut flora is NOT usually pathogenic, is because, they are constantly cleared by a NORMAL transit time.
• BLIND LOOPS• DIVERTICULA• OBSTRUCTION• Bowel PARALYSIS
![Page 118: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/118.jpg)
PARASITES• NEMATODES (ROUNDWORMS)–Ascaris, Strongyloides, Hookworms (Necator &
Anklyostoma), Enterobius, Trichuris
• CESTODES (TAPEWORMS)– FISH (DIPHYLLOBOTHRIUM latum)–PORK (TAENIA solium)–DWARF (HYMENOLEPSIS nana)
• PROTOZOANS: AMOEBA (ENTAMOEBA histolytica), Giardia lamblia
![Page 119: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/119.jpg)
ENTAMOEBA HISTOLYTICA
![Page 120: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/120.jpg)
GIARDIA LAMBLIA
![Page 121: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/121.jpg)
MISC. COLITIS (OTHER)• NECROTIZING ENTEROCOLITIS (neonate) (Cause unclear)
• COLLAGENOUS (Cause unclear)• LYMPHOCYTIC (Cause unclear)• AIDS• GVHD after BMT, as in stomach• DRUGS (NSAIDS, etc., etc., etc.)• RADIATION, CHEMO• NEUTROPENIC (TYPHLITIS), (cecal, caecitis)• “DIVERSION” (like overgrowth)• “SOLITARY” RECTAL ULCER (anterior, motor dysfunction)
![Page 122: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/122.jpg)
MALABSORPTION• INTRALUMINAL• BRUSH BORDER (microvilli)• (TRANS)EPITHELIAL• OTHER– REDUCED MUCOSAL AREA: Celiac, Crohns– LYMPHATIC OBSTRUCTION: Lymphoma, TB– INFECTION– IATROGENIC: Surgical
![Page 123: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/123.jpg)
INTRALUMINAL• PANCREATIC• DEFECTIVE/REDUCED BILE• BACTERIAL OVERGROWTH
![Page 124: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/124.jpg)
BRUSH BORDER• DISACCHARIDASE DEFICIENCY• BRUSH BORDER DAMAGE, e.g., by bacteria
![Page 125: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/125.jpg)
(Trans)EPITHELIAL• ABETALIPOPROTEINEMIA• BILE ACID TRANSPORTATION DEFECTS
![Page 126: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/126.jpg)
CELIAC DISEASE• Also called SPRUE• Also called NON-tropical SPRUE• Also called GLUTEN-SENSITIVE ENTEROPATHY– Sensitivity to GLUTEN, a wheat protein, gliadin– Immobilizes T-cells– Also in oat, barley, rye– Progressive mucosal “atrophy”, i.e. villous flattening– Relieved by gluten withdrawal
![Page 127: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/127.jpg)
CELIAC DISEASE
![Page 128: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/128.jpg)
“TROPICAL” SPRUE
• Epidemic forms• NOT related to gluten, cause UN-
known• RECOVERY with antibiotics
![Page 129: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/129.jpg)
WHIPPLE’s DISEASE
• DISTENDED MACROPHAGES in the LAMINA PROPRIA• PAS positive• ROD SHAPED BACILLI
![Page 130: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/130.jpg)
WHIPPLE’s DISEASE
![Page 131: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/131.jpg)
DISACCHARIDASE DEFICIENCY• LACTASE by far MOST COMMON• ACQUIRED, NOT CONGENITAL• LACTOSE GLUCOSE + GALACTOSE • LACTOSE (fermented)XXXXXXXXX• OSMOTIC DIARRHEA
![Page 132: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/132.jpg)
ABETALIPOPROTEINEMIA
• Autosomal recessive• Rare• Inability to make chylomicrons from
FFAs and MONOGLYCERIDES• Infant failure to thrive, diarrhea,
steatorrhea
![Page 133: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/133.jpg)
(I) IBD• CROHN DISEASE (granulomatous colitis)
• ULCERATIVE COLITIS
![Page 134: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/134.jpg)
(I) IBD• COMMON FEATURES–IDIOPATHIC–DEVELOPED COUNTRIES–COLONIC INFLAMMATION–SIMILAR Rx–BOTH have increased CANCER RISK
![Page 135: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/135.jpg)
(I) IBD DIFFERENCES
• CROHN (CD)– TRANSMURAL, THICK WALL
– NOT LIMITED to COLON
– GRANULOMAS
– FISTULAE COMMON
– TERMINAL ILEUM OFTEN
– SKIP AREAS
– “CRYPT” ABSCESSES NOT COMMON
– NO PSEUDOPOLYPS
– MALABSORPTION
• ULCERATIVE (UC)– MUCOSAL, THICK MUCOSA
– LIMITED to COLON
– NO GRANULOMAS
– FISTULAE RARE
– TERMINAL ILEUM NEVER
– NO SKIP AREAS
– “CRYPT” ABSCESSES COMMON
– PSEUDOPOLYPS
– NO MALABSORPTION
![Page 136: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/136.jpg)
CROHN vs. UC
![Page 137: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/137.jpg)
UC or CD?
![Page 138: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/138.jpg)
VASCULAR DISEASES• ISCHEMIA/INFARCTION•ANGIO-”DYSPLASIA”*•HEMORRHOIDS
![Page 139: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/139.jpg)
ISCHEMIA/INFARCTION• HEMORRHAGE is the main HALLMARK of
ischemic bowel disease– ARTERIAL THROMBUS– ARTERIAL EMBOLISM– VENOUS THROMBUS– CHF, SHOCK– INFILTRATIVE, MECHANICAL
MUCOSAL TRANSMURAL
![Page 140: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/140.jpg)
![Page 141: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/141.jpg)
ANGIODYSPLASIA• NOT really “dysplasia”• NOT neoplastic• TWISTED, DILATED SUBMUCOSAL VESSELS, can
rupture!• Common X-ray finding
![Page 142: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/142.jpg)
HEMORRHOIDS• INCREASED INTRABDOMINAL PRESSURE• i.e., VALSALVA• INTERNAL vs. EXTERNAL
![Page 143: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/143.jpg)
DIVERTICULOSIS/-ITIS• FULL THICKNESS BOWEL OUTPOCKETING• Assoc. w.:– INCREASED LUMINAL PRESSURE, ↑transit
time –AGE– LR (decreased liquidity)–Decreased dietary FIBER–Weakening of wall
![Page 144: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/144.jpg)
DIVERTICULOSIS/-IT IS(CLINICAL)
• IMPACTION• INFLAMMATION (“appendicitis” syndrome)• PERFORATION Peritonitis, local, diffuse• BLEED, silently, even fatally• OBSTRUCT
• EXTREMELY EXTREMELY COMMON• NOT assoc. w. neoplasm, but mimic carcinomas
clinically, radiologically, surgically, and grossly!
![Page 145: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/145.jpg)
Formation of colonic diverticuli
• The most commonly known colonic diverticuli are pseudo diverticuli – composed of only mucosa on the luminal side and serosa externally. Why are these called “pseudo” or false?
• Diverticuli resemble hernias of the colonic wall in that they occur @ sites of entry of mucosal arteries as they pass through the muscularis – this represents a weak spot that leads to a diverticulum if the individual generates high colonic intraluminal pressure (low fiber diet)
![Page 146: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/146.jpg)
DIVERTICULOSIS
![Page 147: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/147.jpg)
DIVERTICULITIS
![Page 148: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/148.jpg)
DIVERTICULITIS
![Page 149: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/149.jpg)
OBSTRUCTION• ANATOMY– ADHESIONS (post-surgical)– IMPACTION– HERNIAS– VOLVULUS– INTUSSUSCEPTION– TUMORS– INFLAMMATION, such as IBD (Crohn) or divertics– STRICTURES/ATRESIAS– STONES, FECALITHS, FOREIGN BODIES– CONGENITAL BANDS, MECOMIUM, INPERF. ANUS
![Page 150: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/150.jpg)
OBSTRUCTION
![Page 151: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/151.jpg)
OBSTRUCTION• PHYSIOLOGY– ILEUS, esp. postsurgical– INFARCTION–MOTILITY DISEASES, esp., HIRSCHSPRUNG DISEASE
![Page 152: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/152.jpg)
TUMORS• NON-NEOPLASTIC • EPITHELIAL• MESENCHYMAL (STROMAL)• LYMPHOID• BENIGN• MALIGNANT
![Page 153: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/153.jpg)
![Page 154: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/154.jpg)
POLYPS• ANY mucosal bulging, blebbing, or bump
•HYPERPLASTIC (NON-NEOPLASTIC)
• HAMARTOMATOUS (NON-NEOPLASTIC)
•ADENOMATOUS (TRUE NEOPLASM, and regarded by many as “potentially” PRE-MALIGNANT as well)
• SESSILE vs. PEDUNCULATED• TUBULAR vs. VILLOUS
![Page 155: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/155.jpg)
POLYPS
![Page 156: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/156.jpg)
PEDUNCULATED vs VILLOUS vs SESSILE
![Page 157: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/157.jpg)
BENIGN vs. MALIGNANT• Usual, atypia, pleo-, hyper-, mitoses, etc.• Stalk invasion!!!
![Page 158: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/158.jpg)
HPERPLASTIC POLYP
![Page 159: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/159.jpg)
ADENOMATOUS POLYP (TUBULAR)
![Page 160: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/160.jpg)
ADENOMATOUS POLYP (VILLOUS)
![Page 161: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/161.jpg)
“FAMILIAL” NEOPLASMS• 1) POLYPOSIS (NON-NEOPLASTIC,
hamartomatous)• 2) POLYPOSIS (NEOPLASTIC, i.e.,
cancer risk)• 3) HNPCC: (Hereditary Non
Polyposis Colorectal Cancer)
![Page 162: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/162.jpg)
CANCER GENETICS• Loss of APC gene• Mutation of K-RAS• Loss of SMADs (regulate transcription)
• Loss of p53• Activation of TELOMERASE
![Page 163: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/163.jpg)
CANCER RISK FACTORS
• Family history• Age (rare <50)• LOW fiber, HIGH meat, LONG
transit time, refined carbs
![Page 164: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/164.jpg)
PATHOGENESIS• From existing ADENOMATOUS POLYPS• DE-NOVO
• DYSPLASIAINFILTRATIONMETASTASIS
![Page 165: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/165.jpg)
GROWTH PATTERNS• POLYPOID• ANNULAR, CONSTRICTING• DIFFUSE
![Page 166: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/166.jpg)
![Page 167: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/167.jpg)
PAPILLARY
![Page 168: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/168.jpg)
TUBULAR
![Page 169: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/169.jpg)
MUCINOUS
![Page 170: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/170.jpg)
SIGNET RING
![Page 171: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/171.jpg)
ADENOSQUAMOUS
![Page 172: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/172.jpg)
Tumor Stage Histologic Features of the Neoplasm
Tis Carcinoma in situ (high-grade dysplasia) or intramucosal carcinoma (lamina propria invasion)
T1 Tumor breaches the musc. muc. invades into submucosa
T2 Extending into the muscularis propria but not penetrating through it
T3 Penetrating through the muscularis propria into subserosa
T4 Tumor directly invades other organs or structures
Nx Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in 1 to 3 lymph nodes
N2 Metastasis in 4 or more lymph nodes
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
![Page 173: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/173.jpg)
OTHER TUMORS• CARCINOID, with or without
syndrome• LYMPHOMA (MALTOMAS, B-Cell)• LEIOMYOMA/-SARCOMA• LIPOMA/-SARCOMA
![Page 174: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/174.jpg)
ANAL CANAL CARCINOMAS
• MORE LIKELY TO BE SQUAMOUS, or “basaloid”• WORSE IN PROGNOSIS• HPV RELATED
![Page 175: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/175.jpg)
APPENDIX
![Page 176: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/176.jpg)
ANATOMY• Junction of 3 tenia coli, variable in location• All 4 layers, true serosa• Thickest layer is submucosal lymphoid tissue
• APPENDICITIS (ACUTE)• MUCOCELE• MUCUS CYSTADENOMA• MUCUS CYSTADENOCARCINOMA
![Page 177: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/177.jpg)
ACUTE APPENDICITIS• GENERALLY, a disease of YOUNGER people• OBSTRUCTION by FECALITH the classic cause but
fecaliths present only about half the time• EARLY APPENDICITIS: NEUTROPHILSMucosa,
submucosa
• NEED NEUTROPHILS in the MUSCULARIS to confirm the DIAGNOSIS
• 25% normal rate, usually• Perforationperitonitis the rule, if no surgery
![Page 178: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/178.jpg)
ACUTE APPENDICITIS
![Page 179: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/179.jpg)
![Page 180: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/180.jpg)
Mucus “TUMORS”• Mucocele (common)• Mucinous Cystadenoma (rather rare)• Mucinous Cystadenocarcinoma (rare)
![Page 181: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/181.jpg)
MUCOCELE• COMMON CYST on APPENDIX filled with
MUCIN• Can RUPTURE to become:
PSEUDOMYXOMA PERITONEII (Jelly Belly)
![Page 182: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/182.jpg)
![Page 183: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/183.jpg)
MUCINOUS CYSTADENO(CARCINO)MA
ADENOMA CARCINOMA
![Page 184: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/184.jpg)
PERITONEUM• Visceral, Parietal: all lined by mesothelium• Peritonitis, acute:–Appendicitis, local or with rupture–Peptic ulcer, local or ruptured–Cholecystitis, local or ruptured–Diverticulitis, local or with rupture– Salpingitis gonococcal or chlamydial, retrograde
or perforated–Ruptured bowel due to any reason–Perforating abdominal wall injuries
![Page 185: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/185.jpg)
PERITONITIS• E. coli• STREP• S. aureus• ENTEROCOCCUS
![Page 186: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/186.jpg)
PERITONITIS, outcomes:
•Complete RESOLUTION•Walled off ABSCESS
•ADHESIONS
![Page 187: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/187.jpg)
SCLEROSING RETROPERITONITIS
• Unknown cause (autoimmune?)• Generalized retroperitoneal fibrosis,
progressive hydronephrosis
![Page 188: Minarcik robbins 2013_ch17-gi](https://reader036.vdocuments.net/reader036/viewer/2022062512/554b11e2b4c9056f098b4a7f/html5/thumbnails/188.jpg)
TUMORS• MESOTHELIOMAS (solitary nodules or
diffuse constricting growth pattern, also asbestos caused)
• METASTATIC, usually diffuse, often looking very much like pseudomyxoma peritoneii, but containing tumor cells, usually adenocarcinoma