PATHOPHYSIOLOGY THE RESPIRATORY SYSTEM

Clinical Examination for Diagnosis Auscultation Chest X-ray Respiratory function tests CT or MRI scan Mediastinoscopy Bone scan Liver ultrasound Complete Blood Work Diseases and Disorders of the Respiratory System

Chapter 8

Reference: Damjanovs Pathology for the Health-Related Professions Chapter 8 pages 174-207

Overview of Major Diseases The respiratory tract may be affected by numerous diseases, the most important of which are Infectious diseases Immune diseases Environmentally induced diseases Circulatory diseases Tumors Factors Important to Understanding Respiratory System Pathology 1. The respiratory system is open-ended and in direct contact with the environment. As a result, upper respiratory infections (URIs) are extremely common and occur from infancy to old age. 2. The respiratory system is exposed to many allergens inhaled in air. 3. Inhaled air contains pollutants, airborne particles, and gases, which cause diseases. 4. The heart and the lungs form a functional unit. 5. Inhaled air contains many potential carcinogens Congenital Diseases Tracheoesophageal fistula Diagnosed shortly after birth when it becomes evident that milk that is swallowed into the esophagus enters the trachea and is aspirated into the lungs. The defect can be surgically repaired but the operation is delicate and has considerable mortality. Infectious Diseases Upper Respiratory Infections (URIs) The flu or common cold is most often caused by influenza virus, parainfluenza virus, and rhinovirus. As other acute viral diseases, URIs are short-lived, heal spontaneously, and do not benefit from treatment with antibiotics.

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Pneumonia Inflammation and infection of the lungs, may be bacterial (75%) or viral, or less commonly, by fungi, protozoa or parasites. Bacteria that may cause pneumonia are Streptococcus pneumoniae Haemophilus influenzae Staphylococcus aureus Mycobacterium tuberculosis Pathogenesis how do the pathogens reach the lungs? Inhalation of pathogens in air droplets (Tuberculosis) Aspiration of infected secretions from the upper respiratory tract (strept or staph) Aspiration of infected particles in gastric contents, food, or drinks (unconscious, alcoholics, drug addicts) Hematogenous spread (the blood transports bacteria from urinary tract infection (UTI) or contaminated needles of drug users Complications of Bacterial Pneumonia Pleuritis Empyema Pleuritis is an extension of inflammation to the pleural surface leading to pleural effusion with pus pockets called empyema. Abscess A localized, destructive collection of pus (dead white blood cells, bacteria, tissue debris and protein from the immune response to bacteria such as staphylococci, Klebsiella and Pseudomonas) Chronic Lung Disease A complication of pneumonia that is unresponsive to treatment, lung tissue is destroyed as fibrosis turns the into honeycomb-like structures. Symptoms of Pneumonia 1. Systemic signs of infection High fever, chills, prostration 2. Local signs of irritation Bronchial inflammation and secreting mucous causes coughing and expectoration 3. Airway obstruction Impaired gas exchange results in shortness of breath(dyspnea) and rapid breathing (tachypnea) 4. Inflammation and tissue destruction Inflammatory exudate (sputum) causes tissue destruction and bleeding Pulmonary Tuberculosis A chronic bacterial infectious disease caused by M. tuberculosis, a rod-shaped acidfast bacillus with waxy capsule
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Symptoms of Primary Pulmonary Tuberculosis Clinically unrecognized in more than 95% of the cases 1. mild pulmonary disease 2. low grade fever Symptoms of Secondary Pulmonary Tuberculosis 1. non-productive (dry) cough 2. low-grade fever 3. loss of appetite 4. malaise 5. night sweats 6. weight loss Diagnosis and Treatment Acid-fast stain test Chest x-ray Tuberculin skin test (not absolute proof) Antibiotics, unless a drug-resistant strain Immunosuppressed AIDS patients do not respond to treatment Fungal Diseases Histoplasmosis and Coccidiodomycosis infections resemble tuberculosis, are acquired by inhaling dried out fungi and their spores in desert dust Hospital-acquired fungal infections common among terminally ill cancer or AIDS patients are Candida albicans and Aspergillus fumigatus Chronic Obstructive Pulmonary Disease (COPD) A catch-all clinical term used for lung diseases characterized by chronic airway obstruction. Two groups are: 1. Chronic Bronchitis Excessive production of tracheobronchial mucous causing cough and expectoration for at least 3 months during 2 consecutive years. Smoking is the cause of chronic bronchitis in more than 90% of the cases Other causes include air pollution and occupational exposure to toxic fumes Permanent dilatation of the bronchi is called Bronchiectasis, a common complication of chronic bronchitis. Mucopurulent material stagnates in the dilated bronchioles cannot be cleared by coughing, and infection spreads. 2. Emphysema A tobacco-induced disease affecting chronic cigarette smokers that involves enlargement of the air spaces. Clinical Features of COPD see Figure 8-14 Patients are divided into two prototypes: 1. Blue bloaters, or those with predominant bronchitis, have coughing episodes producing hypoxia. Right ventricular failure marked by venous stagnation contributes to cyanosis (blue palor).
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2. Pink puffers, or those with predominant emphysema, have no bronchial obstructions and no irritation that would force them to cough or expectorate. Because of reduced respiratory surface, they have compensatory tachypnea. The chest is overexpanded (barrel shaped) and hunch over to use muscles when hyperventilating to oxygenate the blood. Immune Diseases Numerous immune disorders include Allergic rhinitis (hay fever) reaction of nasal mucosa to allergens Bronchial asthma reaction of bronhical tree to allergens or other stimuli Sarcoidosis granulomatous disease of cell-mediated immunity Hypersensitivity pneumonitis immune disorder from inhaled foreign antigens such as moldy hay, fungi, sugar cane, maple bark, mushrooms, pigeon droppings, animal pelts Adult Respiratory Distress Syndrome (ARDS) A clinical term used to describe changes that occur in the lungs under a variety of conditions causing acute respiratory failure. Lungs are damaged, become heavy, filled with fluid, and are airless Common Causes of ARDS: Shock: Trauma, burns, or acute cardiac failure Bacterial or viral pneumonia Toxic lung injury due to toxic fumes, cytotoxic drugs, bacterial endotoxins Aspiration of fluids (near-drowning) Atelectasis Incomplete expansion or collapse of alveoli Causes of atelectasis: Deficiency of surfactant (premature neonates) Compression of the lungs from the outside (fluid in pleural cavity) Resorption of air distal to bronchial obstruction(tumor,mucous plug, foreign matl) Neoplasms of the Respiratory Tract 1. Carcinoma of the Larynx 2. Lung Carcinoma 3. Metastatic Cancer Pleural Diseases Pneumothorax Hemothorax Pleural Effusion Hydrothorax Pleuritis Empyema

entry of air into the pleural cavity hemorrhage into the pleural cavity accumulation of fluid in pleural cavity inflammation/exudate due to pneumonia

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THE GASTROINTESTINAL SYSTEM

Chapter 10

Reference: Damjanovs Pathology for the Health-Related Professions Chapter 10 pages 244-273

Clinical Examination for Diagnosis CT and MRI scan Radiology - x-ray, contrast Endoscopy Blood Work, liver function Fecal occult blood analysis Overview of Major Diseases Most important diseases of the upper and lower gastrointestinal tract are Dental caries and gum disease Infectious gastroenteritis Circulatory disorders and hemorrhagic lesions Peptic ulcer and inflammatory bowel disease Obstructive disorders such as hernias and ileus Functional disorders (maldigestion, malabsorption) Neoplasms Factors Important to Understanding Gastrointestinal Pathology 1. The function of the normal gastrointestinal tract depends on the normal development of anatomic structures and the functional differentiation of their components. 2. The gastrointestinal tract is open-ended and thus is readily accessible to bacteria and other pathogens and allergens. 3. The intestinal mucosa is an interface and a barrier between the external and internal milieu that requires energy to be maintained actively. 4. The gastrointestinal tract is a tube that can dilate or become obstructed. 5. Gastrointestinal diseases may disturb one or more of the basic functions of the gastrointestinal tract. 6. The movement of the intestines depends on the autonomic contraction of smooth muscles, which is under neural and hormonal control. 7. Abundant blood flow through the gastrointestinal tract and the superficial location of the blood vessels in the mucosa make it prone to hemorrhage or ischemia. 8. The gastrointestinal tract is an important source of enzymes, hormones, and biologically active polypeptides. 9. The gastrointestinal tract is exposed to environmental carcinogens in food.

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Diseases of the Oral Cavity Dental caries Tooth enamel eroded by bacterial infection, may extend to root canal Periodontal Disease Massive inflammation of gums and loosening of tooth ligaments due to colonization of pockets of bacteria Stomatitis Inflammation of the mouth commonly caused by Herpesvirus Thrush (C. albicans stomatitis) Canker sores (Aphthous stomatitis) Oral Cancer Lips, tongue, soft palate, anywhere in mouth Complication of smoking, chronic alcoholism Males predominate 10:1 with lip carcinoma Salivary Gland Diseases Sialaneitis inflammation of salivary glands (example: viral infection called mumps) Neoplasms usually benign Diseases of the Esophagus Typical Symptoms Dysphagia Esophageal pain Aspiration and regurgitation of food and liquids Developmental Abnormalities Atresia (lack of lumen) Esophageotracheal fistula Esophagitis Infection Reflux of gastric juice (peptic esophagitis) Exogenous irritants, chemicals and drugs Hiatal Hernia Most common cause of reflux esophagitis Displacement of cardiac portion of stomach into thoracic cavity through diaphragm Motility Disorders of the Esophagus Spasm, dilation, inability to swallow food Circulatory Disturbances Esophageal varices caused by cirrhosis of the liver
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Carcinoma of the Esophagus Geographic differences possible carcinogens in soil in China, Iran. South Africa Racial differences 3x more common in blacks than whites in U.S. Sex differences male to female ratio is 4:1 in U.S. Correlation with tobacco and alcohol abuse Diseases of the Stomach and Duodenum Typical Symptoms of Gastric Diseases Pain Vomiting Bleeding Dyspepsia Systemic consequences Developmental Abnormalities Congenital stenosis (narrowing) of the pylorus Projectile vomiting absent of bile Gastritis Acute or chronic Shallow mucosal defects called erosions if superficial, ulcers if deep Peptic Ulcer Ulcer caused by peptic juice, usually found in stomach or duodenum Hyperacidity of gastric juice Rapid emptying of the stomach overburdening the duodenum Stressful lifestyle Smoking Chronic intake of aspirin, NSAIDS Gastric Neoplasms Benign polyps may progress to carcinoma Carcinoma of the Stomach Carcinoma of the stomach affects 25,000 Americans and causes 14,000 deaths yearly Possibly caused by nitrosamines in food additives Diseases of the Small Intestine and Large Intestine Developmental Abnormalities Atresia of the intestine Hirschsprungs disease Meckels diverticulum complete absence / obstruction of lumen ganglion cells not developed -rectum and sigmoid colon remains in permanent spasm, preventing passage of feces outpouching of small intestine, may become infected

Deiverticula Outpouchings of intestinal wall, mostly sigmoid colon May be solitary, multiple, congenital or acquired

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Intestinal Vascular Diseases Hemorrhoids or Piles varicosities of the anal and perianal region Vascular lesions Ischemic bowel disease (infarction) Thrombosis of mesenteric arteries Inflammatory Bowel Disease (IBD) Recurrent inflammation of the bowel and a chronic, unpredictable course Crohns Disease chronic inflammation involves terminal ileum and colon Ulcerative Colitis inflammation of unknown etiology involving the large intestine Gastrointestinal Infection Cause Small Intestine Bacteria Escherichia coli Vibrio cholerae Viruses rotavirus Parasites Giardia lamblia

large Intestine Escherichia coli shigella sp. Norwalk virus Entamoeba histolytica

Acute Appendicitis see figure 10-12 page 263 Bacterial infection requiring prompt surgical intervention Gangrenous (necrotic) Peritonitis (ruptured) Pain at McBurneys point (RLQ) Peritonitis Bacterial invasion secondary to Ruptured ulcer or appendix Infection of fallopian tubes Ruptured abscess Infection of pre-existing ascites (alcoholic cirrhosis) Sterile peritonitis due to Spill of pancreatic enzymes due to acute pancreatitis Rupture of gallbladder (bile) Talc or chemicals induced to form adhesions Intestinal Obstruction Ileus Adynamic Obstructive

neuromuscular paralysis gallstones, fecaliths, inspissated meconium, abdominal adhesions, hernia, intussusception, volvulus

Hernia see figure 10-13 Inguinal Femoral Periumbilical Diaphragmatic (Hiatal)

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Intussusception Volvulus Malabsorption Abnormalities involving Intraluminal digestion of food (enzyme inbalances) Uptake and processing of nutrients o Celiac sprue hypersensitivity to dietary grain o Tropical sprue bacteria present in tropics o Crohns disease chronic inflammation o Whipples disease bacterium Transportation of nutrients to liver (lymphoma, congestive heart failure) Intestinal Neoplasms One of the 3 most common malignant diseases (lung, breast) 190,000 new cases each year in the U.S. Benign tumors outnumber the malignant 2 to 3, but may progress to cancer May be categorized as 1. Non-Neoplastic Polyps (benign) 2. Neoplastic Polyps (premalignant) 3. Colorectal Adenocarcinoma Rectal cancer is twice as common in men as women 50% of intestinal cancers develop in rectosigmoid area are staged by Dukes as A=85% 5-year survival, B= 55%, C=30% , D=10% CEA Adenocarcinomas release a glycoprotein called CEA. Elevated CEA level tests are useful in follow-up patients whose cancer has been resected.

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