Warthin tumor is a ____ (malignant/benign) cystic

tumor with ____ (germinal/follicular) centers.

A patient presents with a slow-growing mass that is
the most common malignant salivary tumor. What is
it?
A patient has a painless mass in the parotid area.
Histology of the lesion shows mucinous and
squamous components. What do you suspect?
A patient had a salivary gland tumor rupture
intraoperatively, & the tumor recurs a few weeks
later. Type of salivary gland tumor?
A patient has a benign tumor made of heterotopic
salivary gland tissue trapped in a lymph node,
surrounded by lymphatic tissue. Diagnosis?
Salivary gland tumors are generally ____
(benign/malignant) and are located in these
particular salivary glands.
A patient has a painless, moveable salivary gland
mass removed. The tumor is benign, but later recurs.
What type of tumor is it?
Pleomorphic adenomas typically consist of what two
types of connective tissue?
What is another name of the papillary cystadenoma
lymphomatosum?
Achalasia results from the failure of what process to
occur?
In patients with achalasia, the lower esophageal
sphincter cannot relax because of loss of this
innervation.
What is the etymology of the word achalasia?
In a patient with achalasia, what malignancy should
you advise the patient that (s)he is at increased risk
for?
A man travels to South America and contracts this
disease. He later develops secondary achalasia. What
parasitic disease did he contract?
What is the most common presenting symptom of
achalasia?
What is the underlying pathophysiology of
dysphagia associated with CREST?
A patient with numerous allergies and GERD
unresponsive to therapy has an esophageal biopsy.
What is it likely to show?
A man complains of dry cough and chest pain not
associated with activity, worse when supine, and not
relieved by nitroglycerin. Diagnosis?
A man complains of asthma onset in the past few
months and chest pain worse when supine that
frequently wakes him up at night. Diagnosis?
An alcoholic man is brought to the ED copiously
vomiting blood. He does not complain of pain.
Which vessels are likely bleeding?

Benign; germinal

Mucoepidermoid carcinoma
Mucoepidermoid carcinoma, which typically presents as
a painless, slow-growing mass

Pleomorphic adenoma
Warthin tumor (papillary cystadenoma lymphomatosum),
which is a benign cystic tumor with germinal centers

Benign; parotid glands

Pleomorphic adenoma, which is a benign mixed tumor
composed of chondromyxoid stroma and epithelium
Chondromyxoid stroma and epithelium
Warthin tumor
Relaxation of the lower esophageal sphincter

The myenteric (Auerbach) plexus

A = absence of, and chalasia = relaxation

Esophageal squamous cell carcinoma

Chagas disease
Progressive dysphagia to both solids and liquids (vs.
obstruction, which presents as dysphagia to solids only)
Esophageal dysmotility (poor peristalsis) and low
esophageal pressure proximal to the lower esophageal
sphincter
Eosinophilic infiltration (this is eosinophilic esophagitis,
common in patients with atopy)

Gastroesophageal reflux disease

Gastroesophageal reflux disease (lower esophageal
sphincter tone can cause adult-onset asthma, and
nocturnal cough and dyspnea is common)
Submucosal veins in the lower third of the esophagus,
forming varices, which is the result of portal
hypertension (cause painless bleeding)

A 45-year-old woman comes to the ED with

vomiting. Her vomitus becomes bloody and painful.
What is the cause of her hematemesis?
A patient presents with chest pain after severe
vomiting and is found to have substernal crepitus.
What structure has likely ruptured?
Ingestion of what compound classically causes
esophageal strictures?
Esophagitis is commonly associated with what three
etiologies?
Which of these infectious agents is least likely to be
associated with esophagitis: HSV-1,
cytomegalovirus, Candida, H. pylori?
Esophagitis associated with HSV-1 shows ____
ulcers on endoscopy, whereas esophagitis associated
with cytomegalovirus shows ____ ulcers.
Endoscopy is performed on a patient with
esophagitis secondary to Candidainfection. What
gross finding would be expected?
Plummer-Vinson syndrome has a triad of what
symptoms?
A patient with dysphagia has a smooth, swollen,
tender tongue. Lab tests reveal iron deficiency
anemia. What is the most likely diagnosis?
A patient has food allergy that causes dysphagia,
heartburn, and strictures. This allergy is not
responsive to GERD therapy. What is it?
A man has dysphagia. Work-up shows esophageal
smooth muscle atrophy, poor peristalsis, low LES
pressure, reflux, and a stricture. Diagnosis?
What specific malignancy is associated with Barrett
esophagus?
What causes Barrett esophagus?
In patients with Barrett esophagus, there is a
replacement of ____ epithelium with ____
epithelium.
Is Barrett esophagus an example of dysplasia,
hyperplasia, neoplasia, or metaplasia?
Name at least six risk factors associated with
esophageal cancer.
A native of Mexico presents with esophageal cancer.
What type of esophageal cancer is he most likely to
have?
Worldwide, which type of esophageal cancer is most
common?
A patient (native of the United States) presents with
esophageal cancer. What type of esophageal cancer
is he likely to have?
A patient has cancer of the lower third of the
esophagus. What type of cancer is the biopsy likely
to show?
A patient with Hirschsprung disease has progressive

Mallory-Weiss tears, which often result from vomiting

associated with alcoholics and bulimics (cause painful
bleeding)
The esophagus, as seen in Boerhaave (been-heaving)
syndrome
Lye (strictures are also seen with gastroesophageal reflux
disease)
Reflux, infection, or chemical ingestion

H. pylori

Punched-out; linear

White pseudomembranes
Dysphagia due to esophageal webs, iron deficiency
anemia, and glossitis (Plumbers dig)

Plummer-Vinson syndrome

Eosinophilic esophagitis
Sclerodermal esophageal dysmotility (part of CREST
syndrome)
Adenocarcinoma (Barrett
= becomes adenocarcinoma, results from reflux)
Chronic acid reflux resulting in glandular metaplasia

Nonkeratinized squamous; intestinal (columnar)

Metaplasia
Achalasia, alcohol, Barrett esophagus, cigarettes,
diverticula, esophageal web, familial, fat, GERD, hot
liquids
Squamous cell carcinoma is the most common
esophageal cancer worldwide
Esophageal squamous cell carcinoma
Esophageal adenocarcinoma is more common than
squamous cell esophageal cancers in the United States

Esophageal adenocarcinoma
Esophageal cancer

dysphagia and other symptoms of achalasia.What

type of cancer is he at high risk for?
A patient with a history of Barrett esophagus has
dysphagia for solids and liquids and weight loss.
What is the likely diagnosis?
An alcoholic with a Zenker diverticulum has
dysphagia with hot liquids. What type of esophageal
cancer is he at high risk for?
An obese patient with a history of Barrett esophagus
and GERD presents with esophageal cancer. What
type of cancer is he at high risk for?
A smoker presents with progressive dysphagia and
weight loss in the past few months. What is his likely
diagnosis?
Squamous cell carcinoma is most common in which
section(s) of the esophagus?
___ (Acute/Chronic) gastritis is erosive, whereas
____ (acute/chronic) gastritis is nonerosive.
A patient w/rheumatoid arthritis and adherent to his
medication has nausea and abdominal pain. What
type of gastritis are you considering?
Name some causes of acute gastritis.
A patient has severe burns and develops this
complication of acute gastritis.
Cushing ulcers refer to a complication of acute
gastritis arising after ____.
In a patient with type A (fundal) gastritis, the
autoantibodies are directed to what?
Type A (fundal) gastritis is characterized by what
two pathologic states?
Type B (antral) gastritis is caused by infection with
what organism?
Type ____ gastritis is autoimmune related, whereas
type ____ gastritis is caused by infectious diseases
(e.g., H. pylori).
____ (Acute/Subacute/Chronic) gastritis carries an
increased risk of gastric carcinoma.
Chronic gastritis carries an increased risk of what
kind of gastric carcinoma(s)?
A patient on chronic NSAID therapy complains of
stomach pain and is found to be anemic. What is the
likely diagnosis and pathophysiology?
By what mechanism do severe burns cause acute
gastritis?

How can brain injury cause acute gastritis?

A woman with Graves disease is anemic with a high
MCV despite taking iron daily. She has frequent
abdominal pain. Likely diagnosis?
In acute gastritis, there is disruption of what type of
barrier?

Esophageal adenocarcinoma

Esophageal squamous cell cancer

Esophageal adenocarcinoma
Esophageal squamous cell cancer or esophageal
adenocarcinoma
Upper two thirds
Acute; chronic

Acute gastritis (the patient is likely taking NSAIDs daily)

NSAIDs, alcohol, stress, uricemia, burns, brain injury
Curling ulcer (burned by the curling iron)
Brain injury (remember, for Cushing ulcers,
always cushion the brain)
Parietal cells
Type A is caused by pernicious anemia and achlorhydria
(A comes before Bpernicious anemia is autoimmune
in first part of stomach)
Type B is caused by Helicobacter pylori (A comes
before BH. pylori bacteria in second part of stomach)

A; B
Chronic
Mucosa-associated lymphoid tissue (MALT) lymphoma
and gastric adenocarcinoma
Erosive gastritis; NSAIDs reduce prostaglandin E2,
causing erosive gastritis, which causes occult blood loss
and mild anemia
Curling ulcers are caused by a decrease in plasma
volume, leading to a sloughing of gastric mucosa
Cushing ulcers are caused by increased vagal stimulation,
which increases acetylcholine and, in turn, acid
production by parietal cells
Chronic type A gastritis, characterized by pernicious
anemia, which is associated with other autoimmune
disorders (in this case, Graves)
Disruption of mucosal barrier

What type of gastritis is an alcoholic most at risk

for?
Where does type A chronic gastritis occur? Where
does type B occur?
A patient has Mntrier disease. What will you find
on endoscopy?
What is the most common histologic subtype of
stomach cancer?
Where are intestinal stomach cancers most
commonly located in the stomach: lesser curvature,
greater curvature, fundus, or cardiac region?
What organ often is the first to be affected by the
metastases of stomach cancer?

Name at least three risk factors for stomach cancer.

What is meant when stomach cancer is termed linitis
plastica?
A 65-year-old man has a growing periumbilical mass
and lower gastrointestinal discomfort. What are
metastases of the umbilicus known as?
A woman has ovarian cancer with abundant mucus
& signet ring cells. She is told this is a metastasis.
What is the primary site?
A patient presents with dark leathery patches on the
nape of his neck and in the axillae. What two things
should you suspect?
What is the histologic appearance of the Krukenberg
tumor?
What is the Sister Mary Joseph nodule, and where is
it located?
A patient presents with 2 months of fatigue, weight
loss, and new bumps above the collarbone. What
diagnosis do you suspect?
Peptic ulcer disease affects what two regions of the
gastrointestinal tract?
A patient has significant weight loss and abdominal
pain after eating. Endoscopy shows ulcers. What
kind of ulcers are they likely to be?
What etiologic factor is associated with 70% of
gastric ulcers?
A patient on NSAIDs for back pain presents with
abdominal pain exacerbated by meals. What is the
most likely cause of his abdominal pain?
What is the pathophysiology of gastric ulcers?
Does the pain associated with duodenal ulcers
increase, decrease, or remain the same with food?
Which type of peptic ulcer disease puts the patient at
a higher risk of developing a carcinoma?
This bacterium is almost always implicated in
duodenal ulcers.

Acute gastritis
Fundus/body; antrum
Gastric hypertrophy with protein loss, parietal cell
atrophy, increased mucous cells (stomach rugae can look
like brain gyri)
Adenocarcinoma

Lesser curvature
The liver
Nitrosamines (from smoked foods), achlorhydria, chronic
gastritis, smoking, type A blood, H. pylori (the intestinal
kind)
Diffuse infiltrative cancer makes the stomach rigid

Sister Mary Joseph nodules

Stomach
These patches are likely acanthosis nigricans, which
suggest insulin resistance or stomach cancer
Metastatic gastric adenocarcinoma often has mucus-filled
cells termed signet ring cells
It is a metastasis of gastric cancer located in the
subcutaneous periumbilical area
Metastasis from stomach cancer, as suggested by the
supraclavicular nodes (also called Virchow nodes)
The stomach (gastric ulcers) and the duodenum
(duodenal ulcers)
Gastric ulcers, which generally increase in pain after
meals (gastric ulcer pain is greater with meals)
Helicobacter pylori infection

Chronic use of NSAIDs leading to gastric ulcers

Decreased mucosal production leading to destruction of
tissue by gastric acid due to decreased protection
Decrease (duodenal ulcer pain is decreased with food)
Gastric ulcer
Helicobacter pylori

Patients with duodenal ulcers tend to have

hypertrophy of these glands.
A man with stomach pain is found on endoscopy to
have a lesion with irregular, raised margins. Is this
more likely an ulcer or a malignancy?
In a patient with Zollinger-Ellison syndrome, what
type of ulcer is the patient at risk for?
An elderly patient who takes high-dose NSAIDs is
likely to at increased risk for what type of ulcer?
What is the pathology of duodenal ulcers?
This type of gastrointestinal ulcer is more likely to
be associated with weight gain.
A patient has a ruptured gastric ulcer on the lesser
curvature. What artery is most likely to cause
hemorrhage due to bleeding?
Where do perforations from ulcers typically take
place?
Ulcer hemorrhages are likely to occur ____
(anteriorly/posteriorly); ulcer perforations are likely
to occur ____ (anteriorly/posteriorly).
A patient has a ruptured duodenal ulcer on the
posterior wall of the duodenum. What artery is most
likely causing the hemorrhage?
A patient has diarrhea, steatorrhea, weight loss,
weakness, and vitamin/mineral deficiencies; she
likely suffers from what type of illness?
You diagnose a 4-month-old child with
abetalipoproteinemia after intestinal biopsy. What
did you see?
Celiac sprue primarily affects what part(s) of the
bowel?
Tropical sprue can be treated with which class of
drugs?
Which section(s) of the gastrointestinal tract can be
affected by tropical sprue?
PAS-positive macrophages are classically found in
what malabsorptive condition?
An 80-year-old man presents with Whipple disease.
The Gram stain of the causative organism would
show what?
A patient with Whipple disease has PAS-positive
macrophages. Where are such cells located?
What nongastrointestinal symptoms are commonly
associated with Whipple disease?
What is the most common disaccharidase
deficiency?
A patient with lactase deficiency undergoes an
intestinal biopsy. Describe the expected appearance
of the villi.
A patient with lactase deficiency ingests a dairycontaining meal and develops diarrhea. Explain the

Brunner glands
Malignancy (carcinoma)peptic ulcers have clean
margins and a punched-out appearance
Duodenal ulcer (Zollinger-Ellison syndrome is associated
with increased gastric secretions, resulting in ulcer
formation)
Gastric ulcer
Decrease in mucosal protection or increase in gastric acid
secretion
Duodenal ulcer (the pain associated with duodenal ulcers
decreases with meals, thereby resulting in weight gain)

Left gastric artery

The duodenum

Posteriorly; anteriorly

Gastroduodenal artery

A malabsorption syndrome
Lipid accumulation within the intestinal enterocytes due
to the inability to export absorbed lipids as chylomicrons
Distal duodenum and/or proximal jejunum
Antibiotics
The entire small bowel
Whipple disease

Gram-positive rods (Tropheryma whipplei)

Intestinal lamina propria and mesenteric nodes
Cardiac symptoms, arthralgias, neurologic symptoms
(these symptoms occur mostly in older men)
Lactase deficiency
Normal (as opposed to celiac disease in which villi are
blunted)
The inability to cleave lactose causes an osmotic diarrhea

pathophysiology of her diarrhea.

A patient with lactase deficiency undergoes a lactose
tolerance test. Following the administration of
lactose, what do you expect to see?
A 15-year-old patient with chronic respiratory
infections due to Pseudomonashas fatty stools. What
is the most likely etiology?
A chronic alcoholic refuses to stop drinking. He is
finally diagnosed with chronic pancreatitis. What do
you expect to see on stool sample?
A patient is diagnosed with ampullary cancer. What
do you expect to see on stool sample?
Pancreatic insufficiency causes the malabsorption of
which macronutrient(s)?
What is the pathophysiology of
abetalipoproteinemia?
A 3-year-old child has failure to thrive and
neurologic symptoms, and is unable to generate
chylomicrons because of this defect.
An 70-year-old man with arthralgias, cardiac and
neurologic symptoms comes in with foamy
macrophages. What does this patient have?
A patient with pancreatic insufficiency is given the
D-xylose absorption test. What would you observe?
A patient is said to have autoimmune damage to the
small bowel caused by gluten sensitivity. What
illness is described?
A 3-year-old child has voluminous diarrhea and
diffuse rash on extensor surfaces that a change in
diet resolves. What is the skin diagnosis?
In a patient with celiac sprue, what malignancy
would the patient be at increased risk for?
A patient with diarrhea that occurs on a wheatcontaining diet undergoes colonoscopy. What
histologic findings are expected?
What serum test is used to screen for celiac sprue?
A patient is found to have gluten insensitivity. What
is the pathophysiology of his disease?
A patient has anti-endomysial, anti-tissue
transglutaminase, and anti-gliadin antibodies. What
serotypes are associated with this syndrome?
A man returns from the Bahamas with complaints of
diarrhea and decreased mucosal absorption. Will this
patient respond to antibiotics?

Name the six malabsorption syndromes.

A child develops greasy stool and failure to gain

Osmotic diarrhea and a rise in blood glucose <20 mg/dL

Pancreatic insufficiency as a result of cystic fibrosis

Fat in stool (chronic pancreatitis leads to pancreatic
insufficiency, fat malabsorption, steatorrhea, and findings
of fat in stool)
Obstructive cancers of the pancreatic head lead to
pancreatic insufficiency and result in increased neutral fat
in the stool (steatorrhea)
Fat and the fat-soluble vitamins (A, D, E, K)
Decreased apolipoprotein B limits generation of
chylomicrons, causing enterocytic fat, and less
cholesterol and VLDL in the blood
Abetalipoproteinemia (decreased synthesis of
apolipoprotein B results in an inability to generate
chylomicrons)

Whipple disease (remember foamy whipped cream)

Normal urinary excretion (if decreased excretion is seen,
then the pathology is due to intestinal mucosa defects or
bacterial overgrowth)

Celiac sprue

Dermatitis herpetiformis associated with celiac disease

T-cell lymphomas
Blunting of villi and the presence of lymphocytes in the
lamina propria
Serum levels of anti-tissue transglutaminase antibodies
are used for screening
Antibodies destroy villi (primarily distal duodenum and
proximal jejunum), thereby decreasing mucosal
absorption and causing diarrhea

HLA-DQ2, HLA-DQ8
The patient has tropical sprue and will respond to
antibiotics
Tropical sprue, Whipple, celiac
sprue, diasaccharides, abetalipoproteinemia, &pancreatic
(these will cause devastating absorption problems)
Gluten (gliadin), suggesting celiac sprue

weight after the addition of wheat to her diet. She

has autoantibodies to what substance?
What is generally accepted as the etiology of Crohn
disease?
A malnourished 20-year-old man has pyoderma
gangrenosum, crypt abscesses on biopsy, and bloody
diarrhea. What do you give for treatment?
A 20-year-old patient has recurrent diarrhea that is
sometimes bloody, weight loss, oral ulcers, and
perianal fistulas. Likely diagnosis?
Involvement of what part of the gastrointestinal tract
favors a diagnosis of ulcerative colitis over Crohn
disease?
What type of inflammatory bowel disease tends to
show skip lesions (noncontiguous areas of mucosal
involvement)?
A patient has a continuous segment of friable colonic
mucosa that abruptly stops in the mid-transverse
colon. What is the likely diagnosis?
A patient has Crohn disease. What cell mediates the
formation of noncaseating granulomas and lymphoid
aggregates on microscopy?
What is the histologic appearance of ulcerative
colitis?
Is perianal disease mainly a complication of Crohn
disease, ulcerative colitis, or both?
Is malabsorption mainly a complication of Crohn
disease, ulcerative colitis, or both?
Is toxic megacolon mainly a complication of Crohn
disease, ulcerative colitis, or both?
Are strictures mainly a complication of Crohn
disease, ulcerative colitis, or both?
What are the extraintestinal manifestations of Crohn
disease?
A patient suffering from primary sclerosing
cholangitis is likely tocarry a also diagnosis of which
inflammatory bowel disease?
How does mucosal and submucosal inflammation
with pseudopolyps and freely hanging mesentery in
ulcerative colitis appear on imaging?

Name some treatments for ulcerative colitis.

Name some medical treatments for Crohn disease.
Describe the gross morphology typically found in
Crohn disease.
Describe the gross morphology typically found in
ulcerative colitis.
Name at least two complications of ulcerative colitis.

Disordered response to intestinal bacteria

ASA preparations (sulfasalazine), 6-mercaptopurine,
infliximab, or colectomy (diagnosis is ulcerative colitis)

Crohn disease

Rectum

Crohn disease
Ulcerative colitis, which typically has colonic
inflammation always involving the rectum

Th1 cell
Microscopy shows crypt abscesses and ulcers, bleeding,
no granulomas (Th1mediated)
Crohn disease
Crohn disease (ulcerative colitis affects only the colon
and thus does not cause malabsorption)
Ulcerative colitis
Crohn disease (strictures can lead to obstruction and
require multiple resections of small bowel)
Migratory polyarthritis, erythema nodosum, pyoderma
gangrenosum, ankylosing spondylitis, aphthous ulcers,
uveitis, kidney stones

Ulcerative colitis

The loss of haustra leads to lead-pipe appearance

Sulfasalazine, 6-mercaptopurine, infliximab, colectomy
(colectomy is a last measure when medical management
fails)
Corticosteroids, azathioprine, methotrexate, infliximab,
adalimumab
Cobblestone mucosa, creeping fat, bowel wall thickening
(string sign), linear ulcers, fissures, fistulas, transmural
Inflammation
Mucosal and submucosal inflammation. friable mucosa
with freely hanging mesentery (loss of haustra causes
lead-pipe appearance on imaging)
Malnutrition, primary sclerosing cholangitis, toxic

Name at least two extraintestinal manifestations of

ulcerative colitis
Ulcerative colitis is associated with being ____
(autoimmune/infectious).
Irritable bowel syndrome is diagnosed if at least two
of these three criteria are met.

What is the treatment for irritable bowel syndrome?

A middle-aged woman has recurrent abdominal pain
that improves with defection and changes in stool
frequency. Are the symptoms chronic?
On colonoscopy, what is the most common finding
of a patient with irritable bowel syndrome?
A 30-year old man presents with fever and peritonitis
& with positive obturator and Rovsing signs. What
caused these signs?
A patient has belly pain migrating to one third of the
distance between the umbilicus and anterior superior
iliac spine. Diagnosis?
A boy has 2 days of fever, vomiting, and severe
abdominal pain. On exam, RLQ is tender, and WBC
count is 21,000/mm. What is the treatment?
In children, what causes appendicitis?
A 21-year-old woman presents with diffuse
periumbilical pain and nausea. Other than
appendicitis, what condition should be ruled out?
What other physical examination signs will be
observed if the patient has appendicitis?
In elderly patients, what condition must be included
in the differential diagnosis of acute abdominal pain
in addition to appendicitis?
What is a diverticulum?
What is the difference between a true diverticulum
and a false diverticulum?
Diverticula are found most often in what segment of
the gastrointestinal tract?
What is the etiology of diverticulosis?
A patient is concerned about her likelihood of
developing diverticulosis. What dietary change do
you suggest?
A patient presents with vague abdominal discomfort
and painless rectal bleeding. What is the most likely
diagnosis?
A patient has similar symptoms to appendicitis, but

megacolon, colorectal carcinoma (worse with right-sided

colitis or pancolitis)
Pyoderma gangrenosum, erythema nodosum, primary
sclerosing cholangitis, ankylosing spondylitis, aphthous
ulcers, uveitis
Autoimmune
Recurrent abdominal pain associated with pain improved
with defecation, change in stool frequency, change in
appearance of stool
Since the symptoms fluctuate, it is important to reassess
the patient's chief complaint and treat the current
symptoms
Yes (the patient likely has irritable bowel syndrome,
which has chronic symptoms)
Normal mucosa (irritable bowel syndrome is not
associated with structural abnormalities and is therefore a
diagnosis of exclusion)

Appendicitis in adults is due to obstruction by fecalith

Appendicitis (the painful spot is the McBurney point)

Surgery (appendectomy)
Obstruction by lymphoid hyperplasia
Ectopic pregnanc(ruled out by a -human chorionic
gonadotropin test)
Psoas, obturator, McBurney and Rovsing signs

Diverticulitis
A blind pouch leading off of the alimentary tract that
communicates with the lumen of the tract
True diverticulum contains three layers (mucosa,
submucosa, serosa), whereas false diverticulum contains
only two layers (mucosa, submucosa)
The sigmoid colon
Increased intraluminal pressure combined with focal
weakness of the colonic wall

Increase the amount of dietary fiber

Diverticulosis
Diverticulitis

instead has the pain on the left side. What is highest

on your differential?
List the four most common potential complications
of diverticulitis.
A patient with medically managed diverticulitis
develops pneumaturia on day 4 of hospitalization.
What complication has likely occurred?
What is the mainstay of treatment for diverticulitis?
A patient's vasa recta perforate the muscularis
externa. What is this clinically diagnosed as?
An 80-year-old woman has vague GI discomfort and
hematochezia, along with many people her age. She
will most likely have what diagnosis?
Diverticulitis classically causes pain in what region
of the abdomen?

What is a Zenker diverticulum?

What age and gender group is Zenker diverticulum
most common in?
A patient presents with halitosis and decreased oral
intake due to discomfort on swallowing. What is the
most likely diagnosis?
Is Zenker diverticulum a true or false diverticulum?
What is the most common congenital anomaly of the
gastrointestinal tract?
Bleeding, RLQ pain, obstruction, intussusception,
and volvulus are all potential complications of this
congenital anomaly.
Approximately what size is a typical Meckel
diverticulum?
A patient with a Meckel diverticulum has significant
pain. What is most likely to be causing it?
In approximately what percentage of the population
can Meckel diverticula be found?

When in life do Meckel diverticula typically present?

If you suspect a patient has Meckel diverticulum,
what tests or imaging do you need to diagnose?
How far are Meckel diverticula typically located
from the ileocecal valve?
What are the etiologies of intussusception in adults
and children?
A 3-year-old presents with currant-jelly stools and
abdominal pain. Where in the GI tract is the likely
location of this condition?
Is intussusception found more commonly in adults or
infants?

Perforation, peritonitis, abscess formation, and bowel

stenosis

Colovesical fistula
Antibiotics, although surgery may be required
Pseudodiverticulum, or false diverticulum

Diverticulosis
The left lower quadrant
Herniation of mucosal tissue at Killian triangle between
the thyropharyngeal/cricopharyngeal parts of the inferior
pharyngeal constrictor
Elderly men

Zenker diverticulum
False diverticulum (it contains only the mucosa and
submucosa; true diverticulum involves all three layers)
Meckel diverticulum

Meckel diverticulum
2 inches (the five 2's: 2 inches long, 2 feet from ileocecal
valve, 2% of population, first 2 years of life, 2 epithelial
types)
Gastric acid secretion from ectopic tissue growth (gastric
and/or pancreatic)
2% (the five 2's: 2 inches long, 2 feet from ileocecal
valve, 2% of population, first 2 years of life, 2 epithelial
types)
First 2 years (the five 2's: 2 inches long, 2 feet from
ileocecal valve, 2% of population, first 2 years of
life, 2 epithelial types)
Pertechnetate study for uptake by ectopic gastric mucosa
2 feet (the five 2's: 2 inches long, 2 feet from ileocecal
valve, 2% of population, first 2 years of life, 2 epithelial
types)
Adults = intraluminal mass or tumor, and children =
mostly idiopathic, possibly viral

The ileocecal junction (this is intussusception)

Infants

What is intussusception?
An infant has twisting of a portion of the bowels
around its mesentery. Where is this twisting likely
taking place?
An elderly patient has twisting of a portion of the
bowels around its mesentery. Where is this twisting
likely taking place?
Why does volvulus have a predilection for the
midgut and sigmoid colon?
In a patient with Hirschsprung disease, where is the
dilated segment of the colon relative to the
aganglionic segment?
What would the biopsy of a patient with
Hirschsprung disease likely demonstrate?
At birth, a baby presents with an aganglionic
segment of the colon, causing him to not pass
meconium. What disease does this baby have?
Hirschsprung disease results from the failure of what
process?
Colonoscopy is performed on a newborn with
Hirschsprung disease. What will be found proximal
to the diseased segment of bowel?
A 2-year-old child does not pass meconium. Anal
manometry shows increased resting tone. Genetic
testing is abnormal. Likely karyotype?
A newborn has bilious emesis and failure to pass
meconium in 48 hours. What is the treatment for this
disease? How is it diagnosed?
A newborn with Hirschsprung disease is likely to
have mutations in what gene?

How does Hirschsprung disease typically present?

Where does ischemic colitis commonly occur?

Ischemic colitis typically affects ____
(neonates/children/adults/the elderly).
What is a common complaint of patients with
ischemic colitis?
Adhesions cause ____ (acute/chronic) bowel
obstruction and occur most commonly as a result of
____.
What test can confirm a diagnosis of angiodysplasia?
Where is angiodysplasia typically found in the
gastrointestinal tract?
A 70-year-old man complains of bright-red blood per
rectum. Angiography shows tortuous dilation of
vessels at the bleeding site. Diagnosis?
A patient with angiodysplasia will typically
complain of what symptom(s)?
Is angiodysplasia more common in children, young

Telescoping of a bowel segment into a distal segment

Midgut

Sigmoid
Volvulus tends to occur in locations with redundant
mesentery, such as these two locations

Proximal
Lack of ganglionic cells (Auerbach and Meissner
plexuses) that allow relaxation of the affected bowel

Hirschsprung disease
Neural crest cell migration
A transition zone or dilated portion of bowel proximal to
the diseased (aganglionic) segment

Trisomy 21 (leading to Hirschsprung disease)

Treated with resection; diagnosed by rectal suction
biopsy
RET gene
Inability to pass meconium after birth or chronic
constipation in a child, bilateral emesis, abdominal
distention
The splenic flexure (it is a watershed area between the
SMA and IMA circulation and, therefore, has tenuous
blood flow) and distal colon
The elderly
Pain after eating (increased metabolic demand in
intestine and inability to appropriately increase blood
flow leads to an ischemic state)

Acute; abdominal surgery

Angiography
Cecum, terminal ileum, ascending colon

Angiodysplasia
Hematochezia due to bleeding from tortuous dilation of
vessels(patients can also complain of abdominal pain)
The elderly

adults, or the elderly?

A 48-year-old man with many past abdominal
surgeries has a distended abdomen with decreased
bowel sounds.What does this patient likely have?
An opiate abuser complains of increased
constipation and decreased flatus. On CT, no
obstructions are noted. What does he have?
What medical conditions are associated with ileus?
A recent abdominal surgery patient complains of
stomach pain. You believe it is a small bowel
obstruction. What is the likely cause?
A newborn with bilious vomiting since birth has a
distended abdomen. What is the likely diagnosis?
Duodenal atresia is associated with what sign on xray?
Duodenal atresia is due to the failure of ____ of
small bowel during development.
A newborn presents with early bilious vomiting and
double-bubble on x-ray. What chromosomal
abnormality is most associated with his disease?
A newborn fails to pass meconium. Rectal exam and
manometry are normal. His older brother died of
pneumonia. What is the diagnosis?
Which patients are most at risk for necrotizing
enterocolitis?
A premature infant develops feeding intolerance; he
has a distended abdomen and pneumatosis on x-ray.
He has no bilious vomiting. Diagnosis?
An 80-year-old man with coronary artery disease
presents with 6 months of weight loss due to pain
after eating. What do you suspect?
The more ____ (villous/sessile/tubular/hyperplastic)
the colonic polyp, the more likely that it is
malignant.
Where in the colon are polyps most commonly
found?
A child with rectal discomfort has a single rectal
juvenile polyp on colonoscopy. He is otherwise well.
Should be polyp be urgently removed?
What cancer is a child at increased risk for if he has
multiple juvenile polyps in the gastrointestinal tract?
A patient with GI tract hamartomas and dark patches
around his mouth and palms asks if his daughter will
be affected by this disorder.
Of the two pathologies, which is more likely to be
benign: tubular adenomas or villous adenomas?
A patient has multiple GI tract hamartomas and
hyperpigmented hands, mouth, lips, and genitalia.
What is the inheritance pattern?
A patient informs you that she had colonic polyps
before. What symptoms do you expect her to
complain about if the polyps have returned?
The malignancy risk of adenomatous polyps is not

Ileus or intestinal hypomotility without obstruction

Ileus
Hypokalemia and sepsis

Adhesions
Duodenal atresia
Double-bubble sign
Recanalization
Trisomy 21 (Down syndrome)this newborn likely has
duodenal atresia, which is associated with this
chromosomal abnormality
Meconium ileus due to cystic fibrosis, which runs in
families and is associated with pneumonia due to
inability to clear mucous secretions
Premature neonates because of their decreased immunity

Necrotizing enterocolitis

Ischemic colitis

Villous (villous = villainous)

Rectum and sigmoid colon
No; there is no malignant potential if it is truly the only
juvenile polyp
Adenocarcinoma
Probability is 50% (this patient has Peutz-Jeghers
syndrome, an autosomal dominant disorder)
Tubular adenomas
Autosomal dominant; the patient has Peutz-Jeghers
syndrome
Nothing (most polyps are asymptomaticwhen they
become symptomatic, patients have lower GI bleeding,
partial obstruction, diarrhea, pain
Body mass index

associated with ____ (degree of dysplasia/villous

histology/size/body mass index).
What type of polyp is a precursor to colorectal
cancer?
What is the most common non-neoplastic polyp, and
where is it most commonly found?
What is the ranking of colorectal cancer among the
most common cancers?
Colon cancers on the left side tend to ____; colon
cancers on the right side tend to ____.
Name at least three risk factors for colorectal cancer.
At what age is screening for colorectal cancer (CRC)
typically initiated?
How do you screen for colorectal cancer?
A patient with past history of colorectal cancer is
constantly monitored for recurrence. What
nonspecific serum tumor marker is used?
What is the inheritance pattern for familial
adenomatous polyposis?
Familial adenomatous polyposis involves mutation
of the ____ gene on chromosome ____. This disease
follows the ____ hypothesis.
You are going to perform a colonoscopy on a patient
with familial adenomatous polyposis. What do you
expect to find?
A patient is found to have thousands of polyps on
colonoscopy; he has a history of bone and soft tissue
tumors. What syndrome is suspected?
A patient has a family history of familial
adenomatous polyposis. He also presents with a
malignant CNS tumor. What do you suspect?
Hereditary nonpolyposis colon cancer, or Lynch
syndrome, involves mutations of DNA ____ genes.
Hereditary nonpolyposis colon cancer always
involves what part of the colon? What is the chance
that cancer will develop in one's lifetime?
A patient has fever, low blood pressure, and new
murmur. Blood cultures grow Streptococcus bovis.
What do you suspect?
A male patient with iron-deficiency anemia is
concerned about colon cancer risk. Should he be
concerned? Who else would be concerned?
A patient has an Alzheimer mutation of APC gene on
chromosome 5q. He asks about his risk for colorectal
cancer. What do you tell him?
Put in order from most common to least common
where colorectal cancer will present: descending &
ascending colon, rectosigmoid junction
A man is worried about colon cancer. He wants a

Adenomatous polyp
Hyperplastic; rectosigmoid colon
Third most common (and third most deadly cancer in the
U.S0most patients are older than 50 years of age) &
family history in about 25%
Obstruct; bleed
Irritable bowel disease, tobacco use, villous adenomas,
juvenile polyposis syndrome, Peutz-Jeghers syndrome
Age 50 years, or 10 years before an immediate family
member was diagnosed with CRC (if mother had CRC at
55, screen patient at 45)
Colonoscopy or stool occult blood testing

Carcinoembryonic antigen (CEA)

Autosomal dominant (patients inherit one faulty copy of
the gene and lose the other through an acquired mutation
[two-hit hypothesis])

APC; 5q; two-hit

Thousands of polyps (pancolonic involvement, always
involving the rectum)

Gardner syndrome
Turcot syndrome (= FAP + malignant CNS tumor)
Turcot = turban)
Mismatch repair

Proximal colon; 80% chance

Although rare, colorectal cancer can be associated
with Streptococcus bovisbacteremia (this patient needs a
colonoscopy when he is stable)
Yes; postmenopausal women are also at risk for colon
cancer
The patient has familial adenomatous polyposis
syndrome, & there is 100% progression to CRC if the
colon is not removed
Rectosigmoid junction, ascending colon, descending
colon
CEA levels cannot be used for screeningthey can be

screening CEA level drawn, because he is ""scared

of colonoscopies."" What do you tell him?
A patient is diagnosed with right-sided colon cancer.
What type of symptoms would you observe in this
patient to reach your diagnosis?
What are the two major molecular pathways that
lead to colorectal cancer? What is the incidence of
each?
In the microsatellite instability pathway, what type of
mutation is responsible for carcinogenesis in colonic
epithelium?
Loss of function of which gene leads to decreased
intracellular adhesion and increased proliferation in
the colonic epithelium?
The KRAS gene mutation leads to dysregulation of
what cellular function?
APC gene mutations lead to dysregulation of what
cellular function?
Loss of function of which tumor suppressor genes is
often the last step in malignant transformation of
colonic epithelial cells?
What molecular pathway is most commonly used to
generate sporadic colorectal cancer?
What three gene mutations must generally occur for
colorectal cancer to develop? In what order do they
occur?
What are the morphologic correlates for the
microsatellite instability pathway? Is there an
associated syndrome?
Both ____ and ____ gene mutations must be present
for colonic adenoma formation. The ____ gene
mutation simply puts the colon at risk.

used only to monitor for recurrence in previously

diagnosed patients

Dull pain, iron-deficiency anemia, fatigue, weight loss

The microsatellite instability (about15%) and APC/catenin (chromosomal instability, about 85%) pathways
DNA mismatch repair gene mutations, which accumulate
(they occur sporadically or are defective in hereditary
nonpolyposis colorectal cancer)

APC
Signal transduction (the cell will respond abnormally to
growth factors, contributing to tumorigenesis)
Intercellular adhesion (there is decreased intercellular
adhesion and increased proliferation)

p53, DCC
APC/-catenin (chromosomal instability) pathway
In order, they are loss of APC, loss of K-RAS, and loss
ofp53 and DCC (AK-53)
There are none, despite the accumulation of mutations;
yes (HNPCC)

APC; KRAS; APC