Practice question answers A stomach pathology
Practice question answers A
Stomach pathology
Stomach pathology
Updated: 03/08/2019
© Jun Wang, MD, PhD
1. A. The patient has acute
onset of symptoms. Biopsy only reveals scattered neutrophilic infiltrate
without any signs of chronic inflammation, such as lymphoplasmacytic infiltrate
and stromal proliferation. This is consistent with acute
gastritis. Autoimmune
gastritis, although as suggestive by anemia found in this patient, has
diffuse lymphoplasmacytic infiltration, intestinal metaplasia and glandular
atrophy. Helicobacter
gastritis has lymphoplasmacytic infiltration, neutrophilic infiltration and
glandular atrophy and helicobacter
identified by special stains. Curling
ulcer occurs in patients with severe burn or trauma. Peptic
ulcer has mucosa ulceration and is usually associated with helicobacter.
2. D. The history of NSAID
usage is probably the cause of her acute
gastritis. NSAID inhibit COX-1 and COX-2, resulting reduced protection of
gastric mucosa. Autoantibody against intrinsic factor is seen in autoimmune
gastritis. Bacterial toxin induced mucosal damage is seen in helicobacter
gastritis. Hyperacidity may be caused by hypergastrinemia, as seen in Zollinger-Ellison
syndrome, and may present as peptic
ulcer. Mucinous gland atrophy is usually a result of chronic gastritis,
including both autoimmune
gastritis and helicobacter
gastritis.
3. C. This patient has
intracranial tumor that was resected, and presents with GI bleeding caused by
gastric ulcers. This is consistent with Cushing
ulcer, defined as esophageal, gastric and duodenal ulcers associated with intracranial disease. Autoimmune
gastritis has diffuse lymphoplasmacytic infiltration, intestinal metaplasia
and glandular atrophy. Curling
ulcer occurs in patients with severe burn or trauma. Extraneural metastatic
of primary brain tumor is rare, and extremely rare to stomach. Peptic
ulcer has mucosa ulceration and is usually associated with helicobacter.
4. E. Helicobacter
gastritis has lymphoplasmacytic infiltration, neutrophilic infiltration and
glandular atrophy and helicobacter
identified by special stains, including silver stain.
Acid fast bacilli, including Mycobacterium tuberculosis, usually cause granulomatous
inflammation. Anti K/H ATPase is seen in autoimmune
gastritis. C-KIT overexpression is seen in gastrointestinal
stromal tumor. Over expression of gastrin is seen in Zollinger-Ellison
syndrome.
5. D. Helicobacter
gastritis has lymphoplasmacytic infiltration, neutrophilic infiltration and
glandular atrophy and helicobacter
identified by special stains. Autoimmune
gastritis has diffuse lymphoplasmacytic infiltration, intestinal metaplasia
and glandular atrophy, in stomach fundus and body, NOT antrum. Dieulafoy
lesion is submucosal vascular abnormality associated with gastric bleeding.
MALToma is a marginal
zone lymphoma characterized by diffuse B lymphocytic infiltrate with light
chain restriction, but not prominent pleomorphism.
6. E. For the major
pathogenic components of helicobacter,
it attaches to epithelium through adhesins. CagA promotes inflammation and
mitogenesis. VacA forms vacuoles and membrane channels and affects mitochondria
functions. Urease hydrolyzes urea into CO2 and ammonia that raising pH for its
own survival. Anemia due to intrinsic factor deficiency and antoantibody
associated epithelial damage is seen in autoimmune
gastritis.
7. C. Helicobacter
gastritis is a risk factor for intestinal
type adenocarcinoma and MALToma,
etc. Diffuse
type adenocarcinoma has no known risk factors. Gastric Hodgkin
lymphoma is extremely rare, and likely not associated with helicobacter.
Metastasis is seen in tumors, not gastritis. Pernicious anemia is associated
with autoimmune
gastritis.
8. B. Autoimmune
gastritis has diffuse lymphoplasmacytic infiltration, intestinal metaplasia
and glandular atrophy, in stomach fundus and body, with antrum spared. Acute
gastritis has neutrophilic infiltration, but not diffuse lymphoplasmacytic
infiltration, intestinal metaplasia and glandular atrophy. Diffuse
large B cell lymphoma has marked cytological atypia. Helicobacter
gastritis has lymphoplasmacytic infiltration, neutrophilic infiltration and
glandular atrophy and helicobacter
identified by special stains. MALToma is a marginal
zone lymphoma characterized by diffuse B lymphocytic infiltrate with light
chain restriction.
9. A. Autoantibody against
K/H ATPase and/or autoantibody against intrinsic factor are seen in autoimmune
gastritis. Autoimmune
gastritis usually has less acid production due to parietal cell damage.
Inhibition of COX-1 and COX-2 is caused by NSAID. CagA promotes inflammation
and mitogenesis. Urease hydrolyzes urea into CO2 and ammonia that raising pH
for its own survival. These two are associated with helicobacter
infection.
10. B. Autoantibody against
K/H ATPase and/or autoantibody against intrinsic factor are seen in autoimmune
gastritis. Antibody against helicobacter is seen in helicobacter
infection. Lack of intrinsic factor is associated with vitamin B12
deficiency, not folate deficiency. Iron and total iron binding capacity
abnormalities are seen in iron deficiency anemia.
11. E. Pernicious anemia
seen in autoimmune
gastritis is associated with vitamin B12 deficiency due to malabsorption,
resulted from lack of intrinsic factor. Bone marrow stem cell failure is seen
in myelodysplastic
syndrome or aplastic anemia. Neoplastic process involving marrow is seen in
either primary hematopoietic neoplasia or metastatic tumor to bone. Both have
other symptoms or relevant history.
12. C. Gastritis with
diffuse eosinophilic infiltrate is eosinophilic
gastritis. Acute
gastritis has neutrophilic infiltration. Autoimmune
gastritis has diffuse lymphoplasmacytic infiltration, intestinal metaplasia
and glandular atrophy, in stomach fundus and body, with antrum spared. Gastric
antral vascular ectasia is characterized by vascular dilation, with or
without thrombosis, and is associated with gastric bleeding. Lymphocytic
gastritis has diffuse lymphocytic infiltration.
13. E. Helicobacter
associated gastric ulcer with sharp edge without cytological atypia is
consistent with peptic
ulcer. Curling
ulcer occurs in patients with severe burn or trauma. Cushing
ulcer is defined as esophageal, gastric and duodenal ulcers associated with
intracranial disease. Diffuse
type adenocarcinoma does not have discrete mass or ulcer, and has signet
ring cells. Intestinal
type adenocarcinoma has discrete mass, and irregular glands lined by
atypical cells.
14. B. Peptic
ulcer has various risk factors. The most important risk factor is
helicobacter. It is rarely associated with hyperacidity, except in the case of
hypergastrinemia caused by Zollinger-Ellison
syndrome. Monoclonal lymphocytic infiltration is seen in lymphomas, usually
with a discrete mass and induration of ulcer edge.
15. E. One of the consequences
for peptic
ulcer is perforation, as seen in this case with acute abdomen, supported by
history of chronic epigastric pain, helicobacter gastritis, and confirmed by
radiologic finding of free intraperitoneal air. Other four condition may have
acute abdomen, but not free intraperitoneal air.
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