Practice question answers A stomach pathology

Practice question answers A
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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