Osmosis High-Yield Notes Gastrointestinal Pathology PDF

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NOTES BILIARY TRACT DISEASES GENERALLY, WHAT ARE THEY? PATHOLOGY & CAUSES ƒ Diverse spectrum of diseases affecting biliary system (gallbladder, bile ducts, liver) ƒ Bile stored in gallbladder ĺ stasis/chemical constituents change ĺ precipitate to solid stone ĺ travel down biliary tract ĺ obstruction ĺ decreased bile drainage ĺ symptoms

SIGNS & SYMPTOMS ƒ Symptoms vary, based on location Ɠ ¡îĿŠɈŏîƭŠēĿČĚɈĿŠIJĚČƥĿūŠɈĿŠǷîƥūƑNj response, sepsis ƒ Right upper quadrant (RUQ) epigastric pain ƒ Jaundice ƒ Nausea, vomiting ƒ Fever, chills ĺ sepsis

Magnetic resonance cholangiopancreatography (MRCP) ƒ MRI for detailed images of hepatobiliary, pancreatic systems Endoscopic retrograde cholangiopancreatography (ERCP) ƒ Down esophagus, stomach, duodenum, ducts ĺ contrast medium injected into ducts ĺ X-ray shows narrow areas/ blockages Ɠ Complications: pancreatitis (most common); intraluminal/intraductal bleeding, hematomas; perforation; infection (cholangitis, cholecystitis); cardiopulmonary complications (cardiac arrhythmia, hypoxemia, aspiration)

LAB RESULTS ƒ See table

TREATMENT DIAGNOSIS DIAGNOSTIC IMAGING

MEDICATIONS ƒ Antibiotics

CT scan/ultrasound ƒ Locations of stones, gallbladder wall ƥĺĿČŒĚŠĿŠijɓĿŠǷîƥĿūŠ

SURGERY

X-ray ƒ Pigmented gallbladder stones (radiopaque)

OTHER INTERVENTIONS

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ƒ Cholecystectomy

ƒ Sepsis management, biliary drainage, ERCP

Chapter 28 Biliary Tract Diseases

ASCENDING CHOLANGITIS osms.it/ascending-cholangitis PATHOLOGY & CAUSES ƒ Acute infection of bile duct caused by intestinal bacteria ascending from duodenum ƒ Bacterial infection of bile duct superimposed on obstruction of biliary tree; due to choledocholithiasis ƒ Gallstones form in gallbladder ĺ slip out ĺ travel through cystic bile duct, lodge in common bile duct ĺ obstruction of ŠūƑŞîŕċĿŕĚǷūDžĺ bacteria ascend from duodenum to bile duct ĺ infect stagnant bile, surrounding tissue

ƒ Common bacteria: E. coli, Klebsiella, Enterobacter, Enterococcus ƒ Medical emergency

RISK FACTORS ƒ Gallstones (most common) ƒ Stenosis of bile duct due to neoplasm/injury from laparoscopic procedure

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COMPLICATIONS

LAB RESULTS

ƒ Sepsis, septic shock Ɠ High pressure on bile duct ĺ obstruction ĺ cells lining ducts widen ĺ bacteria, bile enter bloodstream ƒ Multiorgan failure

ƒ Assess infection, jaundice Ɠ Increased WBC Ɠ Increased serum C-reactive protein (CRP) Ɠ Elevated LFTs: ALP, GGT, ALT, AST

SIGNS & SYMPTOMS ƒ Charcot’s triad Ɠ RUQ pain, jaundice, fever/chills ƒ Reynold’s pentad Ɠ Charcot’s triad + hypotension/shock, altered consciousness Ɠ ƙƙūČĿîƥĚēDžĿƥĺƙĿijŠĿǶČîŠƥŞūƑċĿēĿƥNjɈ mortality

DIAGNOSIS DIAGNOSTIC IMAGING Ultrasound, ERCP ƒ Biliary dilation ƒ Bile duct wall thickening ƒ Evidence of etiology (stricture/stone/stent)

TREATMENT MEDICATIONS ƒ ŠƥĿċĿūƥĿČƙʋT×ǷƭĿēƙ

SURGERY ƒ Cholecystectomy Ɠ Avoid future complications

OTHER INTERVENTIONS ƒ ERCP Ɠ Removes gallstones ƒ Shockwave lithotripsy Ɠ High frequency sound waves break down stone ƒ Stent Ɠ Widen bile ducts in areas of stricture

Figure 28.1 The pathophysiology of ascending cholangitis.

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Chapter 28 Biliary Tract Diseases

BILIARY COLIC osms.it/biliary-colic PATHOLOGY & CAUSES ƒ AKA “gallbladder attack” ƒ Gallstones lodged in bile ducts ĺ temporary severe abdominal pain ƒ After meal, gallbladder contracts ĺ gallstone ejected into cystic duct, lodged ĺ gallbladder contracts against lodged stone ĺ severe abdominal pain ƒ Pain subsides when gallstone dislodged

SIGNS & SYMPTOMS ƒ Pain Ɠ Severe right upper quandrant pain; radiates to right shoulder/shoulder blades Ɠ Intensity increases for 15 minutes, plateaus for few hours (< six), subsides Ɠ Starts hours after meal/at night/laying Ƿîƥ ƒ Nausea, vomiting, anorexia

CAUSES ƒ ƒ ƒ ƒ ƒ

Gallstones Narrow bile duct Pancreatitis Duodenitis Esophageal spasms

RISK FACTORS ƒ More common in individuals who are biologically female ƒ Obesity ƒ Pregnancy ƒ ijĚʓȅȁ

COMPLICATIONS ƒ Acute cholecystitis Ɠ TŠǷîƥĿūŠūIJijîŕŕċŕîēēĚƑDžîŕŕ Ɠ Gallstone doesn’t dislodge from cystic duct

DIAGNOSIS ƒ Recurrent symptoms

DIAGNOSTIC IMAGING Ultrasound ƒ ūŠǶƑŞîƥĿūŠūIJūċƙƥƑƭČƥĿūŠ X-ray, CT scan, MRI

TREATMENT SURGERY ƒ Cholecystectomy Ɠ Gallbladder removal Ɠ 'ĚǶŠĿƥĿDŽĚ

OTHER INTERVENTIONS ƒ Pain, symptom management

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CHOLECYSTITIS (ACUTE) osms.it/acute-cholecystitis PATHOLOGY & CAUSES ƒ Stone lodged in cystic duct/common bile duct ĺ îČƭƥĚĿŠǷîƥĿūŠ ĺ pain Ɠ ȊȁʣūIJîČƭƥĚČĺūŕĚČNjƙƥĿƥĿƙƑĚƙūŕDŽĚƙ within month as stone dislodges ƒ Fatty meal ĺ small intestine cholecystokinin (CCK) signals gallbladder to secrete bile ĺ gallbladder contracts ĺ stone lodged in cystic duct ĺ blocks ċĿŕĚǷūDžĺ irritates mucosa ĺ mucosa ƙĚČƑĚƥĚƙŞƭČƭƙɈĿŠǷîƥūƑNjĚŠǕNjŞĚƙĺ ĿŠǷîƥĿūŠɈēĿƙƥĚŠƥĿūŠɈƎƑĚƙƙƭƑĚ ƒ Cholesterol stones Ɠ More potent ability to stimulate ĿŠǷîƥĿūŠČūŞƎîƑĚēƥūƎĿijŞĚŠƥ gallstones ƒ Possible progressions Ɠ Stone ejected out of cystic duct ĺ cholecystitis subsides, symptoms subside Ɠ Stone remains in place ĺ pressure builds ĺ pushes down on blood vessels supplying gallbladder ĺ ischemia ĺ gangrenous cell death ĺ gallbladder walls weaken ĺ perforation/rupture ĺ bacteria seeds to bloodstream ĺ sepsis ĺ medical emergency Ɠ Stone lodged in common bile duct ĺ ċŕūČŒƙǷūDžūIJċĿŕĚūƭƥūIJŕĿDŽĚƑ ƒ Bacterial growth (cholangitis) Ɠ Cholelithiasis ĺ stone descends to cystic duct ĺ cholecystitis ĺ stone descends from cystic duct, lodges in common bile duct ĺ choledolithiasis ĺ secondary infection due to obstruction ĺ cholangitis Ɠ Most commonly E. coli, Enterococci, Bacterioides fragilis, Clostridium

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Acalculous cholecystitis ƒ ČƭƥĚĿŠǷîƥĿūŠūIJijîŕŕċŕîēēĚƑDžĿƥĺūƭƥ gallstones/cystic duct obstruction; high morbidity, mortality rate ƒ ȆɝȂȁʣūIJîČƭƥĚČĺūŕĚČNjƙƥĿƥĿƙČîƙĚƙ ƒ ¤îƑĚɈēĿIJǶČƭŕƥƥūēĿîijŠūƙĚ ƒ Multifactorial etiology ƒ Often occurs in critically ill individuals/ following major surgery ƒ Pathogenesis Ɠ Gallbladder ischemia, reperfusion injury Ɠ Bacterial invasion of ischemic tissue

COMPLICATIONS ƒ Biliary peritonitis (from rupture) ƒ Gallbladder ischemia ĺ rupture ĺ sepsis ƒ Acalculous cholecystitis

Figure 28.2 A CT scan in the coronal plane demonstrating a thickened, oedematous gallbladder, indicative of acute cholecystitis.

Chapter 28 Biliary Tract Diseases

SIGNS & SYMPTOMS ƒ Midepigastric pain ĺ dull right upper quadrant pain radiates to right scapula/ shoulders (esp. after a meal in chronic cholecystitis) ƒ Hypoactive bowel sounds; nausea, vomiting, anorexia; jaundice; low grade fever ƒ Blumberg’s sign/rebound tenderness Ɠ RUQ pain when pressure rapidly released from abdomen; peritonitis (secondary to gallbladder perforation/ rupture) ƒ Positive Murphy’s sign Ɠ Sudden cessation of inhalation due to ƎîĿŠDžĺĚŠĿŠǷîŞĚēijîŕŕċŕîēēĚƑƑĚîČĺĚƙ ĚNJîŞĿŠĚƑɫƙǶŠijĚƑƙ Ɠ Examiner asks individual to exhale ĺ places hand below right costal margin in midclavicular line ĺ individual instructed to breathe in ĺ cessation due to pain Ɠ Differentiates cholecystitis from other causes of right upper quadrant pain

Diffusion-weighted MRI ƒ Differentiate between acute, chronic cholecystitis Ultrasound ƒ Gallstones/sludge Ɠ Gallbladder wall thickening, distention Ɠ Air in gallbladder wall (gangrenous cholecystitis) Ɠ ¡ĚƑĿČĺūŕĚČNjƙƥĿČǷƭĿēIJƑūŞƎĚƑIJūƑîƥĿūŠɓ exudate

LAB RESULTS ƒ Elevated ALP Ɠ Concentrated in liver, bile ducts Ɠ Bile backs up, pressure in ducts increase ĺ cells damaged, die ĺ ALP released ƒ Elevated leukocyte count

TREATMENT MEDICATIONS ƒ Antimicrobials

SURGERY ƒ Cholecystectomy

DIAGNOSIS DIAGNOSTIC IMAGING Cholescintigraphy/hepatic iminodiacetic acid (HIDA) scan ƒ Radioactive tracer injected into individual ĺ marked HIDA taken up by hepatocytes, excreted in bile ĺ drains down hepatic ducts ƒ Location of blockage

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CHOLECYSTITIS (CHRONIC) osms.it/chronic-cholecystitis PATHOLOGY & CAUSES ƒ Obstruction of cystic duct (not infection) ĺ ĿŠǷîƥĿūŠūIJijîŕŕċŕîēēĚƑDžîŕŕ ƒ ūŠƙƥîŠƥƙƥîƥĚūIJĿŠǷîƥĿūŠēƭĚƥū gallstones repeatedly blocking ducts Ɠ Changes gallbladder mucosa ĺ deep grooves (Rokatansky–Aschoff sinus) Ɠ Pain esp. after meal; gallbladder attempts to secrete bile to small intestine for digestion ƒ Fatty meal ĺ small intestine cholecystokinin (CCK) signals gallbladder to secrete bile ĺ gallbladder contracts ĺ stone lodged in cystic duct ĺ blocks ċĿŕĚǷūDžĺ irritates mucosa ĺ mucosa ƙĚČƑĚƥĚƙŞƭČƭƙɈĿŠǷîƥūƑNjĚŠǕNjŞĚƙĺ ĿŠǷîƥĿūŠɈēĿƙƥĚŠƥĿūŠɈƎƑĚƙƙƭƑĚ ƒ Cholesterol stones Ɠ More potent ability to stimulate ĿŠǷîƥĿūŠČūŞƎîƑĚēƥūƎĿijŞĚŠƥ gallstones ƒ Possible progressions Ɠ Stone ejected out of cystic duct ĺ cholecystitis subsides, symptoms subside Ɠ Stone remains in place ĺ pressure builds ĺ pushes down on blood vessels supplying gallbladder ĺ ischemia ĺ gangrenous cell death ĺ gallbladder walls weaken ĺ perforation/rupture ĺ bacteria seeds to bloodstream ĺ sepsis ĺ medical emergency Ɠ Stone lodged in common bile duct ĺ ċŕūČŒƙǷūDžūIJċĿŕĚūƭƥūIJŕĿDŽĚƑ ƒ Bacterial growth (cholangitis) Ɠ Cholelithiasis ĺ stone descends to cystic duct ĺ cholecystitis ĺ stone descends from cystic duct, lodges in common bile duct ĺ choledolithiasis ĺ secondary infection due to obstruction ĺ cholangitis Ɠ Most commonly E. coli, Enterococci, Bacterioides fragilis, Clostridium

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COMPLICATIONS ƒ Biliary peritonitis (from rupture) ƒ Gallbladder ischemia ĺ rupture ĺ sepsis ƒ Porcelain gallbladder (chronic cholecystitis) Ɠ ĺƑūŠĿČƙƥîƥĚūIJĿŠǷîƥĿūŠĺ ĚƎĿƥĺĚŕĿîŕǶċƑūƙĿƙɈČîŕČĿǶČîƥĿūŠ Ɠ Bluish discoloration of gallbladder; becomes hard, brittle Ɠ Bile stasis ĺ calcium carbonate bile salts to precipitate out ĺ deposit into walls Ɠ Increased risk of gallbladder cancer ƒ Acalculous cholecystitis

SIGNS & SYMPTOMS ƒ Midepigastric pain ĺ dull right upper quadrant pain radiates to right scapula/ shoulders (esp. after a meal in chronic cholecystitis) ƒ Hypoactive bowel sounds; nausea, vomiting, anorexia; jaundice; low grade fever ƒ Blumberg’s sign/rebound tenderness Ɠ Right upper quadrant pain when pressure rapidly released from abdomen; peritonitis (secondary to gallbladder perforation/rupture) ƒ Positive Murphy’s sign Ɠ Sudden cessation of inhalation due to ƎîĿŠDžĺĚŠĿŠǷîŞĚēijîŕŕċŕîēēĚƑƑĚîČĺĚƙ ĚNJîŞĿŠĚƑɫƙǶŠijĚƑƙ Ɠ Examiner asks individual to exhale ĺ places hand below right costal margin in midclavicular line ĺ individual instructed to breathe in ĺ cessation due to pain Ɠ Differentiates cholecystitis from other causes of right upper quadrant pain

Chapter 28 Biliary Tract Diseases

DIAGNOSIS DIAGNOSTIC IMAGING Cholescintigraphy/hepatic iminodiacetic acid (HIDA) scan ƒ Radioactive tracer injected into individual ĺ marked HIDA taken up by hepatocytes, excreted in bile ĺ drains down hepatic ducts ƒ Location of blockage Diffusion-weighted MRI ƒ Differentiate between acute, chronic cholecystitis Ultrasound ƒ Gallstones/sludge Ɠ Gallbladder wall thickening, distention Ɠ Air in gallbladder wall (gangrenous cholecystitis) Ɠ ¡ĚƑĿČĺūŕĚČNjƙƥĿČǷƭĿēIJƑūŞƎĚƑIJūƑîƥĿūŠɓ exudate

Figure 28.3 Endoscopic retrograde cholangiopancreatography demonstrating gallstones in the cystic duct.

LAB RESULTS ƒ Elevated ALP: concentrated in liver, bile ducts Ɠ Bile backs up, pressure in ducts increase ĺ cells damaged, die ĺ ALP released ƒ Elevated leukocyte count

TREATMENT MEDICATIONS

Figure 28.4 Histological appearance of cholestasis in the liver. There is build up of bile pigment in the hepatic parenchyma.

ƒ Antimicrobials

SURGERY ƒ Cholecystectomy

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Chapter 28 Biliary Tract Diseases

GALLSTONE osms.it/gallstone PATHOLOGY & CAUSES ƒ Solid stones inside gallbladder composed of bile components ƒ Form based on imbalance of chemical constituents ĺ precipitate out to form solid stone

TYPES ƒ

îƥĚijūƑĿǕĚēċNjŕūČîƥĿūŠ (choledocholithiasis, cholelithiasis) or major composition (cholesterol, bilirubin stones)

Choledocholithiasis ƒ Gallstones in common bile duct ĺ ūċƙƥƑƭČƥĿūŠūIJūƭƥǷūDžƥƑîČƥ Ɠ Stasis, infection (primary cause) Ɠ Affects liver function; may cause liver damage Cholelithiasis ƒ Gallstones in gallbladder Ɠ Primary cause: imbalance of bile components Ɠ ĿŕĚǷūDžūƭƥūIJŕĿDŽĚƑŠūƥūċƙƥƑƭČƥĚēɒŕĿDŽĚƑ function not affected Cholesterol stones ƒ qūƙƥČūŞŞūŠɈȉȁʣ ƒ Composed primarily of cholesterol ƒ Cholesterol precipitation out of bile: supersaturation; inadequate salts/acids/ phospholipids; gallbladder stasis ƒ Radiolucent (not visible on X-ray) Bilirubin stones (pigmented stones) ƒ Composed primarily of unconjugated bilirubin Ɠ Formed from nonbacterial, ŠūŠĚŠǕNjŞîƥĿČĺNjēƑūŕNjƙĿƙūIJČūŠŏƭijîƥĚē bilirubin ƒ Occurs when too much bilirubin in bile ƒ Combines with calcium ĺ solid calcium bilirubinate

Figure 28.5 Cholesterol gallstones.

ƒ Radiopaque (visible on X-ray) ƒ Can be caused by excessive extravascular hemolysis Ɠ Extravascular hemolysis ĺ macrophages consume RBCs ĺ increased unconjugated bilirubin production ĺ too much unconjugated bilirubin for liver to conjugate ĺ unconjugated bilirubin binds to calcium instead of bile salts ĺ precipitate out to form black pigmented stones ƒ Brown pigmented gallstone: gallbladder/ biliary tract infection Ɠ Stones enter common bile duct Ɠ Brown pigment due to unconjugated/ hydrolyzed bilirubin, phospholipids: infectious organism brings hydrolytic ĚŠǕNjŞĚƙĺ hydrolysis of conjugated bilirubin, phospholipids ĺ combine with calcium ions ĺ precipitate out to form stones Ɠ Common infections: E. coli, Ascaris lumbricoides, Clonorchis sinensis (trematode endemic to China, Korea, Vietnam) Ɠ Commonly seen in Asian populations

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RISK FACTORS ƒ More common in individuals who are biologically female, who use oral contraceptive Ɠ Ĺ estrogen ĺĹ cholesterol in bile + bile hypomotility ĺĹ risk of gallstones ƒ Obesity ƒ Rapid weight loss Ɠ Imbalance in bile composition ĺĹ risk of calcium-bilirubin precipitation ƒ Total parenteral nutrition (prolonged)

COMPLICATIONS ƒ ĺūŕĚČNjƙƥĿƥĿƙɚĿŠǷîƥĿūŠūIJijîŕŕċŕîēēĚƑɛ ƒ Ascending cholangitis ƒ Blockage of common, pancreatic bile ducts ƒ Gallbladder cancer: history of gallstones ĺ Ĺrisk of gallbladder cancer

DIAGNOSIS DIAGNOSTIC IMAGING Ultrasound, CT scan, X-ray, ERCP ƒ ×ĿƙƭîŕĿǕĚƙƥūŠĚƙ

LAB RESULTS ƒ Elevated bilirubin levels ƒ Liver function tests (LFTs) Ɠ Elevated gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate transaminase (AST)

SIGNS & SYMPTOMS ƒ May be asymptomatic ƒ Sudden, intense abdominal epigastric/ substernal pain; radiates to right shoulder/ shoulder blades ƒ Nausea/vomiting; jaundice; abdominal tenderness, distension; fever, chills; ǷîƥƭŕĚŠČĚɈċĚŕČĺĿŠij ƒ See mnemonic for summary

MNEMONIC: 6 Fs Typical clinical presentation of an individual with gallstones Fat Female Fertile Forty Fatty food intolerance Flatulence

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Figure 28.6 Abdominal ultrasound demonstrating cholelithiasis. The gallstones cast an acoustic shadow.

TREATMENT ƒ Necessary only if symptomatic

MEDICATIONS ƒ Bile salts Ɠ Dissolve cholesterol stones

Chapter 28 Biliary Tract Diseases

SURGERY ƒ Cholecystectomy

OTHER INTERVENTIONS ƒ Pain management ƒ Shock wave therapy (lithotripsy) Ɠ High-frequency sound waves fragment stones

Figure 28.7 Numerous gallstones, of mixedtype, in a cholecystectomy specimen. The wall of the gallbladder is thickened and ǶċƑūƥĿČɈČūŠƙĿƙƥĚŠƥDžĿƥĺŕūŠijɠƙƥîŠēĿŠij disease.

PRIMARY SCLEROSING CHOLANGITIS (PSC) osms.it/primary-sclerosing-cholangitis PATHOLOGY & CAUSES ƒ Autoimmune disorder in which T-cells attack, destroy bile duct epithelial cells in genetically predisposed individuals exposed to environmental stimuli Ɠ HLA-B8, HLA-DR3, HLA-DRw52a ƒ Associated with ulcerative colitis, Crohn’s disease ƒ ¬ČŕĚƑūƙĿƙɈĿŠǷîƥĿūŠūIJĿŠƥƑîɠɈ extrahepatic ducts ƒ ĚŕŕƙîƑūƭŠēċĿŕĚēƭČƥƙĿŠǷîŞĚēɈēĿĚĺ ǶċƑūƙĚ ƒ Death of epithelial cells lining bile ducts ĺ bile leaks into interstitial space, bloodstream ƒ “Beaded” appearance of bile ducts Ɠ Stenosis of affected ducts, dilation of unaffected ducts ƒ Severity depends on bilirubin levels, encephalopathy, presence/absence of ascites, serum albumin level, prothrombin time

COMPLICATIONS ƒ Portal hypertension Ɠ Fibrosis builds around bile ducts ĺ constricts portal veins ĺĹ pressure ƒ Hepatosplenomegaly Ɠ Portal hypertension ĺċîČŒƭƎūIJǷƭĿēɈ enlargement of spleen, liver ƒ Cirrhosis Ɠ ¤ĚČƭƑƑĚŠƥČNjČŕĚūIJĿŠǷîƥĿūŠɈĺĚîŕĿŠij ĺ tissue scarring ĺǶċƑūƙĿƙ ƒ Ĺ risk of cholangiocarcinoma, gallbladder cancer, hepatocellular carcinoma

SIGNS & SYMPTOMS ƒ May remit, recur spontaneously ƒ Jaundice, RUQ pain, weight loss, pruritus (deposition of bile salts, acids in skin), hepatosplenomegaly ƒ Liver failure Ɠ Ascites, muscle atrophy, spider angiomas, increased clotting time, dark urine, pale stool

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DIAGNOSIS DIAGNOSTIC IMAGING MRCP ƒ Intrahepatic and/or extrahepatic bile duct dilation; multifocal or diffuse strictures ERCP ƒ Intrahepatic and/or extrahepatic bile duct dilation; multifocal or diffuse strictures

LAB RESULTS ƒ Liver function tests (LFTs) Ɠ Elevated conjugated bilirubin, ALP, GGT ƒ Elevated serum IgM antibody, p-ANCA (targets antigens in cytoplasm/nucleus of ŠĚƭƥƑūƎĺĿŕƙɒȉȁʣūIJĿŠēĿDŽĿēƭîŕƙDžĿƥĺ¡¬ ɛ ƒ Bilirubinuria ƒ Liver biopsy Ɠ Stage disease, predict prognosis

Figure 28.8 Cholangiogram demonstrating multiple biliary strictures in a case of primary sclerosing cholangitis.

OTHER DIAGNOSTICS ƒ Histology Ɠ ɨ~ŠĿūŠɠƙŒĿŠǶċƑūƙĿƙɩ: concentric rings ūIJǶċƑūƙĿƙîƑūƭŠēċĿŕĚēƭČƥɈƑĚƙĚŞċŕĚƙ onion skin

TREATMENT ƒ No effective treatment

MEDICATIONS ƒ Treat symptoms, manage complications, not curative (e.g. antibiotics) ƒ Immunosuppressants, chelators, steroids

SURGERY ƒ Liver transplant Ɠ Advanced liver disease

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Figure 28.9 Histological appearance of primary sclerosing cholangitis. There is ūŠĿūŠɠƙŒĿŠǶċƑūƙĿƙūIJƥĺĚċĿŕĿîƑNjēƭČƥƙɍ

NOTES

NOTES COLORECTAL POLYP CONDITIONS

GENERALLY, WHAT ARE THEY? PATHOLOGY & CAUSES ƒ Colorectal polyps: overgrowths of epithelial cells lining colon/rectum ƒ Usually benign, can turn malignant

TYPES Adenomatous polyps/colonic adenomas ƒ Gland-like polyps caused by tumor suppressor gene mutation in adenomatous polyposis coli (APC) ƒ Characterized by accelerated division of epithelial cells ĺ epithelial dysplasia ĺ polyp formation ƒ No malignant potential by itself; requires mutations in other tumor suppressants (KRAS, p53) ƒ OĿƙƥūŕūijĿČČŕîƙƙĿǶČîƥĿūŠ Ɠ Tubular: pedunculated polyp, protrudes out in lumen Ɠ Villous:ƙĚƙƙĿŕĚɈČîƭŕĿǷūDžĚƑɠŕĿŒĚ appearance; more often malignant Ɠ Tubulovillous: characteristics of tubular, villous polyps Serrated polyps ƒ Saw-tooth appearance microscopically ƒ Contain methylated CpG islands ĺ silencing of DNA-repair genes, others ĺ more mutations ĺ malignancy Ɠ Small polyps (most common): AKA hyperplastic polyps; rarely malignant Ɠ Large polyps:ūIJƥĚŠǷîƥɈƙĚƙƙĿŕĚɈ malignant

TŠǷîƥūƑNjƎūŕNjƎƙ ƒ Caused by ĿŠǷîƥūƑNjċūDžĚŕēĿƙĚîƙĚƙ Ɠ Crohn’s disease, ulcerative colitis ƒ Not malignant

CAUSES ƒ Genetic mutations ƒ TŠǷîƥūƑNjČūŠēĿƥĿūŠƙɚĚɍijɍ ƑūĺŠɫƙ disease)

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