Copy of Pathology Test 2.pdf

Pathology Test 2 Hiatal Hernia Hiatal hernia is a medical condition where a portion of the stomach protrudes into the thoracic cavity through the esophageal hiatus. There are two main types of hiatal hernias: Sliding Hiatal Hernia: In severe cases, most of the stomach is found within the thoracic...

Pathology Test 2 Hiatal Hernia Hiatal hernia is a medical condition where a portion of the stomach protrudes into the thoracic cavity through the esophageal hiatus. There are two main types of hiatal hernias: Sliding Hiatal Hernia: In severe cases, most of the stomach is found within the thoracic cavity above the diaphragm Causes symptoms like heartburn and difficulty swallowing Rolling (Paraesophageal) Hiatal Hernia: Portion of the stomach rolls up alongside the esophagus, while the gastroesophageal junction remains in place Caused by weakening of a small muscle (esophageal sphincter) located between the terminal esophagus and the diaphragm As a result of aging or other factors, this sphincter may weaken and permit a portion of the stomach to herniate through the esophageal hiatus A sliding hiatal hernia may produce a radiographic sign termed Schatzki’s ring, which is a ringlike constriction at the distal esophagus Radiographic Demonstration of Hiatal Hernia 1. - Barium Swallow (Esophagus & Stomach) Study: Intra-abdominal/Thoracic Pressure: Images can be taken under conditions of increased intra-abdominal or intra-thoracic pressure to visualize herniation of the stomach into the chest. Prone with Bolster: Placing the patient in the prone position with a bolster beneath them may help highlight the hernia. Trendelenburg Position: Tilting the patient head-down can accentuate reflux and herniation. Water Test: Having the patient swallow water while the study is conducted can demonstrate the hernia more clearly. Valsalva Maneuver: Having the patient perform a Valsalva maneuver (straining as if having a bowel movement) can also highlight herniation. Leg Raises: Lifting the patient's legs during the procedure can help show the hernia and reflux more clearly. 2. Chest X-ray: A chest X-ray may be used to visualize the chest and upper abdominal area. - A soft tissue mass in the posterior mediastinum, which could represent herniated stomach. - Air/fluid levels in the chest or upper abdomen, which can be indicative of reflux or herniation. Hiatal Hernia Repair 1. 2. 3. 4. 5. 6. 7. - Patient Preparation: The patient is placed under general anesthesia to ensure they are unconscious and pain-free during the procedure Carbon dioxide gas may be used to inflate the abdominal cavity, creating space for the surgery. Incisions: Several small incisions (usually 3-5) are made in the abdominal wall. These serve as entry points for surgical instruments and a laparoscope, which is a thin, flexible tube with a camera and light at the end. Visualization: The laparoscope is inserted through one of the incisions, allowing the surgeon to see the surgical area on a video monitor. Repositioning the Herniated Stomach: Surgeon repositions the herniated portion of the stomach from the chest cavity back into the abdominal cavity. The hiatus (the opening in the diaphragm through which the esophagus passes) is repaired and tightened to prevent further herniation. Fundoplication: This involves wrapping the top of the stomach (fundus) around the lower esophagus and suturing it in place to prevent acid reflux. Closure: After the repairs are completed, the incisions in the abdominal wall are closed with sutures or surgical staples. Recovery: Minimally invasive, which typically results in less post-operative pain, shorter hospital stays, and quicker recovery times compared to traditional open surgery Peptic Ulcer Disease Peptic ulcer disease (PUD) is a condition characterized by the presence of ulcers in the stomach or the first part of the small intestine (duodenum). 1. Helicobacter pylori (H. pylori) Infection: Bacteria that can infect the lining of the stomach and duodenum. Can lead to inflammation, and over time, it can cause peptic ulcers. Ulcers are typically small and shallow erosions that can perforate or cause hemorrhage. These ulcers are often found in the anterior wall of the stomach or the duodenal bulb (the initial part of the duodenum). 2. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Can also be caused by the use of certain medications, such as aspirin a ibuprofen (Motrin) These drugs can irritate the lining of the stomach and duodenum, leading to the development of ulcers Often found in the stomach, particularly in the lesser curvature, but can also occur in the duodenum. Benign vs malignant Peptic Ulcer Disease Treatment 1. 2. 3. - Lifestyle changes Avoiding spicy foods Quitting smoking Reducing alcohol intake Stress reduction Antacids Short term relief by neutralizing stomach acid H.pylori eradication If bacteria is the cause, antibiotics are given Stomach Cancer 1. 2. 3. 4. - Infiltration of Gastric Wall and Wall Thickening: Stomach cancer can invade the stomach wall, leading to thickening of the stomach wall, which may resemble fibrosis Narrowing and Fixation of the Stomach: As stomach cancer progresses, it can narrow and fix the stomach, resulting in symptoms like difficulty swallowing and discomfort. Large Irregular Polypoid Mass: Stomach cancer can present as a sizeable, irregular, polypoid mass within the stomach, indicative of advanced disease. Location of Stomach Cancer: Most stomach cancers occur in the distal stomach (lower part), especially in the antrum and pylorus, while the upper part, the fundus, is less commonly affected. Hypertrophic Pyloric Stenosis- Acquired Acquired conditions develop after birth as a result of various factors, including infections, lifestyle choices, environmental influences, or trauma. 1. Extrinsic Pressure: - Occurs when external factors, such as tumors or structures outside the pylorus, apply pressure and constrict the pyloric opening, hindering the passage of food. 2. Healing Ulcers and Scar Tissue: - Healing of ulcers in the stomach or duodenum can leave behind scar tissue. - The accumulation of scar tissue narrows the pyloric lumen, leading to symptoms like vomiting and abdominal pain. Hypertrophic Pyloric Stenosis- Congenital Congenital conditions are present at birth or develop during fetal development. 1. 2. - 3. - Gender Predominance: HPS is more common in males, with a male-to-female ratio of around 3:1. Muscular Changes: HPS is characterized by the abnormal enlargement (hypertrophy) and increased cell numbers (hyperplasia) of the circular layer of smooth muscle in the pyloric region of the stomach. Pyloric Lumen Narrowing: The hypertrophied muscle narrows the pyloric opening, obstructing the passage of food from the stomach to the small intestine. This results in a distended stomach and forceful vomiting (acid but no bile) Hypertrophic Pyloric Stenosis- Imaging and Treatment Ultrasound is modality of choice as it is timely If inconclusive, UGI performed Barium Meal Demonstrations: 1. Abnormally Large Dilated Stomach: Can reveal an abnormally large and dilated stomach- may be indicative hypertrophic pyloric stenosis 2. Delayed Passage of Contrast: This delay can occur when there is an obstruction or narrowing in the pathway, such as in hypertrophic pyloric stenosis, where the pyloric canal is constricted. 3. Pyloric Canal Appearance: The pyloric canal may appear as a thin string of barium contrast, measuring only 1-2 cm in length Treatment for Hypertrophic Pyloric Stenosis: Pyloromyotomy, a surgical procedure to release the thickened muscle of the pyloric canal and widen the opening. This surgical intervention allows for the normal passage of food from the stomach to the duodenum. Caterpillar Intestinal Obstruction 1. Mechanical Causes: Result from physical barriers that obstruct the intestinal lumen- tumors, adhesions (bands of scar tissue), volvulus (twisting of the intestines), and inguinal hernias. Tangible Obstructions: Typically tangible and can be visualized or felt Referred to as "simple" and "closed" obstructions. Colon Cancer: Approximately 70% of large bowel obstructions are attributed to colon cancer. 2. Functional (Paralytic or Adynamic Ileus): Causes: Occur when peristalsis (the muscular contractions that move contents through the intestines) is inhibited Toxic: Toxic causes include peritonitis, certain medications, and inflammation that paralyze intestinal motility. Traumatic: Traumatic factors, particularly abdominal surgery, are a common cause of functional obstruction. If the intestines do not regain their normal motility within 72 hours after surgery. Medications like atropine can be used to manage this post-surgical complication. Intestinal Obstruction- Pathogenesis Bowel Distension Due to Swallowed Air: Obstruction can cause a buildup of gas and swallowed air in the affected segment of the intestine As the air accumulates, it results in distension (swelling) of the bowel. More Distension Due to Fluid Accumulation: In response to the initial obstruction and gas accumulation, the body may attempt to secrete fluids into the affected bowel segment This can further exacerbate distension Fluid and Electrolyte Imbalances Due to Suctioning: Medical interventions like suctioning or nasogastric tube insertion may be used to remove gas and fluid from the blocked intestine. This can lead to fluid and electrolyte imbalances as essential fluids are removed. Distension Persists Leading to Complications: If the obstruction persists and is not relieved, it can lead to more severe complications. The ongoing distension can result in reduced blood flow to the affected part of the intestine, leading to ischemia (inadequate blood supply) Ischemia can progress to necrosis (tissue death) and gangrene (gangrenous bowel), which are serious and life-threatening conditions. Mechanical Obstructions 1. Simple Mechanical Obstruction: Characteristics: Develops rapidly. involves a single point of obstruction in the intestine Blood flow to the affected area is usually maintained, which means that there is no interference with the blood supply Gas and fluid can accumulate proximal to the obstruction within a few hours. Treatment: Simple mechanical obstruction often requires early diagnosis and emergency intervention. Treatment may involve surgery or endoscopy. Appearance: Step ladder shape (distended loops) Stacked coins (mucosal folds) 2. Closed Loop Mechanical Obstruction: Characteristics: Involves obstruction at two points in the intestine, creating a loop. Can occur, in cases of volvulus (twisting of the intestines). Blood supply to the affected segment is compromised, leading to increased pressure within the loop. Complications: The compromised blood supply can lead to ischemia (inadequate blood flow) in the looped segment of the intestine. Ischemia can progress to infarction (tissue death), resulting in necrosis. Necrosis can lead to serious complications, including sepsis and peritonitis, and, in some cases, gangrene. Appearance: Inverted U shape Radiographic Appearance Functional Obstruction (adynamic ileus) Functional intestinal obstruction (adynamic ileus) is characterized by reduced or absent peristalsis - Adynamic ileus can affect both the large and small bowel, resulting in a uniformly dilated appearance of the intestines. - Unlike mechanical obstruction, there is no specific, demonstrable point of obstruction or physical blockage in the intestine. - One of the hallmark signs of adynamic ileus is the generalized, uniform distension of the bowel without a clear site of constriction. - Typically resolves on its own without the need for surgical intervention, It may resolve within 36 to 48 hours. Mechanical vs Functional Mechanical Intestinal Obstruction: - Caused by a physical blockage (e.g., tumor, adhesion) - Clear point of obstruction, can be dangerous, with increased fluid accumulation and pressure - May lead to compromised blood supply, necrosis, and severe complications - Treatment often involves surgical intervention to decompress, remove the obstruction, and prevent necrosis or perforation. Functional Intestinal Obstruction (Adynamic Ileus): - Due to a lack of muscle contractions (peristalsis) - Uniform distribution of air - No specific point of obstruction; intestines are diffusely dilated. - Resolves within 36-48 hours - Management focuses on supportive care, including hydration and nutrition. Large bowel obstruction, haustra distended, fewer loops Sigmoid- inverted U Volvulus Volvulus - Volvulus is the complete twisting of a loop of bowel around its mesenteric base, potentially compromising its blood supply Sigmoid Volvulus: - Sigmoid colon twisting on itself, forming an inverted "U" shape - Becomes distended and loses its normal haustral markings, giving it a sausage or balloon-like appearance - Creates a closed loop in the intestine, potentially compromising blood supply Cecal Volvulus: - Involves the cecum, which is the beginning of the large intestine, twisting around its mesentery. - Cecum becomes distended and shifts up and to the left within the abdomen. - The distended cecum can appear as a kidney-shaped mass on imaging. Cecum- kidney Small vs Large Bowel Small Bowel: Location: Distended loops are typically seen in the central abdomen. Appearance: On imaging, the small bowel may resemble stacked coins. Characteristic Sign: The "step ladder sign" may be observed in the small bowel, which is a pattern of parallel lines or markings on the radiograph. Large Bowel: Location: Distended loops of the large bowel are often found in the periphery of the abdomen. Appearance: The haustra (sacculations) of the large bowel are distended, giving it a segmented appearance. Comparison: There are typically fewer loops of the large bowel visible on imaging compared to the small bowel. Pneumoperitoneum Pneumoperitoneum is the presence of air or gas in the peritoneal cavity, which surrounds the abdominal organs - Cause: most common cause being a perforation of an abdominal viscus, such as an ulcer, benign ulcers, tumors, or traumatic injuries. - Induced during laparoscopic surgery for improved visibility and access to abdominal organs. - Diagnosis: involves radiographic imaging, such as an upright chest radiograph, can reveal the presence of air or gas in the abdominal cavity Lower GI Procedures- Barium Enema 1. 2. 3. - Double Contrast Barium Enema: This procedure uses thick barium contrast followed by the introduction of air into the colon It provides detailed visualization of the colon's mucosal patterns, making it suitable for detecting subtle abnormalities. Single Contrast Barium Enema: This version uses only thin barium contrast without introducing air. Broader evaluation of gross pathologies and may be preferred for certain patient populations, such as children or debilitated individuals. Defecogram (Evacuative Proctography): Focuses on assessing rectal and anal function during defecation. It aids in the diagnosis of conditions related to defecation dysfunction. Pancreatic Cancer Pancreatic cancer- is a type of cancer that originates in the tissues of the pancreas. Most common type begins in the cells that line the ducts responsible for carrying enzymes, known as pancreatic ductal adenocarcinoma. Causes: The exact causes of pancreatic cancer are not entirely clear, but there are some associated risk factors. Increased risk factors for pancreatic cancer include smoking, inherited gene mutations (particularly in families with a history of genetic syndromes or pancreatic cancer), obesity, diabetes, and a history of pancreatitis. Most people diagnosed with pancreatic cancer are over the age of 65. Symptoms: Pancreatic cancer is often not detected early, as it typically doesn't produce noticeable symptoms until it has spread to other organs. Symptoms of pancreatic cancer may include abdominal pain that radiates to the back, loss of appetite, unintended weight loss, jaundice (yellowing of the skin and whites of the eyes), changes in stool and urine color, itchy skin, blood clots, and fatigue. Treatment: The choice of treatment for pancreatic cancer depends on the extent of the disease. Treatment options may include surgery, chemotherapy, radiation therapy, or a combination of these. The prognosis for pancreatic cancer can vary greatly based on the stage of the disease at the time of diagnosis. Pancreatic cancer often has a poor prognosis, and survival rates are relatively low. Median survival for untreated cases is around 3.5 months, but treatment can extend survival to around 8 months, and in some cases, individuals may live for several years. Early detection and treatment can significantly improve the prognosis for pancreatic cancer, which is why it's crucial for individuals at higher risk or experiencing symptoms to seek medical attention promptly.