Quiz 3

(Ref: Gi/Liver secrets E-Book, pg. 406)
Abdominal angina is defined as the (postprandial pain that occurs in individuals with mesenteric vascular occlusive disease such that blood flow cannot increase enough to meet visceral demands). The classic feature is abdominal pain, which occurs a few minutes after eating and slowly subsides over next few hours. Gradually, most patients develop fear of eating and lose significant weight. A history of peripheral vascular disease and significant smoking is common.

(Ref: Harrison 20th edition, p 2242; Harrison 19th p 568, 1927)
 Pernicious anemia is associated with auto-immune gastritis. The auto-antibodies against the parietal cells will lead to achlorhydria. This type of gastritis spares the antrum and involves mainly the body.
 Gastric acid plays an important role in feedback inhibition of gastrin release from G cells. Achlorhydria, coupled with relative sparing of the antral mucosa (site of G cells), leads to hyper-gastrinemia. Gastrin levels can be markedly elevated (> 500 pg/mL) in patients with pernicious anemia. Hypergastrinemia and achlorhydria may also be seen in non-pernicious anemia—associated type A gastritis.

(Ref: Harrison 20th edition, p 2237; Harrison 19th p 1926)
 Signs and symptoms arise from the rapid emptying of hyperosmolar gastric contents into the small intestine, resulting in a fluid shift into the gut lumen with plasma volume contraction and acute intestinal distention.
 Release of vasoactive GI hormones (vasoactive intestinal polypeptide, neurotensin, motilin) is also theorized to play a role in early dumping.
 Early dumping takes place 15-30 minutes after meals and consists of crampy abdominal discomfort, nausea, diarrhea, belching, tachycardia, palpitations, diaphoresis, light-headedness, and, rarely, syncope.
 Late phase of dumping is due to hypoglycemia from excessive insulin release.

(Ref: Harrison 20th edition, p 2274-75; Harrison P 1962)
Since UC is a mucosal disease, the rectal mucosa can be dissected and removed down to the dentate line of the anus or about 2 cm proximal to this landmark. The ileum is fashioned into a pouch that serves as a neorectum. This ileal pouch is then sutured circumferentially to the anus in an end to end fashion. If performed carefully, this operation preserves the anal sphincter and maintains continence. The overall operative morbidity is 10%, with the major complication being bowel obstruction.
Indications for surgery in ulcerative colitis
1. Intractable disease
2. Fulminant disease
3. Toxic megacolon
4. Colonic perforation
5. Massive colonic hemorrhage
6. Extracolonic disease
7. Colonic obstruction
8. Colon cancer prophylaxis
9. Colon dysplasia or cancer

(Ref: Harrison 20th edition, p 2269)
The extra- intestinal involvement of ulcerative colitis is primary sclerosing cholangitis Primary sclerosing cholangitis is a disorder characterized by both intrahepatic and extrahepatic bile duct inflammation and fibrosis, frequently leading to biliary cirrhosis and hepatic failure. PSC occurs less often in patients with CD.

(Ref: Harrison 20th edition, p 573; Robbins 8th edition chapter 15, Harrison 19th p 536)
 STK11 is a tumor suppressor gene, in that its over-expression can induce a growth arrest of a cell at the G1 phase of the cell cycle and that somatic inactivation of the unaffected allele of STK11 is often observed in polyps and cancers from patients with Peutz-Jeghers syndrome.
 The second gene involved in Peutz-Jegher's polyps is caused by germ-line mutations in the LKB1 gene.
 Loss of the APC tumor suppressor gene in FAP and Gardner syndrome give rise to hundreds of adenomas that progress to form cancers.
 MALT lymphoma at (11;18) translocation is common (the translocation creates a fusion gene between the apoptosis inhibitor BCL-2 gene in chromosome 11 and the MLT gene in chromosome 18.

(Ref: Harrison 20th edition, p 2243; CMDT, ch. 15, pg. 610)
 The stomach is characterized by large, tortuous gastric folds in the fundus and body of the stomach, with antrum generally spared, giving the mucosa a cobblestone or cerebriform (brain-like) appearance.
 Histologically, the most characteristic feature is massive foveolar hyperplasia (hyperplasia of surface and glandular mucous cells).
 The glands are elongated with a corkscrew-like appearance and cystic dilation is common. Inflammation is usually only modest, although some cases show marked intraepithelial lymphocytosis.
 Diffuse or patchy glandular atrophy, evident as hypoplasia of parietal and chief cells, is typical
 (Twenty-four-hour pH monitoring reveals hypochlorhydria or achlorhydria, and a chromium-labelled albumin test reveals increased GI protein loss). Serum gastrin levels will be within normal limits