Block 14 GI Tumor Polyp Gerd EsophaGItis

1. A 52-year-old Caucasian male has a history of drinking 1 to 2 liters of whisky per day for the past 20 years. He has had numerous episodes of nausea and vomiting in the past 5 years. He experiences a bout of prolonged vomiting, followed by massive hematemesis. On physical examination in the emergency room, he has vital signs with temperature of 36.8 C, pulse of 110 beats per minute, respiratory rate of 22 breaths per minute, and a blood pressure of 80/40 mm Hg. His heart has a regular rate and rhythm with no murmurs and his lungs are clear to auscultation. There is no abdominal tenderness or distension and bowel sounds are present. His stool is negative for occult blood. Which of the following is the most likely diagnosis?

Hiatal hernia

Barrett esophagus

Esophageal squamous cell carcinoma

Esophageal laceration (Mallory-Weiss syndrome)

The most likely diagnosis for this patient is esophageal laceration, also known as Mallory-Weiss syndrome. This condition is often caused by prolonged vomiting or retching, which can lead to tears in the lining of the esophagus and subsequent bleeding. The patient's history of heavy alcohol consumption and episodes of nausea and vomiting, along with the presentation of massive hematemesis, are consistent with Mallory-Weiss syndrome. The absence of other symptoms such as abdominal tenderness, distension, or positive occult blood in the stool helps to differentiate this diagnosis from other possibilities such as hiatal hernia, Barrett esophagus, or esophageal squamous cell carcinoma.

Explanation

The most likely diagnosis for this patient is esophageal laceration, also known as Mallory-Weiss syndrome. This condition is often caused by prolonged vomiting or retching, which can lead to tears in the lining of the esophagus and subsequent bleeding. The patient's history of heavy alcohol consumption and episodes of nausea and vomiting, along with the presentation of massive hematemesis, are consistent with Mallory-Weiss syndrome. The absence of other symptoms such as abdominal tenderness, distension, or positive occult blood in the stool helps to differentiate this diagnosis from other possibilities such as hiatal hernia, Barrett esophagus, or esophageal squamous cell carcinoma.

2. A 45-year-old man has had periodic bouts of extreme vomiting. This photograph is taken from the esophagus of a man with a similar condition. Which of the following is the best description of this condition? (see image)

Achalasia

Barrett esophagus

Mallory-Weis syndrome

Esophageal varices

Squamous cell carcinoma

The photograph shows a tear or laceration in the esophagus, which is characteristic of Mallory-Weis syndrome. This condition is often caused by severe vomiting or retching, leading to the formation of longitudinal tears in the lining of the esophagus. This can result in symptoms such as blood in vomit or stool. Achalasia is a condition characterized by difficulty swallowing, Barrett esophagus is a precancerous condition, esophageal varices are enlarged veins in the esophagus, and squamous cell carcinoma is a type of cancer that can affect the esophagus.

Explanation

The photograph shows a tear or laceration in the esophagus, which is characteristic of Mallory-Weis syndrome. This condition is often caused by severe vomiting or retching, leading to the formation of longitudinal tears in the lining of the esophagus. This can result in symptoms such as blood in vomit or stool. Achalasia is a condition characterized by difficulty swallowing, Barrett esophagus is a precancerous condition, esophageal varices are enlarged veins in the esophagus, and squamous cell carcinoma is a type of cancer that can affect the esophagus.

3. A 15-year-old boy is diagnosed with familial adenomatous polyposis. He asks his physician about his prognosis and what complications he might expect. Which of the following statements will be the physician's reply?

A high incidence of intussusceptions

Multiple diverticuli

Obstruction that leads to infarction of the bowel

Progression to adenocarcinoma

Perforation leading to localized and sometimes generalized peritonitis

The physician would reply that the boy's prognosis includes a progression to adenocarcinoma. Familial adenomatous polyposis is a genetic condition characterized by the development of numerous polyps in the colon and rectum. These polyps have a high likelihood of progressing to adenocarcinoma, a type of colon cancer. Therefore, it is important for the boy to undergo regular screenings and surveillance to monitor and potentially prevent the development of cancer.

Explanation

The physician would reply that the boy's prognosis includes a progression to adenocarcinoma. Familial adenomatous polyposis is a genetic condition characterized by the development of numerous polyps in the colon and rectum. These polyps have a high likelihood of progressing to adenocarcinoma, a type of colon cancer. Therefore, it is important for the boy to undergo regular screenings and surveillance to monitor and potentially prevent the development of cancer.

4. A 39-year-old woman has experienced substernal burning pain following meals for the past 15 years. On physical examination there are no abnormal findings. Upper GI endoscopy is performed and the lower part of the esophagus is shown. Biopsies are performed of this region and microscopic examination shows areas of gastric cardiac-type mucosa and intestinalized mucosa. Which of the following interpretations is most appropriate for this woman's findings?

Her risk for squamous cell carcinoma is increased

She has chronic gastroesophageal reflux

Her anti-centromere antibody test is positive

Her consumption of alcohol is high

The woman's symptoms of substernal burning pain following meals for the past 15 years, along with the findings of gastric cardiac-type mucosa and intestinalized mucosa on microscopic examination, suggest chronic gastroesophageal reflux. This condition occurs when the contents of the stomach flow back into the esophagus, causing irritation and symptoms such as heartburn. The absence of abnormal findings on physical examination further supports this interpretation.

Explanation

The woman's symptoms of substernal burning pain following meals for the past 15 years, along with the findings of gastric cardiac-type mucosa and intestinalized mucosa on microscopic examination, suggest chronic gastroesophageal reflux. This condition occurs when the contents of the stomach flow back into the esophagus, causing irritation and symptoms such as heartburn. The absence of abnormal findings on physical examination further supports this interpretation.

5. A 24 yo HIV positive patient who has had AIDS for 3 years presents with painful swallowing and dysphasia to solids and liquids. He has no previous history of heart burn or reflux disease. He recently required a 3 wk course of antibiotics for Pneumocystis carinii pneumonia. Examination of the pharynx reveals oral thrush. Barium swallow demonstrates multiple nodular filling defects of various sizes that resemble a "cluster of grapes". (see images below)

Reflux disease

Schatzski’s ring

Pneumocystis esophagitis

Candida esophagitis

The patient is a 24-year-old HIV positive individual with a history of AIDS for 3 years. He is experiencing painful swallowing and dysphagia to both solids and liquids, with no previous history of heartburn or reflux disease. Examination reveals oral thrush, and a barium swallow shows multiple nodular filling defects resembling a "cluster of grapes." These findings are consistent with Candida esophagitis, which is a common opportunistic infection in immunocompromised individuals, especially those with HIV/AIDS. The recent course of antibiotics for Pneumocystis carinii pneumonia may have predisposed the patient to this fungal infection.

Explanation

The patient is a 24-year-old HIV positive individual with a history of AIDS for 3 years. He is experiencing painful swallowing and dysphagia to both solids and liquids, with no previous history of heartburn or reflux disease. Examination reveals oral thrush, and a barium swallow shows multiple nodular filling defects resembling a "cluster of grapes." These findings are consistent with Candida esophagitis, which is a common opportunistic infection in immunocompromised individuals, especially those with HIV/AIDS. The recent course of antibiotics for Pneumocystis carinii pneumonia may have predisposed the patient to this fungal infection.

6. A 45 year old woman presents with dysphasia to solids and a long history of iron deficiency anemia. Her most likely diagnosis would be:

Plummer-Vinson syndrome

Pagophagia

Schatzski’s ring

Barrett’s esophagitis

The patient's presentation of dysphagia to solids and a long history of iron deficiency anemia is consistent with Plummer-Vinson syndrome. This syndrome is characterized by the triad of dysphagia, iron deficiency anemia, and esophageal webs. Dysphagia to solids is a key feature of this syndrome, and iron deficiency anemia is often seen due to chronic blood loss from the esophageal webs. The other options, Pagophagia, Schatzki's ring, and Barrett's esophagitis, do not typically present with the same combination of symptoms as seen in this patient.

Explanation

The patient's presentation of dysphagia to solids and a long history of iron deficiency anemia is consistent with Plummer-Vinson syndrome. This syndrome is characterized by the triad of dysphagia, iron deficiency anemia, and esophageal webs. Dysphagia to solids is a key feature of this syndrome, and iron deficiency anemia is often seen due to chronic blood loss from the esophageal webs. The other options, Pagophagia, Schatzki's ring, and Barrett's esophagitis, do not typically present with the same combination of symptoms as seen in this patient.

7. An autopsy was performed on an emaciated 65 year old homeless man who presented to the ER with severe hematemesis. Image "A" is the "inverted" esophagus from the patient. Which of the following autopsy findings is the most likely cause of his death? (See Attached colored images)

Hemorrhagic shock caused by bleeding esophageal varicies

Adenocarcinoma of the esophagus

Squamous cell carcinoma of the esophagus

Mallory Weiss Syndrome

The most likely cause of the homeless man's death is hemorrhagic shock caused by bleeding esophageal varices. This is indicated by the image of the inverted esophagus, which suggests the presence of esophageal varices. Hematemesis, or vomiting of blood, is a common symptom of bleeding esophageal varices. Hemorrhagic shock occurs when there is significant blood loss, leading to a decrease in blood volume and inadequate perfusion of organs, which can be fatal.

Explanation

The most likely cause of the homeless man's death is hemorrhagic shock caused by bleeding esophageal varices. This is indicated by the image of the inverted esophagus, which suggests the presence of esophageal varices. Hematemesis, or vomiting of blood, is a common symptom of bleeding esophageal varices. Hemorrhagic shock occurs when there is significant blood loss, leading to a decrease in blood volume and inadequate perfusion of organs, which can be fatal.

8. An 80-year old woman complains of "always feeling tired and dark colored bowel movements". Percussion and palpation of the abdomen revealed non-shifting dullness and a mass in the lower right abdominal quadrant. A surgical resection reveals the following images. The surgeon also noted nodules in the liver which was confirmed microscopically as metastasis to the liver. What is the most likely diagnosis? (See Attached colored images)

Adenocarcimoma of the cecum, T4, N2, M1

Adenocarcinoma of the rectum, T3, N2, M1

Neuroendocrine tumor of transcending colon, T4, N2, M0

Neuroendocrine tumor of small intestines, T4, N0, M1

The most likely diagnosis is adenocarcinoma of the cecum, T4, N2, M1. This is supported by the presence of a mass in the lower right abdominal quadrant, which is consistent with the location of the cecum. The non-shifting dullness on percussion and palpation suggests the presence of ascites, which is commonly seen in advanced stages of cancer. The nodules in the liver confirmed as metastasis indicate that the cancer has spread to other organs, further supporting the diagnosis of adenocarcinoma of the cecum with metastasis.

Explanation

The most likely diagnosis is adenocarcinoma of the cecum, T4, N2, M1. This is supported by the presence of a mass in the lower right abdominal quadrant, which is consistent with the location of the cecum. The non-shifting dullness on percussion and palpation suggests the presence of ascites, which is commonly seen in advanced stages of cancer. The nodules in the liver confirmed as metastasis indicate that the cancer has spread to other organs, further supporting the diagnosis of adenocarcinoma of the cecum with metastasis.

9. A 45-year-old man presents with dysphagia. He says the onset was insidious and his condition is getting worse. His vital signs are within normal range and there are no significant signs on physical examination. Endoscopy reveals a mass lesion in the middle third of the esophagus. A biopsy is taken. Which of the following is the most likely microscopic appearance of this lesion?

Pleomorphic, anaplastic squamous cells that are hyperchromatic

Fibroblasts arranged in whorls

Nests of well-differentiated cells that stain positively for vasoactive amines

Sheets of “signet ring” cells containing mucus

Well-differentiated goblet cells arranged in glandular patterns

The most likely microscopic appearance of the lesion described in the question is pleomorphic, anaplastic squamous cells that are hyperchromatic. This is suggestive of squamous cell carcinoma, a type of esophageal cancer. The presence of dysphagia, insidious onset, and worsening condition are consistent with the clinical presentation of esophageal cancer. Additionally, the location of the mass in the middle third of the esophagus is also characteristic of squamous cell carcinoma. The description of pleomorphic, anaplastic squamous cells that are hyperchromatic further supports this diagnosis.

Explanation

The most likely microscopic appearance of the lesion described in the question is pleomorphic, anaplastic squamous cells that are hyperchromatic. This is suggestive of squamous cell carcinoma, a type of esophageal cancer. The presence of dysphagia, insidious onset, and worsening condition are consistent with the clinical presentation of esophageal cancer. Additionally, the location of the mass in the middle third of the esophagus is also characteristic of squamous cell carcinoma. The description of pleomorphic, anaplastic squamous cells that are hyperchromatic further supports this diagnosis.

10. A 53-year-old Caucasian woman presented with a one week history of progressive dysphagia with associated sore throat and voice changes. She initially was having difficulty swallowing solid foods which then progressed to swallowing difficulty with liquids. The patient also noted episodes of bright red blood per rectum in the past. She denied any melena and weight loss. Her only medication use was occasional use of naproxen. Her physical was exam was unremarkable including a negative guaiac exam. Her laboratory findings revealed hemoglobin of 5.7 g/dl and RBC count of 3.2X10⁶/mm³. She subsequently underwent a barium swallow test and esophagogastroscopy. Peripheral blood smear, esophageal x-ray and endoscopic appearance of the esophagus are shown for you evaluation.

Which of the following is the most likely diagnosis?

Plummer-Vinson syndrome

Mallory-Weiss syndrome

Zenker diverticulum

Achalasia

The most likely diagnosis in this case is Plummer-Vinson syndrome. This is suggested by the patient's symptoms of progressive dysphagia, sore throat, and voice changes, as well as her history of difficulty swallowing solid foods followed by difficulty with liquids. The episodes of bright red blood per rectum also support this diagnosis. Plummer-Vinson syndrome is characterized by the triad of iron deficiency anemia, esophageal webs, and dysphagia. The patient's laboratory findings of low hemoglobin and RBC count further support the diagnosis. The peripheral blood smear, esophageal x-ray, and endoscopic appearance of the esophagus would likely show characteristic findings associated with Plummer-Vinson syndrome.

Explanation

The most likely diagnosis in this case is Plummer-Vinson syndrome. This is suggested by the patient's symptoms of progressive dysphagia, sore throat, and voice changes, as well as her history of difficulty swallowing solid foods followed by difficulty with liquids. The episodes of bright red blood per rectum also support this diagnosis. Plummer-Vinson syndrome is characterized by the triad of iron deficiency anemia, esophageal webs, and dysphagia. The patient's laboratory findings of low hemoglobin and RBC count further support the diagnosis. The peripheral blood smear, esophageal x-ray, and endoscopic appearance of the esophagus would likely show characteristic findings associated with Plummer-Vinson syndrome.

11. M.S. has the following barium swallow:

One would expect this patient to have the following symptom:

Bilious projectile vomiting

Globus Pharyngeus

Absolute constipation

Odynophagia

Odynophagia refers to the painful sensation experienced while swallowing. In the given scenario, the barium swallow test is a diagnostic procedure used to evaluate the swallowing function and detect any abnormalities or issues in the esophagus. If the test reveals an abnormality or obstruction in the esophagus, it can cause pain during swallowing, leading to odynophagia. Therefore, one would expect this patient to have the symptom of odynophagia.

Explanation

Odynophagia refers to the painful sensation experienced while swallowing. In the given scenario, the barium swallow test is a diagnostic procedure used to evaluate the swallowing function and detect any abnormalities or issues in the esophagus. If the test reveals an abnormality or obstruction in the esophagus, it can cause pain during swallowing, leading to odynophagia. Therefore, one would expect this patient to have the symptom of odynophagia.

12. An 84-year-old woman presents with upper right quadrant abdominal pain, nausea and vomiting. Her vital signs are within normal limits and there is slight tenderness on palpation of her abdomen in the right upper quadrant. Ultrasound reveals a mass in the region of the fundus of the gall bladder. A biopsy of the mass reveals anaplastic glandular tissue. The glands are characterized by pleomorphism, hyperchromaticity and a lack of polarity. What is associated with the vast majority of patients with this condition of the gall bladder?

Biliary cirrhosis as a predisposing condition

Cholelithiasis as a risk factor

Cholangiocarcinoma as a predisposing condition

Hydrops of the gall bladder as a predisposing condition

Ascending cholangitis as a risk factor

Cholelithiasis, or the presence of gallstones, is a risk factor associated with the vast majority of patients with the condition described in the question. The presence of a mass in the region of the gallbladder fundus, along with the biopsy findings of anaplastic glandular tissue with pleomorphism, hyperchromaticity, and a lack of polarity, suggests the possibility of gallbladder cancer. Cholelithiasis is a known risk factor for the development of gallbladder cancer, with gallstones causing chronic inflammation and irritation of the gallbladder epithelium, leading to the development of malignancy in some cases.

Explanation

Cholelithiasis, or the presence of gallstones, is a risk factor associated with the vast majority of patients with the condition described in the question. The presence of a mass in the region of the gallbladder fundus, along with the biopsy findings of anaplastic glandular tissue with pleomorphism, hyperchromaticity, and a lack of polarity, suggests the possibility of gallbladder cancer. Cholelithiasis is a known risk factor for the development of gallbladder cancer, with gallstones causing chronic inflammation and irritation of the gallbladder epithelium, leading to the development of malignancy in some cases.

13. The shown images represent three different tubulovillous colon adenomas. Which of them has the highest malignant potential? (A Peutz-Jeghers polyp is shown below for comparison).

A

B

C

The image labeled A represents a tubulovillous colon adenoma with high-grade dysplasia, which indicates a higher risk of malignancy compared to the other images. High-grade dysplasia refers to cellular changes that are more severe and closer to becoming cancerous. Therefore, image A has the highest malignant potential among the three tubulovillous colon adenomas shown.

Explanation

The image labeled A represents a tubulovillous colon adenoma with high-grade dysplasia, which indicates a higher risk of malignancy compared to the other images. High-grade dysplasia refers to cellular changes that are more severe and closer to becoming cancerous. Therefore, image A has the highest malignant potential among the three tubulovillous colon adenomas shown.

14. This section of colon was removed from a patient with a family history of colon cancer and osteomas. What is the most likely diagnosis?

Familial polyposis (FAP)

Gardner syndrome

Turcot syndrome

Carcinoid syndrome

Gastrointestinal lymphoma

The presence of a family history of colon cancer and osteomas suggests a hereditary condition. Gardner syndrome is a type of familial polyposis that is characterized by the development of multiple polyps in the colon, as well as osteomas (benign bone tumors) and other features such as dental abnormalities and soft tissue tumors. Therefore, Gardner syndrome is the most likely diagnosis in this case.

Explanation

The presence of a family history of colon cancer and osteomas suggests a hereditary condition. Gardner syndrome is a type of familial polyposis that is characterized by the development of multiple polyps in the colon, as well as osteomas (benign bone tumors) and other features such as dental abnormalities and soft tissue tumors. Therefore, Gardner syndrome is the most likely diagnosis in this case.

15. A 75-year-old alcoholic and heavy smoker presents to his physician because of progressive dysphagia, first for solids, then for liquids. He also has lost some weight and is regurgitating food. Endoscopy reveals a large, fungating mass 2 cm above the gastroesophageal junction. Biopsy of the mass demonstrates glands, extending into the muscular layer, containing cells with large hyperchromatic nuclei. Which statement is correct about the disease?

Commonest site is the upper third of esophagus

Commonest spread of tumor is by venous route

Esophageal cancers are always primary

Anaplastic cancers are the commonest histological type

The patient may have sudden death due to severe hemorrhage

Chemoradiotherapy is the cornerstone of treatment

Prognosis of the disease is excellent

The correct answer is "The patient may have sudden death due to severe hemorrhage." In this case, the patient's symptoms of dysphagia, weight loss, and regurgitation are indicative of esophageal cancer. The large, fungating mass found during endoscopy and the biopsy results showing glands extending into the muscular layer with cells displaying large hyperchromatic nuclei further support this diagnosis. Esophageal cancers can cause severe hemorrhage, which can lead to sudden death. This highlights the importance of early detection and prompt treatment in improving outcomes for patients with esophageal cancer.

Explanation

The correct answer is "The patient may have sudden death due to severe hemorrhage." In this case, the patient's symptoms of dysphagia, weight loss, and regurgitation are indicative of esophageal cancer. The large, fungating mass found during endoscopy and the biopsy results showing glands extending into the muscular layer with cells displaying large hyperchromatic nuclei further support this diagnosis. Esophageal cancers can cause severe hemorrhage, which can lead to sudden death. This highlights the importance of early detection and prompt treatment in improving outcomes for patients with esophageal cancer.

16. An autopsy was performed on a 55 year old man who died of a myocardial infarction. A review of his medical records reveals multiple visits to the ER for vague substernal and epigastric pain. His autopsy showed a soft hemorrhagic area in the left ventricular septum as well as the gross and microscopic images shown. What is the most likely diagnosis?

Squamous cell carcinoma of the esophagus

Adenocarcinoma of the esophagus

Intestinal or glandular metaplasia of the esophagus

Adenocarcinoma of the colon

Squamous cell carcinoma of the anus

The most likely diagnosis in this case is adenocarcinoma of the colon. This is supported by the patient's medical history of vague substernal and epigastric pain, which can be associated with colon cancer. Additionally, the autopsy findings of a soft hemorrhagic area in the left ventricular septum do not directly correlate with any of the other options listed. Therefore, adenocarcinoma of the colon is the most plausible explanation.

Explanation

The most likely diagnosis in this case is adenocarcinoma of the colon. This is supported by the patient's medical history of vague substernal and epigastric pain, which can be associated with colon cancer. Additionally, the autopsy findings of a soft hemorrhagic area in the left ventricular septum do not directly correlate with any of the other options listed. Therefore, adenocarcinoma of the colon is the most plausible explanation.