CASE NUMBER 89
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Clinical History: A 73-year-old woman presented to the emergency department with a two-day history of right upper quadrant pain. Laboratory tests revealed an elevated WBC. Ultrasound evaluation showed gallstones present in the gallbladder and thickening of the gallbladder wall. A cholecystectomy was performed.
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(Review Normal Histology - click here)
Webslide 0084_J: Gall bladder, monkey, H&E
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The gall bladder is a distensible sac with extensive folds of mucosa that extend into the lumen. The mucosa consists of a tall, simple columnar epithelium and its underlying connective tissue (constituting a lamina propria). Note that there is NO SUBMUCOSA. The muscularis consists of scattered bundles of smooth muscle. Deep to the muscularis is an adventitia consisting of rather dense connective tissue that binds the gall bladder to the liver. Where the surface of the gall bladder faces the abdominal cavity there is a serosa.
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89-1. What is the differential diagnosis?
89-2. Which of the following is the most common cause of extrahepatic biliary obstruction?
- Bile duct carcinoma
- Carcinoma of the ampulla of Vater
- Carcinoma of the head of the pancreas
- Gallstones
- Phrygian cap
89-3. Which of the following is a risk factor for cholesterol-type gallstones?
- Age less than 25 years
- Asian ethnicity
- Male sex
- Obesity
- Sickle cell anemia
89-4. Which of the following is associated with chronic cholecystitis?
- Atrophy of the gallbladder wall
- Decreased risk of pancreatitis
- History of major trauma and burns
- Increased risk of carcinoma of the gallbladder
- Infection with Salmonella typhi
CASE NUMBER 189
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Clinical History: A 60-year-old African-American man presented to his primary care physician with a 6-month history of intermittent abdominal pain. During the past three weeks, he had noticed chalky and greasy stools and that he felt itchy. Clinical history revealed an unintentional 20-pound weight loss over the previous two months that he attributed to decreased appetite. Physical exam showed icterus. MRI revealed a mass in the head of the pancreas and the patient underwent surgical resection of this mass.
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(Review Normal Histology - click here)
Norm No. 7 Pancreas
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The pancreas is comprised of glandular tissue with endocrine and exocrine function. The exocrine pancreas contains lobular arrays of acini. The acinar secretions of the exocrine pancreas are collected by the pancreatic ducts. The ducts are surrounded by a small amount of connective tissue without inflammation or fibrosis (scarring).The endocrine pancreas resides in the islets which are regularly arranged and present within the pancreatic lobules.
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189-1. What is the differential diagnosis?
189-2. Which of the following is true regarding this disease?
- Although morbidity is high, mortality is typically low
- KRAS mutations are common
- Most tumors arise in the tail of the pancreas
- Saponification is commonly seen
- Serum CA19-9 antigen is usually decreased
189-3. Which of the following familial syndromes is most strongly associated with this entity?
- Familial adenomatous polyposis
- Familial atypical multiple-mole melanoma syndrome
- Hereditary pancreatitis
- Li-Fraumeni syndrome
- Peutz-Jeghers syndrome
189-4. Which of the following is most commonly diagnosed in pediatric patients?
- Acinar cell carcinoma
- Pancreatic adenocarcinoma
- Pancreatoblastoma
- Serous cystadenoma
- Solid-pseudopapillary neoplasm
CASE NUMBER 93
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Clinical History: A 50-year-old alcoholic man presented to the emergency department with severe epigastric pain that radiated to his back. He stated that he had had multiple similar episodes over the previous five years and had been hospitalized several times for pain management. At this admission, laboratory analysis showed elevated levels of serum amylase and lipase. The patient developed refractory shock, peritonitis and died.
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(Review Normal Histology - click here)
Norm No. 7 Pancreas
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The pancreas is comprised of glandular tissue with endocrine and exocrine function. The exocrine pancreas contains lobular arrays of acini. The acinar secretions of the exocrine pancreas are collected by the pancreatic ducts. The ducts are surrounded by a small amount of connective tissue without inflammation or fibrosis (scarring).The endocrine pancreas resides in the islets which are regularly arranged and present within the pancreatic lobules.
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93-1. What is the differential diagnosis?
93-2. Which of the following statements is true regarding this disease?
- Cystic fibrosis is the most common cause
- Diabetes mellitus is an early manifestation of this disease
- Disseminated intravascular coagulation is a potential
complication
- Pancreatic adenocarcinoma arises in approximately 25% of patients within 5 years of diagnosis
- There are increased numbers of IgG4-producing plasma cells
CASE NUMBER 85
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Clinical History: A 64-year-old morbidly obese white woman was admitted to the emergency department with a 6-hour history of nausea, vomiting and jaw pain. While she was in the emergency department she collapsed and died. Autopsy revealed a massive heart attack as well as significant liver pathology.
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(Review Normal Histology - click here)
Norm No. 3 Liver
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The liver is the organ that metabolizes nutrients received from the digestive tract. These nutrients and processed by tissue hepatocytes which are large polygonal cells. The hepatocyes are separated by portal triads. The triads consist of an artery, a vein and a bile duct. The bile duct is lined by cuboidal epithelium. The artery has a muscular wall and a flat endothelial lining. The sinuses are well defined and contain a small amount of blood.
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85-1. What is the differential diagnosis?
85-2. Which of the following is commonly associated with this condition?
- Cirrhosis
- Focal nodular hyperplasia
- Hepatitis B infection
- Kayser-Fleischer rings
- Type 2 diabetes
85-3. Which of the following is one of the proposed mechanisms by which insulin resistance contributes to the accumulation of triglycerides in hepatocytes?
- Decreased serum IL-6 and tumor necrosis factor (TNF)
- Decreased synthesis and uptake of fatty acids
- Impaired oxidation of fatty acids
- Increased synthesis of very-low-density lipoprotein cholesterol
- Peroxidation of membrane phospholipids
CASE NUMBER 601a - slide courtesy of UMich
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Clinical History: A 44-year-old man has developed increasing arthritis pain, swelling of the feet, and reduced exercise tolerance over the past 3 years. He has smoked 1 pack of cigarettes per day for 20 years. Physical exam reveals hepatomegaly. Laboratory studies include serum glucose of 201 mg/dL, creatinine 1.1 mg/dL and ferritin 893 ng/mL.
601a-1. Which of the following tests would be the best one to order at this time?
- Transferrin saturation
- Chest X-ray
- MRI of the foot
- Joint aspirate
- Glucose tolerance test
601a-2. Why is the ferritin level elevated?
- He has iron deficiency
- Excess ferritin comes from cigarette smoke
- This is a consequence of early diabetes
- There is an excess of iron in the body
- He is in renal failure
A chest radiograph shows bilateral pleural effusions, pulmonary edema, and cardiomegaly. Abdominal CT confirms hepatomegaly.
He undergoes a liver biopsy, and the microscopic appearance of a biopsy specimen stained with Prussian blue is shown.
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601a-3. What is the diagnosis?
601a-4. Which of the following genes is mutated in this disease?
- AAT
- APC
- ATP7B
- CYP1B1
- HFE
601a-5. Serum levels of which of the following are reduced in patients with this disease?
- Ceruloplasmin
- Circulating immune complexes
- Hepcidin
- HDL
- PiZ polypeptide
601a-6. Accumulation of toxic levels of copper in many tissues, especially the liver, brain and eye due to a mutation in the ATP7B gene is characteristic of which of the following?
- Alpha 1 antitrypsin deficiency
- Budd-Chiari syndrome
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Wilson disease
CASE NUMBER 521 - slide courtesy of UMich
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Clinical History: A 35-year-old man presents to the emergency department with a 2-week history of fever and jaundice. Physical exam reveals a thin man with skin lesions on his left arm.
521-1. What is the differential diagnosis?
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521-2. Which tests would you order?
Clinical History Continued:
Laboratory analysis shows: tests? Values?
AST: 100 ALT: 82 Alk Phos: 170 T. Bili: 4 Albumin: 2.5
WBC: 7 Hb: 14 HCT: 42 Platelets: 100,000
Hepatitis A Ab: Negative
Hepatitis B surface Ag: Positive
Hepatitis B surface Ab: Positive
Hepatitis B core Ag: Positive
Hepatitis C PCR: Negative
HIV: Negative
After laboratory assessment, a percutaneous needle biopsy of the liver is performed: See virtual slide link above.
The patient is then lost to follow up. He returns to the emergency department 4 years later with a 2-day history of hematemesis. Physical exam reveals jaundice and a prominent abdomen with fluid wave. While he is waiting to be admitted to the hospital, he begins vomiting blood and dies.
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521-3. What is the diagnosis?
521-4. Patients with this disease are at increased risk for developing which of the following?
- Acute pancreatitis
- Hepatic adenoma
- Hepatoblastoma
- Hepatocellular carcinoma
- Wernicke-Korsakoff syndrome
521-5. Which of the following tests is the first to be positive in the setting of hepatitis B infection?
- Anti-HBe antibody
- Anti-HBs antibody
- DNA polymerase
- HBsAg
- HBV-DNA
- IgM-anti-HBc
521-6. Which of the following is the most common cause of chronic viral hepatitis?
- Hepatitis A virus
- Hepatitis B virus
- Hepatitis C virus
- Hepatitis D virus
- Hepatitis E virus
- Hepatitis G virus
CASE NUMBER 81
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Clinical History: A 62-year-old alcoholic man presented to his primary care physician with a 3-month history of increased abdominal girth. Physical exam revealed telangiectasias and fluid wave of the abdomen. Laboratory findings showed elevated aminotransferase and decreased serum albumin; no other significant findings were noted. He was admitted to the hospital for further evaluation, but began retching violently with extensive hematemesis. Volume resuscitation failed and the patient died.
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Norm No. 3
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The liver is the organ that metabolizes nutrients received from the digestive tract. These nutrients and processed by tissue hepatocytes which are large polygonal cells. The hepatocyes are separated by portal triads. The triads consist of an artery, a vein and a bile duct. The bile duct is lined by cuboidal epithelium. The artery has a muscular wall and a flat endothelial lining. The sinuses are well defined and contain a small amount of blood.
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81-1. What is the differential diagnosis?
81-2. A diagnosis of a1-antitrypsin deficiency would be supported by which of the following findings?
- Anti-nuclear antibodies (ANAs)
- Decreased levels of serum ceruloplasmin
- Hepatic vein thrombosis
- Identification of a PiZZ genotype
- Polycystic kidney disease
81-3. Which of the following is the most common cause of micronodular cirrhosis?
- Chronic alcohol abuse
- Hepatitis B
- Hemachromatosis
- Non-alcoholic fatty liver disease
- Wilson disease
81-4. Mallory bodies are intracytoplasmic accumulations of which of the following?
- Cytokeratin
- Desmin
- GFAP
- Glycogen
- Lipid
PANCREAS Review Items
Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)
LEARNING OBJECTIVES
Absolutely critical information you must know to practice medicine is in bold font.
Important information that will be needed for routine patient care is in regular font.
Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics
- Compare and contrast the clinical and pathologic features of:
- Discuss the clinical and pathologic features of cystic fibrosis.
- Compare and contrast acute and chronic pancreatitis, in terms of:
- etiologic/predisposing factors
- pathogenesis
- morphologic features
- laboratory manifestations
- clinical findings and course
- complications
- Compare and contrast the clinical and pathologic features of adenocarcinoma of the:
- pancreatic head
- pancreatic body/tail
- ampulla of Vater
- 5. Discuss islet cell tumors of the pancreas, in terms of:
- incidence
- morphology
- benignity vs. malignancy
- immunohistochemical characteristics
- endocrine function
- clinical features and course
- Discuss indications and complications of pancreatic islet cell transplantion.
LIVER and BILIARY TRACT Review Items
Key Vocabulary Terms (click here to search any additional terms on Stedman's Online Medical Dictionary)
LEARNING OBJECTIVES
Absolutely critical information you must know to practice medicine is in bold font.
Important information that will be needed for routine patient care is in regular font.
Information about less common diseases that you may encounter in clinical practice and that will probably appear on examinations is in italics
- Describe the formation of bile and explain abnormalities that could cause jaundice.
- Discuss the clinical indications for the following laboratory tests:
- Compare and contrast the clinical and pathologic features of
- Compare and contrast biliary atresia and neonatal hepatitis, in terms of:
- etiology and pathogenesis
- morphology
- laboratory findings
- clinical features and course
- complications
- Describe the principal clinical and morphologic findings in chronic liver disease.
- Compare and contrast the clinical and pathologic features of viral hepatitis
- Compare and contrast the clinical and pathologic features of:
- Discuss pathogenesis, morphology, clinical course of alcohol-induced liver diseases:
- Classify types of cirrhosis, in terms of:
- etiology
- pathogenesis
- morphologic pattern (gross and microscopic)
- relationship to neoplasia
- Compare and contrast the clinical and pathologic features of
- Discuss portal hypertension in terms of:
- etiologic factors
- pathogenesis
- clinical features and course
- Compare predictable and unpredictable drug induced liver disease.
- Describe the pathophysiologic mechanism whereby the following hepatotoxic drugs/chemicals cause liver injury:
- Compare and contrast the clinical and pathologic features of:
- Describe typical infectious liver diseases caused by bacteria, protozoa and helminths; in terms of clinical and morphologic findings.
- List causes of fatty change (steatosis) of the liver, in terms of:
- size of fat vacoules
- zonal distribution of fat
- Describe the etiopathogenesis and consequences of:
- Compare and contrast the clinical and pathological features of the following tumors:
- Describe cholelithiasis in terms of
- risk factors
- mechanisms of stone formation
- composition of stones
- morphology of stones and gallbladder
- clinical features
- complications, including those of therapy
- Compare and contrast acute and chronic cholecystitis, in terms of:
- epidemiology and associated diseases
- morphology
- clinical findings
- complications, including complications of therapy
- Compare and contrast empyema and hydrops of the gallbladder, in terms of:
- etiology
- pathogenesis
- morphology
- clinical findings
- Discuss carcinoma of the gallbladder and extrahepatic bile ducts, in terms of:
- epidemiology
- relationship to cholelithiasis
- morphology
- clinical findings and course
- Describe the indications, benefits, and hazards of liver transplantation.
- Describe the morphology of liver transplant rejection.
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