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Intestines II, Intestines II Tumors MESENCHYMAL TUMORS Lipomas in submuc of SI, LI -benign Spindle cell lesions-musc wall anywhere MOSTLY leiomyomas, -sarcomas -bulky->into lumen or out into peritoneum -mets in 1/3 CLINICAL-mostly (-)Sx -can resemble ulcers->bleeding -obstruction, rare intussusceptio, Intestines II Intestinal Obstruction -most often Sm. Int ->abd pain, vomit, obstipation, can't fart ADHESIONS-w/ healing of peritonitis -from infx, surgery, endometriosis -to other segments or wall ->internal herniation thu new canal ->obstruction->strangulation, Intestines II Vascular D/Os ANGIODYSPLASIA Cecum, Right colon ᡪyo -focal dilation, tortuosity -via NL distention/contraction -LaPlace’s law->highest tension in cecum 20% of significant lower GI bleeds -most span muc/submuc, little sm. mm -sep’d from lumen by epith & endo ->bleeds (acute or chronic), Intestines II Appendix Acute Appendicitis Inflammation->obstruction, more secretion ->increased pressure->collapse vv ->ischemia->bac proliferation ->edema, exudation MORPH-serosa->dull, granular, red -necrosis, abscesses in wall -acute suppurative appendicitis ->green ulceration, gangrene -acute gangrenous appendicitis ->rupture->peritonitis Dx-neutrophilic infiltration of muscularis CLINICAL-adolescents, young adults 1. Pain (periumbilical then RLQ) 2. N/V 3. abd tenderness (esp RLQ) 4. Mild fever 5. WBCs up to 15-20,000 False positives 25% of time, Intestines II Tumors COLORECTAL CARCINOMA -adenoCA-98% of large bowel -60-79yo (if អ consider UC) -risks: obesity; physical inactivity, low fiber, high refined carbs, red meat ->death rates highest in US MORPH- -cecum, asc colon>sigmoid>transverse>desc -mostly singly, sporadically -proximal colon-more polypoid -distal-napkin-ring->constrictions -microscopically similar -some produce mucin->helps invasion -some resemble signet rings, some squamous -anorectal canal-squamous CLINICAL-fatigue, weakness, Fe-def anemia -weakness, malaise, wt loss -rt side-at colonoscopy, bloody stools -left-crampy, changes in bowel habit -rectum, sig more invasive at Dx-worse Px Fe def anemia in older man IS GI CA until r/o Spread to LNs->liver->lungs->bone, serosa Px based on EXTENT OF TUMOR, Intestines II Diverticular Dz Almost all acquired -in esoph, stomach, duodenum (1% of adults) Almost all lack/little musc propria-not "True" Refer to outpouching of colon muc/submuc -rare ណyo, but in 50% ᡴyo -“Diverticulosis” -most small, flask-like (0.5-1cm), SIGMOID -often along taeniae coli, elastic HISTO-thin wall, atrophic/flattened muc -little musc propria, big taeniae coli -hypertrophic circular musc propria Obstruction, perforation->inflam -peridiverticulitis-can->fibrosis, narrowing -or->peritonitis, abscess, sinus tracts Pathogenesis- 1. Focal weakness (insertion of nn, vv.), 2. high pressure (exaggerated peristalsis) -esp w/ low fiber diet -sequestration of segments CLINICAL-only 20% show Sx -cramping, constipation, distention -alternating constipation/diarrhea -can regress or get worse, Intestines II Inflammatory Bowel Dz ULCERATIVE COLITIS Nongranulomatous limited to colon -rectum->proximal progression -ONLY Mucosa/Submuc -Extraint: mig polyarth, sacroiliitis, ank spondylitis, skin lesions -or uveitis, hep pericholangitis, renal d/o Epid-global,US-WHITE WOMEN -slightly more common than Crohn -20-25yo onset HLA-DR2 increased MORPH-10% w/ backwash ileitis -extensive, broad-based ulceration -PSEUDOPOLYP-regenerating island -not as linear as Crohn -NO MURAL THICKENING -NL serosa SEVERE-toxic dmg- musc prop, nn plexus ->TOXIC MEGACOLON Mononuc infiltrate in lam prop Neutrophil epith infiltration->crypt abscess Resolutoin->gland atrophy, fibrosis Epithelial DYSPLASIA can->CA -nuclear atypia, loss of cytoplasmic diff ->adenomas, invasive CA, or plaques Older->banal sporadic adenoma CLINICAL-relapsing bloody, mucoid diarr -for days-mos then regress -recur in mos to yrs-flare-ups w/ stress C. diff can also cause flare-up -perforation is lethal -60% w/ mild dz, 30% need colectomy MOST FEARED-CA in multiple sites -20-30-fold increased risk, Intestines II Tumors GI LYMPHOMA- GI most common -NHL systemic dissemination Populations at risk: 1. Helicobacter gastritis, 2. Med. Natives, 3. immunosuppressed, 4.Sprue Mostly B cell MALTomas (11;18) transloc Mostly in stomach, SI, prox colon -H. pylori Tx can reverse CA Sprue-ass’d-T-cell, prox SI, poor Px -30-40yos w/ Hx of malabsorptive syn. Med. Lymphoma-B-cell -plasma cell release ABNL IgA -many w/ malabsorption preceding -‘immunoproliferative SI Dz’ -can regress after ABX Tx MORPH-varied -into musc->splays fiber->immotility ->perforate, esp after CTX CLINICAL-vague weakness, wt loss -or obstruction, blood loss Px-high survival if localized, Intestines II Tumors Carcinoid Tumors Endocrine cells that release hormones Incidence in 50s -2% of colorectal, but half of SI CA -app, rectal don’t mets even w/ invasion -ileal, gastric, colonic DO MORPH -APP>ileum>rectum>stomach>colon ->kinking obstruction -monotonous tumor cells, many organizations CLINICAL-many (-)Sx Gastric, peripanc, panc-> Zollinger-Ellison Syn-> GASTRIN Cushing->ACTH Hyperinsulinism Px-high cure rate (except app) even w/ hep met Carcinoid Syndrome from excess serotonin -w/ liver mets (cuz inactivated in liver) -systemic problems, CROHN DISEASE Granulomatous-skips around -most small int (term. ileum), colon 1. Sharply delineated, transmural 2. Noncaseating granulomas 3. Fissuring->forms fistulas Epidemiology-teens-20s peak -Western developed nations -More often among JEWS, SMOKERS -HLA-DR1/DQw5 CLINICAL-ppt’d by stress -can present as diarrhea, fever, abd pain -can be more abrupt, resemble appendicitis Extraintestinal: mig polyarth, sacroiliitis, ank spondylitis, erythema nodosum, clubbing -or uveitis, hep pericholangitis, renal d/o -CA RISK (not as bad as UC) Morph MORPH- SKIP LESIONS -granular, dull gray serosa -CREEPING FAT -int wall-rubbery, thick(edema, inflam, fib) -hypertrophy of musc propria ->STRING SIGN in small bowel Early Dz-apththous-like ulcers, edema ->Coalesce into LINEAR ULCERS ->COBBLESTONE -narrow fissures penetrate->adhesions ->fistulas, sinus tracts Mucosal inflam-focal PMN infiltrate ->then into crypt->crypt abscess Chronic Mucosal Dmg-villus blunting, Crypt destruction->atrophy, Mucosal metaplasia (pyloric or Paneth cell meta) Ulceration Transmural inflam affects all layers -lymphoid aggs throughout Noncaseating granulomas-sarcoid-like -even in uninvolved regions Musc mucosa reduplication->thickened