Clinical Information: This 45-year-old business executive suffered from epigastric pain for many years. The pain occurred most often at night. It was relieved by the ingestion of food and antacids. A duodenal ulcer was noted on repeated gastrointestinal radiographs, but showed no improvement with treatment. Endoscopy confirmed the presence of the ulceration for which he received medical treatment. Two hours prior to admission he suddenly developed severe abdominal pain and sought medical attention in the hospital emergency room. On physical examination the skin was noted to be pale. Blood pressure = 100/60; pulse = 110; and temperature = 100^oF. The abdomen was described as rigid and bowel sounds were absent. Diffuse rebound tenderness was also noted. On upright abdominal radiographs, air was noted between the liver and diaphragm.

Significant laboratory findings included: Hemoglobin = 9.0 (13.5-18.5) g/dl; Mean corpuscular volume (MCV) = 85 (82-92)u3; Mean corpuscular hemoglobin = 29 (27-31)pg. A slight shift to the left was noted on the WBC differential. He had an emergency operation to close a perforated ulcer, but died 5 hours postoperatively in shock.

Gross Pathology: An ulcer with punched-out edges and a base covered with shaggy, white-gray tissue, was present in the first part of the duodenum. The surrounding mucosa radiated from the ulceration in a spokewheel fashion. The base of the ulcer contained a 2 mm perforation and the edges of this perforation contained small clots of blood. The duodenum was filled with clotted blood.

Microscopic Pathology: - The ulcer is a well circumscribed, punched-out niche, with sharp edges; it occupies all layers of the bowel wall. - The superficial layer contains necrosis and debris. The deepest layer is connective tissue.

Questions:
1. Discuss the pathogenesis of peptic gastrointestinal ulceration.
2. Compare the gross appearance of a peptic ulcer in the stomach with that of an ulcerated adenocarcinoma.
3. What is the significance of the subdiaphragmatic air in the upright films of the abdomen? 4. Describe the pathogenesis of anemia in this patient?

Clinical Information: This 34-year-old white male was employed as an advertising executive. He had a two year history of intermittent, diffuse, crampy abdominal pain that was sometimes accompanied by diarrhea and a low-grade temperature (99-101^oF). The loose stools sometimes contained small amounts of mucus and blood. He had seen a physician several times and was treated for gasteroenteritis. He had no history of travel outside the country. An uncle had been treated for "colitis" for many years. Two weeks prior to this admission he lost his appetite and his weight fell from 180 to 170 pounds. His abdominal pain and diarrhea recurred. The pain became more severe in the last several days and the diarrhea intensified. For the last three weeks he had been working 12-16 hours each day preparing a new advertising campaign for an important client.

Physical examination revealed a thin, ill-appearing white male with pale skin. Vital signs included blood pressure = 140/80; pulse = 100; and temperature = 100.6^oF. The conjunctivae were pale. The abdomen was tense and tenderness was present in the right lower and upper quadrants. A poorly defined mass was palpated in the right mid-abdomen. Small bowel radiographs disclosed distortion of the mucosal folds in the terminal ileum and narrowing of the lumen.

Significant laboratory findings included: hemoglobin = 10.5 g/dl (Normal Ð 13.5-18.5); total serum protein = 5.4 g/dl (Normal = 6.7-7.8); albumin = 2.8 g/dl (Normal 3.2-4.5). Red cell indices showed hypochromic, microcytic changes. A slight shift to the left was noted on the WBC differential.

 

Gross Pathology: A laparotomy was performed and a 22.0 cm segment of abnormal small bowel was resected. The specimen consisted of several adherent loops of small bowel. The mesentery extended over the greatly thickened and firm wall of the resected segment of bowel. The usual folds were absent from the mucosal surface. In other areas no gross changes were evident. Small ulcers were seen here and there and the lumen of the bowel was markedly narrowed.

Microscopic Pathology: - All layers of the bowel wall are involved by either inflammation or fibrosis or both. - Areas between ulcers are covered with mucosa and elevated by edema, inflammation and fibrosis of the underlying tissue, creating the cobblestone appearance on gross examination. - Granulomas typical of this disease are found in only some of the cases and may not be on your slide.

Questions:

1. What are the typical features of regional enteritis in the history of this patient?
2. Why was a mass palpated on the abdomen in this patient?
3. What leads to the formation of enteric adhesions in these patients?

Clinical Information: This 28 year old medical student had a five year history of gradually worsening attacks of intermittent bloody diarrhea. The diarrhea was accompanied by left-sided cramping, abdominal pain, anorexia, weight loss, and low grade fever. Endoscopy with small bowel and colon biopsies was performed. Colon radiographs revealed a dilated left colon with longitudinal and transverse mucosal ulcerations. Stool cultures for bacteria and examination for ova and parasites were negative. CBC showed WBC = 13.2 (Normal=4.5-11.0) x 103/ul; PMN = 76 (Mean Normal = 56)%; Bands = 8 (Mean Normal = 3)%; Lymphocytes = 16 (Mean Normal = 34)%; Hemoglobin = 10 (Normal = 12-16) g/dl. Indices were normal. She was placed on steroid therapy. Physical examination reveals and ill-appearing white female in acute distress. Generalized lower abdominal tenderness was present and bowel sounds were hyperactive. Rigidity and rebound tenderness were absent. Rectal examination showed mild tenderness; stool was watery and mucoid in appearance. Stool hematest was 1+ positive. The diarrhea became refractory to medical therapy and a portion of her colon was removed.

Gross Pathology: The segment of the colon measured 58 cm in length. The serosal surface was hyperemic. The bowel appeared edematous and the wall somewhat thinned. The mucosal surface contained numerous longitudinal ulcerations with evidence of active mild bleeding. Scattered polypoid excrescences were noted.

Microscopic Pathology: - Marked vascular congested ulcerations are noted. - Accumulation of polyps in the crypts of Lieberkuhn = crypt abscesses. - Lack of involvement of underlying wall.

Questions:
1. Why are palpable abdominal masses rare in patients with ulcerative colitis?
2. How are pseudopolyps formed in ulcerative colitis? Why are they pseudopolyps?
3. How often is the rectum involved in ulcerative colitis? The ileum?

Clinical Information: A 53-year-ol man complained of anorexia, belching, and nausea for the last six to eight months. In the last three months he had a weight loss of 12 pounds. A sense of epigastric fullness and occasional vomiting after meals had developed in the last month prior to admission. Physical examination revealed an ill-appearing white male in no acute distress. The abdomen was scaphoid, but hypertympanic in the epigatrium. Bowel sounds were hyperactive and tenderness was not elicited. An upper gastrointestinal radiograph using barium swallow showed a distended stomach with an intact outline. Peristalsis was irregular and the gastric wall was rigid. Gastroscopy revealed a coarse mucosal surface, but gastric brushings were negative. An exploratory laparotomy was performed and the stomach removed. The serosal surface of the stomach appeared pale and the gastric wall was firm to palpation. When the stomach was opened along the greater curvature the wall was somewhat thickened and pale tan in color. The mucosal surface showed somewhat coarse folds and here and there the usual architecture was obliterated.

Questions:
1.How has the number of deaths due to carcinoma of the stomach changed in the last two decades?
2. Relate the clinical findings of belching, epigastric fullness, and postprandial vomiting to the mechanical effects of this pattern of neoplastic growth in the stomach.
3. What explains the radiographic appearance of this tumor?
4. Why are cytologic studies often negative in tumors with this growth pattern?