Gastrointestinal Pathology Practice Questions

Q: The following specimen of esophagus and biopsy performed shows all except:

Napkin Ring Stricture. ***Napkin Ring Stricture*** - A **napkin ring stricture** is characteristic of **adenocarcinoma of the colon**, not typically seen in esophageal squamous cell carcinoma. - Esophageal squamous cell carcinoma usually presents as an **infiltrating mass** or **ulcerative lesion**, causing luminal narrowing but not the classic napkin ring appearance [1]. *Diffuse infiltrating squamous cell cancer of esophagus* - This is a common presentation of **esophageal squamous cell carcinoma**, which is implied by the presence of keratin pearls. - The tumor often grows in an **infiltrative pattern**, leading to luminal narrowing and dysphagia [1]. *Keratin pearls* - **Keratin pearls** are a histological hallmark of **well-differentiated squamous cell carcinoma**, indicating squamous differentiation. - Their presence confirms the diagnosis of squamous cell carcinoma in the biopsy. *Can erode into trachea leading to formation of T.E.F* - **Esophageal squamous cell carcinoma** can locally invade surrounding structures, including the **trachea**, due to its aggressive nature [1]. - This invasion can lead to the formation of a **tracheoesophageal fistula (TEF)**, a serious complication. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 766-767.

Q: All are true about the condition shown except:

Mainly involves antral mucosa. ***Mainly involves antral mucosa*** - The condition described by **cerebral convolutions** and **hyperplastic tortuous foveolae** is **Menetrier's disease**, which primarily affects the **fundus and body of the stomach**, not the antrum [1]. - Involvement of the antrum is **uncommon** in Menetrier's disease [1]. *Hyperplastic tortuous foveolae* - **Menetrier's disease** is characterized by marked **foveolar hyperplasia** and **glandular atrophy**, leading to tortuous and elongated foveolae [1]. - This histological feature is a hallmark of the condition [1]. *Cerebral convolutions in stomach mucosa* - The macroscopic appearance of the gastric mucosa in **Menetrier's disease** is often described as having **giant rugal folds** resembling **cerebral convolutions** [1]. - This gross appearance is due to the extensive foveolar hyperplasia and edema [1]. *Protein losing enteropathy* - **Menetrier's disease** is a form of **protein-losing gastropathy**, where there is excessive loss of plasma proteins (especially albumin) into the gastric lumen. - This leads to **hypoalbuminemia** and peripheral edema, which is a significant clinical feature of the disease. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 775-776.

Q: A 15-year-old patient develops intussusception for which he was operated and a segment of intestine showing multiple polyps was resected. The microscopy showed the following pathology. What is the likely diagnosis?

Hamartomatous polyps. ***Hamartomatous polyps*** - The patient's age (15 years), presentation with **intussusception**, and the presence of **multiple polyps** are highly suggestive of a hamartomatous polyposis syndrome, such as Peutz-Jeghers syndrome [1,2]. - **Hamartomatous polyps** are non-neoplastic malformations of normal tissue components, often leading to complications like intussusception in younger individuals [2]. *Tubulovillous polyps* - These are **adenomatous polyps** with a significant risk of malignant transformation, typically seen in older adults. - While they can cause symptoms, **intussusception** in a 15-year-old with multiple polyps is less characteristic of tubulovillous adenomas. *Inflammatory polyps* - These polyps are usually a result of chronic inflammation, such as in **inflammatory bowel disease**. - They are generally not associated with **intussusception** as a primary presentation in a young patient with multiple polyps. *Adenocarcinoma* - **Adenocarcinoma** is a malignant tumor and is rare in a 15-year-old, especially as multiple primary lesions causing intussusception. - While polyps can transform into adenocarcinoma, the initial presentation in a young patient points more towards a **benign polyposis syndrome** [1,2]. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 813-815. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, p. 813.

Q: A 50-year-old male presents with colicky abdominal pain and recurrent bloody diarrhea. Colonoscopy shows geographical ulcers. Histopathology is shown below. Diagnosis is:

Inflammatory bowel disease. ***Inflammatory bowel disease*** - The presentation of **colicky abdominal pain**, **recurrent bloody diarrhea**, and **geographical ulcers** on colonoscopy are classic features of **Inflammatory Bowel Disease (IBD)**, specifically **Crohn's disease** [1]. - Histopathology in Crohn's disease often shows **transmural inflammation**, **non-caseating granulomas**, and **crypt abscesses**, which align with the clinical picture [1,2]. *Pseudomembranous colitis* - This condition is typically caused by **Clostridium difficile infection** and presents with watery diarrhea, fever, and abdominal pain, often after antibiotic use. - Colonoscopy reveals **yellowish-white plaques (pseudomembranes)**, not geographical ulcers. *NHL (Non-Hodgkin Lymphoma)* - While NHL can affect the colon, it usually presents with symptoms like **abdominal mass**, weight loss, and less commonly with recurrent bloody diarrhea as the primary symptom. - Colonoscopy findings would typically show a **mass lesion** or **polypoid growths**, not geographical ulcers. *Adenocarcinoma colon* - **Adenocarcinoma of the colon** is more common in older adults and typically presents with changes in bowel habits, rectal bleeding, and weight loss. - Colonoscopy would reveal a **polypoid mass** or an **ulcerative lesion** that is often solitary and malignant, not widespread geographical ulcers. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 365-367. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 806-807.

Q: The image shows a histological section of intestinal tissue with a granuloma. What is the most likely diagnosis?

Crohn's. ***Crohn's*** - Crohn's disease is characterized by **non-caseating granulomas** in the intestinal wall, which are a key diagnostic feature [1][3]. - These granulomas are typically **non-necrotizing** and can be found in any part of the gastrointestinal tract from mouth to anus [1][2]. *TB* - Tuberculosis (TB) typically forms **caseating granulomas** with central necrosis, which is distinct from the non-caseating granulomas of Crohn's. - TB granulomas often contain **Langhans giant cells** [4] and are associated with a specific infectious etiology. *Cat scratch disease* - Cat scratch disease, caused by *Bartonella henselae*, presents with **stellate or suppurative granulomas** in lymph nodes. - These granulomas are characterized by a central area of **necrosis and neutrophils**, surrounded by epithelioid cells, differing from Crohn's. *Syphilis* - Syphilis, particularly in its tertiary stage, can form **gummas**, which are granulomatous lesions. - Gummas are characterized by **coagulative necrosis** and a chronic inflammatory infiltrate, but they are not typically found in the intestinal wall as a primary feature like in Crohn's. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 806-807. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 365-366. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 366-367. [4] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Inflammation and Repair, p. 109.

Q: A 40-year-old immunocompromised patient presents with complaints of dysphagia. UGI endoscopy shows multiple ulcers in distal esophagus. Biopsy was performed and histopathology is shown below. Diagnosis is:

CMV esophagitis. ***CMV esophagitis*** - The image shows a classic "owl's eye" inclusion, which is a characteristic cytopathic effect of **Cytomegalovirus (CMV)** infection. - CMV esophagitis typically causes large, linear ulcers in the distal esophagus of **immunocompromised patients**, matching the patient's presentation. *Candida esophagitis* - This condition presents with white plaques and fuzzy exudates on endoscopy, and biopsy reveals **yeast and pseudohyphae**, which are not seen in the image. - While it occurs in immunocompromised patients, the microscopic findings are distinct from those of CMV. *Herpes esophagitis* - Herpes esophagitis is characterized by multiple, small, punched-out ulcers and microscopic findings of **Cowdry A inclusions** and **multinucleated giant cells**. - The "owl's eye" inclusion seen in the image is not typical for herpes simplex virus infection. *Barrett's esophagus* - Barrett's esophagus is a metaplastic change in the esophageal lining where **squamous epithelium** is replaced by **columnar epithelium with goblet cells**, usually due to chronic GERD. - It does not involve viral inclusions or ulcerations in the manner described in the clinical vignette or depicted in the image.

Question 1

The following specimen of esophagus and biopsy performed shows all except:

Accepted Answer

Napkin Ring Stricture

Answer

Diffuse infiltrating squamous cell cancer of esophagus

Answer

Keratin pearls

Answer

Can erode into trachea leading to formation of T.E.F

Question 2

All are true about the condition shown except:

Accepted Answer

Mainly involves antral mucosa

Answer

Hyperplastic tortuous foveolae

Answer

Cerebral convolutions in stomach mucosa

Answer

Protein losing gastropathy

Question 3

All are true about the esophageal condition shown in the image except:

Accepted Answer

Mucosal ablation in high grade dysplasia

Answer

Mucin containing goblet cells

Answer

Goblet cells will stain positive with alcian blue

Answer

Risk of development of adenocarcinoma is $0.5 \%$ per year

Question 4

A 35-year-old male patient presents with a history of heartburn. An upper GI endoscopy was done and a biopsy from a suspicious lesion showed the following picture. What does this show? Which special stain will you use for confirmation and what will you look for?

Accepted Answer

Barrett's esophagus, mucin stain, dysplasia

Answer

H. pylori infection, Silver stain, Gram-negative spiral rods

Answer

Adenocarcinoma esophagus, mucin stain, mitotic figures

Answer

Squamous cell carcinoma, keratin stain, keratin pearls

Question 5

A 15-year-old patient develops intussusception for which he was operated and a segment of intestine showing multiple polyps was resected. The microscopy showed the following pathology. What is the likely diagnosis?

Accepted Answer

Hamartomatous polyps

Answer

Tubulovillous polyps

Answer

Inflammatory polyps

Answer

Adenocarcinoma

Question 6

A 40-year-old patient presents with heart burn and increased salivation. UGI endoscopy was performed and biopsy was taken. What is the diagnosis? (AIIMS May 2017)

Accepted Answer

Barrett's esophagus

Answer

Esophagitis

Answer

Adenocarcinoma esophagus

Answer

Squamous cell carcinoma esophagus

Question 7

A 50-year-old male presents with colicky abdominal pain and recurrent bloody diarrhea. Colonoscopy shows geographical ulcers. Histopathology is shown below. Diagnosis is:

Accepted Answer

Inflammatory bowel disease

Answer

Pseudomembranous colitis

Answer

NHL

Answer

Adenocarcinoma colon

Question 8

Endoscopic and Barium swallow findings of a patient are shown below. Select the correct histopathological slide of the patient.

Accepted Answer

Image A

Answer

Image B

Answer

Image C

Answer

Image D

Question 9

The image shows a histological section of intestinal tissue with a granuloma. What is the most likely diagnosis?

Accepted Answer

Crohn's

Answer

TB

Answer

Cat scratch disease

Answer

Syphilis

Question 10

A 40-year-old immunocompromised patient presents with complaints of dysphagia. UGI endoscopy shows multiple ulcers in distal esophagus. Biopsy was performed and histopathology is shown below. Diagnosis is:

Accepted Answer

CMV esophagitis

Answer

Candida esophagitis

Answer

Herpes esophagitis

Answer

Barrett's esophagus

Gastrointestinal Pathology — MCQs

Gastrointestinal Pathology — MCQs

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