Gastrointestinal Pathology Practice Questions

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: Melanosis coli, which occurs due to long term consumption of stimulant laxatives, presents as brown discolouration of colonic mucosa due to deposition of which one of the following pigments?

Lipofuscin. ***Lipofuscin*** - **Melanosis coli** is characterized by the accumulation of **lipofuscin** in macrophages within the lamina propria of the colon. - This accumulation is typically induced by the long-term use of **stimulant laxatives**, particularly those containing anthraquinones (e.g., senna, cascara). *Haemoglobin* - **Haemoglobin** is the protein in red blood cells responsible for oxygen transport and does not deposit in the colonic mucosa to cause brown discoloration in melanosis coli. - Its presence in stool typically indicates **gastrointestinal bleeding**, which is a distinct condition from melanosis coli. *Haemosiderin* - **Haemosiderin** is an iron-storage complex that can accumulate in tissues as a result of **hemorrhage** or increased iron load [1]. - While it can cause brown discoloration, it is not the pigment responsible for the characteristic appearance of melanosis coli. *Melanin* - **Melanin** is the pigment primarily responsible for skin and hair color, produced by melanocytes [1]. - It is not found in significant amounts in the colonic mucosa and is not involved in the pathogenesis of melanosis coli. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Cellular Responses to Stress and Toxic Insults: Adaptation, Injury, and Death, p. 75.

Q: Which one of the following is correct regarding Gastrointestinal Stromal Tumour (GIST)?

50% arise from stomach.. ***50% arise from stomach.*** - The stomach is the most common primary site for GISTs, accounting for approximately **50-60% of cases**. [1] - Other common sites include the small intestine (25-30%), colon/rectum (5%), and esophagus (<5%). *The male to female ratio is 9 : 1.* - GISTs show **no significant gender predominance**, with the male-to-female ratio being roughly 1:1. - While some gastrointestinal cancers have gender disparities, GISTs affect both sexes almost equally. *Lymphatic spread is seen commonly.* - GISTs rarely spread via the **lymphatic system**; lymphatic metastases are uncommon. - The primary routes of GIST metastasis are **hematogenous** spread, commonly to the liver, and direct seeding within the peritoneal cavity. *It arises from epithelial layer.* - GISTs are **mesenchymal tumors**, specifically believed to originate from the **interstitial cells of Cajal** or their precursor cells. [1] - These cells are found in the muscularis propria layer of the gastrointestinal tract, not the epithelial layer. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 782-784.

Q: A 40 year old male patient complains of severe acute abdominal pain. Radiologic examination reveals multiple gall stones. On histologic examination, foci of necrosis containing shadowy outlines of necrotic cells surrounded by basophilic calcium deposits were seen. Which type of necrosis is seen in this patient?

Fat. ***Fat*** - The description of **foci of necrosis** containing **shadowy outlines of necrotic cells** surrounded by **basophilic calcium deposits** is characteristic of **fat necrosis**, specifically enzymatic fat necrosis [1]. - This typically occurs in the **pancreas** during acute pancreatitis, where activated **lipases** released from damaged pancreatic cells digest fat, leading to the formation of **calcium soaps** [1], [2]. *Liquefactive* - This type of necrosis is characterized by the **dissolution of dead cells** into a viscous liquid mass, often seen in **brain infarcts** or **abscesses**. - It does not present with the shadowy outlines of necrotic cells or calcium deposits as described. *Fibrinoid* - **Fibrinoid necrosis** involves immune-mediated damage to blood vessel walls, where **fibrin** and plasma proteins deposit within the vessel wall. - It is typically seen in conditions like **vasculitis** or **malignant hypertension** and does not involve the saponification of fat. *Coagulative* - **Coagulative necrosis** is characterized by the preservation of the **architectural outline** of dead cells for several days, typically due to **ischemia** in solid organs (e.g., heart, kidney) [1]. - While cells are necrotic, there is no mention of **calcium deposits** or the specific fat saponification associated with the described findings. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Cellular Responses to Stress and Toxic Insults: Adaptation, Injury, and Death, pp. 53-55. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Pancreas, pp. 889-890.

Q: Congenital megacolon is confirmed by:

Rectal biopsy. ***Rectal biopsy*** - **Rectal biopsy** is the **gold standard** for diagnosing congenital megacolon (Hirschsprung disease) by demonstrating the **absence of ganglion cells** in the myenteric and submucosal plexuses [1]. - This absence of innervation leads to a functional obstruction, causing proximal bowel dilation [1]. *Sigmoidoscopy* - While **sigmoidoscopy** allows visualization of the mucosa, it cannot directly confirm the **absence of ganglion cells**, which is the hallmark of Hirschsprung disease. - It may reveal features like a **narrowed segment** transition to a dilated segment but requires further diagnostic confirmation. *Invertogram* - An **invertogram** is used to assess the **anal position** and check for imperforate anus by showing the gas bubble in the rectum relative to the skin marker. - It does not provide information about the **innervation of the rectosigmoid colon** or the presence of ganglion cells. *Barium enema* - A **barium enema** can reveal characteristic findings like a **transition zone** between a narrowed aganglionic segment and a dilated, normally innervated colon. - However, it is a **radiological study** and cannot definitively confirm the histopathological absence of ganglion cells, which requires a tissue biopsy. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 759-760.

Q: Hirschsprung disease is due to

Failure of migration of neural crest cells. ***Failure of migration of neural crest cells*** - Hirschsprung disease is characterized by the **absence of intramural ganglion cells** (Meissner's and Auerbach's plexuses) in the distal colon [1]. - This aganglionosis results from the **failure of neural crest cells to migrate** completely to the distal parts of the gastrointestinal tract during embryonic development [1]. *Mucosa thickening* - **Mucosal thickening** is not the primary pathophysiology of Hirschsprung disease. The core issue is aganglionosis in the bowel wall. - While there can be secondary changes in the colonic wall due to obstruction, primary mucosal thickening does not cause the disease. *Loss of crypts* - **Loss of crypts** is typically associated with conditions like **Crohn's disease** or **ulcerative colitis**, where there is inflammation and damage to the intestinal lining. - This is not a characteristic feature or the underlying cause of Hirschsprung disease. *None of the above* - This option is incorrect because the **failure of neural crest cell migration** is indeed the established cause of Hirschsprung disease [1]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. (Basic Pathology) introduces the student to key general principles of pathology, both as a medical science and as a clinical activity with a vital role in patient care. Part 2 (Disease Mechanisms) provides fundamental knowledge about the cellular and molecular processes involved in diseases, providing the rationale for their treatment. Part 3 (Systematic Pathology) deals in detail with specific diseases, with emphasis on the clinically important aspects., pp. 94-95.

Question 1

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 2

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 3

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 4

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 5

Melanosis coli, which occurs due to long term consumption of stimulant laxatives, presents as brown discolouration of colonic mucosa due to deposition of which one of the following pigments?

Accepted Answer

Lipofuscin

Answer

Haemoglobin

Answer

Haemosiderin

Answer

Melanin

Question 6

Which one of the following is correct regarding Gastrointestinal Stromal Tumour (GIST)?

Accepted Answer

50% arise from stomach.

Answer

The male to female ratio is 9 : 1.

Answer

Lymphatic spread is seen commonly.

Answer

It arises from epithelial layer.

Question 7

Consider the following:

1. Cholesterolosis
2. Adenomyomatosis
3. Polyposis
4. Cholelithiasis

To which of the above does cholecystoses refer to?

Accepted Answer

1 and 2 only

Answer

1 and 3 only

Answer

1, 2 and 3

Answer

2, 3 and 4

Question 8

A 40 year old male patient complains of severe acute abdominal pain. Radiologic examination reveals multiple gall stones. On histologic examination, foci of necrosis containing shadowy outlines of necrotic cells surrounded by basophilic calcium deposits were seen. Which type of necrosis is seen in this patient?

Accepted Answer

Fat

Answer

Liquefactive

Answer

Fibrinoid

Answer

Coagulative

Question 9

Congenital megacolon is confirmed by:

Accepted Answer

Rectal biopsy

Answer

Sigmoidoscopy

Answer

Invertogram

Answer

Barium enema

Question 10

Hirschsprung disease is due to

Accepted Answer

Failure of migration of neural crest cells

Answer

Mucosa thickening

Answer

Loss of crypts

Answer

None of the above

Gastrointestinal Pathology — MCQs

Gastrointestinal Pathology — MCQs

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