Number of questions: 15

PDF File Each question has only one answer.

Case #1 (question #1 and #2):

    A 35 year-old gentleman with a history of familial adenomatous polyposis (FAP), status post colectomy and now with duodenal polyps. Representative images are illustrated below:

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1.   Which of the following statements about small bowel manifestations of these polyps are TRUE? Answer

A.      Polyps develop preferentially in the duodenum.

B.     Polyps are usually evident at about the same age as colorectal polyps.

C.     These polyps carry only a slight lifetime risk of cancer.

D.     These polyps are usually solitary

2.   Which of the following predisposes risks for developing small bowel adenocarcinoma? Answer

A.      Hereditary non-polyposis colorectal cancer syndrome (HNPCC).

B.     Crohn’s disease.

C.     Familial adenomatous polyposis (FAP).

D.     Celiac disease.

E.     All of the above.

Case #2 (question #3):

    A 65 year-old lady with a family history of colon cancer undergoing screening colonoscopy and was found to have a 1.5 cm nodule in the cecum Representative images are illustrated below:

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3.   Which statement is TRUE about this lesion of the colorectum? Answer

A.      Patients generally are diagnosed in the 4th decade.

B.     Patients most commonly present with symptoms of flushing and diarrhea.

C.     It is more commonly found in the rectum than other parts of the colon.

D.     Rectal location is generally associated with a poor prognosis.

Case #3 (question #4 and #5):

    A 65 year-old lady with abdominal pain.  Endoscopy revealed gastric erosions and mucosal granularity. Representative images are illustrated below:

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4.   Prior to immunohistochemical studies, the differential diagnosis includes the following except? Answer

A.      Follicular lymphoma.

B.     Helicobacter gastritis.

C.     Reactive gastropathy.

D.     Small lymphocytic lymphoma/chronic lymphocytic leukemia.

E.     Extranodal marginal zone B-cell lymphoma (MALT lymphoma).

5.   What is the expected immunophenotype of the atypical infiltrate in extranodal marginal zone lymphoma (MALT lymphoma)? Answer

A.      CD20+, CD79a+, CD5-, CD10+, BCL2+, BCL6+, CD43-.

B.     CD20+, CD5+, CD10-, BCL2+, BCL6-, FMC7-, CD43+.

C.     CD20+, CD79a+, CD5-, CD10-, CD23-, CD43+/-, CD11c+/- (weak).

D.     CD20+ (weak), CD79a+, CD5+, CD10-, CD23+, CD43-, FMC7-.

Case #4 (question #6):

    A 58 year-old female with a rectal polyp. Representative images are illustrated below:

Click on thumbnails to see full sized pictures.

6.   Which of the following is NOT typically associated with this diagnosis? Answer

A.      Mucocutaneous pigmentation.

B.     Autosomal recessive inheritance.

C.     Tumors of the ovary.

D.     Increased risk for development of breast and pancreatic cancer.

E.     Mutations in the serine threonine kinase (STK11) tumor suppressor gene on chromosome 19.

Case #5 (question #7 and #8):

    A 50 year-old man with a 5 mm subepithelial lesion along the greater curvature of stomach. Representative images are illustrated below:

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7.   What is the best diagnosis? Answer

A.      Hyperplastic polyp.

B.     Gastric adenocarcinoma, intestinal type.

C.     Fundic gland polyp.

D.     Peutz-Jeghers polyp.

E.     Processing artifact in otherwise normal gastric mucosal biopsy.

8.   These lesions are most commonly identified in patients with familial adenomatous polyposis (FAP)? Answer

A.      True.

B.     False.

Case #6 (question #9):

    A 67 year-old woman with heme-positive stool. Endoscopy revealed a gastric polyp. Representative images are illustrated below:

     Click on thumbnails to see full sized pictures.

9.   Which of the following statements regarding this lesion is TRUE? Answer

A.      Stomach is the least common site in the gastrointestinal tract for this lesion.

B.     It responds to Gleevac treatment.

C.     It is thought to be reactive in nature.

D.     It is associated with peripheral eosinophilia.

Case #7 (question #10 and 11):

    A 51 year-old woman with symptomatic internal hemorrhoids.  Hemorrhoidectomy was performed.  In addition to hemorrhoids, the surgeon felt there was an additional mass in the rectum. Representative images of the hemorrhoid and the rectal lesion are illustrated below:

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10. The patient has hemorrhoids, and in addition a second diagnosis for the rectal lesion is made.  What is the most likely diagnosis for the rectal lesion? Answer

A.      Mucosal prolapse.

B.     Tubular adenoma.

C.     Hyperplastic polyp.

D.     Invasive adenocarcinoma.

E.     Diverticulosis.

11. Which of the following is TRUE of the rectal lesion discussed in question 10? Answer

A.      It occurs exclusively in the rectum.

B.     It is easily confused clinically with the ulcers of Crohn’s disease.

C.     It usually shows ulceration of the mucosa.

D.     The epithelium is seldom hyperplastic.

Case #8 (question #12):

    A 55 year-old woman, 2 months status post lung transplantation, developed abdominal pain and diarrhea.  She subsequently underwent a segmental resection of the colon. Representative images are illustrated below:

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12. Which of the following statements regarding this lesion is FALSE? Answer

A.      It is most likely associated with Clostridium difficile.

B.     It is rarely associated with antibiotic use.

C.     Clostridium difficile toxins are the main cause of this disease.

D.     Similar histologic changes may be seen in ischemia.

Case #9 (question #13):

    A 30 year-old woman presented with chronic watery diarrhea. Colonoscopy showed normal appearing colon and terminal ileum. Representative images are illustrated below:

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13. What is the most likely diagnosis? Answer

A.      Acute self-limited colitis.

B.     Pseudomembranous colitis.

C.     Collagenous colitis.

D.     Crohn’s disease.

E.     Ulcerative colitis.

Case #10 (question #14 and #15):

    A 33 year-old gentleman with intermittent dysphagia and “ringed esophagus” on endoscopy. Biopsy was performed from the mid-esophagus. Representative images are illustrated below:

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14. What is the most likely diagnosis? Answer

A.      Candida esophagitis.

B.     Herpes esophagitis.

C.     Eosinophilic esophagitis.

D.     Reflux esophagitis.

E.     Glycogenic acanthosis.

15. Which of the following statement is FALSE when eosinophilic esophagitis is compared to reflux esophagitis? Answer

A.      Eosinophilic esophagitis responds to steroid treatment.

B.     The number of eosinophils in eosinophilic esophagitis tend to be higher.

C.     The infiltration of eosinophils tends to involve both the epithelium and submucosa in eosinophilic esophagitis.

D.     Eosinophilic infiltration tends to be found in distal esophagus.

References:

1. Hamilton SR, Aaltonen LA.  World Health Organization Classification of Tumours; Pathology & Genetics of Tumours of the Digestive System. IARC Press. Lyon, 2000.

2. Odze RD, Goldblum JR, Crawford JM. Surgical Pathology of the GI tract, Liver, Biliary Tract, and Pancreas. Saunders, Philadelphia, 2004

3. Ming S-C, Goldman H. Pathology of the Gastrointestinal Tract. Williams and Wilkins, second edition, 1998.

4. Riddell RH, Petras RE, Williams GT, Sobin LH. Tumor of the Intestines, Atlas of Tumor Pathology, AFIP Fascicle, 3^rd series, 2003.

5. Day DW, Jass JR, Price AB et al.  Morson and Dawson’s Gastrointestinal Pathology.  Blackwell Publishing, 4th edition, 2003.