Exam 1 Flashcards

Question

What is the principal regulator of the mucus layer of the G.I. tract?

Answer 1

• Absorptive cells that support paracellular and transcellular transportation of nutrients, electrolytes, and water • make up the epithelial barrier, highly regulated, selective permeability, tight junctions

Answer 2

Enterocytes

Answer 3

• tight junctions between epithelial cell • mucus layer provided by the goblet cells • trefoil proteins, rapid plug of breached barrier • apical surface with dense micro villi, layer of filamentous brush border glycocalyx

Answer 4

1.) **neutralizing antibodies:** natural antibodies **IgM, IgG from B1 cell**, and toxins, cap receptors 2.) **aggregating antibodies: IgA,** most abundant antibody produced, non-complement fixing, protease resistant, binds and renders antigen too large to pass through the epithelial wall

Answer 5

• interferons, IFN- Alpha, beta • increase MHC class I expression and induce cell mediated toxicity

Answer 6

• anti-microbial peptides: **defensins** • bacterial permeability increasing proteins (BPI)

Answer 7

• **macrophages and neutrophils** • defensins- aka neutrophils • complement (pro-inflammatory) • lysosome reactive oxygen species, ROS • reactive nitrogen species, RNS

Answer 8

Poly-cysteinyl cationic peptides created by paneth cells (and stores in granules) in the GI crypts that permeabilize membranes * **alpha-defensins:** expressed by neutrophils, NK cells, Paneth cells, epithelial cells * **beta-defensins:** expressed by epithelial cells

Answer 9

• IgE • vasoactive substances (eosinophils) like leukotrienes, prostaglandins, and histamines • mucus • smooth muscle contraction, directional flow (peristalsis)

Answer 10

• chelation • lactoferrin: Fe • Calprotectin: Ca • lipocalin: lipids • indoleamine 2,3-dioxygenase: tryptophan

Answer 11

**M cells,** however there are macrophages on the basolateral side to engulf the microbes ~ how vaccination typically works

Answer 12

1. Lamina propria containing macrophages and lymphocytes 2. Epithelium containing enterocytes with tight junctions

Answer 13

CD8, recognize MHC class I antigen • alpha-beta: thymus derived T cell receptor, common • delta-gamma: non-thymic derived, combination capacity

Answer 14

• villus • crypts • peyers patch

Answer 15

Peyer’s patches

Answer 16

Alpha4beta7 — MAdCAM binding of the lymphocyte and endothelial cell, respectively

Answer 17

• IL-10 • TGF-beta • sIL-1R ~ these are challenged by inflammatory properties such as LPS and NF-kB

Answer 18

• **TLR2:** highly expressed on epithelial cells, proximal colon, senses G+, and lipoteichoic acid • **TLR4, CD14:** express at higher levels in the colon, senses G-, and LPS • **NOD2:** expressed by epithelial cells in the ilium, paneth cells, senses muramyl dipeptide and ssRNA

Answer 19

CD4+ recognizing MHC class II antigen

Answer 20

• cytokines: IFN-gamma, TNF-alpha, IL12 • fxn: defense to intracellular pathogens

Answer 21

• cytokines: IL10, 13, 5, 4 • fxn: defense to helminths

Answer 22

• cytokines: IL17, 21, 22 • fxn: defense to extracellular bacteria and parasites

Answer 23

• cytokines: IL10 • fxn: regulate tolerance

Answer 24

Positioned in lymphoid and intestinal mucosa (**With high density in the caecum**) which allows for rapid recruitment, localization by Beta7 integrins on endothelial cells, in order to alter the balance of Th1:Th2 (recruit more Th1)

Answer 25

• substance P • histamine • serotonin

Answer 26

• Firmicutes (lactobacilli), G+ • bacteroidetes, G- • proteobacteria, G- • actinobacteria, G+ • spirochetes • fusobacteria

Answer 27

Facultative anaerobe streptococci

Answer 28

• stomach has sparse microflora (10^4) • proteobacteria, firmicutes, actinobacteria, and bacteroidetes

Answer 29

* bacilli, streptococcus, actinobacteria, cornibacteria

Answer 30

Firmicutes, bacteroidetes, methanobrevibacter

Answer 31

• decreased peristalsis • aberrant pH (too high, PPI?) • anatomical abnormalities • disturbance in normal microbiome-change in population

Answer 32

* inflammation in response to bacteria/endotoxin relates to damage of epithelium—> * chronic diarrhea/weight loss * abdominal discomfort/bloating/gas * malabsorption of nutrients (A, D, E, B12, iron) * greasy, bulky, smelly stools * anemia

Answer 33

• chronic pancreatic insufficiency • IBS • narcotic use, or post radiation • hypothyroidism • diabetes • scleroderma

Answer 34

1. Therapeutic trials of antibiotics 2. Small bowel aspiration and culture 3. Breath testing for methane and hydrogen

Answer 35

• antibiotics: ciprofloxacin, metronidazole, neomycin, **rifaximin**, tetracyclines **rifa: inhibits bacterial DNA dependent RNA polymerase**

Answer 36

Elemental diet for 14 days, simple nutrients taken up in the proximal section of the small intestine leading to starvation of bacteria

Answer 37

• vaginal: bacteroides spp. • C-section: clostridium spp.

Answer 38

• formula: Higher counts of bacteroides, clostridium, and enterobacteria • breast: anaerobes such as staphylococcus, enterococcus, lactobacilli, enterobacteria; especially **bifidobacteria**

Answer 39

• fermentation of indigestible food • synthesis of essential vitamins • removal of toxic compounds • strengthening the mucosal barrier • stimulate and regulate the development of immune tissues • **prevent establishment and infection of alien microbes by out-competing**

Answer 40

An infection with normal flora typically following broad spectrum antibiotic use. Most commonly seen in hospitalized patients. Symptoms include: 3+ loose, foul smelling stools for 1-2 days with no blood, fever, abdominal pain, dehydration

Answer 41

Pseudomembranous colitis: severe complication leading to perforation of the colon, toxic megacolon, and death ~ white yellow plaques composed of fibrin, inflammatory cells, and cellular debris

Answer 42

• **Toxin A and B (TcdA and TcdB)** which inactivate the host cell **Rho GTPases** leading to formation of pseudomembranes (from hyperstimulation of immune system— neutrophils). They can also drive cytoskeletal disruption and apoptosis of colon epithelial cells

Answer 43

• gram-positive, endospores/spore forming, bacilli, obligate anaerobe, motile

Answer 44

1. Discontinue offending antibiotic, rehydrate 2. Administer abx: *formerly metronidazole,* vancomycin (G+), fidaxomicin (macrolide, low absorption) 3. Potential for fecal transplant, especially in recurring cases

Answer 45

1. Don’t use antidiarrheal meds (this can slow down the removal of bacteria) 2. Don’t treat asymptomatic carriers 3. Remember, diarrhea has other infectious causes

Answer 46

• PCR, molecular (same day, sensitive) • antigen detection (one hour, not specific enough) • toxin testing (ELISA assay, pair with other tests, same day) • stool culture (slow turnaround, highly sensitive)

Answer 47

• RUQ • RLQ • LUQ • LLQ

Answer 48

• right hypochondriac region • epigastric region • left hypochondriac region • right lumbar region • umbilical region • left lumbar region • right iliac region • hypogastric region • left iliac region

Answer 49

1. Skin 2. Campers fascia 3. Scarpa fascia 4. Superficial investing fascia 5. External oblique 6. Intermediate investing fascia 7. Internal oblique 8. Deep investing fascia 9. Transversus abdominis 10. Transversalis fascia 11. Extraperitoneal fat 12. Parietal peritoneum

Answer 50

• double layer of peritoneum that wrap around and connect organs to posterior body wall • continuous reflections of parietal and visceral peritoneum • **allows intraperitoneal organs to be highly mobile**

Answer 51

• fully encased by peritoneum • small intestine, stomach, gallbladder

Answer 52

• organs that sit behind the peritoneum fixed to the posterior wall • kidney, aorta

Answer 53

• they become intraperitoneal but are pushed against the posterior abdominal wall during development • pancreas, ascending and descending colon

Answer 54

• double layer of peritoneum that connects an organ to another organ • hypogastric ligament, gastrosplenic ligament, splenorenal ligament

Answer 55

Four layers of peritoneum that attaches to the stomach and proximal duodenum and then to the **transverse colon**

Answer 56

• double layer of peritoneum that connects the stomach and duodenum to the liver • hepatoduodenal ligament and hepatogastric ligament

Answer 57

• communication between the greater sac and the lesser sac • also allows for fluid and infection to spread

Answer 58

• excess fluid in the peritoneal cavity; commonly in the inferior peritoneal cavity, paracolic gutter, or hepatorenal • can be caused by mechanical injury, or portal hypertension

Answer 59

1. Splenic artery 2. Proper hepatic artery 3. Right gastric artery

Answer 60

• stomach • liver • gallbladder • proximal duodenum • pancreas • spleen

Answer 61

Falciform ligament

Answer 62

Increase surface area in order to increase absorption of nutrients

Answer 63

Parasympathetic: anterior and posterior vagal trunks Sympathetic: celiac plexus: T6-T9 segments of spinal cord via greater splanchnic nerve

Answer 64

• thickening of the smooth muscle in the pylorus which inhibits food from exiting the stomach (resistive gastric emptying) • surgical fix

Answer 65

• filters blood from portal system • secretes bile • stores glycogen

Answer 66

• common bile duct (bile from liver) • proper hepatic artery (blood to liver) • portal vein (blood from intestines) **All contained in the hepatoduodenal ligament**

Answer 67

Hepatocytes are replaced by fat and fibrous tissue. Liver becomes firm and circulation becomes impeded — alcoholic cirrhosis is a common cause of hypertension

Answer 68

Cystic artery <— hepatic artery proper <— common hepatic artery

Answer 69

• composed of: esophagus, stomach, part of duodenum, liver, gallbladder • supplied by: celiac artery

Answer 70

• composed of: remainder of small and large bowel up to splenic flexure • supplied by: superior mesenteric artery

Answer 71

• composed of: remainder of large bowel to superior part of anal canal • supplied by: inferior mesenteric artery

Answer 72

1. Omphaloenteric duct 2. Omphalomesenteric duct 3. Yolk sac

Answer 73

Omphaloenteric duct can persist (blind sac, fibrous, fistula)

Answer 74

• part of the hindgut • separated by the choacal membrane to form the urogenital sinus and the anorectum

Answer 75

• Where ectoderm meets endoderm and visceral mesoderm from the hind gut • delineated change in neurovasculature

Answer 76

• first part of the large intestine • lower right quadrant of the abdomen • common site of bowel obstruction

Answer 77

Vestigial longitudinal muscle on the colon

Answer 78

• small outpouching in the mucosa of the colon • often occur near teniae- where vessels enter the bowel because it is a weak spot • get filled with food bits and become inflamed

Answer 79

• ileal and jejunal • iliocolic • appendicular • right colic • middle colic

Answer 80

• left colic • sigmoid • superior rectal

Answer 81

• pancreaticoduodenal: celiac trunk to superior mesenteric artery • marginal artery: superior mesenteric artery to inferior mesenteric artery • rectal artery: inferior mesenteric artery to internal iliac arteries

Answer 82

Marginal artery

Answer 83

• lower thoracic splanchnic nerves (greater, lesser, least) • lumbar splanchnic nerves

Answer 84

• submucosal plexus: epithelial cells and smooth muscle of the mucosa • myenteric plexus: smooth muscle of the gut tube walls

Answer 85

• Vagus: foregut, midgut • pelvic splanchnic nerves (S2-S4): hindgut

Answer 86

• pain: travels with sympathetic pathways • reflex: travels with parasympathetic pathways

Answer 87

In the dorsal horn

Answer 88

• Meckel’s diverticulum: 2% of people, within 2 feet of ileocecal Junction, 2 inches long

Answer 89

1. Superior 2. Descending 3. Inferior 4. Ascending

Answer 90

The proximal part of the superior duodenum (the rest is retroperitoneal)

Answer 91

The descending part— this is the opening for the hepatopancreatic ampulla; combined bile and main pancreatic duct

Answer 92

Pancreaticoduodenal lymph nodes and the pyloric lymph nodes

Answer 93

Superior mesenteric lymph nodes

Answer 94

• stenosis: incomplete degeneration of the epithelial plug • atresia: usually in the second or third segments of the duodenum

Answer 95

• accessory digestive gland • secondarily retroperitoneal

Answer 96

The hepatopancreatic ampulla (of Vater) which drains into the duodenum via the major duodenal papilla

Answer 97

• vagus • celiac ganglion— splanchnic nerves

Answer 98

• a congenital anomaly that consists of a ring of pancreatic tissue partially or completely encircling the descending portion of the duodenum, and can obstruct the duodenum • anomalous bifid ventral pancreatic bud- half rotates normally, half remains ventral • dorsal and ventral sections fuse leading to a ring around the descending duodenum • **more common in females, down syndrome, cardiac defects, intestinal malrotation**

Answer 99

1. Splenic 2. Superior mesenteric 3. Inferior mesenteric 4. Pancreatic

Answer 100

Paraumbilical

Answer 101

1. **Left gastric** —> esophageal —> azygous 2. **Superior rectal**—> middle and inferior rectal 3. **paraumbilical** —> epigastric 4. **Colic** —> communicating veins of Retzius —> retroperitoneal veins —> IVC **bold is portal**

Answer 102

1. Esophageal varices 2. Caput medusae 3. Ascites 4. Hemorrhoids

Answer 103

• perirenal fat • Renal fascia • pararenal fat

Answer 104

• the left renal vein passes over the aorta and under the superior mesenteric artery— downward traction or aneurysm in the SMA can compress the vein • symptoms: left flank pain, left ovarian/testicular pain

Answer 105

Compression of the third part of the duodenum by the superior mesenteric artery— similar to nutcracker syndrome

Answer 106

Left: drains into the left renal vein Right: drains into the inferior vena cava

Answer 107

Greater thoracic: T5-9 Lesser thoracic: T10-11 Lease thoracic : T12 ~ synapse in pre-aortic ganglia: celiac, superior mantric, aorticorenal

Answer 108

• lumbar: L1-L4 sympathetic trunk ganglia • sacral: S1-S2 sympathetic trunk ganglia ~ actual nerve fibers are from spinal cord levels L1 and L2, synapse in the inferior mesenteric and superior hypogastric pre-aortic ganglia ~ short preganglionic fiber, long postganglionic fiber

Answer 109

• vagus nerve • pelvic splanchnics (craniosacral origin) • long preganglionic fiber, short postganglionic fiber

Answer 110

• S2-S4 • parasympathetic • exit anterior rami, synapse on walls of the target organs (NO interaction with sympathetic trunk)

Answer 111

Celiac, superior mesenteric, aorticorenal, renal, inferior mesenteric, superior hypogastric

Answer 112

* sympathetic: postsynaptic directly from T1-T4 * parasympathetic: upper 1/3 from the recurrent laryngal, lower 2/3 from the vagus nerve ~ vagal trunks: anterior= left, posterior= right

Answer 113

• sympathetic: synapse in the celiac ganglia • parasympathetic: gastric branches of the vagal trunks

Answer 114

• sympathetic: synapse in celiac, superior mesenteric ganglia • parasympathetic: vagal fibers passed through celiac and SM plexus to synapse in the organ wall

Answer 115

**innervation changes at the left colic Flexure** * sympathetic: superior mesenteric before the flexure, inferior mesenteric after * Vagus before, pelvic splanchnic after

Answer 116

Embedded within the G.I. tract, it is within the longitudinal muscle layer and it coordinates peristaltic contractions

Answer 117

• embedded within the G.I. tract, it is within the submucosal layer • controls local secretions, blood flow, immune activity, absorption • most prominent in the small intestine, not found in the superior stomach or esophagus

Answer 118

• sympathetic fibers do not synapse in the pre-aortic ganglia, they synapse directly in the medulla —> adrenal gland acts as the ganglion

Answer 119

• sympathetic: from superior hypogastric plexus, lumbar and sacral splanchnics • parasympathetic: pelvic splanchnics

Answer 120

• digestive: decreased peristalsis and blood flow, contracts internal anal sphincter • liver/gallbladder: promotes breakdown of glycogen for energy • genito/urinary: slow urine production, contracts internal sphincter of the bladder, controls ejaculation

Answer 121

* **stomach and intestines:** increase peristalsis, digestive secretions/enzymes * **descending colon/rectum:** relaxation of the internal anal sphincter * **bladder:** contracts bladder wall, relaxes internal urinary sphincter * **glands:** stimulates fluids secretion * **erectile tissue:** promote visa dilation, increase blood flow lead to an erection

Answer 122

Basal metabolism, physical activity, thermal effective food

Answer 123

• gender • body temperature (increases with fever) • environmental temperature (increases in cold temperature) • thyroid hormone (increases with hyperthyroidism) • reproduction (increases with pregnancy/lactation) • age (decreases as age increases)

Answer 124

1.) direct calorimetry (gold standard) 2.) indirect calorimetry via respiratory quotient 3.) Resting energy expenditure calculator (Harris Benedict equation)

Answer 125

• O2: 4.751 kcal/L • CO2: 6.253 kcal/L ~ these are used to determine basal metabolic rate in 24 hour period

Answer 126

* **fed:** lasts 2 to 4 hours after a meal (primarily uses glucose, storage of glucose) * **fasted:** overnight without eating (primarily breaks down protein, proteolysis) * **starved:** prolonged fasting (primarily uses fatty acids from adipose tissue, ketones, preserves gluconeogenesis for RBCs) * **hypercatabolic:** trauma, sepsis, not related to meals (protein breakdown, fatty acid oxidation, not storing any intake)

Answer 127

Insulin regulates storage pathways in the feds state. It is released from pancreatic beta cells and is directly responsive to the concentration of glucose in the blood. **it inhibits glucagon**

Answer 128

**transmembrane tyrosine kinase** • rapid kinase effects (activation of PP1 via PKB/Akt, and inhibition of GSK3) • sustained transcription effects via Ras/Raf/MAPK/ and Erk1/2

Answer 129

They increase. There is less insulin available

Answer 130

**ones that produce glucose** * glycogenolysis * gluconeogenesis

Answer 131

**ones that store glucose** • fatty acid biosynthesis • cholesterol biosynthesis • protein synthesis • glycogenogenesis

Answer 132

Oxidizes glucose to CO2 and makes ATP through oxidative phosphorylation

Answer 133

Ferment glucose to lactate — no flexibility

Answer 134

Convert glucose to citrate for fatty acid synthesis; ferment glucose to glycerol-3- phosphate, the backbone for triacylglycerol synthesis

Answer 135

Skeletal: Glycolysis, fatty acid beta oxidation, glycogenogenesis (storing glucose as glycogen), and protein synthesis Cardiac: fatty acid beta oxidation, oxidation of glucose and lactate to CO2, glycogenogenesis

Answer 136

• intestinal epithelial cells: convert glutamine, glutamate, aspartate from the diet into alpha–KG • colonocytes: use short chain fatty acids produced by gut bacteria

Answer 137

Glutamine, aspartate, glutamate from the diet to create acetyl CoA/pyruvate

Answer 138

Glucagon, a major regulator of hepatic fuel mobilization, from pancreatic alpha cells (activates AMP-K)

Answer 139

**seven transmembrane domain heterotrimeric G protein coupled receptor** • ligand binding causes activation of adenylate cyclase, production of cAMP, and activation of PKA in low blood glucose states (PP1 inhibits PKA in fed states)

Answer 140

1. Glycogenolysis using hepatic glycogen stores 2. Gluconeogenesis using carbon skeletons from amino acids, lactate, and glycerol to produce glucose

Answer 141

• FAD2H and NADH reduced by fatty acid beta oxidation ~ the **acetyl CoA** produced by FA beta oxidation is a **substrate for ketone body synthesis**

Answer 142

Branched chain amino acids via proteolysis (prolonged state = ketone bodies)

Answer 143

Alanine and glutamine

Answer 144

FA beta oxidation (glycolysis decreases)

Answer 145

Glutamine (from the blood, not the lumen of the gut)

Answer 146

* lipolysis of adipose, liver increases its production of ketone bodies to be used by the brain * cardiac muscle continues to use fatty acids * **skeletal muscle breakdown decreases to preserve muscle mass, the liver decreases gluconeogenesis**

Answer 147

Increased mobilization of fatty acids from adipose tissue. The liver converts these FA to ketone bodies

Answer 148

In the fasting state, when the primary energy source is proteolysis

Answer 149

The rapid mobilization of stored fuels to provide energy for wound repair and immune system function. Characterized by sustained muscle and organ protein breakdown. This can occur after surgery, trauma, burns, or sepsis.

Answer 150

• initial spike of catecholamines followed by low amounts • spike of glucagon with slow decrease • gradual spike of cortisol followed by maintenance of high levels ~ these allow for the increase of proteolysis, gluconeogenesis, and lipolysis

Answer 151

Negative— excreting more nitrogen in the urine than they are intaking. This is not good and hinders recovery

Answer 152

A period of fasting/malnutrition that creates lipids/protein/insulin suppression followed by an increase in intake (glucose) leading to intracellular shifts of phosphate, potassium, magnesium which causes **hypophosphatemia, hypokalemia, hypomagnesmia**

Answer 153

Thiamine, leading to Wernicke-Korsakoff syndrome symptoms

Answer 154

Temporalis, masseter, medial pterygoid

Answer 155

Lateral pterygoid, mylehyoid, geniohyoid, anterior belly of digastric

Answer 156

• pterygoids, temporalis

Answer 157

Cranial nerve 10, cranial nerve 12

Answer 158

• anterior 2/3: cranial nerve 7 via chorda tympani • posterior 1/3: cranial nerve 9 (glossopharyngeal)

Answer 159

Vagus (CN 10)

Answer 160

• parasympathetic: upper= recurrent laryngeal, lower= esophageal plexus (vagus) • sympathetic: cervical and thoracic sympathetic trunk

Answer 161

• fructose • lactose (galactose plus glucose) • sucrose (fructose plus glucose) • amylose (alpha 1,4 bonds) • amylopectin (alpha 1,6 and 1,4 bonds)

Answer 162

Amylopectin

Answer 163

• lactose (galactose plus glucose; beta 1,4) • sucrose (fructose plus glucose; alpha 1,2) • trehalose (glucose plus glucose; alpha 1,1)

Answer 164

It is an Endoglycosidase, it cuts Alpha 1,4 bonds in polysaccharides. It’s activity is highest in the duodenum

Answer 165

1. Glucoamylase 2. Sucrase/ Isomaltase complex 3. Trehalase 4. Beta-glycosidase complex

Answer 166

an exoglycosidase that cleaves alpha 1,4 bonds of maltose to form 2 molecules of glucose. It cuts off the non-reducing ends of starch. It’s activity is highest in the ileum

Answer 167

~ it has two extracellular domains. It’s activity is highest in the jejunum 1. Sucrase cut sucrose into glucose and fructose 2. Isomaltase cuts the alpha 1,6 bond in isomaltose

Answer 168

Trehalose. Two glucose units bonded through the number one carbon. It is found in insects, algae, mushrooms and other fungi

Answer 169

• a glycophosphatidylinositol (GPI) glycan anchored protein with high activity in the jejunum with two catalytic domains: 1. Glucosyl ceramide: cuts glucose and galactose from glucosylceramide and galactosylceramide (gluco/galacto-cerebrosidase) 2. Lactase: splits the beta 1,4 bond in lactose to make galactose and glucose

Answer 170

Loss of lactase activity with age

Answer 171

Loss of lactase from damage to intestinal mucosa

Answer 172

Non-functional lactase enzyme inherited from parents (rare)

Answer 173

A naturally occurring monosaccharide that is only found in honey (it can also be produced by sucrase acting on sucrose to produce glucose and fructose)

Answer 174

Prostaglandins, where PGE3 is less inflammatory, produced by fish oil and linolenic acid

Answer 175

They are more of a liquid state than cis fatty acids, **they can inhibit** the desaturases responsible for generating arachidonic acid and eicosapentanoic acid (which eventually become **PGE2, and PGE3**). Therefore, they are pro-inflammatory. They can also cross the placenta

Answer 176

**Oral:** TG — bile salts—> free FA + 2-MG — **nascent chylomicron** —> MANY TG reformed — **lymph** —> into the blood as a chylomicron

Answer 177

Secretin and cholecystokinin

Answer 178

Two fatty acids and two monoacylglycerol (2-MG)

Answer 179

• ApoC2 • ApoE

Answer 180

An inherited disorder of the **microsomal triglyceride transfer protein** that results in failure to assemble B apoproteins (therefore chylomicrons in the intestine and VLDL in the liver)

Answer 181

Lipoproteinlipase. It is activated by ApoC2

Answer 182

HDL < LDL < IDL < VLDL < chylomicron

Answer 183

Denatures proteins, and activates pepsinogen

Answer 184

Luminal proteases

Answer 185

Intracellular peptidases

Answer 186

Pepsinogen can cleave itself to form pepsin protease

Answer 187

The N-terminal amino acid (the one to the left / just prior to where the cut would happen)

Answer 188

Where the carbonyl (N-terminal side) is provided by an **arginine or lysine**

Answer 189

They they cut single amino acids from the end of peptide chains

Answer 190

Inherited mutations in the SLC6A9 transporter (B^o)in the kidney. This results in symptoms of **pellagra** because **tryptophan is not absorbed** and cannot be synthesized to make **niacin**

Answer 191

Inherited mutations in the SLC7A9 (B^o+) or SLC3A1 (rBAT) transporters. The body cannot uptake cysteine, leading to kidney stones

Answer 192

Reacting with glutathione

Answer 193

It inhibits protein synthesis and promotes autophagy. It also alters metabolism in order to get more energy; it integrates protein metabolism with lipid and carbohydrate metabolism

Answer 194

1. **PLP: transamination, deamination, carbon chain transfers**. ~ without it can lead to seizures, diarrhea, anemia, EEG abnormalities 2. **FH4/tetrahydrofolate: one carbon transfers** ~ without it can lead to megaloblastic anemia 3. **BH4/tetrahydrobiopterin: ring hydroxylations** ~ without it can lead to seizures, developmental delays

Answer 195

• stratified squamous epithelium that is keratinized • stratum basal, stratum spinosum, granulosum, corneum • hair follicles, sebaceous glands, melanin in basal cells

Answer 196

Mucocutaneous junction of the lip. Parakeratinized does not have granulosum, only has basal, spinosum, stratum superficiale

Answer 197

The Vermillion part of the lip. Epithelium of red margin is thicker than that of the cutaneous area. It is keratinized and red color is due to **deep penetration of lamina propria papillae** into the epithelium that contains blood vessels. It has **meissners corpuscles**, which allows high sensitivity to light touch

Answer 198

Stratified squamous non-keratinized epithelium. Mixed glands beneath epithelium

Answer 199

Mucosa which is **stratified squamous keratinized epithelium**, and the supporting wall is made of skeletal muscle in **three planes** Nerve supply: anterior 2/3 by cranial nerve 5 and 7, posterior 1/3 by cranial nerves 9 and 10

Answer 200

1. Fungiform 2. Circumvallate 3. Foliate (Filiform, the most common kind, do not have taste)

Answer 201

Fungiform papillae • reddish tint due to underlying vascularization • supplied by cranial nerve 7 • towards tip of tongue

Answer 202

• adjacent to sulcus terminalis • 7 to 12 total, surrounded by deep trench • taste buds are numerous in the sides of these papillae • supplied by cranial nerve 9 • serous gland of von Ebner empty into the trenches

Answer 203

• vertical folds of non-keratinized epithelium • found on the sides/back of the tongue, usually bilaterally symmetrical • numerous tastebuds present • serous glands drain into the folds

Answer 204

• exocrine (they have ducts) • major: carotid, submandibular, sublingual

Answer 205

* serous: darkly stained cytoplasm, secretes proteins * mucous: lightly stand, foamy cytoplasm, secretes glycoprotein (water)

Answer 206

• prominent connective tissue capsule with separating lobes/lobules • adipose cells and tissue is common • striated and intercalated ducts prominent • **acini almost 100% serous)**

Answer 207

* connective tissue capsule present but not easily visible * striated ducts well defined * intercalated ducts are scarce * **acini are 10- 25% mucus,so the MAJORITY is serous**

Answer 208

• connective tissue capsule is indistinct • excretory ducts prominent • striated/intercalated not prevalent/not existent • **acini are 75% mucus with serous demilunes**

Answer 209

• mucosa: epithelium, basement membrane, lamina propria, muscularis mucosa • submucosa: connective tissue • supporting wall: smooth or skeletal muscle, bone, cartilage • adventitia/serosa: CT that connects to other structures OR connective tissue covered by mesothelium

Answer 210

1. **Mucosa:** stratified squamous epithelium, non-keratinized 2. **Submucosa:** mucus gland in the middle 1/3, submucosal nerves, larger blood vessels, lymphatics 3. **Muscularis externa (supporting wall):** skeletal muscle transitions to smooth muscle, myenteric nerves 4. **Adventitia:** ~no mesothelium

Answer 211

Sphincters, including: • upper and lower esophageal • pylorus • sphincter of Oddi • ileocecal valve • internal and external anal

Answer 212

Gently agitates the mucosal surface and glands leading to the expulsion of contents of the crypts and enhances contact between epithelium and luminal contents

Answer 213

The submucosa containing the blood vessels and lymph

Answer 214

Esophagus: starts out with skeletal muscle in the first 1/3 and then transitions to smooth muscle in the distal 2/3 Rectum: starts out with smooth muscle and then transitions into skeletal muscle for the external anal sphincter

Answer 215

Paracellular and transcellular (between and through)

Answer 216

**The small intestine**

Answer 217

• esophagus: 10 seconds • stomach: 4 to 5 hours • small intestine: 2 to 3 hours • large intestine: 30 to 40 hours

Answer 218

Bulk laxatives and contract cathartics

Answer 219

Osmotic cathartics

Answer 220

1. Parietal cells via cAMP and IP3 2. Smooth muscle contraction via MLCK and MLCP

Answer 221

**The degree of phosphorylation of myosin II** • activation of myosin light chain kinase (MLCK) —> contraction • activation of MLC phosphatase (MLCP) —> relaxation

Answer 222

Intracellular calcium (ACh, M3 receptors)

Answer 223

Cyclic nucleotides (cAMP from VIP and cGMP from NO)

Answer 224

Reflexes within the gut (myenteric and submucosal plexi) that are not signals to the brain

Answer 225

Vagus nerve to the nucleus of the solitary tract

Answer 226

• cholecystokinin • gastrin • motilin • secretin • somatostatin

Answer 227

**Central:** • CCK • CART • CRH • NE • POMC **Peripheral:** • CCK • glucose/AA/FFA • insulin • leptin • PYY

Answer 228

**Central:** • NPY • orexin A • cannabinoids **Peripheral:** • Ghrelin • cortisol

Answer 229

The mucus layer of the large intestine

Answer 230

• small molecules that are uncharged at a pH around 6.3 • glucose via sodium glucose symporter • very small particles (<1um) including viruses and some chemotherapeutic drugs can be taken up by endocytosis which can lead to mucositis

Answer 231

1. Taste (food must be dissolved in saliva to enter the taste pore) 2. Digestion (amylase, lipase, chewing) 3. Protection (diffusion/buffering of toxins, lubrication, anti-microbial, remilitarization and cleansing of teeth)

Answer 232

* it increases the pH of the mouth to 6.3 due to secretion of bicarbonate in the saliva (due to lactic acid from blood/fermentation of carbohydrates by bacteria, the mouth would be a pH of 2 to 4 without saliva) * saliva contains potassium, calcium, magnesium, and phosphate which decreases demineralization of enamel

Answer 233

1. **Production in acinar cells** sodium potassium ATPase and and NKCC1 and chloride channel encourage flow of **chloride, then sodium paracellularly, then H2O transcellularly into the mouth** 2. **Modification by duct cells** where sodium potassium ATPase and sodium/bicarbonate symporter direct NaCl into the duct lumen and water follows

Answer 234

• parasympathetic, M3: watery secretion • sympathetic, beta: viscous secretion ~ paracrine/endocrine regulation is controlled by aldosterone

Answer 235

• perceived/actual dry mouth • consequences: tooth decay, infection, bad breath, decreased appetite, speech difficult difficulties, dysphasia

Answer 236

1. Anti-muscarinic (including antihistamines, TCA, antipsychotics) 2. Cardiac glycosides 3. Diuretics (loop/NKCC2) 4. Aldosterone receptor blockers 5. Statins

Answer 237

Pilocarpine (side effects include bradycardia, hypotension, bronchoconstriction so it is reserved for extreme cases)

Answer 238

**Nucleus ambiguus:** afferent input via vagus nerve, efferent via glossopharyngeal nerve

Answer 239

1. Oral: initiation of swallowing reflex- nucleus ambiguus 2. Pharyngeal: protection of the airway **Where choking in neuroMSK disorders occurs** 3. Esophageal: initiation of peristalsis, skeletal muscle control of top 1/3, smooth muscle (ENS) control of lower 2/3

Answer 240

• a long loop reflex, fixed action pattern • circular muscles contract upstream of the bolus and relax downstream, longitudinal muscles relax upstream of the bolus and contract downstream

Answer 241

• central pattern generator and the nucleus ambiguus —> striated muscle • central pattern generator—> DMN—> enteric nervous system—> smooth muscle

Answer 242

Acetylcholine

Answer 243

Vasoactive intestinal polypeptide (VIP), nitric oxide (NO) from enteric neurons

Answer 244

Reserved for the failure of primary peristalsis, in the smooth muscle section only a short loop reflex can cause contraction of muscle immediately above the obstruction and relaxation of the muscle below the obstruction — any region moderately above the obstruction is unaffected

Answer 245

Chocolate, peppermint, caffeine, alcohol, fatty meals, progesterone, isoproterenol, secretin, VIP, NO, neurotensin, PGE1, cholecystokinin

Answer 246

Protein meal, acetylcholine, phenylephrine, serotonin, gastrin, pancreatic polypeptide, substance P, motilin, neuropeptide Y

Answer 247

• epithelioid cells • chondroid cells • single cells

Answer 248

• the most common salivary gland tumor, predominantly in adults • presents as a painless, slow growing, firm and mass located in the **parotid gland** • potential for reoccurrence/risk of malignant transformation in long-standing cases

Answer 249

Gross path: well circumscribed, encapsulated, lobulated, 4 to 6 cm Histology: duct-like structures, myxoid areas, cartilaginous regions. Cells include epithelial, myoepithelial, mesenchymal differentiation

Answer 250

Surgical excision, careful to avoid facial nerve

Answer 251

• benign tumor of old smokers, 10% of the time bilateral, parotid gland • **“motor oil”** on smear • **three components: cystic background, oncocytes and lymphocyte stroma**

Answer 252

• histology: Papillae covered with columnar oncocytes with lymphoid stoma

Answer 253

• most common malignant salivary gland tumor characterized by a **t(11;19)** translocation resulting in a CRTC1-MAML2 • typically affects the parotid gland • **grading level**: based off the proportion of cystic versus solid growth, cellular atypia, and mitotic activity

Answer 254

• gross: may be cystic, may appear encapsulated, often infiltrates microscopically • microscopic: **essential for diagnosis**, squamous cells, mucus secreting cells, and intermediate cells

Answer 255

• growing in nests composed of squamous cells as well as clear vacuolated cells containing mucin and intermediate cells

Answer 256

* malignant tumor effecting the parotid and submandibular glands (50% in minor salary glands), typically seen in middle-aged adults. * presents as slow growing, firm, and often painful mass * spreads via **perineural invasion** by ourselves which can lead to pain and nerve paralysis * death typically occurs via lung, bone, liver metastasis

Answer 257

* gross: infiltrative poorly encapsulated, calcifications * microscopic: basal cells with scant cytoplasm forming a classic **cribiform pattern**(Swiss cheese) and hyaline material with pseudocystic spaces

Answer 258

Inflammation of the salivary glands due to bacterial infections (staph aureus), viral infections (mumps, HIV), or auto immune diseases (Sjogrens)

Answer 259

Dehydration, reduced salivary flow, and increased calcium concentration in saliva. Obstruction leading to infection can occur (staph aureus, strep viridans)

Answer 260

* mucous dissects out of the glandsand into surrounding tissues creating false cysts with no lining * **mucocele:** lip and minor salivary gland cyst from trauma or duct obstruction * **ranula:** under tongue/floor of the submucosal duct damaged (becomes **plunging ranula** if it dissect through mylohyoid into neck)

Answer 261

• Cyst lined by squamous epithelium +/- columnar epithelium at the midline/base of the tongue to the thyroid which can contribute to thyroid carcinomas

Answer 262

• cyst of the lateral neck, from the second pouch seen in children and young adults. Squamous/columnar or denuded epithelium with lymphoid tissue in the wall

Answer 263

• extraadrenal paraganglioma at the bifurcation of the carotid artery (lyre sign)

Answer 264

* Zellballen * Synptophysin and chromogranin +

Answer 265

• clinical diagnosis meaning white patch or plaque that can’t be diagnosed clinically as something specific (candida, lichen planus, denture irritation) • hyper keratosis causes the white appearance and 5 to 25% are dysplastic

Answer 266

* hyperkeratosis * squamous cell hyperplasia * low-grade dysplasia * high-grade dysplasia * squamous cell carcinoma

Answer 267

• most common oral cancer, typically seen in middle age/older men • 50% occur on the tongue, or floor of the mouth • associated: tobacco, alcohol, P 53 mutation, less HPV related in the mouth/oral cavity

Answer 268

• red velvety plaque/lesion sometimes eroded • lacks keratinization, increased vasculature, inflation in submucosa • **very high risk of dysplasia**

Answer 269

• keratin pearls/whorls • tram tracks (intercellular bridges of the spinosum)

Answer 270

• seen at the base of the tongues, in the tonsillar crypts, young/middle-aged men • presents as an enlarged neck lymph node • often seen in a **non-smoker/non-drinker** • up to 80% are associated with HPV, most commonly **HPV 16**

Answer 271

• basaloid tumor cells in a nested pattern without keratinization • lymphocytes present in the tumor

Answer 272

* High risk HPV type 16 * detected in tumors by in situ hybridization or by IHC stain that detects over expression of P16 (a surrogate marker for HPV upregulated by E7 overexpression * HPV negative oral pharyngeal cancer shows p53 over expression

Answer 273

• benign tumor, typically associated with HPV type 6, and 11 • can involve any squamous mucosa in the upper G.I. tract

Answer 274

• recurrent juvenile laryngal papillomas, may regress at puberty • infected in utero or at birth • may require multiple surgeries, morbidity is from repeat surgical or laser removal resulting in fibrosis/scar

Answer 275

• non-neoplastic, **stromal reactive process** related to inflammation and or trauma • clinical symptom is typically hoarseness and change in voice

Answer 276

• allergic sinusitis: most common nasal polyps have stromal edema/inflammation. Recurrent rhinitis results in mucosal protrusion/polypoid mucosa. **eosinophils** • infection: mucocele abscess and emypema • fungal infection: typically immuno suppressed patients/diabetic patients. Considered a **medical/surgical emergency**

Answer 277

* seen in adults, arising from the sinonasal mucosa composed of squamous or columnar epithelial proliferation * if inverted type arising from lateral nasal wall, there is more of a chance for malignant transformation

Answer 278

• benign but locally aggressive neoplasm of vascular and fibrous tissue • typically CNN young adolescent males and before the age of 25 • symptoms: **persistent nasal obstruction and epistaxis**

Answer 279

• common in EBV related endemic areas (Africa-children, south China-adults) • three patterns of nasopharyngeal carcinoma: 1. Keratinizing squamous cell carcinoma 2. Non-keratinizing squamous cell carcinoma 3. Undifferentiated carcinoma **(EBV RELATED)**

Answer 280

• repetitive feeling of food being stuck beneath the sternum with substernal discomfort, not choking but 100% of people have **dysphagia** • IgE/Th2 mediated • more common in men than women • Tx: dietary modification, cortical steroid, dilatation for structure

Answer 281

• trachealization of the esophagus (fixed white rings secondary to fibrosis, made of linear thick mucosa and white exudate) • crepe paper appearance • Typically seen in the **middle, with strictures**

Answer 282

• eosinophilic microabscesses • basal cell hyperplasia of squamous mucosa

Answer 283

1. Candida 2. Herpes 3. Cytomegalovirus ~ seen in immunocompromised pts, HIV, chemo, elderly

Answer 284

1. Ingestion of corrosives (lye) 2. Pill esophagitis from NSAIDs, antibiotics, iron pills, alendronate 3. Iatrogenic from chemo, radiation, GVHD 4. Bullous pemphigoid, Epidermolysis bullosa 5. Crohn’s disease

Answer 285

Gastro esophageal reflux disease (GERD)

Answer 286

• risk factors: anything that decreases lower esophageal sphincter tone • symptoms: heartburn, pain, esophageal spasm, morning hoarseness, sore throat, bad breath

Answer 287

* non-specific damage to the squamous mucosa * scant eosinophils, ulcers, erosions, +/- neutrophils * **lymphocytes in a squiggle shape** * lamina propria papillae elongation

Answer 288

• intestinal metaplasia in the tubular esophagus (columnar metaplasia with goblet cells) which changes the appearance from white, shiny to bright red on endoscopy “salmon colored”

Answer 289

The lower 1/3 of the esophagus (gastric cardia intestinal metaplasia is not considered Barrett’s)

Answer 290

GERD/Barrett esophagus ~ stepwise accumulation of genetic mutations typically EGFR amplification

Answer 291

1. Endoscopic mucosal resection (early tumors and dysplasia) 2. Neoadjuvant chemo radiation prior to resection for higher stage tumors

Answer 292

1. Dissecting pools of mucin within the muscle layers of the wall, no malignant cells present 2. Rare, highly atypical enlarged treated to moles floating with an a pool of mucin

Answer 293

• seen in the middle 1/3 of the esophagus, typically causing strictures with associated symptoms of dysphasia and odynophagia (pain) and obstruction • risk factors: alcohol, tobacco, scalding hot beverages, esophageal injury, achalasia, tylosis, Plummer-Vinson syndrome

Answer 294

• longitudinal mucosa laceration in the distal esophagus and proximal stomach caused by increased abdominal pressure • traditionally associated with severe vomiting, history of heavy alcohol use is a classic cause • 50% are iatrogenic from therapeutic dilation, varies treatment, endoscopy, intubation

Answer 295

• MWS: longitudinal mucosa laceration • Boerhaave: deep transmural tears extending into mediastium (pneumomediastinum)

Answer 296

• mucosal ring shaped thickening in the lower esophagus causing dysphasia, treated by endoscopic dilatation • can be secondary to reflux disease or hiatal hernia

Answer 297

• above upper esophageal sphincter the mucosa and some mucosa protrude through a defect in the cricopharyngeal muscle • accumulated food can compress the anti-esophagus causing dysphasia and halitosis (bad breath) from degenerating food

Answer 298

The lining goes from stratified squamous epithelium (non-keratinized) to simple columnar epithelium

Answer 299

The lining goes from stratified squamous epithelium (non-keratinized) to simple columnar epithelium

Answer 300

* **Rugae:** larger structure of the fundic region of the stomach. Inner surface folds that allow for distention and absorption. Folds of mucosa with with **submucosal core** * **gastric pits:**smaller structure located throughout the stomach, tubules that empty gastric glands. Deeper in the pylorus, folds of epithelium with **lamina propria core (they are entirely of the mucosal layer)**

Answer 301

1. Mucosa: simple columnar epithelium, includes gastric pits and glands 2. Submucosa: dense connective tissue, adipocytes, nerves/blood vessels 3. Muscular externa: smooth muscle 4. Serosa: mesothelium

Answer 302

• foveolar cells • located in gastric, surface of stomach • columnar in shape, short microvilli on apical surface • secrete soluble mucus (glycoproteins) and bicarbonate

Answer 303

• mucus neck cells, parietal cells, chief cells (zymogenic), enteroendocrine cells, undifferentiated adult stem cells

Answer 304

• located in the neck region of the gastric/fundic gland • cuboidal to low columnar in shape • secrete soluble mucus

Answer 305

• eosinophilic, large, binucleate, spherical centrally placed nucleus, **triangular, Apex toward lumen** • numerous in the neck and of proportion of the gland body, intracellular caniculi with microvilli • **intrinsic factor (b12 absorption), and secretion of HCL**

Answer 306

• cholinergic nerve endings • Gastrin • histamine

Answer 307

• most numerous at the base of the glands • basophilic, protein secreting cells (rER) • **pepsinogen secretion** which is converted to active protease (pepsin) in the presence of HCl

Answer 308

• part of the diffuse neuroendocrine system • found out every level of the gastric glands, more prevalent at the base with the chief cells • small size, clear faintly stained cytoplasm • fxn: sample contents of lumen gland and then release hormones, control taste receptors

Answer 309

• located in the isthmus of the gastric gland • cells can replicate and differentiate to produce mucus cells (move up) or mucus neck, parietal, chief, enteroendocrine (all move down)

Answer 310

* simple columnar epithelium, with mucus secreting cells * **the gastric pits are 1/4 of the mucosal thickness** * constant turnover (4-6 days) of epithelial cells

Answer 311

* simple columnar epithelium, mucus secreting cells * **the gastric pits are 2/3 of the mucosal thickness** * glandular region has simple branched coiled tubular glands * enteroendocrine and parietal cells present **(no chief cell)**

Answer 312

* simple columnar epithelium * **gastric pits are 1/4 of of the thickness of the mucosa** * coiled glands, cells are mucus neck type * **absence of parietal/chief cells**

Answer 313

• abnormal amount of Gastroesophageal reflux leading to heartburn, acid regurgitation, dysphasia, nausea, odynophasia, chest pain, cough • caused by: transient lower esophageal sphincter relaxation, lower esophageal sphincter pressure, hiatal hernia/obesity

Answer 314

EGD looks for erosive esophagitis (damage by gastric contents)

Answer 315

1. 24 hour pH NG catheter 2. Bravo capsule placed in the esophagus during endoscopy (48 hours)

Answer 316

**#1:lifestyle modification:** weight loss, sleep position, avoid eating for three hours prior to lying down 2. **Antacid medication** (proton pump inhibitors, H2 receptor blockers (famotidine), antacids 3. **Surgery**

Answer 317

The parietal cell: Stimulants: histamine, acetylcholine, gastrin Inhibitors: somatostatin, prostaglandins

Answer 318

• **mechanical obstruction:** stricture, esophageal web, cricopharyngeal bar, zenkers diverticulum • **motility disorders:** achalasia, scleroderma • **inflammation:** eosinophilic esophagitis • **infections**

Answer 319

* weight loss * does not want to eat eat/nothing tastes good * choking on liquids/solids * weakness/lightheadedness * cachectic and ill appearing

Answer 320

1. Squamous cell carcinoma 2. Adenocarcinoma

Answer 321

• typically the upper 2/3 of the esophagus, typically flat to the lumen, discolored • high grade dysplasia with hyperchromatic and enlarged cells with loss of nuclear polarity • most common cancer **worldwide** • risk factors: smoking, alcohol, low SES • five-year survival: 3% at stage four, 44% at stage one

Answer 322

• typically found in the lower esophagus, large obstruction • most common type of esophageal cancer in the **US** • risk factors: male, central obesity, GERD, Barrett’s esophagus • five year survival: 0% at stage four, 81% at stage one

Answer 323

• typically seen in patients with asthma/seasonal allergies • food feels “stuck” frequently, usually passes/able to vomit it up • characterized by **numerous eosinophils, dilated intracellular spaces, basal cell hyperplasia, and papillary elongation**

Answer 324

• allergen controlled diet therapy • proton pump inhibitors • endoscopy with dilation • glucocorticoids (fluticasone, budesonide orally) • **dupilumab (IL4R targeted monoclonal antibody to reduce inflammation)**

Answer 325

• esophageal motility disorder caused by failure of relaxation of the lower esophageal sphincter due to nerve damage • common symptoms: regurgitation, heartburn, chest pain, dysphasia, weight loss, **pneumonia** • Treatment: myotomy, or pneumatic dilation to disrupt esophageal sphincter

Answer 326

Red, yellow, orange fruits and vegetables

Answer 327

All-trans-retinol from dietary sources such as retinyl palmitate, beta carotene, and alpha carotene

Answer 328

• aldehyde (all-trans retinal) • carboxylic acid (all-trans retinoic acid) • Esther with fatty acid (retinyl palmitate; the vitamin A storage form)

Answer 329

Retinoic acid. All others are transported in chylomicrons

Answer 330

Stellate cells in the liver

Answer 331

Eye pathology (night blindness or blurred vision)

Answer 332

Cis-retinal (aldehyde)

Answer 333

* RAR (retinoic acid receptors) * RXR (retinoic X receptors) * PPAR beta, and PPAR delta ~ these lead to recruitment of antibody secreting cells to the small intestine, differentiation of goblet cells, maturation of dendritic cells, apoptosis of cancer cells, and inhibition of keratinization

Answer 334

Carotenes (alpha and Beta)

Answer 335

* anorexia * decreased growth * increased susceptibility to infection (GALT loses IgA) * alopecia * keratinization of epithelial cells (can lead to dryness, infertility * night blindness, xeropthalmia/dry eyes, and Bitot’s spots

Answer 336

• toxic level of vitamin A leading to nausea/vomiting, blurred vision, headache, desquamation of skin, alopecia, ataxia, liver damage ~ remember: vitamin A can be a terotogen

Answer 337

• Tocopherols (saturated 16C acyl chains) • tocotrienols (polyunsaturated 16C acyl chains)

Answer 338

Plant oils such as palm oil, sunflower oil, canola oil, wheat germ

Answer 339

• works in the lipid by layers in intracellular and plasma membranes • allows for stabilization of singlet oxygen and free radicals as a part of ROS defense

Answer 340

Alpha- tocopherol —> tocopheryl radical —> tocopheryl quinone ~ vitamin E is able to **neutralize two lipid peroxides**

Answer 341

• myopathy • hemolytic anemia • peripheral neuropathy: ataxia, loss of vibratory sense

Answer 342

**Phylloquinone** ~ another form produced by fermentation is menaquinone

Answer 343

* Vit K acts as a **co-factor for gamma glutamyl carboxylase** ( this enzyme carboxylates glutamic acid side chains on **blood clotting** proteins)

Answer 344

2, 7, 9, 10

Answer 345

• can occur in infants due to low breastmilk vitamin K • symptoms: coagulation disorders such as increased PT time, and increased bleeding

Answer 346

Cholecalciferol

Answer 347

Regulate calcium homeostasis

Answer 348

25-hydroxycholecalciferol created in the liver

Answer 349

In the kidney: producing 1, 25- dihydroxycholecalciferol (calcitriol) ~ this process occurs under the influence of parathyroid hormone which response to low calcium concentrations

Answer 350

1. Calbindin 2. TRPV6 3. PMCA1b ~ these are genes that are encoding calcium transport proteins

Answer 351

**Rickets:** characterized by seizures, growth retardation, failure of bone mineralization (osteomalacia) ~ deficiency can be due to dietary, genetic, or secondary to an absorption problem such as Crohn’s disease

Answer 352

**Vitamin D**—> this can lead to calcification of soft tissue (heart, lungs, blood vessels), hyperphosphatemia, hypertension

Answer 353

Decrease. This is due to vitamin D receptor physically interacting with beta-catenin, preventing its transact activation of genes that promote cellular proliferation, such as cyclin-D1

Answer 354

Two or more species of bacteria that are enclosed in glycocalyx, and protein/DNA

Answer 355

• Adherence • protection from the immune system • protection from antibiotics • symbiotic relationships in order to exist long-term • survival and pH changes, and in a normally inhospitable environment

Answer 356

1. Toxin production 2. Post immune response 3. **microbial proliferation and invasion, growth and spread of microbes** 4. Cancer- microbe promotes uncontrolled proliferation of cells and host organism **Fermentable sugar + acid producing bacteria —> low pH —> demineralization**

Answer 357

• streptococcus viridans/mutans • Gram positive cocci catalyst negative, anaerobe, alpha hemolytic, optochin resistant

Answer 358

* adhesion like surface associated proteins (**AGI/II family**) capable of binding to pecille (teeth) * extracellular glycosyltransferases (**Gtfs**) that can synthesize glucans from sucrose creating an acidic environment

Answer 359

• Infectious disease destroying supporting structures of teeth (gums) • milder form: **gingivitis** • irritation, redness, swelling of the gums • severe form: **periodontitis**, infection of underlying tissue and bones

Answer 360

• less sugar in the diet • brush frequently • fluoride • increased saliva flow (consider sugar-free gum)

Answer 361

* thoroughly clean surfaces to prevent bone damage or further bone damage * Root planing to discourage further bacteria growth * antibiotics— topical is common, empirical use of **amoxicillin and metronidazole**

Answer 362

Aggregatibacter actinomycetemcomitans (facultative anaerobe and gram- bacillus)

Answer 363

**porphyromonas gingivalis** causing a dysbiotic state

Answer 364

Gram-positive

Answer 365

Gram-negative

Answer 366

• heart attack • stroke • lung disease • premature birth or having a baby with low birth weight, in women • diabetes

Answer 367

* diabetes can be worse with pro-inflammatory cytokines * periodontal disease creates pro-inflammatory cytokines that appear to increase insulin resistance

Answer 368

break in mucosal barrier, dental manipulations may also be the cause —> Alpha hemolytic streptococci can implant on previously damaged heart valve surfaces and accumulate

Answer 369

• skin infection on the floor of the mouth, usually results from untreated dental infections. Swelling of infected area may block the airway or prevent swallowing of saliva • symptoms: SOB, confusion, fever, **neck pain, neck swelling, redness of the neck**, weakness/fatigue/tiredness

Answer 370

Double tongue appearance

Answer 371

• babies • denture wearers • diabetics • cancer patient • HIV/aids patient • currently taking antibiotics or corticosteroids • dry mouth (medication or otherwise) • smokers

Answer 372

When it invades the esophagus: life-threatening, highly prone to spreading

Answer 373

• most commonly topical treatment: clotrimazole lozenge or nystatin suspension (swish and swallow) • unresponsive cases: systemic antifungal such as fluconazole • worst case: IV administration of amphotericin B

Answer 374

NOT caused by an organism, thought to be caused by smoking and chewing tobacco/other irritants

Answer 375

Epstein-Barr virus, almost always in HIV+ patients

Answer 376

Gram-negative, flagellated helix-shaped rod (spirilli), microaerophilic, catalase +, oxidase +, urease +, (**triple positive**)

Answer 377

Asymptomatic gastritis —> 1. Symptomatic gastritis 2. Ulcers 3. Carcinoma 4. Lymphoma

Answer 378

• inflammation of the gastric mucosa • burning ache in the upper abdomen. Worse/better with eating • nausea, vomiting • feeling a fullness in upper abdomen after eating

Answer 379

* open sores that develop on the inside stomach lining * burning abdominal pain from naval to breastbone * flares at night * temporarily relieved by eating foods * less common: vomiting/stools that are blood unexplained weight loss, appetite changes

Answer 380

* immune evasion * **urease** - acid tolerance * **motility and chemotaxis** * **VacA**- forms poor that allows leakage of calcium from epithelial cell * **adhesins (BabA and SabA)** * **TFSS + CagA** - pokes hole, CagA travels into the wholesale and affects the proliferative actions, adhesion, cytoskeletal organization **highly pro-inflammatory**

Answer 381

Host damages itself by continual, ineffective immune response

Answer 382

• endoscopy and culture • breath test (second best option considering cost- tests for Urease) • stool test (best option, Ag test) • blood test (cannot show resolution of infection, Ab test)

Answer 383

1. Clarithromycin 2. Amoxicillin 3. Proton pump inhibitor

Answer 384

1. Causes mucosa associated lymphoid tissue lymphoma (MALT) 2. Causes gastric carcinoma 3. **Reduces risk of esophageal adenocarcinoma**

Answer 385

• mucosa associated lymphoid tissue lymphoma in the stomach • symptoms: indigestion, heartburn, inflammation • tumors of B cells • antibiotics are still a part of the treatment strategy

Answer 386

* cancer of the stomach lining (epithelial ), where 65 to 80% of gastric carcinoma is caused by H. pylori * symptoms: indigestion, heartburn, inflammation

Answer 387

* a complication of the obstruction of bile flow due to gallstones migrating into the ducts or bacteria (typhoid bacilli- typhoid fever) * most commonly seen in patients who are predisposed to gallstones, or have reduced arterial blood supply to the gallbladder wall

Answer 388

**Charcot’s Triad** 1. right upper quadrant pain, biliary colic 2. Jaundice 3. Chills and a spiking fever

Answer 389

Cholangitis

Answer 390

* antibiotic to treat the infection * removal of underlying obstruction (stone)

Answer 391

Pairing with proton pump inhibitor (omeprazole) Symptoms: weakness, disequilibrium, nausea/vomiting, altered vision (**yellow haze, xanthopsia**), atrial fibrillation, bigeminy

Answer 392

• bicarbonate • mucus • prostaglandins

Answer 393

• **HCl** • intrinsic factor • Gastroferrin

Answer 394

• pepsinogen • lipase

Answer 395

• gastrin • ghrelin • histamine • somatostatin

Answer 396

• proton pump inhibitors (prazole) • antacids • H2 blockers • Gastrin, acetylcholine, somatostatin

Answer 397

1. Proteolysis, chemical digestion of proteins 2. prevention of infection, kills pathogens

Answer 398

• parietal cell atrophy leading to a gradual decrease in acid production (also includes hyperplasia of the goblet cells —> hypertrophied rugae)

Answer 399

The pumping of bicarbonate into the blood after eating a meal (normal unless following vomiting, can result in metabolic alkalosis)

Answer 400

• omeprazole is a racemic mixture of the R-isomer and S-isomer • esomeprazole is exclusively an S-isomer (**this works better in poor metabolizers**)

Answer 401

1. Increased respiratory/enteric infections including SIBO 2. Increase/decrease absorption of weak acids and bases 3. Rebound acid hypersecretion when stopped

Answer 402

* potassium competitive acid blocker(**PCAB**), reversible inhibitor of the hydrogen-potassium ATPase used to increase stomach pH * SE: hepatotoxicity, nasal pharyngitis, mild moderate constipation/diarrhea, diverticulitis

Answer 403

• aluminum hydroxide • calcium carbonate (Tums) • magnesium hydroxide • sodium bicarbonate

Answer 404

Antacid: can cause constipation, rarely osteomalacia due to decreased phosphate absorption and calcium loss

Answer 405

Antacid: can cause osmotic diarrhea, in patients with renal insufficiency it can cause hyperglycemia and cardio-toxicity

Answer 406

• **systemically absorbed** • metabolic alkalosis, hypercalcemia if taken with dairy products • gastric distention, belching (can be treated with **simethicone**) • alkalinizes urine, can cause fluid retention

Answer 407

1. Cephalic (increase when thinking about food) 2. Gastric (most produced here) 3. Intestinal 4. Interdigestive

Answer 408

• Secreted by G cells in the atrum, duodenum, pancreas and acts on B receptors only • **increases:** acid secretion, histamine (ECL cells), growth, pepsinogen, enzyme secretion in the pancreatic acini, can cause an increase in gastric/pancreatic/colon cancer • **decreases:** somatostatin (D cell)

Answer 409

• secreted by duodenal I cells on both A and B receptors • **increases:** somatostatin (D cell), pepsinogen, enzyme secretion from the pancreatic acini, growth, contraction/motility, pancreatic cancer • **decreases:** acid secretion

Answer 410

Gastrin or acetylcholine from enteric efferent neurons acting on M1 receptors

Answer 411

The actions of histamine— a.k.a. they inhibit adenylate cyclase

Answer 412

• highly selective, competitive H2 antagonist that decrease all forms of gastric acid secretion (especially nocturnal) • SE: increased gastric pH, bradycardia, hypotension, decreased elimination of certain drugs

Answer 413

• classic inhibitor of CYP450 (CYP1A1, 2D6, 3A4) • significantly increases the effectiveness of drugs metabolized by these enzymes • other potential SE: decreased binding of DHT to androgen receptors, decreased estrogen metabolism, increased prolactin leading to gynecomastia or galactorrhea

Answer 414

Acts on the M1 and M3 receptors on ECL cells and M3 receptors on parietal cells —> increases histamine release and increases calcium in parietal cells

Answer 415

• and ulcer in the esophagus, stomach, duodenum associated with in increased intracranial pressure • **Cushing triad: hypertension, bradycardia, respiratory depression (Cheyenne Stokes respiration)**

Answer 416

•Paracrine hormone released by D cells when the pH in the Antrum <3 • decreases the release of gastrin, histamine, and inhibits adenylate cyclase in parietal cells

Answer 417

Decreased- inhibited

Answer 418

Intestinal absorption of B12 and iron

Answer 419

Haptocorrin (R protein)

Answer 420

Iron binding glycoprotein that allows Fe3+ to be transported to the small intestine for absorption without complexing with anions

Answer 421

• neck cells and goblet cells • **catecholamines** suppress bicarbonate secretion from these cells and can contribute to the formation of stress ulcers

Answer 422

1.) increased bicarbonate secretion 2.) decreased gastric acid production ~ this leads to a higher pH, long-term use of NSAIDs cause ulcers because you block these actions of prostaglandins

Answer 423

* a prostaglandin analog that reduces histamine stimulated acid secretion and stimulates mucus and bicarbonate secretion * reverses the action of NSAIDs locally in the stomach while allowing them to systemically act at their target sites * **side effects:** diarrhea, severe nausea and cramping, **stimulates uterine contractions, teratogen - black box warning**

Answer 424

* sucrose sulfate- aluminum hydroxide complex that attaches to the basement membrane of an ulcer acting as a **Band-Aid**. * may stimulate mucosal prostaglandin and bicarbonate secretion, but no acid neutralizing properties * requires acidic environment to be given (empty stomach, cannot give with PPI)

Answer 425

**salicylate toxicity** —> vomiting, tinnitus, confusion, hypothermia, respiratory alkalosis, metabolic acidosis

Answer 426

1. Accommodation 2. Mechanical digestion 3. Peristalsis 4. Migrating motor complex

Answer 427

• the stomach remains at a relatively constant pressure despite dramatic increases and volume due to VIP/NO containing inhibitory neurons that allow relaxation of stomach muscles

Answer 428

Relaxes ileocecal valve to transfer contents of small bowel into large bowel

Answer 429

Induces the need to defecate after eating

Answer 430

* the smooth muscle is electrically coupled, leading to the rhythmic depolarization of smooth muscle cells in all regions distal to the esophagus * **initiated at the interstitial cells of Cajal in the greater curvature of the stomach**

Answer 431

Hypothermia, hypothyroidism, hypoxia, mesenteric ischemia

Answer 432

• growling of the stomach, hunger pangs • cycles of motility during the fasted state lasting around 100 minutes that begin in the stomach and progressed to the large intestine in order to clear indigestible residues from the stomach

Answer 433

1. Quiescence: 40-60% of cycle, no movement 2. Irregular contraction similar to peristalsis: 20-30% 3. Intense contraction: 5-10%, pylorus opens widely leading to the movement of undigested material into the small intestine

Answer 434

motilin: inhibited with eating

Answer 435

• acute transient mucosal damage with mucosal edema, erosion, hemorrhage • caused by imbalance between mucosal defenses and acid (alcohol, NSAIDs, toxins, H. pylori, uremia, radiation, chemotherapy)

Answer 436

• acute transient mucosal damage with mucosal edema, erosion, hemorrhage • caused by imbalance between mucosal defenses and acid (alcohol, NSAIDs, toxins, H. pylori, uremia, radiation, chemotherapy)

Answer 437

• mucus surface protection (foveolar cells) and physical barrier to keep acid out of lamina propria • bicarbonate secretion • rapid cell turnover

Answer 438

COX and prostaglandins

Answer 439

An ulcer resulting from acute physiologic (not psychologic) stress, leading to punched out ulcers in the stomach and duodenum

Answer 440

H. pylori infection. You will see neutrophils in crypts and lamina propria, as well as high lymphocyte presence and reactive germinal centers

Answer 441

**antrum** > cardia > fundus/body ~ typically superficial in the mucus surface and neck of the glands

Answer 442

• peptic ulcer disease (PUD) • gastric adenocarcinoma via atrophy intestinal metaplasia-dysplasia • gastric lymphoma (particularly MALT)

Answer 443

Helicobacter heilmannii (vector is cats and dogs)

Answer 444

1. Acute (toxins, drugs, ischemia, H. pylori) 2. Chronic (H. pylori or autoimmune) 3. Chronic active (flares/inflammation with a background of H. pylori) 4. Gastropathy (injury with little to no inflammation)

Answer 445

• 90% are duodenal ulcers from increased gastric acid secretion from the stomach • 10% are gastric ulcers caused by H. pylori

Answer 446

Pain is relieved with food due to the release of bicarbonate, and the pressure

Answer 447

Worse— influx of acids directly onto the wound make it painful

Answer 448

• **posterior duodenal wall:** gastroduodenal artery hemorrhage • **anterior duodenal wall:** pneumoperitoneum • **curvature of the stomach:** gastric artery hemorrhage

Answer 449

Rupture of the anterior wall of the duodenum leads to air escaping into the peritoneum— visible as air under both diaphragms

Answer 450

• autoimmune gastritis — typically an antibody of the parietal cells (against H-K ATPase or intrinsic factor) • affects the fundus/body of the stomach • leads to hypo/achlorhydria, vitamin B-12 loss, chief cell loss (decreased pepsinogen I levels)

Answer 451

Deep/basal mucosal inflammation with lymphocytes, macrophages, plasma cells

Answer 452

Endocrine cell hyperplasia occurs due to feedback loop of increased gastric secretion in response to the decreasing acid (due to damaged parietal cells)

Answer 453

The antrum

Answer 454

• mucosal and submucosal capillaries/vessels are visible without excessive distention with air • decrease in rugae folds • Hyperplastic or adenomatous polyps

Answer 455

**Pernicious anemia/vitamin B12 deficiency** —> megaloblastic anemia, atrophic glossitis, malabsorptive diarrhea, peripheral neuropathy, CNS alterations

Answer 456

• typically due to chronic NSAID use or bile reflux, mucin loss of surface cells which can lead to gastric erosions and ulceration • **lacks inflammation** • characterized by foveolar hyperplasia and mucin depletion

Answer 457

**congenital:** present 2-6 wks post birth, projectile vomiting of non-bilious fluid, firm “olive” on palpation of the epigastric region **adults acquired:** results from gastritis/ulcers/masses impinging the area

Answer 458

The stomach— MALT lymphoma, DLBCL

Answer 459

• B cell +: CD19, CD 20, monoclonal light chain (Kappa OR lambda- not both) • CD5 negative, positive for CD43 in 25%

Answer 460

**1. Negative for translocation**, associated with H. pylori infection and chronic antigenic stimulation that activates transcription factors promoting B cell growth and survival **2. Positive for translocation t(11;18)**, involving the MALT1 gene on chromosome 18 and API2 gene on 11

Answer 461

**Hyperplastic gastric polyps:** non-neoplastic associated with chronic gastritis and H. pylori. Inflammatory and reactive/hyperplastic. **foveolar hyperplasia**

Answer 462

• sporadic or caused by familial adenomatous polyposis (FAP), typically associated with overuse of PPIs—> increase gastrin secretion • occurs in the body/fundus

Answer 463

Dilated, irregular glands lined by flattened parietal and chief cells and foveolar cells due to too much NSAID use

Answer 464

• FAP • chronic atrophic gastritis • intestinal metaplasia

Answer 465

• cells with nuclear stratification, hyperchromatic pencil-shaped nuclei, and mucin depletion • adenoarcinoma may be present in up to 30% of gastric adenomas

Answer 466

* **gastrinoma: Gastrin secreting tumor, neuroendocrine** * results in marked increase in parietal cells and mucus neck cells (hypertrophic mucosa) * causes intractable ulcers in the stomach, duodenum, esophagus * associated with MEN1 syndrome in 25% of cases

Answer 467

* excessive secretion of **TGF – alpha** * diffuse foveolar hyperplasia of the body and fundus with excess mucus * protein losing enteropathy and hypoproteinemia with diarrhea, weight loss, peripheral edema * can be associated with CMV in children

Answer 468

• found in the antrum • gland/solid nest forming bulky mass lesion/ulcer arising from precursor dysplasia

Answer 469

• **signet ring/linitis plastica cells** • presents with thickened gastric wall and single signet ring cells, discohesive infiltration • seen in young patients

Answer 470

* mutations increasing the signaling via **WNT** pathway * **APC tumor suppressor** gene * **Beta-catenin** overexpression

Answer 471

• loss of function of tumor suppressor genes **CDH1 encoding E-cadherin** • can be seen in familial CDH1 in very young patients

Answer 472

• spindle cell tumor that arises from the cells of Cajal (pacemaker or mesenchymal cells) • most common mesenchymal tumor of the G.I. tract • most commonly occur in the stomach, leading to mass effect (bleeding from ulcerative mucosa)

Answer 473

• cKIT, CD117 (75%) • PDGFRA (8%) ~ Tx: tyrosine kinase inhibitor: **imantimib**

Answer 474

• cirrhosis (most common) • cancer • heart failure • tuberculosis • renal failure that requires dialysis • pancreatic diseases

Answer 475

• CBC with diff • culture, gram stain • albumin, total protein (determine between exudate vs transudate • fluid cytology

Answer 476

• liver cirrhosis • congestive heart failure • hypoalbuminemia • massive liver metastasis

Answer 477

• malignant • tuberculosis peritonitis • pancreatic

Answer 478

**1. Infection from perforation** (ulcer, diverticulum, tumor) **2. Spontaneous bacterial peritonitis** (unknown, neutrophil common, culture and Gram stain required)

Answer 479

Secondary metastatic tumors, typically from the ovaries

Answer 480

• mesothelial inclusion cysts related to inflammation • multicystic benign mesothelioma

Answer 481

• Similar to pleural tumors, associated with asbestos exposure • papillary formations and desmoplastic stromal reaction (hypereosinophilic) • immunoreactivity for **calretinin**

Answer 482

• palpable nodule bulging into the umbilicus as a result of intra-abdominal malignancy (stage 4 cancer staging)

Answer 483

Bright red blood coming from the rectum (bad prognostic sign, indicates blood is flowing very quickly)

Answer 484

Black tarry stools coming from an upper G.I. bleed

Answer 485

Vomit that is the appearance of coffee grounds due to blood coagulation with HCl in the stomach

Answer 486

• iron deficiency anemia • fatigue/paleness • dyspnea • angina

Answer 487

1. ABCs: airway, breathing, circulation/CPR 2. IV access: at least two large bore IVs 3. Infusion of crystalloids (LR, NS) and blood products

Answer 488

• severe cardiac disease (cannot take large volume infusion) • liver disease (varocele bleeds, hard to treat) • coagulopathy (high INR, may need vitamin K or FFPs)

Answer 489

• EGD, a chip on a long flexible tube allowing for the insertion of epinephrine, cautery, and hemoclips in areas that are bleeding

Answer 490

• barium study • tagged RBC scan (radio labeled blood) • capsule endoscopy

Answer 491

• esophageal varices • esophagitis • Malory Weiss tears • tumors

Answer 492

• presents with dramatic bleeding, usually hematemesis • typically caused by portal hypertension and associated with liver disease/cirrhosis • Tx: octreotide/vasopresin to decrease liver pressure, PPI, beta blocker, variceal band ligation, or surgically shunting (TIPS)

Answer 493

Located at the Gastro-esophageal junction, typically caused by aggressive vomiting

Answer 494

Ulcer: break in mucosa with a appreciable depth or involvement with the submucosa Erosion: break in mucosa without significant depth

Answer 495

H. pylori and NSAID use

Answer 496

• NSAIDs • H.pylori, family history of ulcers/infection • cigarette smoking • physiological stress

Answer 497

* antibiotic used for H. pylori infections that inhibits DNA dependent RNA polymerase * actively secreted into stomach lumen, active over wide range of pH * side effects: myelosuppression, hepatotoxicity, CYP450 induction, orange/red stained body fluids

Answer 498

Nocturnal— good for patients that experience GERD at night

Answer 499

* lifestyle modification * drugs that are not normally systemically absorbed (aluminum hydroxide, magnesium hydroxide, calcium carbonate, sucralfate) * H2 blockers (risk) * PPI/PCAB (riskier)

Answer 500

• eradication of H. pylori drugs • promotion of mucosal defense drugs • antacids • H2 blockers • proton pump inhibitors

Answer 501

Foveolar: secrete mucin and line the. Surfaces of the stomach and the gastric Neck: located inside the gastric pits

Exam 1 Flashcards

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