Gastrointestinal Flashcards
(545 cards)
1
Q
What is the first enzyme activated in acute pancreatitis?
A
Trypsinogen –> trypsin
2
Q
What 2 types of necrosis is seen in acute pancreatitis?
A
Fat necrosis seen in peri-pancreatic fat. Liquefactive necrosis of the pancreas itself
3
Q
How does alcohol cause acute pancreatitis?
A
Creates contraction of sphincter of Oddi, decreasing drainage of pancreas
4
Q
Where does pain from pancreatitis typically refer?
A
Back
5
Q
What is Cullen’s sign?
A
Peri-umbilical brusing seen with acute pancreatitis
6
Q
What is Grey-Turner’s sign?
A
Flank hemorrhage seen with acute pancreatitis
7
Q
What two enzymes are increased as a result of pancreatitis?
A
Lipase and amylase. Lipase is more specific, because amylase can be increased with damage to the salivary gland
8
Q
What are the two most common causes of chronic pancreatitis?
A
Alcohol (repeated bouts of acute pancreatitis) and cystic fibrosis (kids)
9
Q
What are the two major risk factors for pancreatic adenocarcinoma?
A
Smoking and chronic pancreatitis
10
Q
Thin, 85 year old female presents with new-onset DM. What should you think about?
A
Pancreatic adenocarcinoma in the body or tail of the pancreas
11
Q
What is the serum tumor marker for pancreatic adenocarcinoma?
A
CA-19-9
12
Q
Why do bile acid binding resins (cholestyramine) lead to gallstones?
A
Decreased bile acids leads to ineffective solublizing of cholesterol, which can cause stones
13
Q
What color are cholesterol gallstones?
A
Yellow
14
Q
Why are women at greater risk for gallstones?
A
Estrogen increases HMG-CoA reductase, which increases cholesterol, which can precipitate and cause gallstones
15
Q
Which gallstones are typically radiopaque?
A
Bilirubin stones
16
Q
Where does pain from cholecystitis typically radiate?
A
Right scapula
17
Q
What is a Rokitansky-Aschoff sinus?
A
Outpouching of gallbladder mucosa into the smooth muscle of the GB wall with CHRONIC cholecystitis
18
Q
What is porcelain gallbladder and how is it treated?
A
Calcified gallbladder due to chronic cholecystitis. Treated by cholecystectomy, because it is considered a pre-cancerous condition.
19
Q
85 year old woman presents with acute cholecystitis, what are you thinking?
A
GB carcinoma
20
Q
What causes black pigment stones?
A
Hemolysis
21
Q
What causes brown pigment stones?
A
Infection
22
Q
How do gallstones cause ascending cholangitis?
A
When stones block the bile duct, bile can’t flow and wash away bacteria, which can then ascend and cause infection/inflammation.
23
Q
How can gallstones cause air in the biliary tree?
A
Gallstone ileus - gallstone erodes through GB wall, into duodenum and blocks the ileocecal valve, causing backup of air all the way to the biliary tree
24
Q
What two drugs given for hyperlipidemia cause cholesterol gallstones?
A
Fibric acid derivatives and cholestyramine
25
What is Charcot's triad for ascending cholangitis?
Fever, RUQ pain, Jaundice
26
What is Reynold's pentad?
Fever, RUQ pain, Jaundice, hypotension, mental status changes
27
What is the result of a pregnant woman being infected with HEV?
Fulminant hepatitis with massive liver necrosis
28
How is HEV typically acquired?
Contaminated water or undercooked seafood
29
What defines chronic HBV infection?
Presence of HBsAG for more than 6 months
30
What is the first serologic marker to rise in HBV infection?
HBsAG
31
What HBV antigen indicates infectivity?
HBeAG
32
What is the only DNA hepatitis virus?
HBV
33
What are the two naked hepatitis viruses?
A and E (nAkEd)
34
Which hepatitis viruses are RNA?
HAV, HCV, HDV, HEV
35
What type of vaccine is HAV?
Killed
36
What type of DNA polymerase does HBV use?
RNA dependent DNA polymerase (reverse transcriptase- can treat with RTI's)
37
What is a Dane particle?
Hepatitis B surface antigen with DNA in it - refers to an infectious HBV particle
38
Where does HBV replicate its DNA?
Cytoplasm
39
What causes symptoms in HAV/HBV/HCV?
Patient's CD8 cells attacking infected hepatocytes
40
Which patients are at a higher risk for progression to cancer/cirrhosis from HBV?
Those with reduced CMI (AIDS/DiGeorge/kids)
41
What is the first antibody to appear in HBV?
HBcAb - presence indicates recent infection
42
What does HBeAg positivity indicate?
Actively replicating (infective) virus
43
What type of vaccine is HBV?
Recombinant
44
What family of virus is HCV in?
Flavivirus
45
What does HCV do that makes the liver take it into hepatocytes?
Coats itself with LDL or VLDL
46
What 2 drugs are used to treat HCV?
Ribavirin and IFN-alpha. These can CURE HCV!
47
Explain HDV superinfection
A person previously infected with HBV acquires HDV. HBV surface antigen exists in great quantities in this patient's blood, and it coats the HDV very rapidly, causing fulminant hepatitis.
48
Explain HDV/HBV co-infection
A person acquires HDV and HBV at the same time. Once enough HBV surface antigen is made, HDV coats itself with the surface antigen, and can destroy hepatocytes
49
What does HDV need from HBV to cause infection?
Needs HBV surface antigen - coats itself with it
50
What can a patient do to protect themselves from HDV?
Get vaccinated for HBV!
51
What is the only population we are concerned about with respect to HEV?
Pregnant women
52
What family is HEV a part of?
Hepevirus (HepEvirus)
53
What two things fail to fuse in cleft lip?
The maxillary and nasal processes
54
What fails to fuse in cleft palate?
The lateral palatine processes, the nasal septum, and/or the medial palatine processes.
55
What 3 things are seen in Bechet syndrome?
Recurrent aphthous ulcers, genital ulcers, and uveitis. Due to vasculitis in vessels of all sizes. Also, injury to an area results in a sterile pustule at the site of pinprick. Associated with HLA B-51
56
What are two risk factors for squamous cell CA of the mouth?
Tobacco and alcohol use
57
Where on the tongue does hairy leukoplakia typically occur?
Lateral tongue (due to EBV in immunocompromised).
58
What 3 sequelae can be seen with mumps infection?
Orchitis, pancreatitis, aseptic meningitis.
59
What is seen on biopsy of a pleiomorphic adenoma of the salivary gland?
Benign tumor with stroma (cartilage) and epithelial tissue (glands). It is a mixed tumor.
60
Why does a pleiomorphic adenoma of the salivary gland recur frequently?
It has irregular margins and is tough to remove completely.
61
What is seen on biopsy of a Warthin's tumor of the parotid?
Cystic tumor with abundant lymphocytes and germinal centers.
62
What is seen on biopsy of a mucoepidermoid carcinoma of the salivary gland?
Malignant tumor composed of mucinous and squamous cells. It invades the facial nerve.
63
Describe the most common form of TE fistula.
Proximal esophagus ends in a blind pouch (atresia) and distal esophagus is attached to the trachea.
64
What is an esophageal web?
Thin protrusion of esophageal mucosa, most often in upper esophagus.
65
Describe the triad seen in Plummer-Vinson syndrome.
Iron deficiency anemia, Glossitis, Esophageal webs
66
What is a Zenker diverticulum?
Outpouching of pharyngeal mucosa through an acquired defect in the muscular wall.
67
Where does a Zenker diverticulum commonly occur?
Above the upper esophageal sphincter at the junction of the esophagus and the pharynx.
68
What is Mallory-Weiss syndrome?
Linear laceration of the mucosa at the GE junction driven by vomiting (alcoholism, bulimia). Presents as painful hematemesis.
69
What is Boerhave syndrome?
Esophageal rupture due to violent retching. Can lead to subcutaneous emphysema.
70
What are the two abnormalities that occur in achalasia?
Decreased peristalsis (due to loss of myenteric plexus) and inability to relax LES (thought to be due to loss of NO/VIP).
71
List two common causes of secondary achalasia.
Chagas disease, CREST syndrome.
72
Bird's beak sign
Achalasia
73
Dysphagia for solids and liquids
Achalasia
74
What is seen on esophageal manometry in achalasia?
High LES pressure.
75
Hourglass appearance of stomach
Hiatal hernia
76
What is a common GI cause of adult-onset asthma?
GERD
77
Describe the "new" cells seen in Barrett's esophagus.
Non-ciliated columnar epithelium with goblet cells.
78
What is the most common esophageal cancer in the USA? Worldwide? Where is each type commonly located?
USA - adenocarcinoma (lower 1/3) Worldwide - squamous cell carcinoma (Upper 2/3).
79
List some risk factors for squamous cell carcinoma of the esophagus.
Alcohol, tobacco, hot tea, achalasia, esophageal web, esophageal injury (IRRITATION).
80
What is the major risk factor for adenocarcioma of the esophagus?
Barrett's esophagus (lower 1/3 of esophagus).
81
Through which nodes does esophageal cancer from the upper, middle, and lower 1/3 of the esophagus spread?
Upper 1/3 - cervical nodes; Middle 1/3 - mediastinal or tracheobronchial nodes; Lower 1/3 - Celiac and gastric nodes
82
What is the most common benign esophageal tumor? How should you biopsy it?
Leiomyoma. Do NOT biopsy it.
83
How can you differentiate an omphalocele from a gastroschisis?
Omphalocele will be covered in peritoneum and amnion, gastroschisis won't.
84
Palpable "olive" in the epigastric region of a newborn.
Pyloric stenosis.
85
Are babies with pyloric stenosis born with the disorder?
No, they acquire it 2-3 weeks after birth (takes time for the pyloris to become hypertrophic)
86
Describe the vomiting seen in pyloric stenosis
Nonbilous, because the stenosis is proximal to the duodenum.
87
What is the underlying cause of acute gastritis?
Imbalance between mucosal defenses and acidic environment.
88
What is a Curling ulcer?
Acute gastritis following a severe burn (due to decreased bloodflow to the mucosa).
89
What is a Cushing ulcer?
Ulcer caused by increased intracranial pressure, which results in increased vagal tone.
90
What causes type A chronic gastritis and where in the stomach does it occur?
Autoimmune attack of parietal cells or intrinsic factor. It is seen in the body and fundus of the stomach.
91
What causes type B chronic gastritis and where in the stomach is it commonly seen?
H. pylori infection. It is commonly seen in the antrum of the stomach.
92
What type of hypersensitivity is type A chronic gastritis?
Type IV (T cell mediated. As a result, the patient develops parietal cell antibodies, but they aren't the cause of the damage, they are a result of it).
93
Describe some clinical features seen with type A chronic gastritis.
Atrophy of mucosa; Achlorhydria (decreased acid) with increased gastrin and antral G cell hyperplasia; Megaloblastic anemia; Increased risk for gastric adenocarcinoma (secondary to metaplasia)
94
H. pylor increases the risk for which two cancers?
Gastric adenocarcinoma and MALT lymphoma
95
What is the #1 cause of duodenal ulcers?
H. pylori.
96
Describe the pain with gastric vs. duodenal ulcers.
Gastric ulcer pain - worse with meals. VS Duodenal ulcer pain - better with meals.
97
Are gastric or duodenal ulcers more likely maignant?
Gastric (duodenal ulcers are almost never malignant).
98
What blood type increases risk for intestinal-type stomach cancer?
A
99
Describe the findings in intestinal-type stomach cancer.
Commonly on lesser curvature, looks like an ulcer with raised margins. Associated with H. pylori infection, nitrosamines increase risk.
100
What is linitis plastica and with what disorder is it associated?
Thickening of the stomach wall seen in diffuse type stomach cancer.
101
What is a signet ring cell and what disorder is it associated with?
A cell with its nucleus pushed to the edge. The nucleus is pushed to the edge by mucin in diffuse-type stomach cancer.
102
Linitis plastica is associated with what disorder?
Diffuse-type (signet ring cell) stomach cancer.
103
H. pylori is associated with what type of stomach cancer?
Intestinal-type
104
Nitrosamines are associated with what type of stomach cancer?
Intestinal-type
105
Signet ring cells are associated with what type of stomach cancer?
Diffuse-type stomach cancer.
106
What are the two types of stomach cancer?
Intestinal-type (Ulcerated, H. pylori, nitrosamines, lesser curvature). Diffuse type (signet ring cells, linitis plastica, Krukenburg tumor).
107
Acanthosis nigricans is associated with what neoplasm?
Gastric cancer
108
What is Leser-Trelat sign?
Sudden development of multiple seborrheic keratoses, often on the back. Associated with gastric carcinoma.
109
What is Virchow's node?
Spread of stomach cancer to the left supraclavicular node.
110
What is a Sister Mary Joseph nodule?
Spread of stomach cancer to superficial umbilical nodes. Seen with intestinal type.
111
What is Krukenburg tumor?
Spread of gastric carcinoma to ovaries. Seen with diffuse type (signet ring).
112
What is Menetrier's disease?
Gastric hypertrophy with protein loss, parietal cell atrophy, and increased mucus cells. It is a precancerous lesion.
113
Duodenal atresia is associated with what developmental disorder?
Down syndrome.
114
What is the "double bubble" sign?
Distension of stomach and blind loop of duodenum seen with duodenal atresia. The "bubbles" are separated by the pyloric sphincter.
115
What causes a Meckel diverticulum?
Persistence of the vitelline duct.
116
What is the rule of 2's in Meckels diverticulum?
2% of the population; 2 ft from ileocecal valve; 2 inches long; 2 types of tissue (pancreatic/gastric); 2 year olds
117
What causes bleeding in a Meckel diverticulum?
Gastric tissue secretes acid that destroys surrounding tissue.
118
How do you diagnose a Meckel diverticulum?
Pertechnitate scan
119
Passage of "currant jelly" stool.
Intussusception
120
Which two HLA subtypes is celiac disease associated with?
HLA DQ2 and DQ8
121
What is the most pathogenic component of gluten?
Gliadin
122
What is seen on duodenal biopsy of a patient with Celiac disease?
Flattening of vili, hyperplasia of crypts, and increased intraepithelial lymphocytes.
123
In what part of the small intestine is celiac disease most prominent?
Duodenum
124
What is the best assay for diagnosis of celiac disease?
IgA or IgG (in IgA deficient patients) against tissue transglutaminase.
125
Celiac disease increases the risk for which two neoplasms?
Small bowel CA and T cell lymphoma
126
What 3 antibodies are found in celiac sprue?
Anti-endomysial, anti-gliadin, anti-tissue transglutaminase.
127
What is tropical sprue?
Malabsorption arising after infectious diarrhea caused by an unknown organism.
128
In what part of the small intestine is tropical sprue most prominent?
Jejunum and ileum (NOT duodenum like in Celiac)
129
Why does tropical sprue cause a folic acid and B12 deficiency?
Because it damages the jejunum (where folic acid is reabsorbed) and the ileum (where B12 is reabsorbed).
130
What will be seen upon biopsy in Whipple disease?
Foamy macrophages that are PAS positive, diastase resistant.
131
What type of malabsorption is caused by Whipple disease?
Fat malabsorption (damage to the lamina propria).
132
What are some non-GI symptoms seen with Whipple disease?
Cardiac valve abnormalities, arthralgias, neurologic symptoms.`
133
Apo-B48 is needed for...
Chylomicron formation
134
Apo-B100 is needed for...
VLDL and LDL formation
135
What will be seen in abetalipoproteinemia?
Inability to generate chylomicrons (apo B 48), LDL and VLDL (apo B 100).
136
What can be used to stain carcinoid tumor?
Chromogranin
137
Carcinoid tumors secrete...
Serotonin
138
What metabolite is excreted in the urine in carcinoid tumor?
5-HIAA (metabolite of serotonin)
139
What is the difference between carcinoid tumor and carcinoid syndrome?
Carcinoid syndrome requires serotonin in the systemic circuit. Serotonin is metabolized by the liver if the lesion is solely in the GI system (carcinoid tumor). If the tumor metastasizes to the liver, it can then be dumped into the hepatic vein (systemic circuit), and cause serotonin syndrome.
140
Why don't you see carcinoid heart disease on the left side of the heart?
Because the lung has monoamine oxidase.
141
Why don't you see carcinoid syndrome if a carcinoid tumor is localized to the GI system only?
Because the liver metabolizes 5-HT into 5-HIAA.
142
What obstructs the appendiceal lumen to cause appendicitis in children?
Lymphoid hyperplasia
143
What is the key histologic hallmark of ulcerative colitis?
Crypt abscess with neutrophils
144
What two factors determine the risk for carcinoma in a patient with ulcerative colitis?
Amount of colon involved and duration of disease (> 10 years = higher risk for dysplasia).
145
What autoantibody can be seen in association with ulcerative colitis?
p-ANCA
146
Is smoking protective for ulcerative colitis or Crohn disease?
Ulcerative colitis
147
Describe the portion of the gut involved in ulcerative colitis.
Always begins in rectum and extends proximally up to the cecum. Only the colon is affected.
148
Is the involvement continuous or skipped in ulcerative colitis?
Continuous
149
Lead pipe colon
Ulcerative colitis
150
Full thickness colonic inflammation with knife-like fissures
Crohn disease
151
Skip lesions
Crohn disease
152
What is the most common site of Crohn disease?
Terminal ileum (can cause a B12 deficiency)
153
What is always spared in Crohn disease?
Rectum
154
TH2 mediated IBD
UC
155
TH1 mediated IBD
Crohn disease
156
Where is the pain typically localized in UC vs. Crohn disease?
LLQ in UC (rectum most commonly involved); RLQ in CD (terminal ileum most commonly involved).
157
Bowel inflammation with granulomas
Crohn disease
158
Cobblestone mucosa
Crohn disease
159
String sign
Crohn disease (narowing of the colonic lumen due to transmural inflammation causing myofibroblast deposition and contraction).
160
IBD with mouth to anus involvement
CD
161
Why does CD increase the risk for nephrolithiasis?
With inflammation of the bowel, absorption of oxalate in the gut is increased.
162
Which IBD increases the risk of fistula?
CD
163
Does smoking increase or decrease the risk for Crohn disease?
Increase
164
What are some extra-intestinal manifestations of Crohn disease?
Migratory polyarthritis, erythema nodosum, ankylosing spondylitis, uveitis, calcium oxalate kidney stones.
165
What are some extra-intestinal manifestations of ulcerative colitis?
Pyoderma gangrenosum, primary sclerosing cholangitis, anyklosing spondylitis, uveitis, urate kidney stones.
166
Hirschsprung disease is associated with what developmental disorder?
Down syndrome
167
What is the underlying pathology in Hirschsprung disease?
Failure of migration of neural crest cells results in absent myenteric (Auerbach's) and submucosal (Meissner's) plexuses in the rectum and distal colon.
168
How is biopsy performed in patients with Hirschsprung disease?
Rectal suction biopsy
169
Anatomically, what is the most common location of colonic diverticula?
Sigmoid colon
170
Histologically, where do colonic diverticula occur?
Where the vasa recta traverses the muscularis propria (weak point in colonic wall).
171
What parts of the colonic wall form the diverticulum in diverticulosis?
Only mucosa and submucosa (false diverticulum).
172
What is angiodysplasia?
Tortuous dilation of mucosal and submucosal capillary beds leading to hematochezia in an older adult.
173
What is Osler-Weber-Rendu syndrome also known as?
Hereditary hemorrhagic telangiectasia
174
What are the findings in hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)?
Telangiectasias, recurrent epistaxis, GI bleeds, skin discoloration. Autosomal dominant.
175
Where does ischemic colitis most commonly occur?
Splenic flexure (SMA/IMA watershed area)
176
T/F - hyperplastic colonic polyps have a possibility of becoming malignant.
False - hyperplastic polyps have no malignant potential.
177
Colonic polyp with serrated appearance.
Hyperplastic polyp. No malignant potential.
178
T/F - adenomatous colonic polyps have a possibility of becoming malignant.
True - they are benign masses, but they are pre-malignant.
179
What are the two types of colonic polyps?
Adenomatous (pre-malignant), hyperplastic (no malignant potential)
180
What does colonic APC mutation cause?
Increased RISK for formation of a polyp (doesn't cause the polyp to form)
181
What does colonic K-RAS mutation cause?
Formation of a polyp (adenoma) - after an APC mutation increased the risk for polyp formation.
182
What does colonic p53 mutation cause?
Progression of an adenomatous polyp to carcinoma (after APC increased the risk for a polyp, which was formed with K-RAS mutation).
183
Why is aspirin protective for colorectal carcinoma?
Because COX is necessary to form colon cancer.
184
List the steps in the colon adenoma-carcinoma sequence.
1. APC mutation increases RISK for formation of a polyp. 2. K-RAS mutation causes formation of an adenomatous polyp. 3. p53 mutation and increased COX expression causes adenoma progression to carcinoma.
185
Mutation of what TSG increases the risk of colonic polyp formation?
APC
186
Mutation of what oncogene causes colonic polyp formation?
K-RAS
187
The APC tumor suppressor gene is located on which chromosome?
5 (5 letters in polyp)
188
Mutation of what tumor suppressor gene allows colonic adenoma to progress to carcinoma?
p53
189
Colon adenomas of what gross and histologic morphology increase the risk of progression to cancer?
Gross - sessile (not pedunculated); Histologic - Villous
190
Formation of hundreds to thousands of colonic polyps
Familial adenomatous polyposis
191
What gene is mutated in FAP?
APC
192
What is Gardner syndrome?
FAP (thousands of polyps) with fibromatosis and osteomas.
193
What is Turcot syndrome?
FAP (thousands of polyps) with CNS tumors.
194
Thousands of colonic polyps with CNS tumors. Dx?
Turcot syndrome
195
Thousands of colonic polyps with fibromatosis and osteomas. Dx?
Gardner syndrome
196
What is a juvenile polyp?
A sporadic hamartoma (benign) polyp arising in children. Presents as a solitary rectal polyp that prolapses and bleeds.
197
What is juvenile polyposis?
Multiple juvenile polyps (hamartomas) in the stomach and colon. Large numbers increase the risk of progression to cancer.
198
Patient has hamartomatous polyps throughout the GI tract with hyperpigmentation on lips. Dx?
Peutz-Jeghers syndrome
199
What is the inheritance pattern of Peutz-Jeghers syndrome?
Autosomal dominant
200
What type of polyps are seen in juvenile polyposis and Peutz-Jeghers syndrome?
Hamartomas (benign)
201
What is the second most common molecular mechanism for formation of colorectal cancer?
Microsatellite instability - DNA mismatch repair mutations (hMSH2, hMLH1) leads to sporadic cancer and HNPCC.
202
What is mutated in HNPCC?
DNA mismatch repair enzymes hMSH-2 and hMLH1 (microsatellite instability).
203
Besides colon, which two other malignancies are patients with HNPCC at increased risk for?
Ovarian and endometrial carcinoma
204
What tumor marker is useful in detecting recurrence of colorectal carcinoma?
CEA (good for monitoring response to treatment, NOT good for screening).
205
What is the use of CEA in colorectal cancer?
Good for monitoring recurrence and treatment response, NOT good for screening.
206
What is the inheritance pattern of HNPCC and FAP?
Both are autosomal dominant.
207
How does right sided colon cancer commonly present?
Manifestations of iron deficiency anemia due to blood loss
208
How does left sided colon cancer commonly present?
Changes in stool caliber (usually thin stools), constipation, "napkin ring" lesions.
209
What is toxic megacolon and what disease increases the risk for it?
Rapid colonic distension following complete cessation of neuromuscular activity in the large intestine seen in ulcerative colitis.
210
A non-compliant patient with known ulcerative colitis presents hypotensive, tachycardic with a distended abdomen. What should be done next? What should be avoided?
The patient likely has toxic megacolon. A flat plain x-ray should be done to diagnose the condition. Avoid colonoscopy or barium enema as they increase the risk for rupture.
211
What is the most common form of appendiceal tumor?
Carcinoid
212
HNPCC is also known as...
Lynch syndrome
213
What is the first step in screening for malabsorption?
Sudan III stool stain to look for fat in the stool
214
What is Courvoisier sign?
Palpable but nontender gallbladder, suggestive of adenocarcinoma of the head of the pancreas
215
Where are anal fissures most commonly located?
Posterior midline, distal to the dentate line (painful).
216
What happens to serum calcium levels in acute pancreatitis and why does this happen?
Patients get hypocalcemia, because of calcium depositing on foci of fat necrosis in the damaged peri-pancreatic fat.
217
What lines pancreatic pseudocysts?
Granulation tissue
218
Why are stools pale with pancreatic adenocarcinoma?
Blockage of the bile duct. Bilirubin gives stool its color.
219
What are the 3 different types of gallstones?
Cholesterol; Black pigment - hemolysis, Brown pigment - infection
220
What is biliary colic?
Waxing and waning RUQ pain caused by gallbladder contracting against a cystic duct that is blocked by a stone.
221
What makes stool brown?
Stercobilin
222
What causes darkening of the urine in excessive extravascular hemolysis?
Increased urine urobilinogen (not unconjugated bilirubin, because it is not water soluble).
223
What is kernicterus and what causes it?
Deposition of fat soluble unconjugated bilirubin in the basal nuclei leads to neurological deficits and death in newborns.
224
What is the treatment for physiologic jaundice of the newborn and why does it work?
Phototherapy - makes unconjugated bilirubin water soluble.
225
Describe the findings in Gilbert syndrome.
Mild decrease in the liver's ability to conjugate bilirubin only causes jaundice in the face of excess stress. Benign.
226
What is decreased in Gilbert syndrome?
UDP-glucuronyl transferase is mildly decreased. Causes benign hyperbilirubinemia with stress/fasting.
227
What form of bilirubin is increased in the blood in Gilbert syndrome?
Unconjugated (mild decrease in the ability of the liver to conjugate bilirubin in times of stress due to decreased UDP-glucuronyl transferase).
228
What form of bilirubin is increased in the blood in extravascular hemolysis?
Unconjugated
229
What form of bilirubin is increased in the blood in physiologic jaundice of the newborn?
Unconjugated (liver can't conjugate it well enough yet).
230
What form of bilirubin is increased in the blood in Crigler-Najjar syndrome?
Unconjugated (absence of UGT)
231
Explain the cause of Crigler-Najjar syndrome.
Absent UDP-glucoronyl transferase = liver can't conjugate bilirubin. Leads to unconjugated hyperbilirubinemia, death at a young age.
232
What is defective in Dubin-Johnson syndrome?
Bilirubin canalicular transport. The liver can conjugate bilirubin, it just can't transport it into bile canaliculi.
233
What form of bilirubin is increased in the serum of patients with Dubin-Johnson syndrome?
Conjugated
234
Describe the appearance of the liver in patients with Dubin-Johnson syndrome.
Grossly black
235
What is the difference between Dubin-Johnson and Rotor syndromes?
Both result from a decrease in the liver's ability to transport conjugated bilirubin into the bile canaliculus. The liver of a patient with DJ syndrome will be grossly black, the liver of a patient with Rotor syndrome won't.
236
What form of bilirubin is increased in the serum of patients with Rotor syndrome?
Conjugated
237
What form of bilirubin is increased in the serum of patients with gallstones?
Conjugated (blockage of the bile duct causes leakage of bilirubin into the blood - could also be unconjugated if gallstones are black pigment stones due to hemolysis).
238
What form of bilirubin is increased in the serum of patients with viral hepatitis?
Both conjugated (damaging bile ductules = conjugated bilirubin leaks out) AND unconjugated (damaging hepatocytes = decreased conjugating ability)
239
Where does the inflammation primarily occur in chronic hepatitis?
In the portal tract (not as much in the lobules)
240
What is the only thing positive during the HBV window phase?
HBcAB IgM
241
What mediates fibrosis in cirrhosis?
Stellate cell - secretes TGF-beta
242
What are Mallory Bodies?
Damaged intermediate filaments in hepatocytes seen in alcoholic hepatitis.
243
What causes damage in hemochromatosis?
Generation of free radicals by iron
244
What gene is most commonly mutated in primary hemochromatosis?
HFE gene
245
What are the two most common mutations seen in primary hemochromatosis?
C282Y or H63D on the HFE gene
| Associated with HLA-A3
246
Describe the changes seen in ferritin, TIBC, serum iron, and transferrin saturation in hemochromatosis.
Increased ferritin, Decreased TIBC (measure of transferrin), Increased serum iron, Increased transferrin saturation
247
What stain can be used to distinguish iron in the liver from lipofuscin?
Prussian blue (will stain iron blue, won't stain lipofuscin, which is a brown wear and tear pigment derived from oxidized lipids).
248
What gene is mutated in Wilson's disease?
ATP7B gene (normally transports copper into bile)
249
What happens to serum ceruloplasmin in patients with Wilson's disease?
Decreases
250
Antimitochondrial antibody
Primary biliary cirrhosis
251
What is the pathophysiology of primary biliary cirrhosis?
Autoimmune attack of intralobular bile ducts results in lymphocytic infiltrate and granulomas.
252
Ulcerative colitis increases the risk for what biliary disease?
Primary sclerosing cholangitis
253
Periductal fibrosis with "onion skin" appearance.
Primary sclerosing cholangitis
254
String of pearl appearance on ECRP.
Primary sclerosing cholangitis
255
Describe the findings on imaging in a patient with primary sclerosing cholangitis.
Alternating strictures and dilation with "beading" of intra and extra-hepatic ducts. Leads to a "string of pearls" appearance.
256
What is Caroli syndrome?
Cystic dilation of intrahepatic bile ducts seen in kids. Associated with renal cystic disease.
257
What is damaged in liver cells in Reye syndrome?
Mitochondria
258
What is the only disease that aspirin is indicated in children?
Kawasaki disease
259
Hepatic adenoma is associated with use of..
Oral contraceptives
260
Aflatoxins increase risk of...
Hepatocellular carcinoma (through p53 mutations).
261
What is Budd-Chiari syndrome?
Hepatic vein obstruction. Can be caused by polycythemia or liver carcinoma invasion of the hepatic vein.
262
What is the serum tumor marker for hepatocellular carcinoma?
Alpha-fetoprotein
263
Polyvinyl chloride increases the risk for what malignancy?
Angiosarcoma of the liver
264
What is seen on biopsy of a liver of a child with Reye syndrome?
Microvesicular steatosis
265
What are Councilman bodies?
Eosinophilic apoptotic hepatocytes seen on liver biopsy in hepatitis
266
What is seen in biopsy of a patient with acute viral hepatitis?
Ballooning degeneration
267
hMSH2 mutations lead to...
Microsatellite instability, defective mismatch repair, and HNPCC (Lynch syndrome)
268
hMLH1 mutations lead to...
Microsatellite instability, defective mismatch repair, and HNPCC (Lynch syndrome)
269
What is alpha-amanitin, what does it cause, and how does it cause it?
Alpha amanitin is a toxin produced by some mushrooms that causes massive hepatic failure through inhibition of eukaryotic RNA polymerase II (which synthesizes mRNA).
270
Anti-saccharomyces cerevisiae antibodies
Crohn disease
271
What makes up the foregut, midgut and hindgut?
Foregut - pharynx to duodenum
Midgut - duodenum to transverse colon
hindgut - distal transverse colon to rectum
272
What occurs if you have a developmental defect of the anterior abdominal wall due to failure of the rostral fold closing?
Sternal defects
273
What occurs if you have a developmental defect of the anterior abdominal wall due to failure of the caudal fold closing?
Bladder exstrophy
274
What occurs if you have a developmental defect of the anterior abdominal wall due to failure of the lateral fold closing?
Omphalocele, gastroschisis
275
what chromosomal abnormality is associated with duodenal atresia?
Trisomy 21
276
When the midgut returns to the abdominal cavity during week 10 of development, what does it rotate around?
SMA
277
Does a gastroschisis or omphalocele typically include the liver in its contents?
Omphalocele
278
Why does an infant with an esophageal atresia with a distal tracheoesophageal fistula develop cyanosis?
The cyanosis is secondary to laryngospasm (to avoid reflux-related aspiration)
279
A patient presents with a palpable "olive" mass in the epigastric region and nonbilious projectile vomiting at about 2 weeks old - what is wrong with the baby?
Congenital pyloric stenosis
occurs more often in the firstborn males
280
if a patient has PROLONGED vomiting (days to week) how would they present?
Decreased HCL will lead to hypochloremia, metabolic alkalosis and hypokalemia (due to H/K pump on cells pushing H into the serum and K into the cells to try to correct for the alkalosis)
281
What is the pancreas derived from?
Foregut (endoderm)
282
What do the ventral and dorsal pancreatic buds become?
Ventral pancreatic bud - contributes tot he pancreatic head and main pancreatic duct
Doral pancreatic bud - becomes every thing else (body, tail, isthmus and accessory pancreatic duct)
note that the uncinate process is formed by the ventral bud alone
283
What is pancreas divisum?
Ventral and dorsal parts of the pancreas fail to fuse at 8 weeks
284
Where does the spleen arise from?
spleen arises in the mesentery of the stomach (mesodermal) but it's supplied by the foregut celiac A
285
Name the retroperitoneal structures
```
A DUCK PEAR
Aorta and IVC
Duodenum 2-4
Ureters
Colon (descending and ascending)
Kidneys
Pancreas
Esophagus below the diaphragm (lower 2/3)
Adrenals
Rectum
```
286
what is contained in the falciform ligament?
Ligamentum teres hepatis (derivative of the fetal umbilical vein)
it connects the liver to the anterior abdominal wall
287
What is the falciform ligament of derivative of?
Ventral mesentery
288
What does the hepatoduodenal ligament contain?
Portal triad (hepatic artery, portal vein and common bile duct
289
What is the pringle maneuver?
Ligament may be compressed between thumb and index finger placed in the omental foramen to control bleeding (hepatoduodenal ligament)
290
Which ligament connects the greater and lesser sacs?
Hepatoduodenal ligament
291
What does the gastrohepatic ligament connect?
Liver to the lesser curvature of the stomach
292
What is contained within the gastrohepatic ligament?
Gastric arteries
293
What separates the greater and lesser omental sacs on the right?
Gastrohepatic ligament - this can be cut during surgery to access the lesser sac
294
What does the gastrocolic ligament connect?
The greater curvature and transverse colon
295
What does the gastrocolic ligament contain?
Gastroepiploic artreries
296
What does the gastrospenic ligament connect?
Greater curvature and spleen
297
What is contained in the gastrosplenic ligament?
Short gastrics, left gastroepiploic vessels
298
What ligament separates the greater and lesser omental sacs on the left?
Gastrosplenic ligament
299
What does the splenorenal ligament connect?
The spleen to the posterior abdominal wall
300
What structures are contained in the splenorenal ligament?
Splenic artery and vein, tail of pancreas
301
What are the layers of the gut wall from the inside to the outside?
MSMS
| Mucosa, Submucosa, Muscularis externa, Serosa
302
Where is the Meissner's plexus located?
In the submucosa
303
Where is the Auerbach's plexus located?
Muscularis externa
304
Where are ulcers vs erosions located in the digestive tract?
Ulcers - into submucosa, inner or outer muscular layer
| erosions - into mucsoa only
305
what is the histology of the esophagus?
nonkeratinized stratified squamous epithelium
306
What is the histology of the stomach?
Gastric glands
307
What is the histology of the Duodenum?
Villi and microvilli increase absorptive surface. Brunner's glands (submucosa) and crypts of Lieberkuhn
308
What is the histology of the jejunum?
Plicase circulares and crypts of Lieberkuhn
309
What is the histology of the ileum?
Peyer's patches (lamina propria, submucosa), plicae circulares (proximal ilium), and crypts of Lieberkuhn
Has the largest number of goblet cells in the small intestine
310
Colon
Colon has crypts but no villi, numerous goblet cells
311
List the branches of the celiac trunk
Common hepatic, splenic, and left gastric arteries
312
List the 4 arterial anastomoses that exist if the abdominal aorta were to be blocked
1. Superior epigastric (internal thoracic/mammary) and inferior epigastric (external iliac)
2. Superior pancreaticoduodenal (celiac trunk) and inferior pancraeticoduodenal (SMA)
3. Middle colic (SMA) and left colic (IMA)
4. superior rectal (IMA) and middle + inferior rectal (internal iliac)
313
What is the portal/systemic anastomosis for esophageal varices?
Left gastric vein (portal) with esophageal vein/Azygous vein (systemic)
314
What is the portal/systemic anastomosis for caput medusa?
Paraumbilical vein with superficial and inferior epigastric veins below the umbilicus and superior epigastric and lateral thoracic veins above the umbilicus
315
What is the portal/systemic anastomosis for Internal hemorrhoids?
Superior rectal vein (portal) with middle and inferior rectal (systemic)
316
What is the pectinate (dentate) line?
Formed where endoderm (hindgut) meets ectoderm
317
What type of hemorrhoids and cancer can occur above the pectinate line?
Internal hemorrhoids and adenocarcinoma
318
What is the blood supply above the pectinate line?
Superior rectal artery (IMA)
319
What is the venous drainage above the pectinate line?
Superior rectal vein to the inferior mesenteric vein to the portal system
320
What is the lymphatic drainage of the area above vs the area below the pecinate line?
Above the pectinate line - deep nodes
| Below the pectinate line - superficial inguinal nodes
321
What type of hemorrhoris and cancer can occur blow the pectinate line?
External hemorrhoids and squmouas cell carcinoma
322
What is the blood supply below the pectinate line?
inferior rectal artery (from the internal pudendal artery)
323
WHat is the venous drainage below the pectinate line?
inferior rectal vein to the internal pudendal vein to the internal iliac vein to the IVC
324
Where does blood from hemorrhoids come from?
VENOUS
325
What are the three zones of the liver?
zone 1 - periportal zone - affected first by viral hepatitis
zone 2 - intermediate
zone 3 - pericentral vein (centrilobular) zone - affected first by ischemia or hypotension
326
Which zone of the liver contains the P450 system?
Zone 3 - therefore this is the most sensitive zone to toxic injury and also is the site of alcoholic hepatitis
327
What are the two sources of blood coming into the liver?
1. hepatic artery (oxygenated)
| 2. portal vein - blood that's been drained from the GI tract (contains the nutrients, drugs, toxins, etc.
328
What is the ligament of treitz?
Demarcation between an upper and lower GI bleed
It arises from CT around the celiac trunk - inserts into the 3rd and 4th portions of the duodenum
329
What makes up the femoral triangle?
Contains the femoral vein, artery and nerve
330
What is contained in the femoral sheath?
Fascial tube 3-4 cm below the inguinal ligament that contains the femoral vein, artery and canal (deep inguinal lymph nodes) but NOT the formal nerve
331
From lateral to medial describe the organization of the femoral region?
lateral to medial to find your NAVL
| Nerve - artery - vein - Lymph
332
What protrudes through the internal inguinal ring?
Indirect hernia
333
What protrudes through the abdominal wall?
Direct hernia
334
Name the layers of the spermatic cord
External spermatic fascia (external oblique)
Cremasteric muscle and fascia (internal oblique)
Internal spermatic fascia (transversalis fascia)
335
Which hernia occurs laterally to the inferior epigastric artery?
Indirect inguinal hernia
336
Which hernia goes through the internal inguinal ring, external inguinal ring and into the scrotum?
Indirect inguinal hernia
337
Which hernia occurs in infants due to a failure of the processus vaginalis to close?
indirect inguinal hernia
can form a hydrocele
338
Which hernia is more common in women?
femoral hernia
339
Which hernia is the leading cause of bowel incarceration?
Femoral hernia
340
Which hernia protrudes through the inguinal triangle (Hesselbach's triangle)
Direct inguinal hernia
341
Which hernia bulges directly though the abdominal wall medial to the inferior epigastric artery?
Direct inguinal hernia
342
Which hernia goes through the external (superficial) inguinal ring only and is covered by external spermatic fascia?
Direct inguinal hernia
343
Which hernia protrudes below the inguinal ligament through the femoral canal below and lateral to the pubic tubercle?
Femoral hernia
344
What is the most common form of diaphragmatic hernia?
Sliding hiatal hernia
GE junction gets displaced superiorly and makes an hour glass stomach
345
Which type of diaphragmatic hernia has the fundus of the stomach protruding into the thorax?
Paraesophageal hernia
346
How do the parasympathetics regulate gastric acid secretion?
via M3 with Ach
stimulates g cells to indirectly increase gastric acid - the Vagus also uses gastrin releasing peptide to indirectly stimulate increased gastric acid
so if you treat a person with anti-muscarinics like atropine, it'll only work in one area - it won't complete block acid production from the parasympathetics
347
What is the source of gastrin?
G cells in the antrum of the stomach
348
How do you increase gastrin secretion?
Increased stomach distension/alkalinization, amino acids like phenylalanine or tryptophan, peptides, or vagal stimulation. also calcium
349
How do you decrease gastrin release?
decreasing the stomach pH to less than 1.5
350
What is the function of gastrin?
Increases gastric acid secretion, increases growth of gastric mucosa, increases gastric motility
note that chronic PPI use can also lead to increased gastrin
351
What hormone is increased in zollinger Ellison syndrome?
Gastrin
352
What is the source of CCK?
I cells in the duodenum and jejunum
353
How is CCK regulated?
CCK is increased by fatty acids and amino acids
354
What is the action of CCK?
Increases pancreatic secretion, increases gallbladder contraction, increases relaxation of the sphincter of oddi
decrease gastric emptying
355
What is the source of Secretin?
S cells in the duodenum
356
How does CCK have its effect?
CCK acts on neural muscarinic pathways to cause pancreatic secretion
357
How is secretin regulated?
Secretin is increased by acid and fatty acids in the lumen of the duodenum
358
What is the action of secretin
Increases pancreatic bicarb secretion, decreases gastric acid secretion (by inhibiting gastric parietal cells) and increase bile secretion
359
What is the source of somatostatin?
D cells in the pancreatic islets and the GI mucosa
360
What regulates somatostatin release?
Increased by acid and decreased by vagal stimulation
361
What is the action of somatostatin?
Decreases gastric acid and pepsinogen secretion, degreases pancreatic and small intestine fluid secretion, degreases GB contraction and decreases insulin and glucagon release
362
What is the source of Glucose dependent insulinotropic peptide?
K cells in the duodenum and jejunum
363
What is the action of Glucose dependent insulinotropic peptide?
Exocrine - decreases gastric acid secretion
| Endocrine - increases insulin release
364
How is Glucose dependent insulinotropic peptide regulated?
Increaesd by fatty acids,, amino acids and oral glucose
365
What is the other name for Glucose dependent insulinotropic peptide?
Gastric inhibitory peptide
366
What hormone is responsible for the fact that an oral glucose load is used more rapidly than the equivalent given by IV?
Glucose dependent insulinotropic peptide AKA gastric inhibitory peptide
367
What is the source of vasoactive intestinal polypeptide (VIP)?
Parasympathetic ganglia in sphincters, gallbladder and small intestine smooth muscle
368
What is the function of VIP?
Increases intestinal water and electrolyte secretion and increases the relaxation of intestinal smooth muscle and sphincters (relaxes LES)
369
How is VIP regulated?
Increased by distension and vagal stimulation
| decreased by adrenergic input
370
What is a VIPoma?
A non-alpha, non-beta islet cell pancreatic tumor that secretes VIP
causes copious watery diarrhea, hypokalemia, and achlorhydria
371
What is WDHA syndrome?
Used to describe the effects of a VIPoma
| Watery diarrhea, hypokalemia and achlorhydria
372
What is the function of nitric oxide in the GI tract?
Increases smooth muscle relaxation, including the lower esophageal sphincter
note that loss of NO secretion is implicated in increased LES tone of achalasia
373
What is the source of motilin?
Small intestine
374
What is the action of motilin?
Produces migrating motor complexes (MMCs)
375
How is Motilin regulated?
Increased during the fasting state
Note that the motilin receptor agonists (like erythromycin) are used to stimulate intestinal peristalsis
376
where are parietal cells located and what do they contain?
Stomach
| contain intrinsic factor and gastric acid
377
How is gastric acid secretion regulated?
Increased by histamine, Ach and gastrin
| Decreased by somatostatin, GIP, prostaglandin and secretin
378
What is a gastrinoma?
Gastrin secreting tumor that causes continuous high levels of acid secretion and ulcers
379
Where is iron absorbed?
duodenum
380
Where is B 12 absorbed?
terminal ileum
381
Where is folate absorbed?
Jejunum
382
Whats the mnemonic for remember where iron, B12 and folate are absorbed?
I'D Be Totally Insane For Jesus
Iron - duodenum
B12 - terminal ileum
Folate - jejunum
383
what is the source of pepsin? What is its function?
Chief cells in the stomach (body)
| It's function is to digest proteins
384
What converts pepsinogen to pepsin?
H+
385
How is pepsin regulated?
Increased by vagal stimulation and local acid
386
What is the source of bicarb in the GI tract?
Mucosal cells in the stomach, duodenum, salivary glands and the pancreas
and the Brunner's glands in the duodenum
387
How is bicarb regulated?
Increased by pancreatic and biliary secretion with secretin
388
What is the osmotic state of saliva?
Normally hypotonic because of absorption but it's more isotonic with higher flow rates because there's less time for absorption
389
What cells are located in the antrum of the stomach?
D cells, mucous cells and G cells
390
What cells are located in the body of the stomach?
Parietal cells and Chief cells
391
How does Gastrin increase acid secretion?
Through its effects on enterochromaffin like cells leading to histamine release (H2 receptors in the parietal cells use Gs to increased cAMP to increase gastric acid)
392
Where are Brunner glands located?
Submucosa of the duodenum - secrete alkaline mucus
| Hypertrophy of these glands is seen in peptic ulcer disease
393
What can activate trypsinogen into trypsin?
Enterokinase/enteropeptidase which is an enzyme secreted from the duodenal mucosa
394
What starts digestion by hydrolyzing alpha 1,4 linkages to yield disaccharides ?
Salivary amylase
395
what can you use to assess brush border absorptive function independent of pancreatic function?
Use D-xylose
| This is a good way to determine if malabsorption is due to pancreatic or intestinal pathology
396
How are monosaccharides absorbed?
Glucose and galactose - sodium dependent transport
| Fructose - facilitated diffusion
397
what is unencapsulated lymphoid tissue that's found in the lamina propria and submucosa of the ileum?
Peyer's patches
contain M cells that take up the antigen
398
What are bile salts?
Bile acids conjugated to glycine or taurine to make them water soluble
399
What catalyzes the rate limiting step of bile synthesis?
Cholesterol 7 alpha hydroxylase
400
can unconjugated bilirubin be found in the urine?
No, it is insoluble in water
401
What is direct bilirubin?
Conjugated with glucuronic acid - water soluble
402
What is the salivary gland tumor: benign mixed tumor that is the most common salivary gland tumor
Pleomorphic adenoma
403
What is the salivary gland tumor: Presents as a painless mobile mass. it's composed of cartilage and epithelium and recurs frequently
Pleomorphic adenoma
404
What is the salivary gland tumor: Papillary cystadenoma lymphomatosum
Warthin's tumor
405
What is the salivary gland tumor: benign cystic tumor with germinal centers
Warthin's tumor
406
What is the salivary gland tumor: Second most common benign tumor
Warthin's tumor
407
What is the salivary gland tumor: The most common malignant tumor
Mucoepidermoid carcinoma
408
What is the salivary gland tumor: Has mucinous and squamous components - it presents as a painful mass because of common involvement of the facial nerve
Mucoepidermoid carcinoma
409
What is Achalasia?
Failure of relaxation of the lower esophageal sphincter due to loss of myenteric (Auerbach's) plexus
410
What cancer is achalasia associated with?
Increased risk of esophageal squamous cell carcinoma
411
How is scleroderma different from achalasia?
CREST syndrome is associated with esophageal dysmotility involving LOW pressure proximal to the LES
412
Commonly presents as heartburn and regurgitation upon lying down. May also present with nocturnal cough and dyspnea, adult onset asthma. Has a decreased in LES tone
GERD
413
Painless bleeding of dilated submucosal veins in the lower 1/3 of esophagus secondary to portal hypertension
Esophageal varices
414
Associated with reflux, infection, or chemical ingestion
Esophagitis
infections:
- candida: white pseudomembrane;
- HSV-1: punched out ulcers;
- CMV: linear ulcers
415
Mucosal lacerations at the GE junction due to severe vomiting. Leads to hematemesis - usually found in alcoholics and bulimics.
Mallory-Weiss tears
Partial thickness tears
416
Transmural esophageal rupture due to violent retching
BoerHaave-Syndrome
Full thickness tear
usually occurs in distal esophagus
417
Associated with lye ingestion and acid reflux
Esophageal strictures
418
Dysphagia due to webs, glossitis, iron deficiency anemia
Plummer Vinson syndrome
419
What metaplasia occurs in Barrett's esophagus?
Glandular metaplasia - replacement of nonkeratinzed (stratified) squamous epithelium with intestinal (nonciliated columnar) epithelium
420
What causes Barretts esophagus? What would a patient have increased risk for?
Due to chronic GERD
| can lead to adenocarcinoma
421
what type of esophageal cancer is more common in the US? worldwide?
US: adenocarcinoma (whites - lower 1/3)
World: squamous cell carcinoma (blacks - upper 1/3)
422
Name 6 malabsorption syndromes?
These Will Cause Devastatin Absorption Problems
```
Tropical Sprue
Whipple's disease
Celiac Sprue
Disaccharidase deficiency
Abetalipoproteinemia
Pancreatic insufficiency
```
423
what is tropical sprue?
Unknown cause but it responds to antibotics. Can affect entire small bowel
424
What disease causes PAS-positive foamy macrophages in the intestinal lamina propria and mesenteric nodes?
Whipple's disease
425
What bug causes Whipples disease?
Gram positive tropheryma whipplei
426
What are some of the non-GI symptoms you can see in Whipple's disease?
Cardiac symptoms, Arthralgias, Neurologic symptoms
427
Where does Celiac sprue most often occur?
Primarily affects the distal duodenum or proximal jejunum
428
What will you see on histology of a patient with celiac sprue?
Loss of villi
429
What causes celiac sprue?
Autoantibodies to gluten (gliadin) in wheat and other grains
| associated with HLA-DQ2 and HLA-DQ8
430
what do the villi look like in a patient with disaccharidase deficiency?
normal
431
What is the lactose tolerance test?
Positive for lactose deficiency if:
- administration of lactose produces symptoms, and
- glucose rises <20 mg/dL
432
What is Abetalipoproteinemia?
Decreased synthesis of apolipoprotein B leading to inability to generate chylomicrons which leads to decreased secretion of cholesterol and VLDL into the blood stream so fat accumulates in enterocytes
433
What are the 3 antibodies you can see in a patient with celiac sprue?
Anti-endomysial, anti-tissue transglutaminase, and anti-gliadin
serum levels of tissue transglutaminase are used for screening
434
What is a Curling's ulcer?
a burn
| leads to decreased plasma volume and sloughing of the gastric mucosa
435
What is a Cushing's ulcer?
Brain injury
| leads to increased vagal stimulation which increased ACH leading to increased acid production
436
Why do NSAIDs lead to acute gastritis?
NSAIDs decrease PGE2 which leads to decreased bicarb and therefore decreased gastric mucosa protection
437
What is the difference between acute and chronic gastritis?
Acute is erosive and chronic is non-erosive
438
What is type A chronic gastritis?
Occurs in the fundus/body; autoimmune disorder characterized by autoantibodies to parietal cells, pernicious anemia and achlorhydria
439
What is type B chronic gastritis?
Occurs in the antrum; most common type, caused by H pylori
| leads to increased risk of MALT lymphoma
440
Gastric hypertrophy with protein loss, parietal cell atrophy and increased mucus cells. Pre cancerous. Rugae of the stomach are so hypertrophied that they look like brain gyri
Menetrier's disease
441
What commonly occurs with stomach cancer?
Acanthosis nigricans
442
What is Virchows node?
involvement of the left supraclavicular node by metastasis from the stomach
443
What is a Krukenberg's tumor?
Bilateral mets to the ovaries. Has abundant mucus and signet ring cells
444
What is sister mary joseph's nodules?
subcutaneous periumbilical metastasis
445
Describe intestinal stomach cancer?
Associated with H. pylori infection, dietary nitrosamines, achlorhydria, chronic gastritis, TYPE A BLOOD, commonly occurs on the lesser curvature
Looks like an ulcer with raised margins
446
Describe Diffuse stomach cancer?
Signet ring cells, stomach wall is grossly thickened and leathery (linitis plastica)
447
What is the risk of carcinoma in gastric vs duodenal ulcer?
Gastric - increased risk
| duodenal - generally benign
448
if a patient has a ruptured gastric ulcer on the lesser curvature of the stomach - where does bleeding occur from?
Left gastric artery
449
If a patient has a ruptured ulcer on the posterior wall of the duodenum - where does bleeding occur from?
Gastroduodenal ulcer
450
A patient has a NOD2 gene mutation - what are they at increased risk for?
Crohn's disease
451
what is the etiology in Crohn's vs Ulcerative colitis?
Crohn's - disordered response to intestinal bacteria
| UC - autoimmune
452
where does Crohn's usuallt occur?
Ileum and colon
453
What is the microscopic morphology of Crohn's disease?
Noncaseating granuloma and lymphoid aggregates - Th1 medated
454
What is the microscopic morphology of ulcerative colitis?
Crypt abscesses and ulcers, bleeding, NO granulomas
| Th2 mediated
455
what are some extraintestinal manifestations of Crohn's disease?
Migratory polyarthritis, erythema nodosum, ankylosing spondylitis, uveitis, kidney stones
456
what are some extraintestinal manifestations of Ulcerative colitis?
Pyoderma gangrenosum, primary sclerosing cholangitis, ankylosing spondylitis, uveitis
457
Name 5 drugs you can use to treat Crohn's disease
Corticosteroids, azathioprine, methotrexate, infliximab, adalimumab
458
Name 4 treatments you can use for Ulcerative colitis
ASA preparations (sulfasalazine), 6-mercaptopurine, infliximab, colectomy
459
what is irritable bowel syndrome?
Recurrent abdominal pain associated with 2 or more of the following:
- pain improves with defecation
- change in stool frequency
- change in appearance of stool
460
what can cause acute appendicitis in adults vs kids?
Obstruction due to:
adults - fecalith
kids - lymphoid hyperplasia (viral infection)
461
what are the chapman points for appendicitis?
tip of 12th rib on the R or posterior is TP of T11
462
Where do diverticulum most commonly occur?
Sigmoid colon
463
What can cause diverticulosis?
Caused by increased intraluminal pressure and focal weakness in the colonic wall - associated with low fiber diets
464
A patient presents with LLQ pain, fever and leukocytosis - what might this be?
Diverticulitis
"left sided appendicitis"
stool occult blood is common with or without hematochezia
465
What is a Zenkers diverticulum?
Most commonly above UES
false diverticulum
herniation of mucosal tissue at Killian'striangle - between the thyropharyngeal and cricopharyngeal parts of the inferior pharyngeal constrictor
can occur due to weakness in the cricopharyngeus muscle
466
what is the most common congenital anomaly of the GI tract?
Meckle's diverticulum
467
how do you DX meckles diverticulum?
Pertechnetate study for ectopic uptake - shows ectopic gastric tissue
468
Where does intussusception most commonly occur?
Ileocecal junction
469
What causes intussusception in children and adults?
Children - usually idiopathic, may be viral like adenovirus
| Adults - rare can be due to intraluminal mass or tumor
470
how would an infant present with an intussusception?
6 mo male with vomiting, blood in stools, intermittent periods of abdominal pain, fussy and kicks legs up in the air
471
What is seen on US in a patient with intussusception?
Bulls eye coil spring appearance
472
Where are common places for volvulus to occur?
In areas where there is redundant mesentery like the cecum and sigmoid colon
473
Birds beak or ace of spades sign with abdominal distension and vomiting
volvulus
474
What causes Hirschsprung's disease?
Congenital megacolon - characterized by lack of ganglion cells/enteric nervous plexuses ( auerbach's and mmeissner's plexuses)
due to failure of neural crest cell migration
475
how do you diagnose Hirschsprung's diease?
Rectal suction biopsy
476
double bubble sign on X ray
Duodenal atresia
due to failure of recanalization of small bowel
477
Necrosis of intestinal mucosa and possible perforation. Colon is usually involved but can involve the entire GI tract
Necrotizing enterocolitis
In neonates, more common in preemies
may have pneumatosis - gas in the wall
478
Where does ischemic colitis often occur?
Splenic flexure and distal colon
479
What is ischemic colitis?
reduction in intestinal blood flow causing ischemia (pain is out of proportion with physical findings)
patients get pain after they eat so they end up with weight loss. Typically affects the elderly
480
What is an adhesion?
Fibrous band of scar tissue; commonly forms after surgery; most common cause of small bowel obstruction. can have well-demarcated necrotic zones
481
What is Angiodysplasia?
Tortuous dilation of vessels leading to hematochezia. Most often found In cecum, terminal ileum and ascending colon. more common in older patients.
Confirmed by angiography
482
What types of polyps are precancerous?
Adenomatous polyps
malignant risk is associated with increased size, villous (villainous) histology, increased epithelial dysplasia
483
What is the most common non-neoplastic polyp in the colon?
Hyperplastic
484
What is juvenile polyps?
Mostly sporadic lesions in children younger than 5yo, 80% occur in rectum. if single - has no malignant potential
485
What is juvenile polyposis syndrome?
Multiple juvenile polyps in the GI tract
| Has increased risk of adenocarcinoma
486
Describe Peutz-Jeghers syndrome
AD syndrome featuring multiple nonmalignant hamartomas throughout the GI tract along with hyperpigmented mouth, lips, hands, genitalia
Associated with increased risk of CRC and other visceral malignancies
487
List 4 syndromes that progress to colorectal cancer
FAP, Gardner's syndrome, Turcot's syndrome, Heretidary nonpolyposis colorectal cancer (lynch syndrome)
488
Describe Familial adenomatous polyposis
AT mutation of APC gene on chromosome 5q - 2 hit hypothesis, thousands of polpys, pancolonic, always involves the rectum
489
Describe Gardner's syndrome
FAP + osseous and soft tissue tumors, congenital hypertrophy of retinal pigment epithelium
490
Describe Turcot's syndrome
FAP + Malignant CNS tumor like medulloblastoma
491
Describe HNPSS/Lynch syndrome
AG mutation of DNA mismatch repair genes - proximal colon is always involved
492
Where does colorectal cancer occur?
Rectosigmoid > Ascending > Descending
493
How does ascending colorectal cancer present?
exophytic mass, iron deficiency anemia, weight loss
494
How does descending colorectal cancer present?
Infiltrating mass, partial obstruction, colicky pain, hematochezia
495
What is the tumor maker for colorectal cancer?
CEA - good for monitoring recurrence but not useful for screenign
496
what are the symptoms of carcinoid syndrome?
B-FDR
| Bronchospasm, Flushing, Diarrhea, Right sided heart problems
497
what are the most common sites of carcinoid tumor?
Appendix, ileum, rectum
| most common malignancy of the small intestine
498
Dense core bodies seen on electron microscopy
Carcinoid tumor
499
What is the treatment for carcinoid tumor?
Resection, octreotide, somatostatin
500
what are diagnostic uses for gamma-glutamyl transpeptidase?
increased in various liver and biliary diseases like ALP, but NON in bone disease - also a marker for alcohol use
501
What is amylase a marker for?
acute pancreatitis, mumps
502
What is lipase a marker for?
acute pancreatitis
503
rare often fatal childhood hepatoencephalopathy
Reye syndrome
504
what is the mechanism of reye syndrome?
Aspirin metabolits decrease beta oxidation by reversible inhibition of mitochondrial enzyme
505
swollen and necrotic hepatocytes with neutrophilic infiltration.
Alcoholic hepatitis
506
What are Mallory bodies?
intracytoplasmic eosinophilic inclusions - seen in alcoholic hepatitis
507
What does alcoholic cirrhosis look like?
micronodular irregularly shrunked liver with hobnail appearance. Sclerosis around central vein in zone 3
508
what are common findings in hepatocellular carcinoma?
jaundice, tender hepatomegaly, ascites, polycythemia, and hypoglycemia
509
Common, benign liver tumor; typically occurs at age 30-50yo
Cavernous hemangioma
biopsy is contraindicated because of risk of hemorrhage
510
Benign liver tumor, often related to oral contraceptive or steroid use. can regress spontaneously
Hepatic adenoma
511
What is an angiosarcoma?
Malignant tumor of endothelial origin; associated with exposure to arsenic, PVC
512
What is nutmeg liver and what are some things that can cause it?
Backup of blood into the liver. Commonly caused by R sided heart failure and Budd chiari syndrome
513
What can occur with persistent congested liver?
centrilobular congestion and necrosis can result in cardiac cirrhosis
514
what is Buff chiari syndrome?
Occlusion of IVC or hepatic veins with centrilobular congestion and necrosis, leading to congestive liver disease (hepatomegaly, ascites, abdominal pain and eventual liver failure) ABSENCE OF JVD
515
What is Budd chiari syndrome associated with?
hypercoagulable state, polycythemia vera, pregnancy and hepatocellular carcinoma
516
Misfolded gene product protein aggregates in hepatocellular ER leading to cirrhosis with PAS positive globules in the liver
alpha 1 antitrypsin deficiency
AR
517
What's the inheritance pattern of Gilbert syndrome?
AR
518
which is more severe? Crigler Najjar type 1 or type 2?
Type 1 is more severe
you can treat type 2 with phenobarbital which will increase liver enzyme synthesis
519
what is another name for Wilson's disease?
hepatolenticular degeneration
leads to basal ganglia degeneration --> parkinsonian symptoms
520
What is the inheritance pattern of Wilson's disease?
AR, chromosome 13; copper is normally excreted into bile by hepatocyte copper transporting ATPase (ATP7B gene)
521
triad of cirrhosis, diabetes mellitus and skin pigmentation (Bronze diabetes)
Hemochromatosis
522
What is secondary biliary cirrhosis complicated by?
Ascending cholangitis
523
increased serum mitochondrial antibodies, including IgM
primary biliary cirrhosis
524
Most commonly see in Women with other autoimmune conditions like REST or rheumatoid arthritis
Primary biliary cirrhosis
525
Most commonly seen in men, p-ANCA positive, associated with ulcerative colitis, hypergammaglobulinemia (IgM)
Primary sclerosing cholangitis
526
what's the pathophysiology of primary biliary cirrhosis?
autoimmune reaction leading to lymphocytic infiltrate and granulomas
527
What's the pathophysiology of primary sclerosis cholangitis
unknown cause of concentric "onion skin" bile duct fibrosis leading to alternating strictures and dilation with beading of intra and extrahepatic bild ducts on ERCP
528
which gallstones are radiolucent?
Cholesterol stones are radiolucent most of the time
| pigment stones are radiopaque
529
what is the liver fluke that infects the biliary tree and is associated with pigmented gallstones and cholangiocarcinoma?
Clonorchis sinensis
530
What are black and brown gallstones due to?
brown are infection
| black are hemolysis
531
what is charcot's triad of cholangitis?
jaundice, fever, RUQ pain
532
how do you diagnose gallstones?
ultrasound, radionuclide biliary scan (HIDA)
| TX with cholecystectomy
533
if a patient has infectious cholcystitis what is a common cause?
CMV
534
what are the number 1 and 2 causes of acute pancreatitis?
Gallstones (1) alcohol (2)
| check CT for pancreatitis
535
What are the major causes of CHRONIC pancreatitis?
alcohol abuse and idiopathic
536
What does pancreatic adenocarcinoma arise from?
pancreatic ducts
537
What's the tumor marker for pancreatitis
CA-19-9
| check CT scan
538
What are the risk factors for adenocarcinoma?
Tobacco use (but not ethanol!)
chronic pancreatitis
Jewish and African American
Age older than 50
539
How does pancreatic adenocarcinoma present?
abdominal pain radiating to the back, weight loss, migratory thrombophlebitis, obstructive jaundice
540
What is Trousseau's sign?
Migratory thrombophlebitis - redness and tenderness on palpation of extremities
associated with pancreatic adenocarcinoma
541
What is Courvoisier's sign?
Obstructive jaundice with palpable, nontender gallbladder
542
What is the treatment for pancreatic adenocarcinoma?
Whipple procedure, chemotherapy, radiation therapy
543
Name 4 H2 blockers
Cimetidine, ranitidine, famotidine, nizatidine
544
Why would you use H2 blockers?
reversible block of histamine H2 receptors leads to decreased acid secretion by parietal cells for peptic ulcer disease, gastritis, mild esophageal reflux
545
What does cimetidine do to the Cyp450 system?
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