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Flashcards in GI Deck (427):
1

Why is a pancreatic pseudocyst called a "pseudo"cyst?

Lined by granulation tissue and fibrosis not epithelium. Filled with enzymes and inflammatory debris

2

pancrease lesion shows glycogen rich cuboidal epithelium

serous pancreatic neoplasm

3

pancreatic lesion with columnar mucinous epithelium

mucinous cystic neoplasm of pancreas

4

What causes fatty liver (mechanism) of alcoholics?

Excess NADH (from alch dehydrogenase and aldehyde dehydrogense)
-->decrease in fatty acid oxidation

5

What do you see on histology of kaposi's sarcoma? Macroscopically?

1. Spindle shaped tumor cells with angiogenesis
2. red/violat flat lesions or hemorrhagic nodules

6

Histology of cryptosporidium

Basophilic clusters on surface of intestinal mucosal cells

7

tx: wilson's dz

lactulose to treat the cirrhosis
penicillamine to remove the excess copper

8

tx: hemachromatosis

defuroxamine

9

Sequelae/complications of ulcerative colitis

toxic megacolon

10

Main clinical manifestation of crohn's

abdominal pain

11

main clinical manifestation of UC

bloody diarrhea

12

Skip lesions

Crohns. terminal ileum usually but lesions ANYWHERE form mouth to anus.

13

Granulomas in intestine

Crohns

14

Rectum is always involved in which IBD

Ulcerative colitis

15

mesenteric adenitis in children with abd pain, fever, nausea

Yersinia enterocolitica

16

Describe the schilling test

Give oral labeled B12 and IM b12 and measure excretion in urine. If normal urinary excretion of radiolabeled B12, this means normal absorption
--Administer with intrinsic factor to see if pernicious anemia or malabsorption
--If celiac/diphyllobothrium, no correction with intrinsic factor

17

Drugs causing esophagitis

tetracycline
potassium chloride
bisphosphonates

18

What do patients on opioid NOT develop tolerance to?

constipation

19

histology findings in alcoholic hep

hepatocellular swelling/necrosis

20

Hist: Acetaminophen tox

centrilobular necrosis

21

His: reye's syndrome

microvesicular steatosis of the liver

22

Hist: Primary biliary cirrhosis

granulomatous bile duct destruction with lots of lymphocytes "florid ducts"

23

What are the four types of non-neoplastic polyps?

1. hyperplastic polyps: from mucosal gland/crypt cells
2. hamartomatous polyps: from smooth muscle/CT. Seen in juvenile polyposis and peutz-jegers
3. inflammatory polyps: UC and Crohns
4. lymphoid polyps: children

24

What factors tell you malignant potential of polyps?

1. degree of dysplasia, sessile (not pedunculated)
2. villous vs tubular
3. size: adenomas < 2 cm usually benign.

25

Secretin is produced by

duodenum.

26

Action of secretin

increased bicarbonate secretion from exocrine pancreas

27

What stimulates secretin release?

HCl in the duodenum

28

Sx: PBC

pruritis
fatigue
xanthomas, hepatosplenomegally leading to jaundice

29

Labs: PBC

Elevated alkaline phosphatase, elevated IgM
-anti-mitochondrial antibodies

30

PBC associated with

Sjogren''s
raynaud's
scleroderma
hypothyroid
celiacs
BASICALLY AUTOIMMUNITY

31

Budd chiari

thrombosis of hepatic veins/IVC
--Portal HTN
ascites
hepatosplenomegaly

32

OATP (organic anion transporting polypeptide)

Used to take up indirect (unconjugated bilirubin). Passive process

33

Organic anion transporter (MRP2)

energy dependent transporter for excreting conjugated bilirubin. Without this, will have elevated direct hemoglobin which is excreted in urine

34

PSC associated with

Ulcerative colitis. Will have a high Alk Phos

35

Cobblestone colonoscopy

Crohn's

36

string sign

colonal stricture on barium swallow seen in Crohn's

37

Cause of duodenal atresia:

failure of recanalization--congenital defect

38

Cause of jejunal, ileal, and colonic atresia in newborn:

Vascular ischemia causing necrosis. Gives "appeal peel" appearance.

39

sternal defects in baby=

problem with rostral abdominal fold closure

40

bladder exstrophy caused by

failure of caudal abdominal wall to fold

41

duodenal atresia caused by

failure to recanalize

42

when does the midgut herniate through the umbilical ring

6th week

43

When does the midgut return to the abdominal cavity and rotate around the SMA?

10th week

44

malrotation of gut, volvulus arise from

pathology of midgut herniation/rotation

45

What is gastroschisis

extrusion of abdominal contents through abdominal folds, not covered by peritonium

46

what is omphalocele

persistence of herniation of abdominal contents into umbilical cord, not covered by peritoneum

47

Most common type of tracheoesophageal anomaly

esophageal atresia with distal tracheoesophageal fistula.

48

sx of EA with distal TEF

chocking
Air in stomach,
failure to pass NG tube into stomach

49

H type TE anomaly

Normal except with a fistula only

50

Pure EA

atresia or stenosus of esophagus alone

51

CSR of pure esophageal atresia

No gas in abdomen

52

olive like mass in epigastric region with projectile vomiting (nonbilius) at 2 weeks

congenital pyloric stenosis

53

congenital pyloric stenosis occurs in

first born males.

54

Tx: cong pyloric stenosis

surgery

55

Annular pancreas causes narrowing of

duodenum

56

Ventral pancreatic bud makes

pancreatic head, main pancreatic duct and uncinate process

57

GI retroperitoneal structures. These can cause blood or gas accumulation in retroperitoneal space

Suprarenal
Aorta and IVC
Duodenum (2nd and third parts)
Pancreas
Ureters
Colon (ascending, descending)
Kidneys
Esophagus (lower 2/3)
Rectum (lower 2/3)

58

falciform ligament connects

liver to anterior abdominal wall

59

falciform contains

ligamentum teres hepatis

60

hepatoduodenal ligament connects

liver to duodenum
--also connects greater and lesser sacs

61

hepatoduodenal ligament contains

portal triad: hep arter, portal vein, common bile

62

Gastrohepatic ligament connects

Liver to lesser curvature of stomach

63

gastrohepatic contains

gastric arteries

64

You need to cut this during surgery to access the lesser sac

gastrohepatic ligament

65

You can use the pringle maneuver to compress this ligament to control bleeding in the omental foramen

hepatoduodenal

66

gastrocolic connects

greater curvature to transverse colon

67

gastrocolic contains

gastroepiploic arteries

68

gastroplenic connects

greater curvature and spleen

69

structures inside gastrosplenic

short gastrics, left gastroepiploic vessles

70

separates greater and lesser sacs on the left

gastrosplenic

71

splenorenal lig contains

splenic artery+V, tail of pancreas

72

erosions of digestive tract only extend to

mucosa

73

submucosa contains

meissner's plexus

74

muscularis externa contains

myenteric nerve plexus

75

How fast do stomach/duodenum/ileum contract?

stomach: 3 waves/min
duodenum: 12 waves/min
ileum: 8-9 waves/min

76

where do you see crypts of liberkuhn

duodenum, jejunum, and ileum

77

where do you see peyer's patches?

ileum

78

where do you see brunner's glands

duodenum

79

where do you see the largest number of goblet cells in the small intestine?

ileum

80

what do you see in the colon?

no villi, numerous goblet cells

81

When the third part of the duodenum is entrapped between SMA and aorta, causing intestinal obstruction in females

Superior mesenteric artery syndrome

82

parasympathetic innervation of hindgut

pelvic (errything else is vagus)

83

celiac artery exits at

T12/L1

84

SMA artery exits at

L1

85

IMA artery exists at

L3

86

supplies distal duodenum to prox 2/3 or transverse colon

SMA

87

supplies stomach, prox duodenum, liver, gallbladder, pancreas, spleen (mesoderm)

Celiac artery

88

Branches of the celiac trunk

common hepatic
splenic
left gastric

89

Which arteries do not have good anastamoses?

short gastrics (splenic artery blockage)
However, left and right gastrics and epiploics have good anastamoses

90

branches of the common hepatic

hepatic artery proper
-->right gastric
gastroduodenal
-->right gastroepiploic

91

branches of the splenic

L gastroepiploic
short gastric arteries

92

branches of the L gastric

esophageal branches

93

anastamoses between external iliac and internal thoracic

superior/inferior epigastric

94

anastamoses between celiac trunk and SMA

superior/inferior pancreaticoduodenal

95

anastamoses between SMA and IMA

middle/left colic

96

anastamoses between IMA and internal iliac

superior rectal/middle and inferior rectal

97

Name the three portosystemic shunt systems

1. left gastric(portal)-->esophageal(systemic)
2. paraumbilical-->epigastric veins (systemic)
3. superior rectal (portal)-->middle and inferior rectal (systemic)

98

How do the three portosystemic shunt explain portal HTN findings?

1. esophageal varices
2. caput medusa
3. internal hemorroids

99

rectal adenocarcinoma

above pectinate line

100

rectal squamous cell carcinoma

below pectinate

101

rectal internal hemorrhoids vs external

internal: above pectinate
external: below

102

blood supply above pectinate

superior rectal (IMA)

103

blood supply below pectinate

inferior rectal (internal pudendal)

104

venous drainage above pectinate line

superior rectal-->inferior mesenteric-->portal system

105

venous drainage below pectinate line

inferior rectal-->internal pudendal vein-->internal iliac vein-->IVC

106

innervation below pectinate

painful external hemorrhoids
--inferior rectal branch of pudendal nerve

107

lymphatic drainage above pectinate line

deep nodes

108

lymphatic drainage below pectinate line

superficial inguinal nodes

109

which liver zone affected first by viral hepatitis?

Zone 1 (periportal)

110

Which liver zone affected first by ischemia and alcoholic hepatitis?

Zone 3 (central vein)

111

which liver zone has the P450 system

Zone 3

112

Order of structures in femoral region

nerve, artery, vein, empty space, lymph (from lateral to medial)

113

femoral triangle

femoral vein, artery, nerve

114

femoral sheath

femoral vein, artery, and canal with deep inguinal nodes
NO NERVE

115

External spermatic cord

external oblique

116

cremaster muscle and fascia made of

internal oblique

117

internal spermatic fascia made of

transversalis fascia

118

Why doesn't the spermatic cord have transversus abdominis muscle?

There's a hole in the muscle where it passes through. The normal order is
1. transversalis
2. transversus abdominis
3. internal oblique
4. external oblique

119

GE junction is displaced upwards through diaphragm=hourglass stomach

sliding hiatal hernia

120

fundus of stomach protrudes into thorax, although GE junction is normal

paraesophageal hernia. bowel sounds in the lung fields

121

This type of hernia passes lateral to the inferior epigastric artery

indirect inguinal hernia

122

cause of indirect inguinal hernia

failure of processus vaginalis to close. Occurs in infants

123

this inguinal hernia passes medial to inferior epigastric

direct inguinal hernia. passes through hesselbach's triangle

124

Indirect hernias are covered by

all three layers of spermatic fascia

125

direct hernias are covered by

only external spermatic fascia. usually happens in old men

126

which Amino acids are potent stimulators of gastrin

phenylalanine
tryptophan

127

what produces cholecystokinin?

I cells

128

Where are I cells found

duodenum/jejunum

129

Action: CCK

pancreatic secretions
gallbladder contractions
sphincter of oddi relaxation
decreased gastric emptying
THINK: RELEASE OF PANCREATIC ENZYMES

130

stimulant: CCK

fatty acids/amino acids

131

where do you find S cells?

duodenum

132

action: secretin

pancreatic HCO3
decrease gastric acid
increase bile secretion
THINK: DECREASING ACIDITY

133

How is secretin regulated?

Increased by acid, fatty acids in lumen of duodenum

134

action: somatostatin

decreases gastric acid secretion
decreases pancreatic secretions
decreases gallbladder
decreases insulin/glucaton

135

regulation: somatostatin

Increased by acid
decreased by vagal stimulation

136

which cells release somatostatin?

D cells of pancreas, GI mucosa

137

glucose dependent insulinotropic peptide (GIP) effects

decrease gastric acid
Increase insulin release

138

which cells release GIP?

K cells of duodenum/jejunum

139

source: vasoactive intestinal polypeptide (VIP)

parasympathetic ganglia

140

Action: VIP

increase water/electrolyte secretion
relaxation of intestinal smooth muscle

141

Stimulation: VIP

vagal stimulation and distention
inhibited by adrenergics (duh)

142

copious watery diarrhea, hypokalemia, and achlorhydria (little to no stomach acid)

VIPoma

143

Nitric oxide's role in GI

relaxes GEJ sphincter

144

motilin action

migrating motor complexes for peristalsis in small intestin

145

when is motilin high

fasting state

146

which drugs work as motilin agonists

erythromycin

147

How do you regulate gastric acid?

Increase: histamine, ACh, gastrin
Decrease: somatostatin, GIP, prostaglandin, secretin

148

which cells secrete pepsin

chief cells

149

what stimulates pepsin release

vagal stimulation, acid

150

What secretes HCO3

Mucosal cells and brunner's glands

151

Stimulation: HCO3

increased pancreatic/biliary secretion

152

is saliva stimulated by sympathetic or parasympathetic activity?

Both. Note that it is hypotonic with low flow rates but isotonic at high flow rates

153

vagus nerve stimulates

Parietal cells and G cells

154

what happens in stomach when you give atropine?

Mild decrease in stomach acid.
-vagus nerve releases ACh on parietal cells
-vagus nerve releases GRP on G cells-->gastrin-->ECL cells-->histamine-->parietal cells

The pathway through GRP and histamine is much stronger stimulator

155

brunner gland hypertrophy

peptic ulcer disease. Because working overtime to secrete alkaline mucus

156

How else can gastrin release acid?

binds to CCK receptor and upregulates H/K ATPase

157

intracellular signaling of H2 receptor:

cAMP increases-->H/KATPase

158

intracelular signalling of Ach and Gastrin

Gq

159

intracellular signaling of somatostatin

Gi

160

Describe the flow of pancreatic secretions

low flow=high Cl-
high flow=high HCO3-

161

Pancreatic acid secretions

alpha-amylase
Lipases (phospholipase A, colipase)
Proteases (trypsin, chymotrypsin, elastase)
trypsinogen

162

salivary amylase hydrolyzes

alpha 1,4 linkages-->disaccharides

163

glucose/galactose transporter

SGLT1 (sodium dependent)

164

fructose transporter

GLUT-5 (facilitate difusion)

165

GLUT2

transports monosaccharides to gut

166

iron absorbed in

duodenum

167

folate absorbed in

jejunum

168

D xylose tells you

integrity of gastric mucosa in absorption.

D xylose requires NO breakdown! If problem is with breakdown (i.e. no secretions) then D xylose should be normal

169

Maltose is made of

glucose+glucose

170

lactose is made of

glucose+galactose

171

where are lipids digested/absorbed?

digested in duodenum, absorbed in jejunum

172

special cells in peyer's patches that take up antigen

M cells

173

what happens when B cells in peyer's patches are stimulated?

differentiate into IgA secreting plasma cells

174

difference between bile acids vs salts?

bile acids are conjugated to glycine/taurine

175

rate limiting step of bile acid secretion

cholesterol 7a-hydroxylase

176

What carries bilirubin in blood?

albumin

177

urobilinogen

conjugated bilirubin that has been processed by the gut bacteria

178

how much of urobilinogen is reabsorbed?

20%. Of that, 10% is excreted in urine and 90% goes back to liver

179

painless mobile mass in neck made of cartilage and epithelium and recurs frequently. A salivary tumor

pleomorphic adenoma. Most common!

180

salivary tumor: A benign cystic tumor in germinal centers

warthin's tumor

181

salivary gland: mucinous and squamous components. presents as a PAINFUL mass

mucoepidermoid carcinoma

182

achalasia=increased risk for

esophageal squamous cell carcinoma

183

secondary achalasia

chagas, CREST

184

pts with achalasia have problems swallowing

BOTH solids in liquids!
If obstructive mass, liquids are fine

185

Can also present as nocturnal cough/dyspnea or adult onset asthma

GERD

186

causes of esophagitis

reflux
infections (like candida etc)
chemical ingestion

187

punched out ulcers in esophagus

HSV-1

188

linear ulcers in the esophagus

CMV

189

mucosal lacerations at the GEJ from severe vomiting

mallory weiss syndrome

190

who is at risk of mallory weiss?

alcoholics/bulimics

191

transmural esophageal rupture from violent retching

boerhaave syndrome. May have crackling beneath skin from air in mediastinum

192

esophageal strictures associated with

lye ingestion and acid reflux

193

Plummer vinson syndrome

dysphagia
glossitis
iron deficiency anemia

194

barrett's esophagus predisposes to what cancer

esophageal ADENOcarcinoma (not squamous)

195

which esophageal cancer is most common worldwide?

squamous

196

alcohol=type of esophageal cancer?

squamous

197

cigarettes=type of esophageal cancer?

both

198

diverticula=type of esophageal cancer?

squamous

199

esophagela web=type of esophageal cancer?

squamous

200

fat=type of esophageal cancer?

adeno

201

GERD=type of esophageal cancer?

adeno

202

hot liquids=type of esophageal cancer?

squamous

203

How to treat tropical sprue?

antibiotics. We don't understand the cause! but it looks similar to celiac's
--AFFECTS JEJUNUM AND ILEUM not duodenum

204

PAS positive foamy macrophages in intestine and mesenteric nodes

Whipple's disease

205

Presentation: Whipple's disease

cardiac symptoms
arthralgias
neuro sx
-->usually presents in older men

206

Which part of the intestine is affected in celiac's

distal duodenum
--LESS so jejunum/ileum
--hyperplasia of crypts seen

207

histology of lactose intolerant peeps

normal villi!!!!

208

lactose tolerance test

1. symptomatic
2. glucose rises t absorbing that milk!)

209

child presents with malabsorption and neuro deficits, biopsy shows fat accumulation within enterocytes. Also no VLDL or LDL

abetalipoproteinemia. Missing B48 and B100

210

Three causes of pancreatic insufficiency

1. cystic fibrosis
2. cancer
3. chronic pancreatitis

211

Celiac HLA predisposition

HLA-DQ2, HLA-DQ8

212

Antibodies in celiac sprue?

anti-TTG
anti-endomysial
anti-gliadin

213

histology findings in celiacs

blunting of villi
lymphocytes in lamina propria

214

skin condition associated with celiac's

dermatitis herpetiformis

215

celiac malignancy

T cell lymphoma. Think about refractory celiacs that has been well controlled

216

Gastric ulcer in burn victim

curling's ulcer. Happens cuz low plasma volume allows sloughing of mucosa

217

gastric ulcer in pt with TBI

cushing's ulcer
-->increased vagal sitmulation increases acid production

218

Type A chronic gastritis

pernicious anemia

219

pernicious anemia affects which part of the stomach?

fundus/body

220

Type B chronic gastritis

H pylori.

221

H pylori affects which part of stomach?

antrum

222

Gastric hypertrophy with protein loss, parietal cell atrophy and lots of mucous cells. Rugae look like brain gyri

Menetrier's disease

223

what are you worried about with menetrier's?

gastric cancer

224

skin findings in stomach cancer

acanthosis nigracans
LOTS of seborrheic keratoses (leser-Trelat sign)

225

possible nodal spread of stomach cancer

1. virchow's node
2. krukenberg's tumor: bilateral metastases to ovaries
3. sister mary joseph's nodule: periumbilical metastasis

226

histology findings of krukenberg tumor

mucus and signet ring cells

227

Intestinal stomach cancer associated with

H pylori
nitrosamines (smoked food)
achlorhydria
chronic gastritis
TYPE A BLOOD?! weird!

228

what does intestinal stomach cancer look like?

ulcer with raised margins

229

Appearance of diffuse stomach cancer

thick and leathery stomach (linitis plastica)

230

histology of diffuse stomach cancer

signet cell rings

231

which type of ulcer has more pain with meals? less pain with meals?

gastric: more pain
duodenal: less pain

232

which ulcer is more associated with H pylori?

duodenal ulcers almost always H pylori
gastric ulcer 70%

233

zollinger ellison causes which type of ulcer

duodenal. caused by increased acid secretion

Note that increased acid secretion does not cause gastric ulcers! The stomach is prepared to handle acidity. usually caused by a problem with mucosal barrier.

234

Which type of ulcer is associated with carcinomas?

gastric ulcer.

-->duodenal ulcers are more benign

235

Which type of ulcer can hemorrhage?

Both!

236

You find a duodenal ulcer that is hemorrhaging. is it more likely to bleed from the posterior or anterior wall?

posterior--from gastroduodenal artery

237

You find a duodenal ulcer that is perforated. Is it more likely to perforate on the posterior or anterior wall?

anterior

238

etiology of crohn's disease

disordered response to intestinal bacteria

239

which IBD is Th1 mediated? Th2?

Th1=crohn's
Th2=UC

240

IBD: pyoderma gangrenosum

UC

241

IBD: erythema nodosum

Crohn's

242

IBD: primary sclerosing cholangitis

UC

243

IBD: migratory polyarthritis and calcium oxalate stones

Crohn's

244

IBD: histology shows crypt abscesses and ulcers

UC

245

IBD: "lead pipe appearance" on imaging

UC
--from loss of haustra in the colon

246

IBD: creeping fat (fat growing out closer to serosa)

Crohn's

247

IBD: friable mucosal pseudopolyps with freely hanging mesentary

UC

248

IBD treatment: steroidx, TNF-alpha inhibitors, azathioprine, methotrexate

crohn's

249

IBD tx: sulfazalazine, 6MP, TNF-alpha inhibitors, colectomy

UC

250

Sx of IBS

1. pain improves with defecation
2. change in stool frequency
3. change in appearance of stool

251

Causes of appendicitis in kids

fecalith in adults
lymphoid hyperplasia in kids

252

false diverticula are missing

muscularis externa. Only mucosa and submucosa

253

diverticulosis

many false diverticulae in elderly from weakness of colonic walls

254

diverticulosis associated with

low fiber diets

255

sx of diverticulosis

hematochezia

256

LLQ pain, fever, leukocytosis

diverticulitis

257

complication of diverticulitis

fistula with bladder forms.
--pneumaturia: gas or air in the urine

258

Zencker's occurs btw which muscles

thyropharyngeal and cricopharyngeal portions of the inferior pharyngeal constrictor

259

Meckel's diverticulum caused by

persistence of vitelline (omphalomesenteric) duct

260

The five 2's of meck

2 inches long, 2 feet from ileocecal valve, 2% of population, presents in first 2 years of life

261

Dx: meckel's

pertechnetate study for ectopic uptake (gastric/pancreatic mucosa)

262

complications of meckel's

intussusception
volvulus
obstruction

263

currant jelly stools

intussusception

264

Volvulus usually occurs in what age group

Elderly.

265

which section of colon susceptible to volvulus?

cecum/sigmoid colon

266

vitelline sinus vs vitelline cyst etiology

Same as meckels, only varying degrees of malformation.

vitelline sinus--just a small string of mesentery connecting to umbilicus.

vitelline cyst has a small area of dilation outside of intestine

267

chronic constipation early in life with a congenital megacolon

hirschsprung

268

Dx: hirschsprung's

rectal suction biopsy. treat with resection

269

who is at risk for hirschsprungs

down's syndrome

270

bilious vomiting

duodenal atresia

271

double bubble on X ray

duodenal atresia
--proximal stomach distention

272

meconium ileus common in

cystic fibrosis
--meconium plug blocks intestine

273

neonate with necrosis of intestinal mucosa

necrotizing enterocolitis

274

extreme pain after eating and weight loss but normal abdominal exam in an elderly patient

ischemic colitis

275

which areas of colon most susceptible to ischemic colitis?

splenic flexure and distal colon. USUALLY ATHEROSCLEROSIS OF SMA.

276

most common cause of small bowel obstruction

adhesion

277

tortuous dilation of vessels and hematochezia in an older adult located in CECUM terminal ileum, and ascending colon (right side)

angiodysplazia

278

malignancy risk in adenomatous polyp

size > 1cm
villous
epithelial dysplasia

279

most common type of non-neoplastic polyp?

hyperplastic

280

juvenil polyps occur in

rectum

281

a 4 yr old child presents with a single juvenile polyp. Does he have increased cancer risk?

No. However, if he has juvenile polyposis syndrome, he IS at increased risk of adenocarcinoma

282

inheritance of peutz-Jeghers

autosomal dominant

283

associated sx of peutz-jeghers

hyperpigmented mouth, lips, hands, genitalia

284

pts with peutz jegers SYNDROME (not single polyp) are at risk for

CRC and other visceral malignancies

285

Third most common cancer in US and third most deadly

CRC

286

APC gene chromosome #

5q

287

FAP+osseous and soft tissue tumors AND congenital hypertrophy of retinal pigment epithelium

Gardner's syndrome

288

FAP + malignant CNS tumor

Turcot's syndrome

289

CRC caused by DNA mismatch repair genes

HNPCC (aka lynch)
--Causes microsatellite instability

290

inheritance of HNPCC

Autosomal dominant

291

HNPCC usually involves which part of colon?

proximal. Also at risk for ovarian and endometrial carcinoma.

292

FAP usually involves which part of colon?

rectum and the entire colon

293

CRC usually affects which parts of colon?

rectosigmoid>ascending>descending

294

CRC with exophytic mass, iron deficiency anemia, weight loss

ascending colon. Usually with HNPCC

295

CRC with infiltrating mass, partial obstruction, hematochezia.

napkin ring lesion with decreased stool caliber

descending colon

296

apple core lesion on barium enema

THINK CRC!!

297

amrker for CRC

CEA

298

APC gene codes for

beta catenin which is important for chromosomal stability

299

Progression of CRC mutations

1. APC=formation of polyp
2. Kras=growth of polyp
3. p53 and DCC=adenoma and carcinoma

300

most common malignancy in the small intestine

carcinoid tumors

301

pt presents with wheezing, diarrhea, flushing and right sided heart murmurs.

carcinoid syndrome

302

dense core bodies on EM of small intestine

carcinoid

303

pt has 5-HIAA in urine

Dx: carcinoid tumor!

304

pt has 5-HIAA in urine but no carcinoid sx. What does this tell you?

The tumor is confined to the GI. All of the serotonin product is brought through portal vein to the liver, which breaks down serotonin

305

Tx: carcinoid tumor

resection
octreotide
somatostatin

306

breath smells musty and asterixis

liver failure

307

uncommon causes of liver failure

hemachromatosis and biliary disease

308

LFTs with viral hepatitis

ALT>AST

309

Alkaline phosphatase tells you presence of:

1. obstructive liver disease
2. bone disease
3. bile duct disease

310

Alkaline phosphatase is elevated. What other test do you need to make sure caused by hepatic system and not by bone disease?

Get a gamma-glutamyl transpeptidase (GGT)
--will not be elevated in bone disease

311

elevated amylase

pancreatitis
mumps

312

decreased ceruloplasmin

wilson's disease

313

Hist: reye's syndrome

microvesicular fatty change

314

Sx: reye's

hypoglycemia
vomiting
hepatomegaly
coma

315

Mech: reye's

aspirin inhibits enzyme causing beta oxidation of fat in mitochondria

316

Hist: alcoholic hepatitis

swollen and necrotic hepatocytes with neutrophilic infiltration
-mallory bodies

317

Hist: alcoholic cirrhosis

sclerosis around central vein (zone III)

318

uncommon causes of HCC

wilson's
hemachromatosis
a1-AT deficiency
aflatoxin exposure from aspergillus

319

which marker is elevated in hepatocellular carcinoma?

alpha-fetoprotein

320

common benign liver tumor in peeps age 30-50.

cavernous hemangioma

321

what is contraindicated in cavernous hemangioma?

biopsy--hemorrhage risk

322

liver tumor: malignant tumor of endothelial origin

angiosarcoma

323

benign liver tumor associated with oral contraceptive use

hepatic adenoma

324

associated with arsenic and polyvinylchloride

angiosarcoma

325

Pt with signs of liver failure (ascites, hepatomegaly) with prominent abdominal and back veins and an absent JVD

Budd chiari syndrome. Caused by occlusion of IVC or hepatic veins

326

Cause of budd chiari

hypercoagulable state
polycythemia vera
pregnancy
HCC

327

PAS positive globules in liver with cirrhosis

alpha-1AT

328

inheritance of a1AT

codominant

329

Urine bilirubin is increased:

Heptaocellular and obstructive jaundice (none in hemolytic)

330

urine urobilinogen is decreased

obstructive jaundice

331

urine urobilinogen is increased

hemolytic jaundice

332

labs: hepatocellular jaundice

direct/indirect bilirubin increased
increased urine bilirubin
normal or decrease urobilinogen (may not be secreting enough to GI tract)

333

Pathophysiology of neonatal jaundice

immature UDP glucuronyltransferase
-->causes unconjugated hyperbilirubinemia

334

Tx of neonatal jaundice

phototherapy
--converts unconjugated bilirubin to a soluble form

335

Asymptomatic patient with high unconjugated bilirubin but not hemolysis. Labs are higher when pt is fasting or stressed

gilbert's (mild decrease in UDP glucuronyltransferase)

336

Tx: gilbert's

none!

337

Baby has jaundice. Labs show high levels of unconjugated bilirubin. Despite phototherapy, she still dies. Autopsy finds kernicterus.

Dx? how should she have been treated?

Crigler Najjer TYPE I. pts die in a few days. CANNOT conjugate ANY bilirubin!!

Tx: plasmapheresis and phototherapy

338

Type II crigler-Najjar tx?

Less severe form
Tx: phenobarbital, which increases liver enzyme synthesis

339

Asymptomatic patient presents with elevated direct bilirubin and jaundice. gross examination of liver biopsy shows a black liver

Dubin Johnson

340

Tx: dubin johnson?

nothing. it's benign.

341

Rotor's vs dubin johnson?

Rotor's syndrome is milder and does not have a back liver

342

inheritance of wilson's disease

autosomal recessive

343

chromosome wilson's

13

344

gene wilson's

ATP7B

345

Presentation of wilson's

Cirrhosis
hemolytic anemia
basal ganglia--parkinsonian sx
asterixis
dementia, dyskinesia, dysarthria

346

pt has cirrhosis, diabetes, and bronze skin

hemochromatosis

347

hemochromatosis mutation

C282Y
H63D
-->ON HFE gene

348

HLA association hemochrom

HLA-A3

349

Tx of hemochrom

1. phlebotomy
defersirox/defuroxamine

350

hemochromatosis risk:

CHF, HCC, testicular atrophy

351

cause of 2ndary hemochromatosis

chronic transfusions (beta-thalassemia major)

352

Labs: biliary cirrhosis

Increased conjugated bili
Increased cholesterol
Increased alkaline phosphatase

353

Pathophys: Primary biliary cirrhosis

autoimmune rxn

354

Hist: PBC

lymphocytic infiltrate and granulomas of the biliary tree

355

Pathophys: primary sclerosing cholangitis

Unknown

356

histology: PSC

onion skin bile duct fibrosis
--"beading" of bile ducts on ERCP
--alternate stricture and dilation

357

antibodies in PBC

mitochondrial antibodies and IgM

358

PBC associated with

Other autoimmune conditions (Crest, RA etc)

359

PSC antibodies

hypergaammaglobulinemia IgM

360

PSC associated with

UC

361

Radiolucent gallstones

cholesterol. 80% of stones

362

cholesterol stones associated with

Crohn's
CF
rapid weight loss, clofibrate (Fat)
Age (forties)
Native Americans
estrogens (female)
multiparity (fertile)

363

air in biliary tree

gallstone fistula with small intestine

364

gallstone ileus: presentation

elderly female with a history of gallstone disease presents with recurrent bowel obstructions. Usually examination of nidus will show cholesterol

365

Dx of gallstone

ultrasound, radionuclide biliary scan (HIDA scan). HIDA is definitive

366

pigment stone: causes

chronic hemolysis (black)
alcoholic cirrhosis
biliary infection (brown)

367

Causes of acute pancreatitis

GET SMASHED

1. gallstone
2. ethanol
3. trauma
4. steroids
5. mumps
6. autoimmune
7. scorpion sting
8. hypercalcemia/hypertriglyceridemia
9. ERCP
10. Drugs (sulfa)

368

Complications of acute pancreatitis

DIC
ARDS
fat necrosis
hypocalcemia
pseudocyst
multiorgan failure

369

why r u worried about a pancreatic pseudocyst?

Can rupture=hemorrhage

370

do gallstones cause chronic pancreatitis?

NO!

371

major causes of chronic pancreatitis

alcohol and idiopathic

372

Marker for pancreatic carcinoma

CA-19-9

373

most common site of pancreatic adenocarcinoma

pancreatic head--usually in ducts

374

risk factors for pancreatic adenocarcinoma

tobacco
chronic pancreatitis
age>50
Jewish and AA males

375

Sx of pancreatic cancer

weightloss
abdominal pain-->back
redness and tenderness on palpitation of extremities (migratory thrombophlebitis)
obstructive jaundice with NONTENDER gallbladder

376

which h2 blocker inhibits CytoP450?

cimetidine

377

side effects cimetidine

anti-androgenic effects
Dizziness (crosses BBB)

378

Pt comes in with GERD. doc prescribes an H2 blocker. Follow up shows an increased creatinine level, pt has never had an history of renal disease. Which drug did the doc prescribe?

cimetidine or ranitidine

379

Mechanism PPI

irreversibly inhibit H/K ATPase

380

Tox: PPI

C. diff
pneumonia
hip fracture
decreased Mg2+

381

mech: bismuth/sucralfate

bind to ulcer base, protects

382

misoprostol mech

PGE1 analog. Increases production and secretion of gastric mucous. Decreases acid production

383

Indications misoprostol

1. prevention of NSAID INDUCED ulcers
2. maintenance of patent ductus
3. Induce labor

384

tox: misoprostol

diarrhea
women who are trying to conceive!! (abortion)

385

Mechanism: octreotide

Long-acting somatostatin analog

386

Indications: octreotide

somatostatin analog

387

Indications for octreotide

1. VIPoma/carcinoid tumors
2. acute variceal bleeds
3. acromegaly

388

Tox of antacids

hypokalemia

389

Tox aluminum hydroxide

constipation (aluminimum amount of feces)
hypophosphatemia
osteodystrophy
muscle weakness

390

Tox: mg OH

diarrhea (Mg must go to the bathroom)
cardiac arrest
hyporeflexia/hypotension

391

Tox: Calcium carbonate

Hypercalcemia
Rebound acidemia
Can decrease effectiveness of other drugs like Tetracycline

392

Osmotic laxatives

magnesium hydroxide, magnesium citrate

393

which laxative can treat hepatic encephalopathy (ammonia in the brain)?

lactulose. Lactic acid promotes nitrogen excretion

394

Tox of infliximab

TB reactivation, fever, hypotension

395

Infliximab indications

Crohns
UC

396

Sulfasalazine indications

UC
Crohns

397

Tox: sulfasalazine

sulfonamide
oligospermia
malaise/nausea

398

Ondansetron mechanism

5-HT3 antagonist. good for chemo pts

399

mech: metoclopramide:

D2 antagonist
Increases gastric resting tone/motility/contractility
LES tone

400

Indications for metoclopramide

Diabetic and post surgical gastroparesis

401

Tox: metoclopramide

Parkinsons (Duh duz it's a D2 antagonist!)
Interacts with digoxin and diabetic agents

402

Metoclopramide is contraindicated in

pts with small bowel obstruction/parkinson's

403

Recurrent aphthous ulcer, genital ulcers, and uveitis

behcet syndrome. Aphthous is grey.

404

Oral SCC risk factors

tobacco and alcohol

405

hairy leukoplakis caused by

EBV in immunocompomised. NO dysplasia, only squamous hyperplasia.

Occurs on side of tongue!

406

what virus can cause pancreatitis?

mumps

407

which gland affected by pleomorphic adenoma?

parotid. high rate of recurrence. irregular margins.

408

how do you know if pleomorphic adenoma has become cancerous?

facial nerve damage (pain)

409

warthin tumor histology

lymphocytes and germinal centers in parotid

410

where does esophagus spread (lymph nodes?)

upper 1/3: cervical
middle 1/3: mediastinal
lower 1/3: celiac/gastric nodes

411

how do you make sure H pylori is gone?

urea breath test and stool antigen

412

duodenal ulcer histology

hypertorphy of brunner's glands

413

intestinal gastric adeno distant metastases

periumbilical

414

diffuse gastric adeno distant metastases

krukenberg

415

Double bubble sign

duodenal atresia (bubble on either side of the atresed area)

416

elderly volvulus vs teenage volulus

elderly=sigmoid
teen=cecum

417

cause of intussusception in an adult

tumor

418

transmural vs mucosal infarction

mucosa: hypotension
transmural: thrombosis

419

Cause of dermatitis herpetiformis

deposition of IgA at dermal papillae. SHould resolve with a gluten free diet

420

why test for IgG antibodies as well in celiacs?

Because many celiac patients also have IgA deficiency.

421

carcinoid tumors stain positive with

chromogranin. Most common site is in the small bowel!! This is the only carcinoma in the small bowel.

422

why does carinoid tumor only cause right sided valvular fibrosis?

lung also has monoamine oxidase to break down serotonin

423

p-ANCA positive IBD

Ulcerative colitis

424

smoking is protective against what type of IBD

UC

425

Crohn's disease in terminal ileum--risk for CRC?

NO-only if inflammation occurs in colon

426

most common type of polyp

hyperplastic polyp. Serrated apperance.

427

Enzymes that shut down trypsin

SPINK1
Trypsin also cleaves itself
-->without these, recurrent pancreatitis