GI Flashcards
(422 cards)
1
Q
Foregut becomes
A
Esophagus to upper duodenum
2
Q
Midgut becomes
A
Lower duodenum to prox 2/3 transverse colon
3
Q
Hindgut becomes
A
Distal 1.3 of transverse colon to anal canal over pectinate line
4
Q
Midgut herniates at…
A
6wks
5
Q
Midgut returns to cavity and rotates around SMA at…
A
10 wks
6
Q
Degree rotation of midgut
A
270
7
Q
Rostral fold closure defect–>
A
Sternal defect (ectopic cordis)
8
Q
Lateral fold closure defect–>
A
Omphalocele and gastroschisis
9
Q
Caudal fold closure defect–>
A
Bladder extrophy
10
Q
Gastroschisis
A
Abdomen contents extrude through abdominal folds (usually rt of umbilius) – no covering
11
Q
Omphalocele
A
Persistent herniation of abdomen contents into umbility cord – SEALED by peritoneum
12
Q
Congenital umbility hernia
A
Incomplete closure of umbilical ring - can close spontaneously
13
Q
Most common tracheoesophageal abnormality
A
Esophageal atresia w/ distal TEF
14
Q
Esophageal atresia w/ distal TEF symptoms
A
Polyhydramnios (can’t swallow), drool/choke/vomit at first feeding, air in stomach, cyanosis due to reflux mediated larygospasm, cannot pass nasogastric tube into stomach
15
Q
Pure EA presentation
A
CXR – gasless abdomen
16
Q
Intestinal atresia presentation
A
Billious vom and abdominal distension w/ first 1-2 days of life
17
Q
Duodenal atresia
A
Didn’t recanalize! Double bubble (dilates stomach, prox duodenum), DS association
18
Q
Jejunal and ileal atresia
A
Disruption of mesenteric vessels, ischemic necrosis, segmental resorption (bowel discontinuity/apple peel)
19
Q
Most common gastric outlet obstrxn in infants
A
Hypertrophic pyloric stenosis – palpable olive shaped mass at epigastric region, visible peristaltic waves, nonbiliious projective vom at 2-6 wks
First born male assc, macrolide exposure
Results in hypokalemic hypochloremia metabolic alkalosis (2o to vom and volume contraction
Tx: incision pyloromyotomy
20
Q
Pancreas derivation
A
Foregut
21
Q
Ventral pancreatic buds –>
A
Uncinate process and main pancreatic ducts
22
Q
Dorsal pancreatic bud–>
A
Body, tail, isthmus, accessory pan duct – both cont to pancreatic head
23
Q
Annular pancreas
A
Ventral bud encircles 2nd part of duoedenum -> ring of pancreatic tissue can cause obstruction
24
Q
Pancreas divisum
A
Ventral and dorsal dont fuse at 8 wks – common, usually asymptomatic but can cause chronic abdominal pain/pancreatitis
25
Spleen arises in...
Mesentery of stomach
26
Spleen derivation
Mesodermal
27
Spleen blood supply
Celiac truck --> splenic a.
28
Retroperitoneal stuctures defined
GI structures w/ no messentery and non GI structures
29
Injuries to retroperitoneal structures ->
```
Suprarenal glands (adrneal)
Aorta and IVC
Duodenum (2-4 parts)
Pancreas (except tail)
Ureters
Colon (Descending and ascending)
Kidneys
Esophagus (thoracic)
Rectum (partial)
```
SAD PUCKER
30
Falciform ligament
Connects liver --> ant abdominal wall, has ligamentum teres hepatis in it
31
Falciform ligament derivation
Ventral mesentery
32
Ligatmentum teres hepatis derivation
Fetal umbilical v
33
Hepatoduodenal ligament
Connects liver-->duodenum
34
In the hepatoduodenal ligament...
Portal triad -- proper hep a, portal v., common bile duct
35
Pringle maneuver
Compress ligament between thumb/index finger in omental foramen to control bleeding
36
Gastrohepatic ligament
Connects liver to lesser curvature of stomach
37
Contents of gastrohepatic ligament
Gastric arteries
38
Separates greater/lesser sacs on the right
Gastrohepatic ligament
39
Lesser omentum ligamnets
Hepatoduodenal, gastrohepatic
40
Gastrocolic
Connects greater curvature and transverse colon
41
Within gastrocolic
Gastroepiploic aas.
42
Greater omentum ligatments
Gastrocolic, gastrosplenic
43
Gastroc splenic
Connects greater curvature and spleen
44
Contents of gastrosplenic
Short gastrics, left gastroepiploic vessels
45
Separates greater/lesser sac on the left
Gastrosplenic lig
46
Splenorenal ligament
Spleen to post ab wall
47
Splenorenal lig contents
Splenic a and v, tail of pancreas
48
Serosa
Intraperitoneal
49
Adventitia
Retroperitoneal
50
Ulcer
Extend into submucosa, muscle layers
51
Erosion
Mucosa only
52
Freq of stomach basal waves
3/min
53
Freq of duodenal basal waves
12/min
54
Freq of ileal basacl waves
8-9/min
55
Brunner glands
Secrete HCO3, in submucosa of duodenum
56
Crypts of Lieberkuhn
Have stem cells to replace enterocytes/goblet cells; in small intestine and colon
57
Paneth cells
Secrete defensins, lysozyme, TNF -- duodenal
58
Plicae circulares
In distal duodenum, jejunum, ileum
59
Peyer patches
Lymphoid aggs in lamina propia, submucosa -- ileum
60
Villi are in...
SI but not colon
61
Colon has many
Goblet cells
62
SMA syndrome
Intermittent intestinal obstruction sx (postprandial pain) when transverse (3rd portion duodenum) is compressed between SMA and aorta -- usually in conditions w/ diminished mesenteric fat (e.g. low body wt, malnutrition)
63
Forgut artery
Celiac
64
Foregut PNS
Vagus
65
Foregut vertebral level
T12/L1
66
Foregut structures
Pharynx (vagus only), lower esophagus (celiac a only) to prox duodenum, liver, gallbladder, pancreas, spleen (mesoderm)
67
Midgut artery
SMA
68
Midgut PNS innervation
Vagus
69
Midgut vertebral level
L1
70
Midgut structures
Distal duodenum to prox 2/3 transverse colon
71
Hindgut artery
IMA
72
Hindgut PNS
Pelvic
73
Hindgut vertebral level
L3
74
Hindgut structures
Distal 1/3 transverse colon to upper portion of rectum
75
T12 arteries
inf Phrenic, Sup suprarenal, mid supraprenal, celiac
76
L1 aa's
SMA, Inf suprarenal, half renal
77
L2 aas
Half renal, gonadal
78
L3 aas
IMA
79
L4...
Bifurcation
80
L5 aas
Right/left common iliac, int iliac, median sacral
81
Celiac trunk branches
Common hepatic, splenic, lft gastric
82
Anastamoses at...
Left/right gastroepiploics, lft/right gastrics
83
Post duodenal ulcers-->
Pentrate gastroduocenal a -->hemorrhage
84
Ant duodenal ulcer-->
Pneumoperitoneum
85
Anastamoses sites
Esophagus, umbilicus, rectum
86
Esophageal portal/systemic
Lft gastric/azygos
87
Umbilical portal/system
Paraumbilical/small epigastric vvs of ant. abdominal wall
88
Rectal portal/systemic
Sup rectal/inf. and middle rectal
89
Tx of portal HTN and complication
TIPS hepatic v and portal v shunt but can cause hepatic encephalopathy
90
Pectinate line
Endoderm of hindgut meets ectoderm
91
Above pectinate line -- a, v, l, what can go wrong
IMA branch -- sup. rectal a
Drained by sup rectal v --> IMV -->splenic v-->portal v
Internal iliac lymphatic drainage
Internal hemorrhoids (not painful -- visceral innervation, adenocarcinoma
92
Below pectinate line -- a, v, l, what can go wrong
Inf rectal a. (branch of int. pudendal)
Inf rectal v -->int. pudendal v.-->int iliac v.--> common iliac v-->IVC
Superficial inguinal lymph nodes
Ext. hemorrhoids (painful if thrombose -- innervated somatically by inf. rectal branch of int. pudendal n), anal fissures, squamous cell carcinoma
93
Anal fissue
Tear in anal mucosa below pectinate line --> pain while pooping, blood on TP -- located posteriorly because poor perfusion
Assc. low-fiber diets and constipatioin
94
Stellate cells in liver
Store vit A when quiescent
| Produce ECM when activated
95
Zone I
Periportal -- affected 1st by viral hepatitis and ingested toxins (e.g. cocaine)
96
Zone II
Intermediate zone -- yellow fever
97
Zone III
Pericentral vein/centrilobular -- affected 1st by ischemia, contains P450 -- most sensitive to metabolic toxins, alcoholic hepatitis
98
Site of gallstone lodging to cause double duct sign
Confluence of common bile and pancreatic ducts at the ampulla of Vater --> cholangitis and pancreatitis
99
Tumors in head of pancreas
Most often ductal adenocarcinoma --> obstruction of CBD --> large gallbladder, painless jaundice (Courvosier sign)
100
Femoral triangle
Femoral n, a, v
101
Femoral sheath
Femoral a, v and canacl (deep inguinal lymph nodes)
102
Indirect inguinal hernia --
Through internal (deep) inguinal ring, external and into scrotum
Enters inguinal ring LATERAL to inf epigastric vessels
Infants -- no closure of processus vaginalis (can form hydrocele)
MALES
Covered by all 3 payers of spermatic fascia and follows descent of testes
103
Laters of fascia on spermatic cord
Internal spermatic fascia (transversalis fascia)
Creamasteric muscle/fascia (int. oblique)
External spermatic fascia (Ext. oblique)
ICE TIE
104
Direct inguinal hernia
Protrues through inguinal (Hesselbach) triangle -- bulges directly through parietal peritoneum MEDIAL to inf epigastric vvs but lateral to rectus abdominis
Goes through external/superficial inguinal ring onlly
Covered by external spermatic fascia
Older men -- acquired weakness in transversalis fascia
105
Femoral hernia
Protrudes below inquinal ligament though femoral canal below/lateral to pubic tubercle
FEMALES! (but overall inguinal most common)
More likely to have incarceration or strangulation
106
Hesselbach tirangle
Inf epigastric vessels
Lat border of rectus abdominus
Inguinal ligament
107
Gastrin source and location
G cells in antrum of stomach, duodenum
108
Actinon of gastrin
Increase gastric H secretion, growth of gastric mucosa, motility
109
Gastrin regulation
Increased by stomach distension/alkalinization, amino acids, peptides, vagal stim via GRP
Lowered by low pH (<1.5)
110
Gastrin is increased in which syndromes/drugs
PPI, chronic atrophic gastritis (H pylori), Z-E syndrome (gastrinoma)
111
Somatostatin source and location
D cells in pancreas and GI mucosa
112
Action of somatostatin
Lower gastric acid/pepsinogen secretion, pancreatic/small intestine fluid secretion, gallbladder contraction, insulin/glucagon release
113
Regulation of somatostatin
Increased by acid, decreased by vagal stim
114
Cholecystokinin source and location
I cells in duodenum and jejunum
115
CCK action
Increases pancreatic secretion (via neural muscarinic pathways), gallbladder contraction, sphincter of Oddie relaxation
Decreases gastric emptying
116
CCK regulation
Increased by fatty acids and amino acids
117
Secretin source and location
S cells in duodenum
118
Secretin action
INcreases pancreatic bicarb secretion (lowers pH so pancreatic enzymes fxn) and bile secretion
Decreases gastric acid secretion
119
Secretin regulation
Increased by acid, fatty acids in lumen of duodenum
120
Glucose dependent insulinotropic peptide source/location
K cells in duodenum and jejunum
121
Exocrine fxn of GIP
Lower gastric H secretion
122
Endocrine fxn of GIP
Increased insulin release
123
GIp regulation
Increased by fatty acids, amino acids, oral glucose
124
Motilin source
Small intestine
125
Motilin action
Produces migrating motor complexes
126
Motilin regulation
Increased in fastin state
127
Motilin receptor agonists
Erythromycin -- can stimulate intestinal peristalsis
128
VIP source
Parasympathetic ganglia in sphincters, gallbladder, small intestine
129
VIP action
Increase intestinal water and electrolyte secretion, as well as relxation of intestinal smooth muscle/sphincters
130
Regulation of VIP
Increased by distension and vagal stim
| Lowered by adrenergic input
131
VIPoma
non alpha or beta islet cell pancreatic tumor --> secretes VIP --> Watery Diarrhea, Hypokalemia, Achlorhydria syndrome
132
NO action
Relaxes smooth muscle, including lower esophageal sphincter
133
NO in achalasia
Lower NO secretion--> increased LES tone
134
Ghrelin source
Stomach
135
Ghrelin action
Increase appetite
136
Ghrelin regulation
Increased in fasting state
| Decreased by food
137
Ghrelin is increased in
Prader Willi
138
Ghrelin is decreased in
Post-gastric bypass
139
Intrinsic factor source and location
Parietal cells in stomach
140
Action of IF
Binds B12 for uptake in terminal ileum
141
Pernicious anemia pathophys
Autoimmune destruction of parietal cells-->chronic gastritis and pernicious anemia from low B12
142
Gastric acid source/location
Parietal cells in stomach
143
Action of gastric acid
Lower stomach pH
144
Gastric acid is increased by
Histamine, ACh, gastrin
145
Gastric acid decreased by
Somatostatin, GIP, prostaglandin, secretin
146
Pepsin source and location
Chief cells in stomach
147
Pepsin action
Protein digestion
148
Pepsin regulation
INcreased by vagal stim and local acid
149
What activates pepsinogen
H+
150
Bicarb source and location
Mucosal cells in stomach/duodenum/salivary glands/pancreas
| Brunner glands in duodenum
151
Bicarb action
Acid neutralization
152
Bicarb regulation
Increased by panctreatic/biliary secretion w/ secretin
153
Main method of gastrin mediated acid secretion
+ on ECL --> Histamine --> + on parietal cells --> H+ (indirect -- also works direct but this is more of the primary effect)
154
WHen pancreas senses low flow
More Cl- secretion
155
When pancreas senses high flow
More HCO3 secretion
156
Alpha amylase
Starch digestion -- secreted active by pancreas
157
Lipases
Secreted by pancreas for fat digestion
158
Proteases
Protein digestion enzymes trypsin, chymotripsin, elastase, carboxypeptidases secreted by pancreas as zymogens
159
Trypsinogen
First converted by brunch border enteropeptidase in duodenum and jejunal mucoase -- cleaved to be activated and cleaves more enzymes and itself -- secreted by pancreas
160
Carb absorption
Must be monosaccharides
SGLT1 (Na dependent -- glucose and galactose)
GLUT5 (fructose -- facilitated diffusion)
Blood transported via GLUT2
161
Fe absorbed
Fe2+ in duodenum
162
Folate absorption
Small bowel
163
B12 absorption
Terminal ileum w/ bile salts, req IF
164
Peyer patches -- capsule?
Nope
165
Peyer patches found
Malmina propria and submucosa of ileum
166
Fxn of M cells
Sample/present ags to immune cells in peyer patches --> IgA plama cells which ultimately reside in LP
167
Bile composition
Bile salts (bile acids conjugate to glycine or taurine to be water soluble), pospholipids, cholesterol, bilirubin, water, ions
168
Rate limiting step of bile acid synthesis
Catalyzed by cholesterol 7a hydroxylase
169
Fxns of bile
Digest/absorb lipids and fat soluble vitamins, cholesterol excretion (primary method), antimibrobial (membrane disruption)
170
Heme-->biliverdin enzyme
Heme oxygenase
171
Biliverdin-->
bilirubin
172
Unconjugated bilirubin-->
removed from blood by liver--> conjugated w/ glucuronate --> excreted in bile
173
Direct bilirubin=
Conjugated --water soluble
174
Indirect bilirubin
Unconjugate --water insoluble
175
Conjugation of bilirubin enzyme
UDL glucouronosyl transferase
176
Suggestion of malignancy in salivary gland tumor
Smaller glands, facial pain or paralysis (involvedment of CN7)
177
Pleomorphic adenoma
Benign mixed tumor -- most common; chondromyxoid stroma/epithelium and recurs if incompletely excised or ruptured intraoperatively
178
Mucoepidermoid carcinoma
Most common malignant tumor -- mucinous and squamous components
179
Warthin tumor
Papillary cystadenoma lymphomatosum -- benign cystic tumor w/ germinal centers typically in smokers, can be bilateral/malignant (10%)
180
Cause of achalasia
Lost of myenteric (Auerbach plexus)--> lost of post ganglionic inhibitory neurons w/ NO and VIP --> failure of LES to relax/uncoordinated/absent peristalsis-->progressive dysphagis to solids and liquirds
181
Achalasia imagin
Dilated esophagus and are aof distal stenosis -- birds beak
182
Achalasia assocation
Increased risk of esophageal cancer, can arise 2o to Chagas diease or extra esophageal malignancies (mass effect or paraneoplastic)
183
Boerhaave syndrome
Transmural usually distal esophageal rupture w/ pneumomediastinum due to biolent retching -- may detect subcutaneous emphysema due to dissecting air w/ crepitus in neck or chest wall -- surgical emergency
184
Eosinophilic esophagitis
Infilitration of eos in the esophagus in atopic patients; food allergy-->dysphagia/food impaction; see esophageal rings and linear furrows on endoscopy and will be unresponsive to GERD therapy
185
Esophageal strictures assocatiation
Caustic ingestion and acid reflux
186
Esophageal varices
Dilated submucosa vvs in lower 1/3 of esophagus due to portal HTN -- common in cirrhosis and may cause life threatening hematemesis
187
Esophagitis associations
Reflux, infxn in immunocompromised (candida, HSV, CMV), caustic ingestion or pill esophagitis (bisphosphonates, tetracycline, NSAIDs, iron, KCl)
188
Candida esophagitis
White pseudomembrane (immunocompromised)
189
HSV 1 esophagitis
Punched out ulcers (immunocompromised)
190
CMV esophagitis
Linear ulcers (immunocompromised)
191
GERD
Heartburn, regurg, dysphagia, chronic cough, hoarseness (laryngopharyngeal reflux) due ot transient decrease in LES tone
192
GERD assocation
Asthma
193
Mallory Weiss syndrome
Partial thickness mucosal lacerations at GE jxn due to severe vomiting --> hematemesis -- alcoholics and bulemics
194
Plummer Vinson
Dysphagia, Iron deficiency anemia, Esophageal webs -- can be associated w/ glossitis; higher risk of esophageal SCC
"Plumbers DIE"
195
Sclerodermal esophageal dysmotility
Esophageal smooth muscle atrophy --> lower LES pressure and dysmotility --> acid reflux/dysphagia --> stricture, Barrett esophagus, aspiration
Part of CREST
196
Barrett Esophagus
Intestinal metaplasia in previously nonkeratinized strat squamous epithelium in esophagus due to chronic GERD --> increased risk of esophageal ADENOcarcinoma
197
Intestinal metaplasia
Nonciliated columnar w/ goblet cells
198
Presentation of esophageal cancer
Progressive dysphagia starting w/ solids, wt loss, poor prognosis
199
SCC of esophagus location
Upper 2/3 esophagus
200
SCC of esophagus risk factors
Alcohol, hot liquires, caustic strictures, smoking, achalasia
201
Adenocarcinoma of esophagus location
Lower 1/3
202
Adenocarcimona risk factors
GERD, Barrett esophagus, obesity, smoking, achalasia
203
Prevalence of esophageal cancers
SCC more worldwide but adeno more in America
204
Cause of erosions (acute gastritis)
NSAIDs --> less PGE2-->less gastric mucosa protection
Burns (curling ulcer) hypovolemia-->mucosal ischemia
Brain injury (Cushing ulcer) -- more vagal stim--> more ACh-->more H prodxn
205
Chronis gstritis
Mucosal inflamation --> atrophy (hypochlorhydria-->hypergastrinemia) and intestinal G cell metaplasia (higher risk of gastric cancers)
206
H pylori
Most common chronic gastritis; increased risk of PUD, MALT lymphoma -- antrom first and spreads to body
207
Autoimmune chronic gastritis
Autoabs to parietal cells and IF --> higher risk of pernicious anemia; affects body/fundus of stomach
208
Menetrier disease
Hyperplasia of gastric mucosa --> hypertrophied rugae (look like brain gyri), excess mucus and protein loss/parietal cell atrophy --> less acid production
Precancerous
209
Gastric cancer most common
Gastric adenocarinoma
210
Signs of gastric cancer
Usually present late -- wt loss, early satiety, acanthosis nigricans or Leser Trelat
211
Instestinal gastric cancer associations
H pylori, dietary nitrosamines, tobacco smoking, achorhydria, chronic gastritis
212
Intestinal gastric cancer most commonly located
Lesser curvature (ulcer w/ raised margins)
213
Diffuse gastric cancer histology
Signet ring cells
214
Diffuse gastric cancer grossly
Stomach wall grossly thickend and leathery (linitus plastica)
215
Virchow node
Left suprclavicular spread from gastric metastatses
216
Krukenberg tumor
Bilateral ovarian metastatses in diffuse CA
217
Sister mary joseph nodule
Subcutaneous periumbilical metastatsis
218
Gastric ulcer pain
Made greater w/ meals --> wt loss
219
Gastric ulcer causes
H pylori, NSAIDs
220
Gastric ulcer cause
Less mucosal protection against gastric acid
221
Duodenal ulcer pain
Less w/ meals --> weight gain
222
Mechanism of duodenal ulcer
Less mucosal protection or increased gastric acid secretion
223
Causes of duodenal ulcer
H pylori or ZE syndrome
224
Seen in duodenal ulcer
Hypertrophy of Brunner glands
225
Complications of ulcers
Hemorrhage (gastric or duodenal (post>ant), obstruction (pyloric channel, duodenal) perforation (duodenal -- ant>post)
226
Lesser curvature ulcer hemorrhage-->
Bleeding from lft gastric a
227
Duodenal post. hemorrhage-->
Bleeding form gastroduodenal a
228
Duodenal ulcer -->perforation --> sx
Free air under diaphragm w/ referred pain to shoulder via phrenic n irritation
229
In celiac disease, autoimmune mediated intolerance of...
Gliadin (gluten protein found in wheat)
230
HLA w/ celiac
HLA DQ2, DQ8
231
Seen in celiac disease
European descent, dermatitis herpetiformis, lower bone density, IgA TTG, antiendomysial and anti deamidated gliadin peptide abs
Histology: villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis
Increased risk of T cell lymphoma
Mucosal malabsorption primary affects distal duodenum/proximal jejunum
232
D xylose test
Passively absorbed in prox SI -- blood and urine levels decrease w mucosa defects or bacterial overgrowth, normal in pancreatic inufficiency
233
Lactose intolerance causes
Lactase deficiency -- viral or acquired
234
Histology/labs in lactose intolerance
Normal appearing villi (except when 2o injury at tips due to viral enteritis --> osmotic diarrhea w/ low stool pH (colonic bacteria ferment); lactose hydrogen breath test (pos for lactos malabsorption if postlactose breath hydrogen rises > 20 ppm compared to baseline)
235
Pancreatic insufficiency causes
Chronic pancreatitis, CF< obstructive cancer
236
Pancreatic insufficiency results in
Malabsorption of fat/fat soluble vitamins (ADEK) and B12 -- low duodenal pH (bicarb) and fecal elastase
237
Tropical sprue
Like celiac sprue but respons to Abx -
238
Whipple disease bug
Tropheryma whipplei -- PAS +
239
Whipple disease histology
PAS foamy macrophages in lamina propia and mesenteric nodes
240
Signs of Whipple disease
Cardiac symptoms, Arthralgias, Neuro symptoms, later --> diarrhea/steatorrhea
241
Whpple disease demographic
Older men
242
Crjohn disease location
Any part of GI tract -- usually terminal ileum and colon w/ skip lesion and rectal sparing
243
Grossly Crohn disease
Transmural inflamm --> fistula, cobblestone mucosa, creeping fat, bowel wall thickening (string sign on barium swallow), linear ulcers, fissure
244
Microscopic Crohns
Moncaseating granulomas and lymphoid aggregates -- Th1 mediated
245
Complications of Crohn
Malabsorption/malnutrition, colorectal cancer, fistulas (enterovesicular --> recurrent UTI, pneumaturia), phlemon/abcess, strictures (-->obstruction), perianal disease
246
Crohn disease diarrhea
Bloody or nah
247
Extraintestinal manifestations common to both IBDs
Rash (pyoderma gangrenosum, erythema nodosum), eye inflammation (episcleritis, uveitis), oral ulcers (apthous stomatitis), arhtritis (peripheral, spondylitis)
248
Crohn specific extraintestinal manifestations
Kidney stones (Ca oxalate), gallstones, may have positive anti Saccharomyces cervisiae abs (ASCA)
249
Tx of Crohns
Corticosteroids, AZA, abx (cipro, metro), infliximab, adalimumab
250
Ulcerative colitis location
Continuous from rectum up (not past end of colon)
251
Grossly ulcerative colitis
Mucosal and submucosal inflam only -- firable mucosa w/ superficial/deep ulcerations, loss of haustra (lead pipe appearance on imaging)
252
Histology of UC
Crypt abcesses and ulcers, bleeding, no granulomas, Th2 mediated
253
Complications of UC
Malabsorption/malnutrition, colorectal CA 9increased risk w pancolitis), fulminant colitis, toxic megacolon, perf
254
Diarrhea in UC
Always bloody
255
UC specific extraintestinal manifestations
1o sclerosing cholangitis (pANCA)
256
Tx of UC
5ASA preps (mesalamine), 6MP, infliximab, colectomy
257
IBS
```
Recurrent abdominal pain w/ 2+:
- Related to defecation
-Change in stool freq
-Chain in form (consistency) of stool
w/ no structural abnormalities
Can be diarrhea predom, constipation predom, or mix
```
258
IBS demographic
Middle aged women
259
Appedicitis most common cause
Kids: lymphoid hyperplasia
Adults: fecalith
260
Complication of appendicits
Perf-->peritonitis
261
Buzzwords for appendicits
McBurney's point pain, posas, obturator, Rovsing signs
262
True diverticulum
All 3 gut wall layers outpouch (meckl)
263
False diverticulum
Only mucosa and submucosa outpouch (esp where vasa recta perforate muscularis externa)
264
Diverticulosis
Many false diverticula of colon, commonly in sigmoid
265
Diverticulosis cause
Increased intraluminal pressure and focal weakness in colonic wall, low fiber diets
266
Complications of diverticulosis
Diverticular bleeding (painless hematochezia) or diverticulitis
267
Diverticulitis
Inflammation fo diverticula -- LLQ pain, fever, leukocytosis (tx w/ abx)
268
Diverticulitis complications
Abscess, fistula (colovesical-->pneumaturia), obstruction (inflammatory stenosis), perf -->peritonitis
269
Zenker diverticulum
Pharyngoesophageal false diverticulum -- esophageal dysmotility --> herniation of mucosa at Killian triangle vtween thyropharyngeal and cricopharygeal parts of inf pharyngeal contricture --> dysphagia, obstruction, gurgling, aspiration, foul breath, neck mass (usually elderly males)
270
Meckle diverticulum
True diverticulum -- persistence of vitellin duct, may contain ectopic acid secreting gastric mucosa +/- pancreatic tissue; most common congenital anomaly of GI tract --> hematochezia/melena, RLQ pain, intussusception, volvulus, obstruction near terminal ileum
271
Omphalomestnteric cycst
Cystic dilation of vitelline duct
272
Diagnose meckel diverticulum
Pertechnetate study for uptake by ectopic gastric mucosa
273
Rule of 2s in Meckle's
2x more likely in males, 2 inches long, 2 feet from ileocecal vavle, 2% of population, presents in first 2 years of life, 2 types of epithelia
274
Hirschprung disease
Congenital megacolon due to lack of ganglion cells/enteric nervous plexuses (Auerbach, Meissner) in distal colon due to failure of neural crest migration
275
Hirschprung genetics
RET mutations, higher in DS
276
Presentation of Hirschprung
Bilious emesis, abdominal distention/failure to pass meconium w/in 48 hrs --> chronic constipation; explosive expulsion of feces (squirt sign) --> empty rectum on digital exam
277
Hirschsprung diagnosis
Rectal suctino biopsy
278
Malrotation
Anomaly of midgut rotation during fetal development --> improper position of bowel, formation of fibrous bands (Ladd bands)
279
Malrotation complications
Volvulus, duodenal obstruction
280
Volvulus
Twisting of part of bowel around its mesentary --> obstruction or infactrion
281
Common volvulus in kids
Midgut
282
Elderly volvulus
Sigmoid (coffee bean)
283
Intussusception
Telescoping of prox bowel into distal -- usually at ileocecal jxn --> compromised blood supply --> abdominal pain w/ currant jelly stools
284
Cause of intussusception in adults
Intraluminal mass or tumor
285
Most common lead point in intussuception
Meckel diverticulum (usually kids)
286
Associations w/ intussusception
Recent viral infxn (adenovirus --> Peyer patch hypertrophy --> lead point; rotavirus vax
287
Acute mesenteric ischemia
Critical blockage of intestinal blood flow (often embolic occlusion of SMA) --> SI necrosis --> abdominal pain out of proportion to physical findings, may see current jelly stools
288
Chronic mesenteric ischemia
Intestinal angina -- atherosclerosis of celiac a, SMA, IMA --> intestinal hypoperfusion --> posprandial epigastric pain --> food aversion/wt loss
289
Colonic ischemia
Reduction in intestinal blood flow --> ischemia --> crampy abdominal pain followed by hematochexia
290
Location of colonic ischemia
Watershed areas (splenic flexure, distal colon)
291
Colonic ischemia demographics
Elderly
292
Clonoic ischemia imaging
Thumbprint sign due to mucosal edema/hemorrhage
293
Angiodysplasia
Tortuous dilation of vessels -->hematochezia; confirmed by angiography
294
Angiodysplasia location
Rt colon
295
Angiodysplasia demographics
Elderly
296
Adhesion
Fibrous band of scar tissue, commonly after surgery --> most common cause of SI obstruction, can have well demarkated necrotic zones
297
Ileus
Intestinal mypomotility w/o obstruction --> constipation and less flatus
298
Presentation of ileus
Constipation, less flatus, distended/tympanic abdomen w/ less bowel sounds
299
Associations w/ ileus
Abdominal surgeries, opiates, hypokaemia, sepsis,
300
Tx of ileus
Bowel rest, electrolyte correction, cholinergic drugs (stim intestinal motility)
301
Meconium ileus
In CF -- meconium plub obstructs intesting preventing stool passage at birth
302
Necrotizing enterocolitis
Premature forumla fed infants w/ immature immune system -- necrosis of intestinal mucosa (esp colonic) w/ possible perfs --> pneumatosis intestinalis, free air in abdomen, portal venous gas
303
Hamartmoatous polyps
Generally non neoplastic and solitary -- growths of normal colonic tissue w/ distorteed architecture
304
Associated with hamartomatous polyps
Peutz-Jeghers, juvenile polyposis
305
Mucosal polyps
Small, less than 5 mm, look similar to normal, clinically insignificant (non neoplastic)
306
Inflammatory pseudopolyps
Result of mucosal erosion in inflam bowel disease (non neoplastic)
307
Submucosal polyps
Lipomas, leimyomas, fibromas, etc (non neoplastic)
308
Hyperplastic polyps
Smaller and mostly in rectosigmoid region -- only rarely evolve into serrated and more advanced lesions
309
Adenomatous polyps
Neoplastic via chromosomal instability pathway with mutation in APC and KRAS -- tubular worse than villous, tubulovillous in the middle; usually asymptomatic but may present w/ occult bleeding
310
Serrated polyps
Premalignant via CpG hypermethylation phenotype w/ microsatillite instability and BRAF mutations; saw tooth crypts -- up to 20% of sporadic CRC
311
FAP genetics
AD mutation of APC tumor suppressor (2 hit) on chr 5q21
312
FAP sx
Thousands of polyps after puberty -- pancolonic and always involves rectum
313
FAP tx
Prophylactic colectomy -- 100% progression
314
Gardner syndrome
FAP+osseous and soft tissue tumors, congenital hypertrophy of RPE, impacted/supernumerary teeth
315
Turcot syndrome
FAP/Lynch syndrome and malignant CNS tumor (medulloblastoma, glioma)
316
Peutz Jeghers syndrome genetics
AD
317
Peutz Jeghers sx
Numerous hamartomas through GI tract, hyperpigmented mouth, lips, hands, genitalia
318
Peutz Jeghers assoc
Higher risk of breast and Gi cancers (colorectal, stomach, SI, pancreatic
319
Juvenile polyposis syndrome genetics
AD
320
JPS demographics
Children under 5
321
JPS sx
Numerous hamartomatous polyps in colon, stomach, SI
322
JPS assoc
Higher risk of CRC
323
Lynch syndrome aka
HNPCC
324
Lynch syndrome genetics
AD mutation of DNA mismatch repair gene --> microsatillite instability
325
Lynch prognosis
80% progression to CRC
326
Lynch syndrome assoc
Endometrial, ovarian, skin CA and CRC
327
CRC demographics
most >50, 25% family hx
328
CRC risk factors
Adenomatous/serrated polyps, familiar CA syndromes, IBD, tobacco use, diet of processed meat w/ low fiber
329
CRC sx
Rectosigmoid>
ascending -- exophytic, IDA, wt loss>
descending -- infiltrating, partial obstruction, colicky pain, hematochezia
330
Assoc w/ CRC
S bovis bacteremia
| IDA in males >50 and postmenopausal females
331
Screening for CRC
Starts at 50 w/ colonoscopy (40 or 10 yrs prior to family member if family hx in 1st degree relative)
332
Tumor marker for CRC
CEA -- mointors recurrence/tx, not screening
333
Molecular pathogenesis of CRC chromosomal instability
APC mutation --> less adhesion and more proliferation (at risk) --> KRAS mut --> unregulated incracell signalling --> adenoma --> loss of tumor suppressor gene (e.g. p53) -->increased tumorienesis --> carcinoma
334
Molecular pathogenesis of CRC microsatilite instability
Mutations or methylation of mismatch repair genes (e.g. MLH1)
335
May cause or prevent CRC
Overexpression of COX2 linked to CRC -- NSAIDs chemoprotective
336
Cells most involved in cirrhosis
Stellate
337
Causes of portal HTN
Cirrhosis (most), vascular obstruction (e.g. portal vein thrombosis, Budd chiari), schistosomiasis
338
Metabolic changes in portal HTN
Hyponatremia, hyperbilirubinemia
339
Spontaneous bacterial peritonitis aka
Primary bacterial peritonitis
340
Predisposes to spontaneous bacterial peritonitis
Cirrhosis/ascites
341
Sx of spontaneous bacterial peritonitis
Often asymptomatic, but can cause fevers, chiils, abdominal pain, ileus, worsening encephalopathy
342
Causes spontanoeous bact peritonitis
Aerobic gram neg organism -- esp E coli
343
Diagnose spont. bact peritonitis
Paracentesis w/ ascitic fluid abs. neutrophil count >250cells/mm3
344
Most liver disease liver enzymes and exception to rule
ALT>AST
Exception alcohol (AST>ALT)
If AST>ALT in non alcoholic liver disease -- probably progression to advanced fibrosis of cirrhosis
345
Alk phos
Increased in cholestasis, infiltrative disorders, and bone disease
346
GGT
Increased in liver and billiary disease (like alk phos) but not in bone disease; assc w/ alcohol use
347
Why are plts low in liver disease?
Low TPO, liver sequestration
348
Why are plts low in portal HTN?
Splenomealy, spenic sequestration
349
Reye syndrome
Oft fatal hepatic encephalopathy in kids; sx: mitochondrial abnormalities, fatty liver (microvesicular fatty change), hypoglycemia, vomiting, hepatomegaly, coma
350
Cause of Reyes syndrome
Viral infxn (esp VZV and influenza B) tx w/ aspirin
351
Reye syndrome mechanism
Aspirin metabolites decrease B-oxidation by reversible inhib of mitochondrial enzymes
352
Hepatic steatosis
MACROvesicular fatty change -- may be reversible w/ alcohol cessation
353
Alcoholic hepatitis
Req sustained long-term consumption -- swollen/necrotic hepatocytes w/ neutrophilic infiltration, Mallory bodies (intracytoplasmic eosinophilic inclusions of damaged keratin filaments)
354
Alcoholic cirrhosis
Final and irreversible form of liver damage -- regnerative nodules surrounded by fibrous bands in response to chronic liver injury --> portal HTN and end stage liver disease; sclerosis around central vein in early disease
355
Nonalcoholic fatty liver disease
Metabolic syndrome (insulin resistance, obesity) --> fatty infiltratin of hepatocytes --> cellular ballooning and eventual necrosis --> can -->cirrhosis and HCC
356
Hepatic encephalopathy
Cirrhosis -->portosystemic shunts --> less HN3 metabolism --> neuropsych dysfxn (from disorientation/asterixis to difficult arousal or coma)
357
Triggers of hepatic encephalopathy
Increase NH3 prodxn and absorption (due to dietary protein, GI bleed, constipation, infxn)
or
Less NH3 removal (due to renal failure, diuretics, TIPS)
358
Tx of hepatic encephalopathy
Lactulose (increased NH4 prodxn) and refaximen or neomycin (less NH3 producing gut bacteria)
359
HCC assoc
HBV (w/ or w/o cirrhosis), HCV, alcoholic and nonalcoholic fatty liver disease, autoimmune disease, hemochromatosis, alpha1 AT def, aflatoxin
360
Findings in HCC
Jaundice, TENDER hepatomegaly, ascites, polycythemia, anorexia
361
Spread of HCC
Hematogenously
362
What can HCC progress to cause?
Budd chiari
363
Diagnosis of HCC
AFP, ultrasound or contrast CT/MRI, biopsy
364
Cavernous hemangioma
Common benign liver tumor occuring 30-50 yrs
| DO NOT BIOPSY -- risk of hemorrhage
365
Hepatic adenoma
Rare benign liver tumo r-- related to OCP or anabolic steroids -- can regress spontaneously or rupture (abdominal pain/shock)
366
Angiosarcoma
Malignant tumor of endothelium -- assoc w/ exposure to arsenic, vinyl chloride
367
Metastases
Most common liver tumor altogether -- usually multiple; most commonly GI, breast, and lung cancer
368
Budd chiari
Thrombosis/compression of hepatic vvs w/ centrilobular congestion/necrosis -->congestive liver disease (hepatomegaly, ascities, varices, abdominal pain, liver failure) -- can cause nutmeg liver
No JVD
369
Budd chiari assoc
Hypercoagulable states, polycythemia vera, postpartum, HCC
370
a1 AT deficiency
Misfolded gene product protein aggregates in hepatocellular ER --> cirrhosis w/ PAS + globules in liver
371
a1 AT genetics
codominant
372
Presentation of a1AT def
young pt w/ liver damage and dyspnea and no hx of smoking
373
Common causes of jaundice (increased bili)
```
HOT Liver
Hemolysis
Obstruction
Tumor
Liver disease
```
374
Unconjugated hyperbilirubinemia
Hemolytic, physiologic in newborns, Crigler-Najjar, Gilbert
375
Conjugated hyperbilirubinemia
Biliary tract obstruction -- gallstones, cholangiocarcinoma, pancreatic/liver cancer, liver fluke
Biliary tract disease: 1o sclerosis cholangitis or 1o biliary cholangitis
Excretion defect: duin-Johnson, Rotor syndrome
376
Cuase of neonatal jaundice and danger
Immature UDP glucuronosyltransferase -- can cause kernicterus esp in basal ganglia
Usually w/in 24 hours of life and resolves in 1-2 wks
Tx: phototerapy
377
Gilber syndrome v Crigler Najjar
```
Mildly low UDPGTase vs. absent UDPGTase
Relatively asymptomatic (sx on fasting/stress) vs early in life presentation and death w/in a few years
```
378
Type I vs Type II C-N
Type II is less severe and responds to phenobarb (increases liver enzyme synth)
379
Dubin johnson
Defective liver secretion -- grossly black liver (Rotor -- same, no black liver)
380
Wilson disease genetics
AR mutation in hepatocyte copper transporting ATPase -- ATP7B gene on Chr 13
381
Wilson disease mechanism
Less Cu exretion into bile and incorporation into apoceruloplasmin --> less serum ceruloplasmi --> Cu accumulation, esp in liver, brain, cornea, kidneys; higher urine Cu
382
Wilson disease presentation
Before age 40 -- liver disease (hepatitis, acute liver failure, cirrhosis), neurologic disease (e.g. dysarthria, dystonia, treamor, parkinsonism), psych disease, K-F rings (deposits in Descemet membrane of cornea), hemolytic anemia, renal disease (Fanconi syndrome)
383
Tx of Wilson disease
Chelation w/ penicillamine or trientine, oral Zn
384
Hemochromatosis genetics
AR mutation in HFE gene (C282Y>H63D) chr 6, assc w/ HLA A3
385
Hemochromatosis mechanism
Abnormal Fe sensing and increased int absorption (high ferritin, high iron, low TIBC --> high transferrin sat), OR 2o to chronic blood transfusion --> Iron accumulation in liver, pancreas, skin, heart, pituitary, joints
386
Hemochromatosis findings
Hemosiderin identified on liver MRI or biopsy w/ Prussian blue stain
387
Demographics of hemochromatosis
Pts older than 40 when total body iron >20 g -- iron loss through menstruation slows progression in women
388
Presentation of hemochromatosis
Cirrhosis, DM, skin pigmentation (bronze), restrictive cardiomyopathy or dilated (reversible), hypogonadism, arthropathy (Ca pyrophosphate deposition -- esp in MCP jnts), can lead to HCC
389
Tx of hemochromatosis
Repeated phlebotomy, chelation w/ desfersirox, deferoxamine, oral deferiprone
390
Presentation of biliary tract disease
Pruritis, jaundice, dark urine, light colored stool, hepatosplenomegaly --> cholestatic pattern of LFT (high conj bilirubin, high chol, high alk phos)
391
PSC pathology
Something causes concentric onion skin bile duct fibrosis --> alternating strictures and dilation w/ beading of intra/extrahepatic bile ducts on ERCP or MRCP
392
Epidemiology of PSC
Middle aged men w/ IBD
393
Associations of PSC
Assc w/ UC, pANCA+, can lead to 2o biliary cholangitis, higher risk of cholangiocarcinoma and gallbladder CA
394
PBC pathology
Autoimmune rxn --> lymphocytic infilitrate and granulomas --> destruction of intralobular bile ducts
395
Epidemilogy of PBC
Middle aged women
396
Assoc w/ PBC
Anti mitochondrial ab +, high igM; assc w/ other autoimmune conditions (Sjogrens, Hashimotos, CREST< RA, celiac)
397
2o biliary cholangitis pathology
Extrahepatic biliary obstruction --> higher pressure in intrahepatic ducts --> injury/fibrosis and bile statsis
398
2o BCitis assc.
Pts w/ gallstones, biliary strictures, pancreatic carcinoma (can be complicated by ascending cholangitis)
399
Cholesterol stones --
Radioluscent (most common_ assc w/ obesity, Crohn disease, advanced age, estrogen therapy, multiparity, rapid wt loss, Native American origin
400
Pigment stone --
Radiopaque, bilirubinate, hemolysis (black) or radiolucent from infxn (brown)
Assc w/ Crohn disease, chronic hemolysis, alcoholic cirrhosis, advanced age, biliary infxns, TPN
401
Most common complication of cholelithiasis
Cholecystitis (can also cause acute pancreatitis, ascending cholangitis, fistula btween gallbladder and GI tract -->air in biliary tree (pneumobilia) --> passage of gallstones into intestine -->obstruction of ileocecal valve (gallstone ileus))
402
Risk factors for cholelithiasis
```
Female
Fat
Fertile (preggers)
Forty
(4Fs)
```
403
Biliary colic
Cholelithiasis complicatio. Assc w/ NV, dull RUQ; neurohormonal activation by CCK after fatty meal --> contraction of gallbladder --> stone into cystic duct; normal labs (see stone on US)
404
Choledocholithiasis
Gallstone in common bile duct --> elevated ALP, GGT, direct bili, AST/ALT
405
Cholecytisis
Acute or chronic inflam of gallbladder from cholelithiasis (stone at neck of gallbladder) w/ gall bladder wall thickening
406
Calculous cholecystitis
Most common -- gallstone impaction in cystic duct --> inflammation (can produce 2o infxn)
407
Acalculous cholecystitis
Due to gallbladder stasis, hypoperfusion, infxn (CMV) in critically ill pts
408
Cholecystitis test
Murphy sign (inspiratory arrest on RUQ palpation due to pain), increased ALp if bile duct involved (ascending cholangitis)< diagnosed w/ US or HIDA (can't visulaize gallbladder on HIDA -- obstruction)
409
Porcelain gallblader
Calcified gallbladder due to chronic cholecystitis -- usually inceidental finding
410
Tx of porcelain gallbladder
Prophylactic cholecystectromy -- high rates of gallbadder adenocarcinoma
411
Ascending cholangitis
Infxn of biliary tree usually due to obstruction --> stasis/bacterial overgrowth
412
Charcot triad of cholangitis
Jaundice, fever, RUQ pain; reynolds pentad adds alteed mental status and shock (hypotension)
413
Acute pancreatitis
Autodigestion of pancreas by pancreatic enzymes
414
Causes of acute pancreatitis
Idiopathic, Gallstones, EtOH, Trauma, Steroids, Mumps< Autoimmune, Scorpion sting, Hypercalcemia/hypertriglyceridemia (>1000 mg/dL), ERCP, Drugs (e.g. sulfa, NRTIs, protease inhibs)
I GET SMASHED
415
Diagnosis of acute pancreatitis
2 of 3: acute epigastric pain radiating to back, high serum amylase or lipase (more specific) to 3x ULN, characteristic imaging
416
Complications of acute pancreatitis
Pseudocyst (lined by granulation tissue -- not epithelium), necrosis, hemorrhage, infxn, organ failures (ARDS, shock, renal failure), hypocalcemia (precipiation of Ca soaps)
417
Chronic pancreatitis major causes
EtOH abuse, idiopathic
418
Sx of chronic pancreattitis
Pancreatic insufficiency -- statorrhea, fat soluble vit def, DM
+/- on lipase/amylase changes
419
Panctic adenocarcinoma
Arises from pancreatic ducts (disorganized gladular sturctionw/ cellular infiltration) --- most common in pancreatic head --> obstructive jaundice
420
Tumor marker for pancreatic adenocarcinoma
CA199
421
Risk factors for pancreatic adenocarcinoma
Tobacco use, chronic pancreatitis (esp > 20 yrs), DM, age >50 yrs, Jewish and AfAm males
422
Presentation of pancreatic adenocarcinoma
Abdominal pain radiating to neck, wt loss (malabsorption, anorexia), migratory thrombophleibitis (redness and tenderness on palpation of extremeties -- Troussea syndrome), obstructive jaundice w/ palpable nontender gallbladder (Courvosier sign)
