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Flashcards in GI - DIT Deck (304):
1

Anterior part of the tongue innervation

Taste?
Movement?
sensation

Taste - CN7
Sensation - CN 5, V3 Mandibular
Movement - CN12

2

Posterior part of the tongue innervation ?

Taste
Sensation
Movement

Taste - CN 9
- Very posterior CN10
Sensation - CN 9
Movement CN 12

3

anterior part of the tounge derived from?

Posterior 2/3?

pharyngeal arch 1

Pharyngeal arch 3/4

Just think of the innervation

4

Glossitis may be due to ? (5)

B12
B6
B2
B3
and Fe deficiency

5

muscle responsible for tongue protrusion

genioglossus

hyloglossus retracts

6

3 salivary glands: innervation and secretions

sublingual- CN7, secretes mucous

submandibular - CN 7 secretes mixed

Parotid is CN 9, secretes serous

7

Secretions found in saliva (5)

increased w/ what kind of stimulation?

HCO3
Amyalase
IgaA
Mucins
Growth factor

sympathetic (thick) and parasympathetic (watery)

8

Sialadenitis is ?

due to ? Causal agents?

inflammation of the submandibular of parotid ducts (Stensen duct) most likely

lilathis or stone

bacteria: Staph aureus or Strep mutants

9

Cleft lip is failure of fusion w?

lateral maxillary and medial nasal processes
( formation of the primary palate)

10

Cleft palate is failure of fusion of?

lateral palatine prcesses (shelves), the nasal septum and the median palatine processes

(secondary palate formation)

11

most common salivary gland tumor and associated histology

Pleomorphic adenoma

in the parotid gland usually with epithelial and mesenchymal tissue

12

2nd most common salivary tumor that is benign

Warthin tumor

looks like a geminal center

13

Most common malignant salivary tumor and associated histology

mucoepidermoid carcinoma

mutinous and squamous components w/ complications leading to pain w/ involvement of the facial nerve

14

2 causes of rhinitis and associated symptoms

infectious rhinitis - cold
- irritation, congestion, rhinorrhea, post nasla drip

Allergic rhinitis
-rhinorrea, congestion, cough, intermittent

15

Top 4 causes of infectious rhinitis

Corona virus
adeno virus
echo virus
rhino virus

16

Nasal polyps are?

overgrowths of the mucosal that are freely moving that are associated with allergic rhinitis

Surgical removable or internasal steriods

17

Cocaines effects on the nose?

Potent vasoconstrictor -> ischemia and necrosis, perforation of the nasal tube

18

4 sinuses of the face

Frontal - above the eye
Maxillary - in the cheek
sphenoid- behind the nose
ethmoid - kind of behind the eyes

19

Sinusitis symptoms

fever, purulent discharge, facial pain

20

3 regions of the gut and associated innervation and blood supply

Foregut w/ (stomach, spleen, pancreas etc)
-vagus innervation
-celiac artery

Midgut
( Distal duodenum -> proximal 1/3 transverse colon)
-vagus innervation
-Supermesenteric artery

Hindgut
(distal 1/3 transverse colon onward)
-Pelvic innervation
-Infereior mesenteric artery

21

4 layers of the gut wall - inner to outer

Mucosal
-epithelium
-lP
-muscularis mucosa

Submucosa
-submucosa plexi/ meisseners

Muscularis externais
-myenteric plexus/ auerbachs

Serosa

22

Muscularization of espophagus

top third skeletal

bottom third smooth

23

Anal agenesis often due to?

improper formation of urorectal septum
- Fistulas

24

extrusion of the abdominal contents not covered in peritoneum

defect more likely found
associated problems?

Gastrochisis - NO peritoneum

defect to R>L of umbilicus
-liver NEVER found

rarely associated problems

25

extrusion of the abdominal contents covered by the peritoneum

Associated pro

Ophalocele

- involves the liver sometimes

Other issues w/ GU, CV, CNS, MS 50% of the time

26

Child presents w/ drooling choking, and vomiting in their first feeding, non bilious

X ray finding?

Clinical warning prior to delivery

esophageal atreaia w/ distal tracheoesophageal fistula

air seen in the stomach on x ray

polyhydrominos

27

nonbilios projectile vomiting at around 2 weeks of age?

Associated finding sometimes?

plyloric stenosis

palpable olive mass in epigastric

28

dark urine w/ clay colored stools and jaundice in a newborn may be?

extrahepatic biliary atresia

incomplete recanalization of the bile duct

29

hourglass stomach with the GE junction displaced above the diaphragm

sliding hiatial hernia

- vs. paraesphageal hernia the GE junction is normal, the funds protrudes

30

Chronic constipation and abdominal distention early in life where 1st dtool may be with Digital rectal exam but no more after Dx?

Hirsprungs colon,

Always involves the rectum

31

Most common esophageal tumor in the US

In the world?

US - adenocarcinoma w/ Barrets prior

World - squamous cell

32

Risk factors for esophageal adenocarcinoma (5)

Barrets esophagus
Obesity
Smoking
Nitrosamines
GERD

33

Histology change seen in Barrets esophagus?

Metaplasia of the squamous nonkeritinizing epithelium to columnar epithelium and goblet cells in the lower 3rd

34

Achelasia is due to?
Presents as?

2 secondar causes of esophageal dysmotility

lack of of LES relax -> loss of myenteric plexus(auerbachs)

-Difficulty swallowing solids and liquids


Chagas disease (typanosoma cruzi)
Scleroderma (CREST)

35

Infectious agent that may lead to seconday achelasia

Typransoma cruzi - Chagas disease

-> cardiomegaly
- Esophageal dysmotility

36

Pain associated after eating and especially lying down. higher risk with obesity: Dx?

Rx?

GERD

PPIs and H2 blockers

37

Painless bleeding that may present as hematemesis?

Causal agent?

Esophageal varices

Portal hypertension that may be due to alcohol cirrosis

38

Rx for esophageal varices

vassopressin to constrict the lowe 1/3 dilated submucosal veins

Alsi scerotherapy

39

Mucosal lacerations at the gastroesophageal junction due to repetitive trauma

Commonly seen in?

Mallory weiss syndrome

Alcoholics and bulemics

40

Protrusion of the mucosa in the upper esophagus with history of fatigue

esphageal webs w/

Plummer vinsun syndrome chance - Fe deficient -> microcytic anemia

also need glossitis

41

Plummer vincint syndrome triad

Esophageal webs - dysphagia

Fe deficiency -> microcytic anemia

glossitis

42

Biospy of a patient w/ esophagitis reveals large pink intranuclear inclusions and host cell chromatin that is pushed to the edge of the nucleus

esphagitis due to HSV

43

Biopsy of a patient w. esophagitis reveals enlarged cells, intranuclear and cytoplasmic inclusions and a clear perinuclaer halo

esophagitis due to CMV

44

A PAS stain on biopsy obtained from a patient w/ esophagitis reveals hyphat organisms

esophagitis due to Candidia

45

2 causal organisms of esophagitis

CMV - peri nuclear inclusions
Candidia
HSV - glassy intranuclear

46

transmural esophageal rupture due to violent retching?

CXR reveals?

BoerHaave Syndrome

Air in inappropriate space

may have L pneumothorax

47

ingestion of caustic materials such as lye can lead to

esophageal strictures

48

The Right gastric is a branch of what artery and anatomizes what what artery of what branch

Branch of common hepatic
-Gastroduodenal
-hepatic proper as well

Connects to the L gastric which comes directly off the celiac

49

7 arteries coming directly off the abdominal Aorta

Celiac
SMA
IMA
inferior phrenic arteries
middle adrenal arteries
renal arteries
gonadal arteries

50

Rx for zollinger ellison

Associated with what genetic syndrome?

PPIs +/- octreotide

MEN 1

51

Recurrent ulcers that persist w/out H pylori and receiving other treatment

signal coming from where (2)

Zollinger ellison

due to gastrinoma in the pancreas or the duodeum

52

Secretary products of Parietal cells(2)

HCl

Intrinsic factor -> binds to B12 to be taken up in terminal illieum

53

Where is B 12 absorbed and what is needed?

Where can there be dysfunction?

In the terminal ileum and it needs intrinsic factor from the parietal cell

Chronic autoimmune parietal cells -> chronic gastritis and pernicious anemai

54

Chief cells in the stomach produce?

Pepsinogen

converted to pepsin in the presence of acid

55

Bicard is secreted in 4 locations in the GI tract

Salivary glands
Mucous cell of the stomach
Brenners gland the duodenum
Pancreas ( secretin stimulates release)

56

prostaglandins role in the stomach (2)

induces mucin secretion

Directly inhibits acid secretion in the parietal cell via Gq

57

Receptors on the parietal cell and respectful stimulator/response(5)

Vagus -> ACh on M3 -> Gq

Gastrin (direct) -> CCKb -> Gq

Histamine -> H2 -> Gs

Somatostatin -> Gi

Prostaglandin ->Gi

58

What happens to serum pH with increase of HCl production

H/K ATPase pumps the H out into the lumen w/ ATP and the remaining bicard goes into the serum raising the pH

59

Gastin is released by what cell?

What stimulates gastrin release
- 1 innervation
-3 substrates

Vagus nerve enervates the G cell in addition to the Parietal cell releasing GRP (Gastrin releasing peptide)

Phenylalanine
Tryptophan
Calcium

60

Why would hyperparathyroidism lead to stomach ulcer hypothetically?

Increased Ca -> increase in gastrin release from the G cells

61

Gastrin effect on digestion (2)

1. Direct stimulation of Parietal cell via CCKb receptor

2. MAIN - stimulation of ECL release of histamine

62

the splenic flexure is at risk of perfusion when

During times of hypo volume
-Shock

63

Cushing ulcer

acute gastric ulcer associated w/ elevated ICP or head trauma (high vagal stim -> increase ACh)

64

Curling ulcer

acute gastric ulcer associated with severe burns (low plasma volume -> sloughing of mucosa)

65

Acute gastritis is what?

Common caues(5)

disruption of mucosal barrier- inflammation

Stress
NSAIDS
Alcohol
burns
brain injury

66

Chronic gastritis is due to (2)

H pylori - most common
-> increased MALT and gastric adenocarcinoma risk)

Autoimmune attack of parietal cell/intrinsic factor-> pernicious anemia

67

thought to be a precancerous lesion of the stomach where first sign may be edema and hypoalbumemia. Stomach looks like a brain

Pathology

Menetriers disease

Due to hypertrophy of the mucous cells-> atrophy of the parietal cells and associated protein losing enteropathy

68

Peptic ulcer's 2 locations and 2 most common causes leading to maybe a bleeding ulcer

Gastric or Duodenal

H pylori or NSAIDs

less common zollinger ellison

69

Patient has epigastric pain that gets better after eating. The most common cause and location of the lesion

hypetrophed brunners glands are associated

Duodenal ulcer, most commonly due to H pylori, occasionally zollinger ellison

Weight gain associate

70

Patient has epigastric pain that gets worse with eating and as a result has weight loss. What is the most common cause and location?

other risks?

Gastric peptic ulcer due to H pylori 70% , NSAIDs also

Associated gastric adenocarcioma risk

71

Signet cells described as ?

Seen in what 2 cancers?

the nucleus of the cell is pushed off to the side

Seen in
Lobular carcinoma In Situ - breast
gastric Adenocarcioma( METs to the ovary -> kruckenberg)

72

Most common cancer type in the GI tract?

Adenocarcinoma excluding the esophagus

73

Risk factors for gastric adenocarcinoma

Nitrosamines (smoked/preservative)
H pylori
chronic gastritis
Men >50

74

Virchows node?

hints at underlying METS from the a stomach adenocarcinoma

75

subcutaneous periumbilical mass in an male >50 that eats a lot of smoked fish

Sister Mary Joseph nodule
- Underlying stomach adenocarcinoma

76

bilateral ovary tumor with signet cells on histology

Kruckenberg tumor - METs from a stomach adenocarcinoma

77

Patient presents in their 50s with sudden onset of acathosis nigricans, need to be worked up for? (2)

Diabetes
Visceral adenocarcinoma - Stomach

78

Ulcer complication fo concern (2)

Hemorrhage -
-gastric(left gastric artery)
-Duodenal (gastroduodenal artery)

Perforation
-deuodenal

79

Rx for a hemorragic ulcer

Somatostatin

80

stomach pathology more commonly seen in first born males

congenital pyloric stenosis

81

therapy for H pylori?

Tripple therapy
-PPI
-Clarithromycin
-Amoxicillin/metronidazole

82

antacid drugs that cause hypokaleimia

magnesium hydroxide
aluminum hydroxide
Calcium carbonate

83

Antiacid associated w/ diarrhea?

Magnesium hydroxide

84

Antiacid associated w/ constipation?

Associated complication?

Aluminum hydroxide

hypophosphatemia

85

Antiacid associated w/ rebound epigastric pain?

Calcium carbonate -> hypercalcemia increases gastrin release

86

Drug that would best work directly with a patient that has epigastric pain with eating that is taking an NSAID

Misoprostal PGE1

87

Serum electrolyte status after throwing up is what in relation to pH?

Body cells compensate in this situation how?

Alkalotic with throwing up of bicarb
Low chloride as well w/ Cl lost with the H

Body cells use H/K exchanger to pump H into the serum and K into-> serum hypokalemia (opposite is also true)

88

What is one way the body maintains serum disruptions of pH

H/K exchanger where serum hyperkalemia and hypokalemia can result in attempt to balancing the pH

89

BIG issues w/ a particular H2 Blocker (4)

which one

Cimetidine

-P 450 inhibitor
antiandrogenic
loather mthemoglobin levels
thrombocytopenia - class issue

90

which antacid needs an acidic environment to work

sucrafate -> binds to ulcer base providing physical barrier after being allowed to polymerize

91

2 important seratonin receptors that are acted upon in opposite ways - drugs and use

5HT3
5 HT1

5HT3 antagonists Oldansetron is an antiemetic, can have HA w/ vasodialtion

5Ht1 agonists like sumatriptan helps w/ HA and causes vasoconstriction

92

Toxicity associated w. Odansetron

receptor?

5HT3

Leads to constipation and HA

93

G cells secrete? -> function(3)

Location

Stimulated

Gastrin
-increases Gastric H secretion
-increases gastric growth
- increases gastric motility

Located in the antrum

Stim - stomach distension, vagal stim

94

I cells secrete ? -> function(3)

Location

Stimulated by?

CCK
-increases pancreatic secretion
-increases bile duct contraction
-SLOWs gastric emptying

Located in the duodenum, jejunum

Stim by FA, little by AA

95

S cells secrete? -> function (2)

Location?

Stimulated by?

Secretin
-increases bicarb secretion from pancreas
-decreases gastric acid production

Located in the duodenum

Stimulated by decrease of pH

96

D cells secrete? -> function(4)

Location? (2)

Simulated by?

Somatostatin
-Decreased gastric acid
-decreased pancreatic and small intestine secretion
-decreased gallbladder contraction
-decreased insulin/glucagon

Located in pancreas and GI mucosa

stimulated by acid

97

K cells secrete? -> 2 functions

Location

Stimualted by?

glucose-dependent insulinotropic peptide (GIP)

-decreases gastric acid production
- increases insulin release ** (oral glucose taken in better than iv)

located in the duodenum

Stimulated by FA, AA, oral glucose

98

Parasympathetic enteric system and smooth muscles secrete?

Function (2)

Locates in

Stimulated by

Vasoactive intestinal protein

increases smooth muscle relaxation
increases intestinal water and electrolyte secretion

VIPomas-> diarrhea (severe)

Located in the smooth muscle of intestine

Stimulated by dissension and vagal stim

99

Glands that are only founding the duodenum

Brenner glands secrete bicarb

100

Ligament containing the portal triad?

hepatoduodenal ligament

101

Ligament containing the splenic artery and vein

Splenorenal ligament

spleen to posterior wall

102

Ligament containing the short gastric arteries

Gastrosplenic ligament

103

lesser omentum made up of(2)

Hepatoduodenal ligamant
Gastrocolic ligament

104

Ligament connecting anterior cavity to the liver

Derived from?

falciform ligament

contains the ligamentum teres (derivative of fetal umbilical vein)

105

9 retroperitoneal organs

ADUCKPEAR

Adrenals
Duodeum - last 2/3
Ureters
Colon - ascending/descending
Kidneys
Pancreas
Esophagus
Aorta
Rectum - lower 2/3

106

dubble bubble sign seen on X-ray and bilious vomitting seen early in life

Higher association w/ what other condition

duodenal atresia

Down syndrome

107

3 targets to increase motility and overcome illeus

Increase ACh
Increase 5HT
Decrease D2

108

Why does carcinoid syndrome lead to diarrhea?

increase 5HT stimulates motility

109

Antibiotic associated w/ gut motility?

Macrolides stimulate motilin receptor

110

Go to drug for diabetic or post surgical illeus

may have parkisonian like symptoms w/ excess

Metoclopramide- D2 antogonist; 5HT4 agonists

-Also could use bethanechol, neostigamine, to increase ACh

111

weight loss, diarrhea, arthritis, fever, LAD, hyperpigmentation

Whipple disease

112

enzymes responsible for starch digestion

located?

amylase in the mouth and pancreas break carbs down to disacharides.

Disacharides are broken down to monosacharides by brush border enzymes to be absorbed

113

Responsible transporters for absorption of carbohydrate breakdown products

SGLT 1 - cotransports in w/ Na
-Glucose
-Galactose

GLUT5 - facillitated diffusion
-Fructose

114

Enzymes responsible for the breakdown of fats?

located where?

Lipases released primarily by the pancreas

absorbed by enterocytes

- highly susceptible to pancreatic insufficiency

115

Absorption of fats?

Done by absorption of FA and 2 monoacylglycerol after being broken down by lipase.

Bile salt important for emulsifying and forming micelles

Reassembled into triacyglcerol in the enterocyte for release

116

Protein metabolization done by what enzymes where?

Pepsin does some initial cleaving in the stomach

proteases such as trypsin(released as trysinogen from the pancreas- activated by enterokinase on the brush border)

lysises lysine and arginine bonds

117

Protein absorption?

can be done w/ di or tripeptides

Done w/ Na dependent co-transport

118

Iron is absorbed where?

Causes of deficiency (4)

duodeum

neutral environment (antacids)
tetracycline and quinalone
Cereal/eggs/milk/fiber/coffee/tea
Gastric bypass surgery*

119

B12 is absorbed where?

Causes of deficiency?(2)

Terminal illeum w/ intrinsic factor

Malnutrition - vegan
Pernicious anemia -> auto immune attack of the parietal cells

120

Folate is absorbed where?

Casuses of deficiency?

duodeum/jejunum

Malnutition
Alcoholics
Goats milk*

121

Schilling test is used for what?

What is normal

Tests for B12 absorption- radioactive cyanocobalamin is given and measure urinary excretion of radioactive B12

>8% of oral dose recovered is normal

122

Tropical spue presents as?

Differs from celiac sprue how?

Presents as celiac sprue but

-responds to antibiotics
-affects the ENTIRE small bowel instead of just the proximal

Issues w/ ADEK deficiency and megaloblastic anemia

123

PAS positive foamy macrophages found in the intestinal lamina propia leading to weight loss, LAD and hyper pigmentation

3 other major complications?

Whipple disease due to tropheryma whipplei

Cardiac symptoms
Arthralgias
Neurologic symptoms

124

Whipple disease has what sort of presentation (7)

PAS positive foamy macrophages found in the intestinal lamina propia
weight loss,
LAD
hyper pigmentation
Cardiac symptoms
Arthralgias
Neurologic symptoms

125

Celiac sprue is associated w/ what autoantibodies (2)

Anti gliadin

Anti transglutaminase

126

Child presents w/ pale bulky stools that smell and histology shows atrophy of the villi in the proximal duodenum Dx?

What is there a higher risk of?

Celiac sprue

Higher risk of intestinal t cell lymphoma, esophageal carcinoma, non hodgkin lymphoma

127

Haplotype associated w/ celiac? (2)

HLA DQ8

HLA DG2

128

Itchy rash found w/ celiac sprue

dermatitis herpatiformis on the extensors

129

Osmotic diarrhea is associated w/ lactase deficiency why?

Undigested lactose gets broken down by bacteria leading to pull of water into the lumen

Gas
bloating
Cramping also

130

No chylomicrons seen in the serum w/ an young kid that has FTT and some ataxia

Cause?

Abetatlipoproteinemia
-decreased synthesis of APO B48 and APO B100

less VLDL as well

131

Pancreatic insufficiency is associated w/ 3 problems

Leads to?

Cystic fibrosis
Obstruction - Tumor/gulls stone
Chronic pancreatitis

malabsorbtion and ADEK insufficiency, streatorrhea

132

Crypts of lieberkuhn are found where?

in the small intestine - secretory in function

133

Presentation of cramps abdominal pain that improves with dedication. may switch between diarrhea and constipation

Irritable bowel syndrome

134

Symptoms of irritable bowel syndrome 3 categories

variable crampy pain
improves with dedication
Alternating diarrhea/constipation

GERD, dyphagia, early satiety, nausea and chest pain

Urinary frequency urgency, dysmenorrhea, hysparenuiria, fibromyalgia

135

Important ABSCENCES in the the diagnosis of IBS(6)

blood in stool
nocturnal ab pain
weight loss
anemia
elevated infalm markers
electrolyte abnormalities

136

Rx for IBD (5)

Dietary modification
fiber supplement
antispamotics
-dicyclomine
-hypscyclamine
Antidepressants
-TCA
-SSRIs
Guanylate cyclase agonists
- constipation

137

Most common causes of small bowel obstruction?(3)

A - adhesions - post surgical
B - bulges/herniation
C - Cancer/tumors

138

bezoar

undigested conglomerate that obstructs

139

Pertchnetate Study: Technetium 99m is used for what?

Scanning for ectopic gastric mucosa like in Meckels diverticulum - secretes acid

Another ectopic tissue found in the diverticulum is pancreatic

140

Presentation of meckels diverticulum? (3)

RUQ
Rectal bleeding
usually <2 yrs of age

141

Currant jelly stools commonly associated w?

intussusception - telescoping of the bowel segment

usually at the ilieocecal valve w/ kids less than 2

142

Bulls eye or coiled spring on imaging think of

intraception

143

Intestinal illeus is often due to?

Lack of blood flow to tare due to blood flowing to other areas of need for healing

common post surgical or in the ICU

144

Meconium Illeus is commonly associated w/ 2 underlying pathologies

Hirschsprungs
Cystic fibrosis

145

Premie patient is fed orally maybe a little sooner than should and presents with feeding intolerance, abdominal dissension and bloody stools?

Further risks?

necrotizing enterocolitis

perforation

146

On Xray in a premie see:
dilated loops of bowel
paucity of gas
pneumutosis intesinalis (gas w.in or around the small bowel)

necrotizing enterocolitis

perforation risk -> sepsis

147

elderly patient present w/ severe pain out of proportion to exam - Dx?

Are most commonly affected?

Ischemic colitis

often the splenic flexure or distal colon

Pain after eating, looks sickly and has associated weightless.

148

Angiodysplasia in the intestine

Can lead to?

tortuous dilation of vessels
- cecum, terminal illeus, and ascending colon

Unexplained GI bleeds and anemia

149

Symptoms of carcinoid syndrome(4)

What causes it?

BFDR

Bronchoconstriction
Flushing
Diarrhea
Right sided heart disease/murmur

Due to 5HT release from a neuroendocrine tumor often found in the small bowel, symptoms only w/ METs

150

Common location of carcinoid tumor

Most common malignancy of the small intestine
-illieum
rectum
lung - bronchial tree
Appendix** - most common

Carcinoid syndrome when outside of portal system and 5HT products are not degraded by the liver - can measure metabolite to confirm diagnosis

151

Most common bacteria in the Colon

Bacteriodes fragilis

2nd E coli

152

Gi Problems associated w/ Downs Syndrome (4)

Hirschprungs
Duodenal atresia
Annular pancreas
Celiac disease

153

Causes of appendicitis in (2)

occluding fecolith -> obstruction and infection in adults

lymphoid hyperplasia in ids

154

Need to r/o what with appendicitis in women and elderly?

Ectopic pregnancy

Diverticulitis

155

2 types of hemmoroids and their presentation

Internal hemorrhoids are painless and may bleed
- located above the pectinate (dentate line)

External hemorrhoids are painful and located below the pectinate line

156

2 anal cancers associated with the rectum

Associated lymph node drainage?

Adenocarcinoma above the pectinate line
-goes to deep nodes

Squamous cell carcinoma below
-goes to superficial inguinal nodes

157

Arterial supply to the rectum above the pectinate line

Superior rectal artery (IMA branch) -> superior rectal vein -> inferior mesenteric vein -> portal system

158

Arterial supply to the rectum below the pectinate line

inferior rectal artery (internal pudendal branch) -> inferior rectal vein -> internal pudendal vein -> IVC

159

most common tumor of the appendix?

Carcinoid tumor

only have syndrome if in the bronchial tree or METs to the liver

160

GI harmatomas, hyper pigmentation of the mouth and hands

Peutz Jeghers Syndrome

161

apple core lesion on barium enema

Colorectal CA

162

Multiple colon polyps, osteomas and soft tissue tumors

Gardners Syndrome

163

Polyps that are precancersous compared to those that are not

Adenomatous polyps (3 types)
-tubular adenomas
-tubular villi adenomas
-villinous adenoms (most likely)

Compared to hyperplastic polyps

164

Sawtooth appearance in the rectosigmoid colon?

most likely a hyper plastic polyp - no cancer risk

165

Sporadic lesions in kids colon under rthe age of 5, risk of CA?

Juvenile polyp. one is not risk,

Many leads to increased risk

Juveile polyposis syndrome -> increased risk of adenocarcinoma

166

Peutz Jeghers syndrome presentation (2)

Increased risk of?(2)

Auto dominant

multiple harmatomas
hyper pigmented mouth, lips, hands, genitalia

increased colorectal CA and visceral CA

167

Gene progression with polyps becoming tumors (3)

loss APC
K ras
p53

168

Pateint presents w/ thousands of colon polyps at an early age defect in what gene located on what chromosome

Always involves what part of the colon?

APC gene on chromosome 5
- Auto dominant

the rectum

169

Patient presents with many colon polyps at the age of 40. Due to defect in what gene?

Usually involves what part of the colon?

hMSH2 and hMLH 1 due to DNA mismatch repair gene mutation

-auto dominant

- the proximal colon

- increased risk for endometrial CA, ovary , stomach etc..)

170

Risk factors for colon cancer?(7)

IBD (UC>crohns)
Inherited - Lynch/FAP/Puetz Jeghers
Smoking
Drinking
obesity
High fat/low fiber diet
Villinous polyps

171

Tumor marker for colorectal CA

CEA

172

Patient presents with numerous polyps in the colon and also has a medulloblastoma

Turcot's syndrome

FAP and CNS malignancy

173

Gardner's syndrome? (4)

FAP
plus osseous and soft tumor tissue tumors
congenital hypertrophy of retinal pigment epithelium

174

Ascending colorectal CA presents as? (4)

watery
+/- blood in the stool
weight loss
iron deficiency anemia

175

Descending colorectal CA presents as?(4)

Obstruction - parial
colicky pain
pencil thin stools
hematochezia (blood more readily seen)

176

Diverticulum

blind pouch protruding from the ailimetry tract - communicates w/ lumen of the gut,

177

diveticulosis presentation

many false diverticulum, seen in people older than 60

asymptotmatic. Maybe LLQ discomfort, maybe blood

178

diverticulitis presentation

INflammation and pain in the LLQ. Blood in stool is common w. fever and leukocytosis

Due to an infection usually

179

what is meant by a false diverticulum

only 2 of the 3 layers go through - such as the mucusa and submucosa in diverticulum

180

What causes diverticulumn

pressure along the weakened areas where the vasa recta supply blood through the muscularis mucosa

181

Rx for diverticulitis (3)

Metronidazole,
Floroquinolones
TMP-SMX

182

lead pipe sign on X ray

Ulcerative colitis

183

String sign barium swallow

Crohns disease

184

Transmural inflammation leading to a cobblestone appearance to the colon

Location of the lesion?

Crohns disease

Skip lesion where it can present anywhere from mouth to anus, usually rectal sparing

- also see creeping fat

185

Complications of crohns disease(8)

strictures
fistulas
malabsobtion
diarrhea (+/- blood)
B27 associated disorders
erythema nodosum
uveitis
weight loss


low colorectal risk

186

noncaseating granulomas and lymphoid aggregates seen w/ this IBD

Crohns

187

Rx for Crohns disease?
4 classes

5ASA
-mesalamine
-sulfapiridine

Azathioprine
methrotrexate

Corticosteriods

TNF alpha
-infliximab
-adalimumab

188

Autoimmune process that always involves the rectum?

Depth of the lesion

Ulcerative colitis
continuos from the rectum

Mucosal and submucosal inflammation only

189

Presence of pseudo polyps and mucosal and submucosal inflammation starting from the rectum?

Expect to see what w/ the microscope?

Ulcerative colitis

Expect to see crypt abcesses and ulcers w/ bleeding

190

Complications of ulcerative colitis(7)

Malnutrition
Slcerosing cholangitis
pyoderma gangresome - skin disease
primary sclerosing cholangitis
B27 disorders
Higher colorectal cancer risk
Bloody diarrhea**

191

primary sclerosing cholangitis places a higher risk for what IFB

Ulcerative colitis

192

Rx for Ulcerative cholangitis?(4)

5 ASA
- sulfazalazine
6 mercaptopurine
colectomy*
Anti TNF
-Infliximab

193

Which IFB is treatable by colectomy

Ulcerative Colitis

194

Biggest concern w/ diverticulitis?

What can you do to see if it has happened?

perforation

See free air in the abdomen on chest X-ray

195

painless jaundice

pancreatic adenocarcinoma

196

Most common cause of chronic pancreatitis

alcohol abuse

197

Annular pancreas associations in infants/fetus(5)

poyhydraminos, down syndrome, esophageal atresia, imperforate anus, meckel diverticulum

198

Annular presentation in children and adults

2/3 asymptomatic

- kids gastric obstruction

-adults ab pain, postprandil fullness and nausea, peptic ulcers, pancreatitis

199

Pancreas is derived from?

endoderm
-ventral pancreatic bud from the hepatic diverticululm fuses with the dorsal pancreatic bud

-> annular pancreas potential

200

Pancreas divisum

-> failure of the ventral and dorsal parts to fuse at 8 weeks

201

Spleen arises from what embryonic structure?

Mesenchyme despite being a foregut structure which normally derives from endoderm and artery is still the celiac

202

Pancreatic enzymes are secreted in response to what 3 signals?

Secretin -> bicarb
CCK -> digestive enzymes
Vagus /ACh -> digestive enzymes

203

Rate limiting step of carbohydrate digestion

brush border enzymes - oligopolysacharide hydralases (Sucrase, lactase, maltase, isomaltase)

204

What stimulates trypsinogen activation and what is the result

enterokinase and enteropeptidase from the duodeum converts trypsinogen to trypsin

Trypsin then activates chromotripsin, elastase, and carboxypeptidase

205

Causes of acute pancreatitis (8)

BAD HHITS

Biliary - gallstones
Alcohol
Drugs (NRTIs, ritonvir, sulfa)
Hypertriglycemia
Hypercalcemia
Idiopathic
Trauma
Scorpion stings

206

Complications of acute pancreatitis(6)

DIC
ARDS
diffuse fat necrosis
hypocalcemia -> saponification parapancrease

pseudocyst formation(granulation/not epithelial bound)

hemorrhage and rupture

207

Sitophobia?

Can be associated w?

Fear of eating and anorexia that can be associated w/ acute pancreatitis

208

Precipitations of acute pancreatic hemorrhage?

Alcohol intake or large food

209

4 complications of chronic pancreatitis?

steatorrhea
ADEK malabsorbtion
increased pancreatic adenocarcinoma risk
Diabetes mellitus (islet destruction)

210

Calcification of the pancreases and atrophy is most commonly due to

Chronic alcohol abuse

211

Tumor markers for pancreatic Ca

CA 19-9

CEA also but less specific (colon cancer as well)

212

Why does pancreatic CA have such a low prognosis?

Most common location?

Presents after METS

Located at the head and presents w/ obstructive biliary complications, Migratory thrombosis and weight loss

213

Nontender gallbladder and rapid onset of jaundice

Obstructive jaundice w/ pancreatic CA

214

Migratrory thromboembolitis is associated w/

Means?

Pancreatic Ca

it is a hypercoagble state - > redness and tenderness venous thrombosis

215

Risk factors for Pancreatic Ca?(4)

Tobacco
Jewish/Black
>50
chronic pancreatitis

216

Liver is derived from what embryonic layer?

endoderm

217

Which zone of the liver is susceptible to ischemia?

Which zone to viral hepatitis?

Zone 1 - peri-triad susceptible to viral

Zone 3 - peri lobular is susceptible to ischemia and also toxins

218

4 main jobs of the liver

proteins production - albumin, complement, coag factors

make bile and excrete bilirubin

metabolize drugs and toxins and hormones (estrogen/ testosterone)

storage - glycogen, cholesterol, fat soluble vitamins

219

What is bilirubin?

the left over product when the globulin from blood gets degraded and the Fe is recycled you get 4 bilirubin molecules for each of the 4 globulin molecules

toxic and needs to be excreted, also insoluble-binds to albumin

220

Direct vs indirect bilirubin?

Direct bilirubin is conjugated bilirubin that has a glucouronyl acid moiety on it placed by UDP glucouronyl transferase in the liver

Makes it polar and water soluble to be excreted. Measured w/ direct and a part of the total bilirubin

221

How does phototherapy help w/ hyperbilirubinemia?

it converts bilirubin to an isomer that allows excretion

222

Kernicterus?

Symptoms (3)

excessive nitrogen products in the serum that become neurotoxic due to excess bilirubin -> chorea, cerebral palsy and hearing loss

223

Gilbert syndrome?

mild decrease in UDP glucuronyl transferase -> unsymptomatic increase in unconjugated bilirubin found incidentally

May be due symptomatic w/ stress

224

Difference between Crigler Nijjar Syndrome Type I and II

Type one - absent UDP Glucouronyl transferase leading to symptoms of kernicterius and death if not treated

Type II has mild UDP gluconyl transferase activity and milder symptoms. Responds to phenobarbitol which induces enzymatic processing

225

Role of phenobarbitol in diagnosis of hyperbilirubinemia?

Type II Crigler Nijaar responds by reducing unconjugated/indirect bilirubin levels while Type I does not

226

2 congenital forms of elevated conjugated hyperbilirubinemia

Dubin Johnsson -> black liver, generally asymptomatic

Rotor Syndrome, milder and no black liver

227

Dubin johnson syndrome?

inability to excrete conjugated bilirubin leading to a black liver, benign, can't put conjugated bilirubin into bile

Rotor syndrome is similar w/out the black liver

228

triglyceride accumulation in hepatocytes

fatty liver disease

229

eosinophilic inclusions in the cytoplasm of hepatocytes

mallory bodies
-seen in alcoholic hepatitis

230

Cancer closely linked w/ cirrhosis?

hepatocellular carcinoma

231

prognosis of hepatic seatosis

fatty liver disease

reversible if abstinence is maintained

232

Alcoholic hepatitis is characterized by?

biopsy?

inflammation

seen as swollen and necrotic hepatocytes w/ PMN infiltration

Mallory bodies

233

Mallory bodies?

eosinophilic inclusions in the cytoplasm of hepatocytes

Seen in alcoholic hepatitis

234

Biopsy of alcoholic cirrhosis

scarring anf fibrosis w. sclerosis around the central vein

Liver may be hard and nodular

235

Transaminase profile in a patient w/ chronic alcohol abuse

AST> ALT by 2

236

asterixis

liver flap - associated w/ hepatoencephalopathy and lack of liver degradation of toxins

hand flaps due to inability to maintain extension

237

Liver failure may manifest w?(3)

coagupathy (high PT and PTT)

peripheral edema w/ lack of albumin

hepatic encephalopathy w/ lack of toxin degradation -> confusion, delirium and hypersomnia w/ NH3 toxicity

elevated estradiol effects w/ lack of breakdown -> palmar erythema, gynectomastia, testicular atrophy

238

palmar erythema, gynectomastia, testicular atrophy, tenagectasia may be manifestations due to increased estradiol in a male due to

liver failure

239

Decreased LDL is normally good but w less HDL as well is associated w/ what systemic problem

liver failure

240

Portal hypertension presents w/(5)

Esophageal varicies -> hematoemesis, melana

Carput medusae

ascites

splenomegaly

hemorrhoids

241

Ascities has what associated complication

infection
- spontaneous bacterial peritonitis

242

SAAG higher than 1.1 is indicative of what?

ascities due to portal hypertension
- very watery ascities

Serum ascities albumin gradient
[albumin]serum - [albumin]ascities

less that 1.1 indicates CA, TB, nephrotic syndrome, pancreatitis, biliary disease

243

SAAG - serum albumin ascitis formula

[albumin]serum - [albumin]ascities

less that 1.1 indicates CA, TB, nephrotic syndrome, pancreatitis, biliary disease

ascities due to portal hypertension

244

laculose is used for?

hepatic encephalopathy, traps nitrogen in the gut to be excreted and pooped out

245

General Rx drugs for liver failure (4)

dieuretics
Beta blockers - propranolol and nadolol
lactulose - traps NH3 in the gut
Vitamin K

246

Transjugular intrahepatic portoseptic shunt is useful in Portal hypertension due to what?

Increased risk associated?

reliving the portal HTN pressure shunting around the liver

have increased brain encephalopathy due to lack of detox

247

Rx for esophageal bleeding (2 drugs)

octreotide

Beta blockers

can also do banding

248

McConkeys agar works by?

Contains (3)

selecting for gram - bacteria that are lactose fermenters

- bile salts
-crystal violate
lactose w/ neutral red (makes them pink)

249

2 causes of nut meg liver

Budd Chiari syndrome

R sided Heart failure (cardiac cirrhosis)


Back up of blood into the liver -> mottled appearance -> centrilobular congestion and necrosis

250

Centrilobular congestion and necrosis can lead to ?

nutmeg liver

blood is backing up into the liver

251

hepatomegaly. as cities and abdominal pain, no JVD

Budd Chiari

252

Budd chiari syndrome is due to ?

Presentation(5)

Occlusion of the hepatic veins or IVC

See central lobular necrosis, and hepatomegaly, ascitits and abdominal pain -> liver failure; associated Portal HTN issues

NO JVD

253

4 causes of buds chiari syndrome

hepatocellular carcinoma
polycythemia
pregnancy
hypercoagable states

254

Risk factors of hepatoocellular carcinoma(6)

Hep B and C
Wilsons
Hemochromatosis
alcoholic Cirrosis
alpha 1 antitripsin
aflatoxin from aspergillus

255

Findings of hepatocellular carcinoma? (5)

Tumor marker

Jaundice
tender hepatomegaly
ascities
polycythemia (increased epo)
hypoglycemia

AFP increases

256

Cause of wilsons disease ?(2 problems)

Auto recessive defect in ATP7B -> Chromosome 13

1. decreased Cu excretion in the bile
2. decreasued conversion of Cu to ceruloplasm in serum

-> deposition of Cu in the liver, brain, eye and kidney

257

Presentation of wilsons disease?(6)

Cirrosis
Kayser Flescher rings
Basal ganglia degeneration -> parkinson syndromes*
Hepatic encephalopathy
-Dementia, dysarthia, dyskinesia
Fanconi's syndrome
hemolytic anemia

hepatocellular CA risk

258

Fanconis syndrome in Wilsons disease is what

proximal tubule dysfunction leading to loss of vital things, loss of reabsorbtion

259

Hemochormatosis is due to?(2)

Rx? (2)

Primary - increased absorption of Fe

Secondary - increased transfusions

Phlobotomy
Defexamine

260

Labs in hemochromatosis

-ferratin
-TIBC
-Transferrin
-iron

Ferratin is increased
TIBC is decreased
Transferrin is increased
iron is increased

261

Ceruloplasm in Wilsons disease?

Copper in serum

decreased in Wilsons Disease

262

Triad in hemochromatosis

Associated issues(3)

DM
Cirrosis
Hyperpigmentation

all due to excessive Fe deposition, can set off metal detectors in airports

CHF, atrophy of testies, hepatocellular carcinoma risk

263

alpha 1 antitrypsin deficiency leads to what what pathology?

liver cirrosis - deposition of misfolded gene products

panacinar emphysema - excessive elastase activity

264

Hepatic adenoma is commonly associated w?

Symptoms?

females in their 20-40s taking OCPs

also in anabolic steroid use and glycogen protein storage disease 1 and III

Often asymptomatic but can have RUQ pain

265

Hepatic angiosarcoma risk factors

vinyl chlorids
arsenic

266

Dane particle

intact HBV particle

267

Superinfection viral hepatis

Chronic HBV infection w/ HDV infection after

268

Hepatitis lab values(3)

Elevated ALT and AST
-ALT > AST w/ viral; may be equal too
High bilirubin -> billubinurea
Alk phos elevated

269

Causes of hepatitis(3)

Alcohol
Viral
Toxin

270

Presentation of hepatitis

RUQ pain
tender LAD
malaise
fatigue
jaundice
arthalgia
N/V
tender hepatomegaly

271

Interfereron Beta vs interferon alpha use in treatment

interferon alpha is for hep B and C

interferon beta is for MS

272

Heb B serology that indicates history of disease

HBcAg

acute -IgM
chronic - IgG
+ in window
- w/ vaccination

273

HBsAb indicates?

immunization or
successful eradication of the virus

274

window period of hep B?

Only HBcAg is positive (IgM)

HBsAb and HBsAg are equal and balancing each other out

275

HBeAg vs ABeAb means

HBe Ag means there is high transmissibility potential w/ envelope protein around

HBeAb means low transmission

276

autoimmune hepatitis markers (4)

Type 1
-anti smooth muscle antibody
-ANA

Type 2
-liver/kidney anti microsomal antibody
-liver cytosol antibody

277

Have hepatitis presentation w/ serology (-) for virus

Dx?

Autoimmune hepatits
Type 1
-anti smooth muscle antibody
-ANA

Type 2
-liver/kidney anti microsomal antibody
-liver cytosol antibody

278

anti smooth muscle antibody and ANA seen in serum


Autoimmune hepatitis risk type 1

279

liver/kidney anti microsomal antibody and liver cytosol antibody

Autoimmune hepatitis risk type 2

280

liver fluke associated w/ undercooked fish

Causes?(2)

clonorchis sinensis

biliary tract inflammation -> pigmented gallstones

cholangiocarcinoma association

281

What is in bile?

What of excreting what 3 products?

phospholipids
bile salts
water
electrolytes

Excreted:
cholesterol
bilirubin - Direct
Cu

282

what happens to the bile after excretion from the gallbladder? Converted to?

Converted to Urobilirubin where 80% is excreted in the feces as stercobilin

20% is reabsorbed in the ileum where
-90% is reabsorbed by the liver in enterohepatic circulation
-10% excreted in the urine as urobilin

283

3 functions of Bile

Emulsify fats for digestion and absorbtion

Excretion of Cholesterol, Cu and bilirubin

Antimicrobial function

284

Bile acid is what essentially?

oxidized cholesterol(cholic acid, deoxycholic acid, chenodeoxyxholic acid)

that get conjugated to glycine or taurine to make - >taurcholic acid or glycocholic acid

285

Cholelithias def

gallstones

286

Cholecystitis def

inflammation/infection of the gallbladder

287

Cholangitis def

inflammation/infection of the biliary tree

288

choledocholithiasis

stones in the biliary tree

289

Differential of unconjugated hyperbilirubinemia? (3 general categories - 8 pathologies)

increased bilirubin production
-hematoma breakdown
-hemolytic anemia
-sickle cell

Decreased UDP-GT activity
-Gilberts
-Crigler Nijjar syndrome
-neonatal jaundice

Impaired bilirubin uptake and storage
- Viruses
-Drugs

290

Differential of conjugated hyperbilirubinemia (4 categories - 12 pathologies)

Impaired transport
-Dubin Johnson syndrome
-Rotor syndrome

Biliary epithelial damage
-Hepatitis
-Cirrosis
-liver failure

Intrahepatic biliary obstruction
-Primary biliary cirrhosis
-Primary Sclerosing cholangitis
-Drugs (chlorpromazine and arsenic)

extrahepatic biliary obstruction
- Pancreatitis
-Pancreatic carcinoma
- choledocholithiasis
-cholangiocarinoma

291

Drugs that may cause intrahepatic biliary obstrucion

chlorpromazine
arsenic

292

Causes of intrahepatic and extra hepatic biliary obstruction? (7 total)

Intrahepatic biliary obstruction
-Primary biliary cirrhosis
-Primary Sclerosing cholangitis
-Drugs (chlorpromazine and arsenic)

extrahepatic biliary obstruction
- Pancreatitis
-Pancreatic carcinoma
- choledocholithiasis
-cholangiocarinoma

293

see onion skin bile duct fibrosis and beading of hepatic ducts in what type of patient population

primary sclerosing cholangitis

Seen in men in their 40s who may also have UC or cholangiocarcinoma

positive pANCA and hypergammagobulinemia

294

lymphocyte infiltration w/ potentially granulomas with hyperbilirubinemia (conjugated) seen on labs affects what patient population?

primary biliary cirrosis - autoimmune attack in middle aged females

Labs may show positive antimitochondrial antibodies

295

Treatment for Primary Biliary Cirrhosis

Ursodiol
- naturally occur ing bile acid that decreases synthesis of cholesterol in the liver and changes the composition of PBC.

Delays progression

296

Symptoms of biliary tract disease(PSC, PBC, Secondary biliary cirrhosis)

General labs?

Dark urine
Pale stools
jaundice
puritis

increased alk phos and cholesterol and conjugated bilirubin

297

Secondary biliary cirrosis is due to?

extrahepatic biliary obstruction
- gallstone, biliary stricture, chronic pancreatitis

Vs primary which is due to autoimmune attack w/ T cells and a positive antimitochondrial

298

cholcystitis vs choleangitis?

cholecystits is inflammation of the gallbladder while choleangitis is inflammation of the biliary tree

299

Cholelithias risk factors

Fat
Forty
Fertile
Female

Also - Crohns, CF, native american, rapid weight loss

Pigment - hemolysis, alcoholic cirrosis

300

3 types of cholelithias?

Best test?

Cholesteral radio luscent
pigmentes - radio opaqe
mixed

US

radionuclide biliary scan shows uptake of HIDA into the gallbladder

301

Charcots triad of cholangitis

Add on reynolds pented?

Fever
RUQ pain
Jaundice

hypotension
Altered mental status

302

Positive murphys sign indicative of?

Cholecystitis - have the patient breath in and if sharp paso when pressing on the gallbladder indicates pathology

303

Complications of gallstones(3)

biliary cholic - pain after eating and CCK release

fistula formation between the small bowel and gallbladder

obstruction of the ileocecal valve (gallstone illeus)

the later 2 will have air in the biliary tree (pneumobilia)

304

pneumobilia

air in the biliary tree indicating later complications of choleithias presence such as fistula formation or obstruction of ileocecal valve