GI - DIT Flashcards
(304 cards)
1
Q
Anterior part of the tongue innervation
Taste?
Movement?
sensation
A
Taste - CN7
Sensation - CN 5, V3 Mandibular
Movement - CN12
2
Q
Posterior part of the tongue innervation ?
Taste
Sensation
Movement
A
Taste - CN 9
- Very posterior CN10
Sensation - CN 9
Movement CN 12
3
Q
anterior part of the tounge derived from?
Posterior 2/3?
A
pharyngeal arch 1
Pharyngeal arch 3/4
Just think of the innervation
4
Q
Glossitis may be due to ? (5)
A
B12 B6 B2 B3 and Fe deficiency
5
Q
muscle responsible for tongue protrusion
A
genioglossus
hyloglossus retracts
6
Q
3 salivary glands: innervation and secretions
A
sublingual- CN7, secretes mucous
submandibular - CN 7 secretes mixed
Parotid is CN 9, secretes serous
7
Q
Secretions found in saliva (5)
increased w/ what kind of stimulation?
A
HCO3 Amyalase IgaA Mucins Growth factor
sympathetic (thick) and parasympathetic (watery)
8
Q
Sialadenitis is ?
due to ? Causal agents?
A
inflammation of the submandibular of parotid ducts (Stensen duct) most likely
lilathis or stone
bacteria: Staph aureus or Strep mutants
9
Q
Cleft lip is failure of fusion w?
A
lateral maxillary and medial nasal processes
( formation of the primary palate)
10
Q
Cleft palate is failure of fusion of?
A
lateral palatine prcesses (shelves), the nasal septum and the median palatine processes
(secondary palate formation)
11
Q
most common salivary gland tumor and associated histology
A
Pleomorphic adenoma
in the parotid gland usually with epithelial and mesenchymal tissue
12
Q
2nd most common salivary tumor that is benign
A
Warthin tumor
looks like a geminal center
13
Q
Most common malignant salivary tumor and associated histology
A
mucoepidermoid carcinoma
mutinous and squamous components w/ complications leading to pain w/ involvement of the facial nerve
14
Q
2 causes of rhinitis and associated symptoms
A
infectious rhinitis - cold
- irritation, congestion, rhinorrhea, post nasla drip
Allergic rhinitis
-rhinorrea, congestion, cough, intermittent
15
Q
Top 4 causes of infectious rhinitis
A
Corona virus
adeno virus
echo virus
rhino virus
16
Q
Nasal polyps are?
A
overgrowths of the mucosal that are freely moving that are associated with allergic rhinitis
Surgical removable or internasal steriods
17
Q
Cocaines effects on the nose?
A
Potent vasoconstrictor -> ischemia and necrosis, perforation of the nasal tube
18
Q
4 sinuses of the face
A
Frontal - above the eye
Maxillary - in the cheek
sphenoid- behind the nose
ethmoid - kind of behind the eyes
19
Q
Sinusitis symptoms
A
fever, purulent discharge, facial pain
20
Q
3 regions of the gut and associated innervation and blood supply
A
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
Q
4 layers of the gut wall - inner to outer
A
Mucosal
- epithelium
- lP
- muscularis mucosa
Submucosa
-submucosa plexi/ meisseners
Muscularis externais
-myenteric plexus/ auerbachs
Serosa
22
Q
Muscularization of espophagus
A
top third skeletal
bottom third smooth
23
Q
Anal agenesis often due to?
A
improper formation of urorectal septum
- Fistulas
24
Q
extrusion of the abdominal contents not covered in peritoneum
defect more likely found
associated problems?
A
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
