Stomach & Duodenum Flashcards
(201 cards)
1
Q
ACUTE injury to the gastric mucosa caused by NSAIDs or chmicals like ALCOHOL which DOES NOT HAVE an INFLAMMATORY INFILTRATE on histology?
A
ACUTE REACTIVE GASTROPATHY (not gastritis as there is no inflammatory infiltrate)
2
Q
To accurately diagnose the varois forms of GASTRITIS, where must biopsies be obtained from?
A
3
Q
Microaerophilic, Gram-Negative, Urease-producing Spiral bacteria?
A
Helicobacter Pylori
4
Q
What does H.pylori cause in most individuals?
A
ASYMPTOMATIC CHRONIC ACTIVE GASTRITIS (can cause peptic ulcers and cancer) - presence of NEUTROPHILS and LYMPHOCYTES
5
Q
Genta, Giemsa, Warthin-Starry?
A
Immunohistochemical stains to identify H.pylori
6
Q
What is the ONLY thing that needs to be measured when checking H.pylori exposure SEROLOGICALLY?
A
H.pylori IgG (many false positives in low-prevalence areas, but if negative, it is reliable)
7
Q
What is the DIFFERENCE between gastric EROSIONS and gastric ULCERS?
A
EROSIONS do NOT penetrated the MUSCULARIS MUCOSA, ULCERS DO
8
Q
Wahat test is POOR for H.pylori if there is gastric BLEEDING?
A
Biopsy
9
Q
What are the REQUIREMENTS of a UREA BREATH test and FECAL ANTIGEN TEST to avoid FALSE NEGATIVE results when testing for H.pylori?
A
Pt MUST be off PPI for 2 WEEKS and off ANTIBIOTICS for 4 WEEKS (H2 blockers do NOT affect this)
10
Q
What is a LOW-GRADE B-CELL malignancy that can be caused by H.pylori and if not eradicated, it can undergo malignant transformation?
A
MALT
11
Q
Pts who are about to start CHRONIC NSAID therapy, have unexplained chronic iron-deficiency ANEMIA, have ACTIVE or prior PUD, gastgric MALT lymphoma, and s/p early gastric CANCER, are ALL indications for testing for what?
A
H.pylori
12
Q
In which patients is the use of Clarithromycin + Amoxicillin + PPI appropriate therapy for H.pylori infection?
A
Those who have NOT used a MACROLIDE before, and come from an area with LOW prevalence (<15%) of clarithromycin-resistance)
13
Q
In which patients is the regimen to treat H.pylori consising of BISMUTH + PPI + TETRACYCLINE + METRONIDAZOLE used?
A
Those who are PENNICILIN ALLERGIC or who failed prior therapy, or PRIOR MACROLIDE EXPOSURE
14
Q
In which patients is the regiment to treat H.pylori consisting of PPI + CLARITHROMYCIN + AMOXICILLIN + METRONIDAZOLE + TINIDAZOLE used?
A
15
Q
What regimens to treat H.pylori are available for thos who have had PRIOR MACROLIDE therapy?
A
BISMUTH QUADRUPLE therapy or LEVOFLOXACIN-based tripple therapy
16
Q
What should be done in ALL patients whp have been treated for H.pylori?
A
Test for ERADICATION
17
Q
In a patient who FAILED prior H.pylori therapy, what regimens are available for re-treatment?
A
Bismuth QUADRUPLE therapy or,
LEVOFLOXACIN + PPI + AMOXICILLIN or
RIFABUTIN + PPI + AMOXICILLIN
18
Q
Is GASTRITIS symptomatic?
A
NO (histologic diagnosis only, by presendce of neutrophils and lymphocytes)
19
Q
Abdominal pain, anorexia, occult bleeding, weight loss and HYPOalbuminemia with EGD findgins of HYPERtrophic gastric folds, association with CELIAC disease, mucosal NODULARITY with EROSIONS, volcano-like lesions?
A
LYMPHOCYTIC gastritis
20
Q
What is the MOST IMPORTANT management of LYMPHOCYTIC gastritis?
A
Rule-out MALT lymphoma (EUS or full-thickness biopsy) - anti-ulcer therapy, steroids
21
Q
Mucosal ULCERATION, DYSMOTILITY (impaired gastric emptying), abdominal PAIN, luminal OBSTRUCTION and is treated with steroids?
A
EOSINOPHILIC gastritis - presence of PERIPHERAL EOSINOPHILIA, check for PARASITES
22
Q
What type of GASSTRITIS is CROHN’s, SARCOIDOSIS and SYPHILIS associated with?
A
GRANULOMATOUS gastritis
23
Q
A type of GASTRITIS that is ANTRUM-SPARING, involving the BODY of the stomach, with HYPERgastrinemia, ACHLORHYDRIA, decreased PEPSINOGEN-1 and IF-deficiency and is associated with gastric CARCINOIDS?
A
AUTOIMMUNE ATROPHIC gastritis (anti-IF Abs, anti-parietal cell Abs, B12-deficiency)
24
Q
GIANT gastric FOLDS sparing the antrum, massive FOVEOLAR hyperplasia with CYSTIC dilation?
A
Menetrier’s Disease - eradicate H.pylori if this is the cause
25
What manifestation do **PARIETAL-CELL** mass, **Zollinger-Ellison** Syndrome, gastric **LYMPHOMA**, **LYMPHOCYTIC** gastritis, gastric **ADENOCARCINOMA** and **AMYLOIDOSIS** all have in common?
**HYPERtrophied Gastric Folds**
26
How do **GASTROPATHIES** differ from **GASTRITIS**?
Gastropathies have little to **NO INFLAMMATION**
27
Prior history of **PUD**, **Elderly**, taking **HIGH-DOSE** or **MULTIPLE NSAIDs** and those who **ALSO** take **CORTICOSTEROIDS**, **ANTICOAGULANTS** or **SSRIs** are pre-disposed to what?
Gastric **ULCERS**
28
What can be used as ulcer **PROPHYLAXIS** in patients taking **NSAIDs**?
**PPIs** (or misopropstol which is poorly-tolerated)
29
For a patient who had a prior **BLEEDING ULCER** while in **NSAID** therapy, what is recommended if they require anti-inflammatories?
**PPIs** + **COX-2** inhibitor (Celecoxib)
30
Patients who suffered **CNS INJURY**, **PROLONGED VENTILATION** and **BURNS** are at **HIGH** **RISK** of what?
**PUD** due to **HYPERsecretion** of gastric acid and require PPI (OMEPRAZOLE) or **continuous H2-blockers** or Sucralfate treatment
31
Nocturnal abdominal pain **RELIEVED** with **ANTACIDS** usually indicates what?
**PUD** (also relived with FOOD)
32
Which **ULCERS DO NOT** required endoscopic therapy and can be treated with **PO** **PPIs**?
**CLEAN-BASED** ulcers (no visible vessel, have not bled, no stigmata)
33
What is a gastroduodenal **ULCER** called when it affects the liver or the pancreas and how is it treated?
**PENETRATING ULCER**, it is treated expectantly with **OBSERVATION**
34
How effective is **SUCRALFATE**?
As effective as **H2-blockers** in treating duodenal ulcers and same as **Misoprostol** (causes diarrhea)
35
Serum **GASTRIN \>100 pg/mL** with **PUD**, **REFLUX** **ESOPHAGITIS** and **DIARRHEA**?
**Zollinger-Ellison** Syndrome form a **GASTRINOMA** - **Basal Acid Output \>15 meq/Hr** and **POSITIVE SECRETIN TEST** or **SOMATOSTATIN SCAN** (25% part of MEN-I: **P**ancreas, **P**ituitary, **P**arathyroid) Gastrinomas are found in the pancreas and duodenum
36
If a patient **NOT** on **PPI** therapy is found to have **MULTIPLE GASTRIC POLYPS** (fundic-gland type) what should be advised and why?
**COLONOSCOPY** (may have FAP)
37
**Hyperplastic** **Gastric polyps** are most often associated with what?
**Autoimmune** Atrophic gastritis or **H.pylori**
38
How should **GASTRIC ADENOMAS** be treated?
Endoscopic **REMOVAL** with surveillance
39
In what region of the **UPPER GI TRACT** are polyps in **FAP** with the **HIGHEST** risk for **MALIGNANT** transformation?
By the **AMPULLA of VATER**
40
**Atrophic** **Gastritis**, **Intestinal Metaplasia** and **Dysplasia** are all associated with this condition?
**Gastric Adenocarcinoma**
41
Which **H.pylori STRAIN** is associated with **GASTRIC ADENICARCINOMA**?
**cagA** (cytotoxin-associated gene A)
42
How is **GASTRIC ADENOCARCINOMA** staged after it is diagnosed?
**EUS LOCALLY** and **CT** or **PET** for any metastatic disease
43
What **GENE** is expressed by **GIST** and diagnosed by testing for this?
**cKIT**
44
How are **malignant** **GISTs** treated?
**IMATINIB** (low-grade GISTs can just be observed)
45
**NESTS** of small, bland-looking cells, functional or non-functional and may release **SEROTONIN** and occur in the **FUNDUS**, **BODY** of the stomach in patients with **ATROPHIC** (autoimmune) gastritis and **PERNICIOUS ANEMIA** and the **DUODENUM**
**CARCINOID** Tumors - can be removed endosocopically
46
**Type II CARCINOID** tumors are known to be associared with **MEN-I** and **ZES**, therefore what must be done when these are found?
Look for any **PANCREATIC** lesions (3P's of MEN-I)
47
This **GASTRIC CARCINOID** tumor has **NORMAL GASTRIN** levels, is derived from **EC** (enterochromaffin cells) and carries a **HIGH RISK** of malignant transformation?
**Type-III** Carcinoid tumor (normal gastrin)
48
Which types of **MALT** lymphomas can be treated by **EARDICATING** **H.pylori**?
**LOW-GRADE** Lymphomas **ONLY** (**HIGH-grade** lymhomas require surgical resection) - CT and EUS staging
49
Epigastric **PAIN**, 1.5 cm **SUBEPITHELIAL** gastric mass, **NEUROENDOCRINE** cells on **EUS/FNA**, **no** gastric **atrophy** on biopises and **no** **PUD** noted, what is the **NEXT STEP**?
NO **GASTRIC ATROPHY** on biopsies, so NOT **TYPE I** (multiple lesions) - elevated gastrin
NO associated **PUD**, so NOT **TYPE II** (multiple lesions, MEN-I, ZES) - elevated gastrin
**TYPE III** - so **MUST** **STOP** the **PPI** and check **SERUM GASTRIN** and if **NORMAL** - **SURGERY** (high malignant potential)
50
What is the **EXPECTED** histologic finding of **ALCOHOLIC** **GASTRITIS**?
**EROSIONS** and **SUBEPITHELIAL HEMORRHAGES**
51
**CHRONIC DIARRHEA**, **POST-BULBAR DUODENAL ULCER**, **SEVERE EROSIVE ESOPHAGITIS** are all aspectss of what **CONDITION**?
**ZOLLINGER-ELLISON SYNDROME** (test for **FASTING SERUM GASTRIN**)
52
**PROTEIN LOSING ENTEROPATHY** (low albumin, low total protein, **DIARRHEA**, **EDEMA**) with **HYPERTROPHIED** gastric folds (also in H.pylori, lymphoma, gastrinoma, amyloidosis) is likely due to what condition and how is it **TESTED** for?
**MENETRIER's DISEASE** (ELEVATED **α-1 antitrypsin** in the **STOOL**)
53
Are biopsies in the setting of **BLOOD** useful for **H.pylori**?
**NO**
54
If there is **HIGH** suspicion for **H.pylori** infection, should you **START TREATMENT** **BEFORE** positive testing for H.pylori?
**NO**, there is **NO urgency** in starting H.pylori treatment
55
Bothersome **SYMPTOMS** of epigastric pain, burning, early satiety and early post-prandial fulness in the **ABSENCE** of any **STRUCTURAL** disease on **EGD** is undicative of what condition?
**FUNCTIONAL DYSPEPSIA**
56
**ATROPHIC GASTRITIS** and **INTESTINAL METAPLASIA** only require **SURVIELLANCE** when?
When **STAGE 3-4**
57
What is recommended for the management of **FUNDIC GLAND POLYPS**?
**OBSERVATION**, **NO SURVEILLANCE**
58
**WHEN** should **HYPERPLASTIC** polyps be removed?
When **\>1 cm** (**MODERATE** risk of malignant transformation)
59
Severe **ATROPHIC GASTRITIS**, severe **INTESTINAL METAPLASIA**, **FAMILY HISTORY** and **SMOKING** are all risk factors for what?
**GASTRIC CANCER**
60
**cKIT** (**CD117**) positive, **RESECT if \>2 cm**, can metastasize to **LIVER**, treat with **IMATINIB** if metastatic?
**GIST**
61
Is **INJECTION MONOTHERAPY** with sclerosant such as epinephrine recommended for a bleeding ulcer?
**NO**
62
If an **ULCER** has a **FLAT HEMATIN SPOT**, does it **REQUIRE ENDOSCOPIC** treatment?
**NO** (\<10% chance of re-bleed)
63
How should be patients with a **CLEAN BASED ULCER** be treated?
**NO ENDOSCOPIC** therapy required, dishcarge **HOME** on PPI
64
How should a patient with **BLEEDING ULCER** or tightly-adherent **CLOT** be treated?
**AFTER** endoscopic therapy, with I**V PPI BOLUS** and **DRIP** for **72 HOURS**
65
When are **ORAL PPIs** appropriate for treatment of **ULCERS**?
When there are **NO ENDOSCOPIC** findings of **HIGH-RISK BLEEDING STIGMATA**
66
In which patients are **UPPER GI ANGIODYSPLASIAS** noted?
Those with **CHRONIC RENAL FAILURE**, **LVAD**
67
**WHEN** might you use **ESTROGEN/PROGESTERONE** therapy in treatment of **GIB** caused by vascular ectasias?
In cases such as OSLER-WEBER-RENDU or CREST wehre these are very numerous and bleed often
68
This consition occurs in **OLDER WOMEN** with **IRON-DEF ANEMIA**, histologically you see **DILATED VENULES**, **FOCAL THROMBOSIS** and **FIBROMUSCULAR HYPERPLASIA** and besides **ENDOSCOPY**, can be treated with **IRON SUPPLEMENTATION**?
**GAVE**
69
**HYPOPERFUSION** due to **COMORBIDITY** with **MULTIPLE SUPERFICIAL ULCERS** in the **PROXIMAL** stomach with bleeding from superficial vessels (respiratory failure, burns, coagulopathy, sepsis and organ failure) - treated **PREVENTIVELY** and with **CIMETIDINE** **INFUSION** or **OMEPRAZOLE** with **BICARBONATE**?
**STRESS ULCERS**
70
Patients with which **BLEEDING STIGMATA** of **PUD** have the **HIGHEST RISK** of re-bleeding and require endoscopic therapy with adjuvant **IV PPI**?
Those with a **VISIBLE VESSEL** in the **ULCER BED** (not those with clot, 50% vs 15% risk)
71
If **NEGATIVE EGD** and **COLONOSCOPY** in a patient with **SYMPTOMATIC IRON DEFICIENCY ANEMIA**, what is **RECOMMENDED NEXT**?
**VIDEO CAPSULE ENTEROSCOPY** (if negative too, supplement iron)
72
Does **IV PPI INFUSION** therapy have any **ROLE** in esophageal **VARICEAL BLEEDING**?
**NO**
73
What does **PRE-TREATMENT** of a patient with an **UPPER GI BLEED** do **ENDOSCOPICALLY**?
**DOWNGRADES ENDOSCOPIC STIGMATA** and therefore **REDUCES** the need for **ENDOSCOPIC INTERVENTION** of the lesion
74
Is there **ANY EVIDENCE** of **ANY LONG-TERM RISK** of **HIGH DOSE PPI THERAPY**?
**NONE** (no osteoporosis, no renal disease, nothing)
75
What is the **MEDICAL** treatment in **PUD** of an **ACTIVE GIB**, **NON-BLEEDING VISIBLE VESSEL** or **ADHERENT CLOT** after EGD?
**IV PPI BOLUS + INFUSION x 72 HOURS** (if pigmented flat spot, ORAL PPI ONLY)
76
In a patient with **GIB**, endoscopically you find a **CLEAN-BASED ULCER** or a **PIGMENTED FLAT SPOT**, besides **ORAL PPI** therapy, what intervention should be done endoscopically?
**NOTHING**
77
If **ASPIRIN** is used in **PRIMARY PREVENTION** of **CV** disease, what should be done with it if patient presents and is treated for an **UGIB**?
**DISCONTINUE IT** (continue for SECONDARY prevention)
78
What is the **RECOMMENDED** treatment for **SLOW**, **RECURRENT** **GIB** from **AVMs**?
Maintenance **IRON** therapy
79
How is **ANEMIA** due to the slow bleed from **PHG** or **Cameron's Lesions** treated?
**PPIs** and **IRON SUPPLEMENTATION**
80
What are the **TWO HIGHEST RISK FACTORS** for **GIB** in patients admitted to the **ICU** who develop **STRESS ULCERS**?
**RESPIRATORY FAILURE** and **COAGULOPATHY**
81
If an **AORTO-ENTERIC** fistula is suspected, what is the **TEST** of choice?
**ANGIOGRAPHY**
82
In a patient with **OCCULT-OBSCURE GIB** who is **\<50 yo**, and continues to bleed with **NO IDENTIFIABLE** source, what **SHOULD** be tested for?
**MECKEL's** Scan
83
What can be **RARELY** used when there is continued **OCCULT-OBSCURE GIB** with NO identifiable source in spite of EGD, COLONOSCOPY, VCE, CTA, NM BLEEDING SCAN, PUSH ENTEROSCOPY?
**PROVOCATIVE TESTING** (use **HEPARIN** and be ready to scope)
84
What regulates gastric **MOTILITY** (relaxation, accomodation, food grinding and propulsion)?
**ENTERIC** Nervous System, **VAGUS** nerve and **SPINAL**
85
**POST-INFECTION**, patient presents with **NAUSEA**, **EARLY SATIETY**, **WEIGHT LOSS**. What is the mechanism?
**IMPAIRED ACCOMODATION** due to **FUNCTIONAL DYSPEPSIA** caused by post-infection effect
86
What determies and controls the **ANTRAL PUMP** responsible for **GRINDING** and **PROPULSION** of food **ACCOMODATED** in the **GASTRIC BODY**?
The **GASTRIC PACEMAKER**, located in the **MID-BODY** of the stomach (controls velocity, frequency and direction)
87
What are the **FIRST THREE** tests to use in working-up **GASTROPARESIS** if **IDIOPATHIC** (majority of cases) and not diabetic, or neurological (parkinson's)?
**1. UGI Series** (excludes anatomic and mechanical obstruction)
**2. EGD** - presence of BEZOAR without GOO
**3. Nuclear Gastric Emptying Study**
88
What is considered **NORMAL GASTRIC EMPTYING** at **30 min**, **1 HOUR**, **2 HOUR** and **4 HOUR**?
30 min (70%)
1 HOUR (30-90%)
2 HOURS (60%)
4 HOURS (10%)
89
What are the **DIETARY MODIFICATIONS** recommended in **GASTROPARESIS**?
1. **SMALL FREQUENT MEALS**
2. **AVOID FIBER** (causes **BEZOAR**)
3. **REDUCE FAT**
4. **LIQUID CALORIE** supplementaion
90
What **DRUG** for **GASTROPARESIS** should **NOT** be used in patients with **HYPERPROLACTINEMIA**?
**METOCLOPRAMIDE**
91
**NEW** drug for **GASTROPARESIS** that **IMPROVES** gastric **EMPTYING**, and **REDUCES VOMITING**?
**RELAMORELIN**
92
What **SURGICAL PROCEDURE** is available for **GASTROPARESIS** with good symptomatic relief?
**COMPLETION GASTRECTOMY** (total gastrectomy)
93
**Cyclical Vomiting** syndrome (nasuea, vomiting, abdominal pain) **COMPULSIVE HOT SHOWERS**, does **NOT** respond to **TCAs**?
**CANNABINOID HYPEREMESIS**
94
What other **NEUROLGICAL** condition is **NON-CANNABINOID** **Cyclical Vomiting Syndrome** associated with ?
**MIGRAINE HEADACHES**
95
What are the **NEUROMUSCULAR** components of the small bowel responsible for **PERISTALTIC** movement?
1. **MYENTERIC** (Auerbach's) **PLEXUS** between circular and longitudinal muscle layer
2. **SUBMUCOSAL** (Meissner's) **PLEXUS** - secretory
96
What are the **EXCITATORY** and **INHIBITORY** neurotransmitters in the small bowel?
1. **EXCITATORY** (acetylcholine, substance P, serotonin - 5HT)
2. **INHIBITORY** (vasoactive intestinal polypeptide - VIP and nitric oxide)
97
What is **RESPONSIBLE** for the **FREQUENCY** and **PROPAGATION** of **GASTRIC** and **DUODENAL CONTRACTIONS**?
Interstitial cells of **CAJAL**
98
What is the **GASTRIC** and **INTESTINAL MOTOR** pattern of the **INTERDIGESTIVE** (fasting) **STATE**?
**MIGRATING MOTOR COMPLEX** (**MMC**) - in the FED state, the stomach (3/min), proximal small intestine (12/min) and distal small intestine (8/min) - MMC is TIRGGERED by MOTILIN and INHIBITED by GASTRIN (so food can be digested in stomach and moved away when ready)
99
What **DETERMINES** the **RATE** of **PERISTALSIS** in the **FED** state?
**CALORIC** content of foods (FASTER for triglycerides and **SLOWER** for proteins) - this is **MESSED UP** by **OPIOIDS** (causes **SIMULTANEOUS** contractions throughout the intestine)
100
**MYOPATHIES** (familial, collagen, amyloidosis) and **NEUROPATHIES** (Hirschprung, Chagas, paraneoplastic) affect the small bowel by causing HYPOacitve motility - myopathies, or HYPERactive motility - neuropathies. What condition does this result in?
**INTESTINAL PSEUDOOBSTRUCTION**
101
Clinical manifestations of **GI DYSMOTILITY** (gasgtroparesis, SIBO, small bowel diverticula, intestinal pseudoobstruction) are seen in this **MIXED** neuropahty/myopathy causing nausea, vomiting, intestinal cramps, abdominal distention, weight loss, malabsorption, diarrhea and constipation?
**Systemic Sclerosis**
102
Which **CONDITIONS** are associated with **PARANEOPLASTIC INTESTINAL PSEUDOOBSTRUCTION**?
**SMALL CELL LUNG CANCER** and **CARCINOID TUMORS** - **DYSMOTILITY PRECEDES DIAGNOSIS of CANCER** (patients with NEW onset dysmotility and abnormal gastric emptying or manometry) - DO **CXR**, **CT CHEST**
103
Anti Neuronal Nuclear Antibodies (ANNA-1 and ANNA-2), N-type calcium channel antibody, and the Purkinje cell cytoplasmic antibody (PCA-1) are all associated with what conditions?
**PARANEOPLASTIC INTESTINAL PSEUDOOBSTRUCTION**
104
Where in the **INTESTINAL TRACT** do you test for **AMYLOIDOSIS** if an **INTESTINAL** **PSEUDOOBSTRUCTION** is suspected?
**RECTAL BIOPSY**
105
In a patient with **MOTILITY** issues such as in **INTESTINAL PSEUDOOBSTRUCTION**, evidence of **STEATORRHEA** and **VIT B12** deficiency suggests what?
**SIBO**
106
How is **INTESTINAL** **PSEUDOOBSTRUCTION** treated in the **ACUTE** hospital setting and maintenance?
In the **HOSPTIAL** - **IV ERYTHROMYCIN** at 3 mg/kg every 8 HOURS for 5-7 DAYS
**Metoclopramide** for MAINTENANCE
107
In a patient with **RECURRENT BEZOAR** formation who does **NOT HAVE SIBO**, what can be used for effective treatment of their dysmotility?
**SUBCUTANEOUS OCTREOTIDE** qHS
108
What is the **MOST IMPORTANT** dietary **STIMULANT** for the **GASTROCOLONIC** **RESPONSE** where taking in food causes **COLONIC MOTILITY**?
**FAT**
109
What is the **ONLY VISCERAL SENSATION** the colon can feel which is elevated in conditions like **IBS** and **IBD**?
**WALL DISTENTION** (NON-FOCAL)
110
In a patient s/p resolution of an **ACUTE ILLNESS** with lingering symptoms of nausa, vomiting and weight loss, bloating and diarrhea with no response to a gastroparesis diet, **UGIS**, **EGD** and **GES** normal, what is the **BEST TREATMENT**?
**FUNCTIONAL DYSPEPSIA** - due to impaired gastric accomodation and hypersensitivity to gastric distention - treat with **BUSPIRONE** (no effect of TCAs or SSRIs if not gastroparesis)
111
Does **BOTOX** play a role in patients with **GASTROPARESIS**?
**NO** (no better than SHAM injections)
112
How is **POST-INFECTIOUS GASTROPARESIS** best treated?
**IV ERYTHROMYCIN** (do NOT start with metoclopramide)
113
In **WHICH** patients with **REFRACTORY GASTROPARESIS** has the gastric **PACEMAKER** been shown to be the most **EFFICACIOUS**?
**DIABETIC** PATIENTS with **NAUSEA** and **VOMITING**
114
Episodes of **VOMITING** and **ABDOMINAL PAIN** separated by **SYMPTOM-FREE** intervals?
**CYCLICAL VOMITING SYNDROME** (if **cannabinoid** related - relieved by **hot showers** and abstinence from cannabinoids; if **idiopathic**, responds to TCAs and associated with **migraines**)
115
**MEGADUODENUM** (also affects esophagus and anorectum) is seen on **UGIS** in patients with this **CONDITION**
**SCLERODERMA** (often manifests as **SIBO** and **MALABSORPTION** - hydrogen breath test)
116
What **MEDICATIONS** have been shown to **DELAY GASTRIC EMPTYING** causing **GASTROPARESIS**?
**TCAs**, **OPIOIDS**, **PPIs**, **LITHIUM**, **CANNABINOIDS**, **TOBACCO**
117
**UGIS** with **RETENTION of BARIUM**, **WITHOUT OBSTRUCTION**, **EGD** with **BEZOAR** **WITHOUT OBSTRUCTION**, abnormal **SOLID GES**?
**GASTROPARESIS**
118
Does **ACCELERATING** **GASTRIC EMPTYING** improve symptoms of **GASTROPARESIS**?
**NO**
119
What is the MECHANISM of **GI MUCOSAL DAMAGE** (ulcers, etc.) that occurs with NSAID use?
The systemic **INHIBITION** of **PROSTAGLANDIN** **SYNTHESIS**
120
Chronic **GASTRIC ANTRAL INFLAMMATION** caused by **THIS**, can decrease the number of **ANTRAL D-cells** and level of **SOMATOSTAIN** leading to an increased rate of gastric acid secretion and duodenal ulcer formation?
**Helicobacter Pylori**
121
Which **MEDICATION** is **CONTRAINDICATED** in the **TREATMENT** of **PUD** in the **PREGNANT** patient?
**MISOPROSTOL** (almost all antacids are safe including H2 blockers, PPIs and Sucralfate)
122
What should be done for **ALL** patients who **TEST POSITIV**E for **H.pylori**?
**ALL** should be **OFFERED TREATMENT**
123
**ALL** patients with **H.pylori** and **GASTRIC ADENOCARCINOMA**, or **EXTRA-NODAL MARGINAL ZONE B-CELL LYMPHOMA** (**MALTOMA**) or **FIRST**-**DEGREE RELATIVES** of **H.pylori-INFECTED** patients with **GASTRIC** **ADENOCARCINOMA** should be treated **HOW**?
**H.pylori TREATMENT**
124
How do you **TREAT PREGNANT** patients with **H.pylori** infection?
**ACID-SUPPRESSION ONLY!!** **TREAT FULL COURSE, ONLY AFTER DELIVERY** (DO NOT TEST WHEN PREGNANT)
125
Which **ENVIRONMENTAL FACTOR** is **MOST** **ASSOCIATED** with **PUD**?
**SMOKING**
126
What is the **MOST** **COST**-**EFFECTIVE** way of testing for **H.pylori** in a **PREVIOUSLY** **UNTESTED** or **UNTREATED** patient?
**SEROLOGIC Ab TESTING** (highest sensitivity and specificity)
127
**POSITIVE ANTI**-**PARIETAL** **CELL** **Ab**, **POSITIVE ANTI**-**INTRINSIC** **FACTOR** **Ab**, **HIGH** **GASTRIN LEVEL**, **LOW** **Vit B-12** **LEVEL** are found in what **CONDITION**?
**AUTOIMMUNE** (**ATROPHIC**) **GASTRITIS** (older white women, antrum and fundus) - loss of parietal cells causes a low-acid state stimulating gastrin cell hyperplasia
128
What is **HIGHLY**-**SUGGESTIVE** when **LYMPHOCYTIC GASTRITIS** is histologically found on **BIOPSY**?
**H.pylori INFECTION**
129
In what **CONDITION** on **GASTRIC BIOPSY** do you see **FIBRIN** **THROMBI**, dilted mucosal cappilaries, fibromuscular hyperplasia of the lamina propria and almost NO inflammation?
**GAVE**
130
In what **CONDITION** on **GASTRIC BIOPSY** do you see **CONGESTIVE** **VASCULOPATHY**?
**PORTAL HYPERTENSIVE GASTROPATHY**
131
In what **CONDITION** on **GASTRIC BIOPSY** do you see **SUPERFICIAL** **LAMINA PROPRIA HEMORRHAGE**?
**ACUTE EROSIVE GASTRITIS**
132
In what **CONDITION** on **GASTRIC BIOPSY** do you see **INFLAMMATION** with **EOSINOPHILIC INFILTRATE**?
**EOSINOPHILIC GASTRITIS**
133
What is the **MOST LIKELY** cause for a **GASTRIC** **ULCER** in a patient with **HIV** and **CD \<200**?
**CMV** infection (**CENTER** of the **ULCER BIOPSY** - **VASCULAR ENDOTHELIAL INVOLVEMENT** with **ENLARGED CELL INTRANUCLEAR INCLUSIONS**) - Owel's Eyes
134
In a patient with **HIV** infection with **LOW CD** count (**\<200**) and a gastric **ULCER**, **WHERE DO YOU TAKE BIOPSIES**?
**CENTER** of the ulcer (**CMV**) and **EDGES** of the ulcer (**HSV**)
135
In a patient with **HIV** infection with **LOW CD** count (**\<200**) and a gastric **ULCER** on which biopsies reveal **NUCLEAR INCLUSIONS** with **MULTINUCLEATION**, MARGINATION and **MOLDING**?
**HSV** (**EDGE of ULCER BIOPSY**)
136
In a patient with **HIV** infection with **LOW CD** count (**\<200**) and a gastric **ULCER** on which biopises reveal **INTENSE PLASMA CELL INFILTRATION** and **MONONUCLEAR VASCULITIS** with a **POSITIVE SILVER WARTHIN-STARRY STAIN**?
**SYPHILIS**
137
In a patient with **HIV** infection with **LOW CD** count (**\<200**) and a gastric **ULCER** on which biopsies reveal **MARKED LYMPHOPLASMACYTIC INFLAMMATION** and **NEUTROPHILS**?
**CHRONIC ACTIVE GASTRITIS** from **H.pylori** INFECTION
138
In **CHEMICAL GASTROPATHY** caused by **BILE SALTS**, **ALCOHOL**, **NSAIDs**, it is important to do **WHAT**, before increasing frequency and dosage of **PPIs**?
**ELIMINATE** the causative factors (**ALCOHOL** and **NSAIDs**)
139
Is **CHOLESTYRAMINE** likely to be **HELPFUL** for excess **BILE SALTS** in the stomach as far as **RELFUX** is concerned?
**NO**
140
What is the most **COMMON** **CAUSE** of **GRANULOMATOUS GASTRITIS**?
**CROHN's DISEASE** (52% of cases)
141
**FLUSHING**, **DIARRHEA**, **WHEEZING** and **HEART DISEASE** are symptoms of **WHAT GI PATHOLOGY** and **WHERE** is it **MOST COMMONLY FOUND**?
**CARCINOID** - **SMALL BOWEL** (JEJUNUM, etc.) - with mets to the LIVER
142
Is **CHROMOGRANIN A** measurement a good **SCREENING** **TEST** for the diagnosis of a **CARCINOID TUMOR**?
**NO**
143
IN which **DISEASE PROCESS** is **EGD** **SCREENING** for **GASTRIC CANCER RECOMMENDED**?
**FAP**
144
The **REALTIVE RISK** of **H.pylori** infection leading to **GASTRIC ADENOCARCINOMA** is greatest in whom?
**YOUNG** patients **\<29** yo
145
Nearly **HALF** (**50%**) of GASTRIC **CANCERS** in **DEVELOPING** **COUNTRIES** are **ATTRIBUTED** **TO**?
**H.pylori** infection
146
**WHERE** in the **STOMACH** do **GASTRIC CANCERS** associated with **H.pylori** develop?
**BODY** and **ANTRUM** (distal stomach)
147
In which of these **EASTERN EUROPE**, **AUSTRALIA**, **WESTERN SOUTH AMERICA**, **JAPAN** and **EAST ASIA**, is the **INCIDENCE** of **GASTRIC CANCER** the **LOWEST**?
**AUSTRALIA**
148
A patient has a **GLUCAGON LEVEL \>1,000 pg/mL** and a **BLOOD GLUCOSE LEVEL of \>200 mg/dL** and pt has **DIARRHEA**, what is this and **WHERE** is it found?
**GLUCAGONOMA** (in the **PANCREAS** and usually with **METS** to the **LIVER**) - **UNRESECTABLE**
149
In the **GUT**, ACTIVATION of **PARASYMPATHETIC OUTFLOW** to **NON-SPHINCTERIC SMOOTH MUSCLE** are components of **EXTRINSIC NEURAL CONTROL** that **PROMOTE** what?
**INTESTINAL TRANSIT**
150
**Parkisnon's** Disease, **DM**, **MS**, **Anticholinergics** are ALL **NEUROPATHIC** **DISORDERS** of GUT MOTILITY, which is a **MYOPATHIC DISORDER**?
**DERMATOMYOSITIS**
151
**The presence of GAS or FLUID in an OBSTRUCTED ORGAN** (GOO) on abdominal auscultation while moving patient?
**SUCCUSSION SPLASH**
152
**WHICH** **CANCER** can **CAUSE** a **PARANEOPLASTIC PSEUDO-OBSTRUCTION** of the **STOMACH**, **SMALL BOWEL** and **COLON**?
**SMALL CELL LUNG CANCER** (SMOKER)
153
In what **MANNER** are **LIQUIDS EMPTIED** from the **STOMACH**?
**EXPONENTIAL** (not linear)
154
**HOW LARGE** can an **INDIGESTIBLE SOLID** be to EXIT the **STOMACH** during an **MMC**?
**2 CM**
155
**WHAT** is the **MAXIMUM SPEED** at which **GASTRIC CONTRACTIONS OCCUR** during an **MMC**?
**3 CYCLES/MINUTE**
156
**WHAT** is **EMPTIED** from the **STOMACH** after an **INITIAL LAG PHASE** followed by a **LINEAR EMPTYING PHASE**?
**SOLIDS**
157
What **SHOULD** be done with **SHARP OBJECTS** when swallowed **BEFORE** the **REACH** and **INJURE** the **SMALL BOWEL**?
**REMOVE** by **EGD**
158
In a patient with **HIV** and **LOW CD COUNT**, with **FEVER**, **WEIGHT LOSS** and **SEVERE DIARRHEA,** with M**ESENTERIC LNs** and on **EGD** you note patchy areas of **EDEMA**, **ERYTHEMA** and **NODULARITY** with **FROSTED** **YELLOWISH** **PLAQUES** in the **DUODENUM**, what is the **CAUSATIVE** **AGENT**?
**MAC** (mycobaterium avium-intracellulare complex)
159
A patient with **HIV** was noted to have these **LESIONS** in their **DUODENUM**, what is the **CAUSATIVE AGENT**?
**Kaposi Sarcoma** (HSV-8)
160
A **CHRONICALLY**-**ILL** patient with **HIV** presents with **BLOODY DIARRHEA**, **FEVER** and **ABDOMINAL PAIN**. Colonoscopy demonstrates **PATCHY** **ULCERATIONS**, **INTRANUCLEAR INCLUSION**S, **PERINUCLEAR HALO** and **CYTOPLASMIC INCLUSIONS**?
**CMV** infection
161
A **CHRONICALLY**-**ILL** patient with **HIV** presents with **BLOODY DIARRHEA**, **FEVER** and **ABDOMINAL PAIN**. Colonoscopy demonstrates **PATCHY** **ULCERATIONS**, **GROUND**-**GLASS** **NUCLEI**, **EOSINOPHILIC** **INTRANUCLEAR INCLUSIONS** and **MULTINUCLEATE CELLS**?
**HSV** infection
162
A **CHRONICALLY**-**ILL** patient with **HIV** presents with **BLOODY DIARRHEA**, **FEVER** and **ABDOMINAL PAIN**. Colonoscopy demonstrates TERMINAL ILEUM EDEMA, MILD VILLOUS ATROPHY with APICAL INTRACELLULAR, EXTRACYTOPLASMIC ICLUSIONS?
**CRYPTOSPORIDIUM**
163
Which **MEDICATIONS** have been **IMPLICATED** in **CAUSING** **PANCREATITIS** in patients with **HIV** infection?
**DIDANOSINE**, **PENTAMIDINE**, **DAPSONE**, **TMP-SMX,** **FUROSEMIDE**, **METRONIDAZOLE** and **NELFINAVIR**
164
**HIV** patient presents with **12-WEEKS** of **WATERY**, **NON-BLOODY DIARRHEA** and **WEIGHT** **LOSS**, **NO** fever or chills, no nausea, vomiting, abdominal pain?
**ENTEROADHERENT E.coli** (chronic diarrhea) - can also cause ACUTE DIARRHEA in travelers and children who are NOT immunocompromised
165
**HIV** patients easily get **INFECTED** with this **AGENT** which causes **CHRONIC** **WATERY DIARRHEA** - treated with **CIPROFLOXACIN**?
**ENTEROADHERENT E.coli** (chronic diarrhea) - can also cause ACUTE DIARRHEA in travelers and children who are NOT immunocompromised
166
What is found in a patient that is infected with **ENTEROHEMORRHAGIC** or **ENTEROINVASIVE E.coli**?
**SHIGA TOXIN** in stool cultures, fecal **LEUKOCYTES**, and **BLOODY DIARRHEA**
167
**WATERY DIARRHEA** found **MOSTLY** in **TRAVELERS** is caused by this **E.coli**?
**ENTEROTOXIGENIC E.coli**
168
**WATERY DIARRHEA MOST COMMON** in **CHILDREN** **\<6 yo** is caused by this **E.coli**?
**ENTEROPATHOGENIC E.coli**
169
**WELL TREATED HIV PATIENTS** who stick to their medication protocols and **AVOID** **TROUBLESOME SUBSTANCES**, who present with **DYSPHAGIA**, are generally found to have **WHAT**?
**GERD** with **ESOPHAGITIS** (not CMV, not EOE)
170
**HIV** patient with **POOR MEDICAL COMPLIANCE** and **LOW CD COUNT**, handles **FISH** and presents with **PAINFUL SWOLLEN AREA** around **CUT** in **ARM** which is **ENLARGING** and **PAINFUL**?
**VIBRIO VULNIFICUS** (wound infections with cellulitis, myositis and fasciitis)
171
What do **VIBRIO** ***mimicus***, ***parahemolyticus**, **cholerae*** and ***fluvialis*** **CAUSE**?
**DIARRHEA**
172
**SLOW DECREASE** in **Hb** after the **TREATMENT** of a **BLEEDING ULCER** is **INDICATIVE** of **WHAT**?
**REEQUILIBRATION** (no repeat EGD or intervention is required)
173
**POST** **UGIB**, a **FORMED BLACK STOOL** vs **LIQUID BLACK STOOLS** is consistent with **WHAT**?
**RECENT** bleed (clearing of GIT), **NOT ACTIVE** bleed
174
**WHERE** are the **MAJORITY** of **DIEULAFOY** lesions found?
**UPPER STOMACH**
175
What is **RECOMMENDED** for the **TREATMENT** of a **DUODENAL ULCER AFTER EGD** intervention?
**ONCE**-**DAILY** **PPI** for **4 WEEKS**
176
What happens when a patient with an **UGIB** is tested for **H.pylori** with a **RAPID UREASE TEST**?
**FALSE**-**NEGATIVE** with an **UGIB**
177
What is the **RISK** of **RE-BLEED** in a patient with **PUD** **WITHOUT** a **CORRECTABLE CAUSE**? **HOW DO YOU TREAT**?
**30%** in the **next 5 YEARS**
Treat with **ONCE DAILY PPI LIFE-LONG**
178
**GIB** after **NECROTIZING PANCREATITIS** is caused by **WHAT** and **HOW** is it **TREATED**?
Bleeding from a **PSEUDOANEURYSM** (via pancreatic duct)
## Footnote
**IR ANGIOGRAPHIC EMBOLIZATION**
179
**LARGE**-**VOLUME** **STOOL** with **BLOOD** and **PAINLESS ABDOMEN** with **NORMAL** **Hb** and **MINOR ORTHOSTATIC CHANGE**, **VAGAL**-**INDUCED** **SYNCOPE** associated with **MULTIPLE RED STOOLS**?
**DIVERTICULAR BLEED**
180
**WHERE** in the **GIT** is it **COMMON** to find an **AORTO**-**ENTERIC** **FISTULA**?
**DISTAL** **3rd** of **DUODENUM**
181
**WHERE** in the **GIT** is it **COMMON** to find a **DUODENAL** **ULCER** associated with the **POSTERIOR GASTRODUODENAL ARTERY**?
**POSTERIOR DUODENAL BULB**
182
**WHERE** in the **GIT** is it **COMMON** to find an **ULCER ASSOCIATED** with the **LEFT GASTRIC ARTERY**?
**LESSER CURVATURE** of the **STOMACH**
183
An **ADHERENT CLOT** over a **DUODENAL BULB ULCER** that is **NOT** **ACTIVELY BLEEDING** has **WHAT RISK** of **BLEED** if **LEFT UNTREATED**? **HOW DO YOU TREAT**?
**25% RISK of RE-BLEED**
**TREAT** with **EGD CLOT REMOVAL+ INTERVENTION + IV PPI**
184
**CONSTANT ABDOMINAL PAIN** with **URGE** to have **BROWN BOWEL MOVEMENT** followed by **LOOSE BLOODY TOOLS**, no fever or chills, on **COLONOSCOPY** you see a **WELL-DEMARCATED AREA** of **ULCERATION**, **EDEMA** and **ERYHTEMA**?
**ISCHEMIC COLITIS** (WELL DEMARCATED) - use of TRIPTAN (migraines)
185
**YOUNG** patient with **CHRONIC VASCULAR THROMBOSIS** with **OCCLUSION** of the **IVC** (inferior vena cava) is **SUGGESTIVE** of what pathology?
**FACTOR V LEIDEN** genetic mutation
186
**HYPERTHYROIDISM** with a tender thryoid (nervousness, loose stools, weight loss, a-fib) and a **NEW**, **PERIUMBILICAL PAIN** without much **TENDERNESS** on **PALPATION** (**mesenteric ischemia**) which is most likely **CAUSED** by **WHAT**?
**SMA OCCLUSION** (embolus - a-fib)
187
**POST**-**OP** (cholecystectomy), pt with **CAD**, **DM**, **HTN**, **CANNOT BE WEANED** off **NGT** and imaging shows a **MILD**, **NON**-**SPECIFIC** **DILATION** of a **FEW SMALL BOWEL LOOPS WITH INCREASED GAS** and **FLUID** but **NO TRANSITION POINT** (**ILEUS**), what is **RECOMMENDED**?
**CHECK** for **SMALL BOWEL VASCULAR DISEASE** (doppler **US** of abdominal arteries)
188
What **DIAGNOSTIC TEST SHOULD BE AVOIDED** in a patient with elevated **Cr**?
**CONTRAST STUDIES** (**CT**, including enterography)
189
**WHEN** **SHOULD** a **SPLENIC ARTERY ANEURYSM** (**SYMTOMATIC** or **NOT**) be **TREATED** (IR)?
**ALL SYMPTOMATIC** ANEURYSMS (abd pain, nausea) - **HIGH** risk of **BLEED**
**ASYMTOMATIC** ANEURYSMS **\>2 cm**
190
**ABDOMINAL PAIN AFTER MEALS** (**30 min**), **DULL**, **ACHY**, **PERIUMBILICAL** and lasts **~1 HOUR**, with **WEIGHT LOSS**, **FEVERS**, **FATIGUE**, **ARTHRALGIA** and **HTN**, **LIVEDO RETICULARIS** with **LE EDEMA**, **ELEVATED ESR** and **Cr**?
**POLYARTERITIS NODOSA** (**mesenteric angiography** - **MICROANEURYSMS**)
191
A patient with **HEREDITARY** **HEMORRHAGIC** **TELANGIECTASIA** (HHT) will have symptoms of **HF** and **LIVER INVOLVEMENT** (**VASCULAR MALFORMATIONS**). What are the **THREE** (**3**) **DIFFERENT TYPES** of **ABNORMAL LIVER COMMUNICATIONS** that can form?
1. PORTAL VEIN - HEPATIC VEIN (PORTOVENOUS) FISTULA
2. HEPATIC ARTERY - HEPATIC VEIN (ARTERIOVENOUS) FISTULA
3. HEPATIC ARTERY - PORTAL VEIN (ARTERIOPORTAL) FISTULA
192
What are the THREE **LIVER** MANIFESTATIONS that can **OCCUR** **CLINICALLY** in patients with **HEREDITARY HEMORRHAGIC TELANGIECTASIA** (HHT)?
**HIGH**-**OUTPUT** **CARDIAC FAILURE**
## Footnote
**BILIARY ISCHEMIA**
**PORTAL HTN**
193
What is the most **COMMON MANIFESTATION** of **HEREDITARY** **HEMORRHAGIC** **TELANGIECTASIA** (HHT) due to **LIVER INVOLVEMENT**?
**HEPATIC ARTERY - HEPATIC VEIN** (ARTERIOVENOUS) **FISTULA** causing **HIGH-OUTPUT HEART FAILURE** (fatigue, dyspnea on exertion, orthopnea, JVD, systolic murmur, LE edema)
194
**INTERMITTENT EPISODES** of **PAINLESS HEMATOCHEZIA**, **REQUIRING TRANSFUSIONS**, no melena. **ONE** of his **LEGS** is **LARGER** than the **OTHER**, one of his **LEGS** has **CUTANEOUS HEMANGIOMAS** and **BOTH** **LE's** have **VENOUS VERICOSITIES**. Why is he bleeding?
**KTW** (Klippel-Trenaunay-Weber Syndrome) - **RECTAL HEMANGIOMAS**
195
A **CONGENITAL VASCULAR DISORDER** with **LIMB HYPERTROPHY**, **CUTANEOUS HEMANGIOMAS** and **VARICOSITIES** - also **CARVERNOUS HEMANGIOMAS** of **RECTUM** with catastrophic bleeds?
**Klippel-Trenaunay-Weber** syndrome (KTW)
196
**YOUNG** patient presents with **SEVERE**, **DIFFUSE ABDOMINAL PAIN** for **12 HOURS ASSOCIATED** with **NAUSEA** and **CONSTIPATION** and this has been happening over the **PAST 5 YEARS** with **HTN** and **TACCHYCARDIA**. **WHAT** is it and how is it **TREATED**?
**INTERMITTENT PORPHYRIA**
TREAT PAIN with acetaminophen, meperidine or morphine
TREAT NAUSEA ONLY with ONDANSETRON (not promethazine)
**IV HEMIN** and glucose
197
Why do patients with **SCLERODERMA** often present with **NAUSEA**, **VOMITING**, **ABDOMINAL** **PAIN**, **DISTENDED** **ABDOMEN** with **DIMINISHED** **BOWEL SOUNDS**? How do you **TREAT**?
**CHRONIC INTESTINAL PSEUDO-OBSTRUCTION** (CIPO) - intestinal stasis
**TREAT** with antibiotics (**CIPROFLOXACIN**) - causes **SIBO**
198
What can be used to **TREAT** the chronic intestinal pseudo-obstruction that causes **SIBO** due to intestinal **STASIS** in **SCLERODERMA** patients (besides antibiotics) that promotes small bowel **MOTILITY**?
**LOW**-**DOSE** **OCTREOTIDE** (20 mcg SC) - high-dose does not work
199
**PROGRESSIVE SOLID-FOOD DYSPHAGIA**, **SMALL-CALIBER ESOPHAGUS**, **MUCOSAL RINGS**, **MIDDLE-AGED WOMAN**, **PROXIMAL ESOPHAGUS STRICTURE** with **DENSE SUBEPITHELIAL LYMPHOCYTIC INFILTRATE**, **INTRAEPITHELIAL LYMPHOCYTES** and **MULTIPLE EOSINOPHILIC NECROTIC KERATINOCYTES**?
Esophageal **LICHEN PLANUS** (systemic corticosteroids, topical tacrolimus)
200
This **DISEASE** occurs almost **EXCLUSIVELY** in **MIDDLE-AGED WOMEN** and **MIMICS EOE**?
Esophageal **LICHEN PLANUS** (systemic corticosteroids, topical tacrolimus)
201
What is the **MOST COMMON SITE** of **GUT INVOLVEMENT** of **AMYLOIDOSIS**?
**DUODENUM** (then colon, then esophagus)
