AAW - GI Flashcards
behcet syndrome
recurrent aphthous ulcers, genital ulcers, and uveitis
due to immune complex vasculitis
what part of the mouth are you most likely to see squamous cell
floor
when you see leukoplakia what cancers do you have to be concerned about
squamous cell
especially if seen with erythroplakia (in fact, erythroplakia is even more worrisome because it means there is new vascularization)
where do you see hairy leukoplakia
due to what?
lateral tongue
EBV
immunocompromised patients
it is a hyperplasia of squamous cells, not dysplasia
orchitis is assc with what virus
mumps, which commonly affects the parotid glands
causes sterility in teens
elevated serum amylase is someone with mumps - what parts of the body are affected
serum amylase is increased due to salivary gland OR pancreatic involvement
two nerve plexuses of GI
meissner’s - in submucosa of just the small and large intestine
auerbachs’s AKA myenteric - in between the two layers of the muscularis externa
they are both intrinsic to the gut (whereas the extrinsic would be like the vagus)
H2 blockers for the gut
ranitidine
cimetidine
what cells secrete pepsinogen in the stomach
chief cells
what cells secrete gastrin
g cells
what cells secrete intrinsic factor
parietal cells
what upregulates the mucous cells of the stomach
vagal stimulation and pancreatic biliary secretion
they protect the stomach against acid
what cells secrete mucous in the small intistine
what cells secrete bicarb
goblet and brunner’s secrete mucous
brunner’s secrete bicarb - Located in duodenal submucosa. Secrete alkaline mucus. Hypertrophy seen in peptic ulcer disease.
what cells secrete lysozymes and defensins in the small intestines
paneth cells
calcium and iron absorbed in
absorbed in duodenum
interstitial cells of cajal
can these cells be altered in their amplitude? frequency?
“nodal cells of the enteric system”
(remember cajon, like a drum that keeps the beat)
they initiate slow wave electrical activity
they are phasic and prolongated over a few centimeters
can be altered in amplitude but not frequency
what are the neurotransmitter(s) involved in the downstream effects of gastric stretching and what cells release the it(them)
serotonin released from mucosal enterochromaffin cells
substance P’s effects on enteric motorneurons
excitatory (pain perception)
often released with acetylcholine
aka tachykinin
function of gastrin
released by g cells in the antrum in response to AA’s and cause pepdinogen and H+ release from the parietal cells
CCK
secreted by what cells
what does it do
responsible for stimulating the digestion of fat and protein. Cholecystokinin is synthesized and secreted by I cells in the duodenum/jejunum
secretin
released by S cell, inhibits the secretion of gastric acid from the parietal cells of the stomach, stimulates the production of bicarbonate from the centroacinar cells and intercalated ducts of the pancreas
Gastric Inhibitory Peptide or Glucose-Dependent Insulinotropic Peptide (GIP)-
what does it do
what cells make it
K cells in D/J detect carbohydrates and fat to inhibit gastric acid secretion and stimulate insulin release from pancreas
what does the D cell make
somatostatin
Inhibits secretion by parietal cells
(D for Done, stops digestion)
what do the ECL cells make
aka enterochromaffin like cells
histamine
butyrate
bacteria in the colon convert fiber into short chain fatty acids and butyrate
it protects the colonocytes from inflammation and is used by them for energy…..
achalasia
increased lower esophageal tone with disordered esophageal motility (both of these contribute to the fact that patients get dysphagia with solids and liquids)
due to damaged ganglion cells in the myenteric plexus - idiopathic or chagas
makes it hard to swallow
increased chance of squamous cancer
what nerve innervates masseter and temporalis
trigeminal
lactoferrin
competes with bacteria for iron and inhibits their growth
found in secretory fluids and neutrophils
Sialolithiasis
usually due to what organism
stone in the salivary glands
staph A.
Zenker diverticulum
Pharyngoesophageal false diverticulum A .
Herniation of mucosal tissue at Killian
triangle between the thyropharyngeal
and cricopharyngeal parts of the inferior
pharyngeal constrictor. Presenting symptoms:
dysphagia, obstruction, foul breath from
trapped food particles (halitosis). Most
common in elderly males.
alpha cells of the pancreas produce what
what are the downstream signals of this
glucagon
production goes up in the fasted state
receptor is a g protein
second messenger is cAMP, activation of protein kinase A
the ATP to power gluconeogenesis comes from
FAD(2H) and NADH reduced by fatty acid beta oxidation.
how do proteins enter the TCA cycle
glutamine to glutamate to alpha ketoglutarate
Familial adenomatous polyposis (FAP) genetics
autosomal dominant mutation of APC gene on chromosome 5q. 2 hit hypothesis. 100% progress to colorectal cancer unless colon is resected. thousands of polyps at young age
gardner syndrome
FAP + osseous (of the head) and soft tissue tumors, congenital hypertrophy of retinal pigment epithelium
turcot syndrome
FAP + malignant CNS tumor (medulloblastoma, glial tumors)
Turcot = Turban
Hereditary nonpolyposis colorectal cancer AKA lynch syndrome
autosomal dominant mutation of DNA mismatch repair genes. ~80 percent progress to colorectal cancer. proximal colon always involved.
barrett esophagus
what is it
what assc cancer
squamous cells in lower esophagous turn columnar because of chronic reflux, get metaplasia of goblet cells
adeno
stomach ulcerations and high gastrin levels
what are you thinking
Zollinger-ellison syndrome (gastrinoma of duodenum or pancreas) - neuroendocrine tumors
increased gastrin drives parietal cells to make more acid
hyrdogen ions can overwhelm bicarb in duodenum, leading to decreased lipase and colipase activity, leading to steatorrhea and diarrhea because of malabsorption
omeprazole
aka prilosec
Proton pump inhibitor
lansoprazole
PPI
famotidine, nizatidine
H2 receptor antagonists along side cimetidine and ranitidine
Infiltration of eosinophils in the esophagus in atopic patients. Food allergens, dysphagia,
heartburn, strictures. Unresponsive to GERD therapy.
Eosinophilic
esophagitis
dysphagia, iron deficiency anemia, glossitis
plummer-vinson syndrome
plummers DIG
may progress to esophageal squamous cell
glossitis is a “beefy red tounge”
what does vit b12 deficiency do to the mouth area
causes glossitis
what drugs can cause osteonecrosis of the jaw
mech, use, tox
bisphosphonate medications used to treat osteoporosis like alendronate (and other -dronates)
pyrophosphate analogs, bind hydroxyapatite in bone, inhibit osteoclast activity
used for osteoporosis, hypercalcemia, Paget disease
can also cause corrosive esophagitis (patients are advised to take with water and remain upright for 30 minutes
white shit you cannot scrape off of the sides of the tounge
called?
organism?
hairy leukoplakia
caused by EBV
in immunocompromised individuals
p16 gene
tumor suppressor gene for melanoma and squamous cell
its a cyclin dependent kinase inhibitor (2A)
mucormycosis
Mucor and Rhizopus spp. of fungus
Disease mostly in ketoacidotic
diabetic and leukemic patients. Fungi
proliferate in blood vessel walls when
there is excess ketone and glucose,
penetrate cribriform plate, and enter brain.
Rhinocerebral, frontal lobe abscesses.
Headache, facial pain, black necrotic eschar
on face; may have cranial nerve involvement.
Treatment: amphotericin B.
Nasopharyngeal angiofibroma
benign neoplasm composed of admixture of vascular and fibrous tissue. Occurring almost exclusively in young adolescent males and men before the age of 25. Most common clinical complaints are persistent nasal obstruction and epistaxis.
xerostomia
aka dry mouth
sjogrens, previous radiation, meds
Sialadenitis
inflammation of the salivary glands
Mucocele
blockage or traumatic injury to a minor salivary gland, with leakage of contents into the surrounding connective tissue stroma
ranula
mucocele of sublingual duct
pleomorphic adenoma
benign tumor
most common salivary gland tumor
simple resection will lead to high recurrace rate (25%) because full resection is hard
composed of chondromyxoid stroma and epithelium
painless - has not invaded the facial nerve that runs through the parotid.
Mobile and circumscribed - has not invaded surrounding tissue
warthin tumor
benign cystic tumor with lymphoid tissue with germinal centers
usually in the parotid
aka papillary cystadenoma lymphomatosum
mucoepidermoid carcinoma
the most common malignant tumor of the salivary glands and has mucinous and
squamous components. It typically presents as a painless, slow-growing mass but involves the facial nerve when it hits it
you can stain the cumin in the cells with mucicarmine (which can also stain cryptococcus)
boerhaave syndrome
transmural, usually distal esophageal rupture with possible pneumomediastinum due to violent retching; surgical emergency
mallory-weiss syndrome
PAINFUL hematemesis
longitudinal mucosal laceration at the gastroesophageal junction due to severe vomiting. leads to hematemesis. Usually found in alcoholics and bulimics.
if it ruptures the esophagus, it can lead to boerhaave syndrome with subcutaneous emphysema (air in the tissue beneath the skin, pushing on it sounds crackly)
mallory is bulemic, vomits blood, and drink weiss beer
guy from south america that has achalasia and heart problems
what are you thinking
chagas
trypanosoma cruzii
cancer in the bottom 1/3 of the esophagous
in the upper 2/3?
bottom - adeno
top - squamous cell
what infectious condition can cause secondary lactase deficiency
gastroenteritis (e.g. rotavirus)
via destruction of brush border cells
hartnup disease
defect in phenelalanine transporter in the gut
Leads to neutral aminoaciduria
and decreased absorption from the gut; results in pellagra-like symptoms; treat with high-protein diet and niacin
autosomal recessive
SGLT1
absorbes glucose and galactose in the enterocytes (Na dependent)
(secondary active transport)
how does fructose enter the enterocyte in the small intestine
GLUT-5
what transfers all monosaccharides from the lumen of the epithelial cells of the intestine to the blood
GLUT-2
asymptomatic mild jaundice
elevated unconjugated bilirubin without overt hemolysis
bilirubin goes up with fasting as stress
Gilbert syndrome, low levels of UDP-glucuronosyltransferase
conjugation activity, decreased bilirubin uptake by hepatocytes
common, no clinical consequences
cancers assc with H.pylori
MALT-lymphoma (b-cell) and gastric adenocarcinoma
patients can have high acid production
Stain for H. pylori
silver
helicobacter pylori characteristics
gram -
oxidase +
comma shaped
urase +
“triple therapy for H. Pylori
ppi
clarithromycin
metronidazole/tinidazole/amoxacillin
Chronic gastritis type A/B
A - Autoimmune disorder characterized by
Autoantibodies to parietal cells, pernicious
Anemia, and Achlorhydria. Associated with
other autoimmune disorders.
T cells destroy parietal cells
Vit b12 def (megaloblastic anemia, atrophic glossitis, malabsorptive diarrhea)
B - Most common type. Caused by H. pylori infection. increased risk of MALT lymphoma and
gastric adenocarcinoma.
A comes before B
A in body, B in antrum
cause of pneumoperitoneum
perforated peptic ulcer
lymphocytic gastritis
what cells
intraepithelial lymphocytic inflammation (CD8+)
assc with celiac
granulomatous gastritis causes
crohn’s, sarcoidosis, mycobacterial and fungal infections would cause what type of gastritis
polyp that form with the use of ppis
cystic fundic gland polyp, secondary to increased gastrin secretion in response to decreased acid
2 morphological types of gastric adenocarcinoma
present with dyspepsia, dysphagia, nausea
intestinal type: large, irregular ulcer with heaped up margins. tumor shows glandular (intestinal) differentiation. lesser curvature of antrum
Diffuse type: involvement and thickening of gastric wall. Signet-ring cells. can occur in youths. rigidity and leather bottle appearance of the gastric wall (linitis plastica)
sister mary joseph umbilical nodule
gastric adenocarcinoma that has spread to the umbilicus
Virchow’s node
metastasis of gastric adenocarcinoma to the left supraclavicular lymph node
c-kit gene
gain of function causes GIST - cells mutate towards cells of cajal, assc with neurofibromatosis 1.
gene product is for a tyrosine kinase RECEPTOR, can Tx with imatinib.
GIST
gastrointestinal stromal tumor
c-kit gene activation
cells mutate towards “cells of Cajal” (cells involved in gut peristalsis)
can be assc with neurofibromatosis type 1
imatinib is a tyrosine kinase inhibitors that can be used
C-KIT = Cajon drum KIT - cajal cells keep the beat in the intestines like a cajon
malt lymphoma
what cell
B-cells
assc with h. pylori
H2 blockers
-tidine
cimetidine, ranitidine
ppis
PRazoles
what converts trypsinogen to trypsin
enteropeptidase
it is secreted by the duodenum and also makes the pancreas secrete trypsinogen
Pyloric stenosis
more common in males, bottle fed, if mom had it as a baby
improper innervation of pyloric smooth muscle. Have projectile, non-bilious vom
baby is hungry after vom
baby is dehydrated
palpable olive in RUQ is diagnostic on exam
intussusception
inversion of the small bowel into the large (usually)
think of the water snake toys
colicky abdominal pain “bring up their legs for a couple minutes, cry, and then they are fine. repeat every couple minutes. Bilious emesis, previous URI (causes lymphoid aggregates in the terminal ileum to increase), currant jelly stool (mucosal ischemia - order is lymphatic obstruction, venous congestion, arterial congestion, ischemia and necrosis)
Tx - barium enema
operate after two tries of barium enema
ultrasound or CT of abdomen shows target sign
intussusception
most common cause of appendicitis
obstruction of the appendix by feces
psoas sign
lit leg agaisnt resistance
checks for psoas muscle irritation
indicative of appendicitis
obturator sign
knee flexed, internal rotation causes pain
indicative of appendicitis
Rovsing sign
palpate left lower quadrant and remove hand, right lower quadrant hurts
Meckel’s diverticulum
2 inches long. 2 feet from the ileocecal valve. 2% of population. Commonly presents in first 2 years of life. May have 2 types of epithelia (gastric/ pancreatic).
True diverticulum. Persistence of the vitelline
duct. May contain ectopic acid–secreting
gastric mucosa and/or pancreatic tissue. Most
common congenital anomaly of the GI tract.
Can cause melena, RLQ pain, intussusception,
volvulus, or obstruction near the terminal
ileum. Contrast with omphalomesenteric cyst
= cystic dilation of vitelline duct.
Diagnosis: pertechnetate study for uptake by
ectopic gastric mucosa.
volvulus
obstruction of the bowel because of twisting
newborn with bilious emesis, abdominal distention, and failure to mass meconium in the first 48 hr
hirschsprung disease
gold standard is a full thickness rectal biopsy showing aganglionosis
failure of neural crest migration
aganglionic portion can never dilate
ASSC with trisomy 21, mutations in RET gene
omphalocele, hyperinsulinemia, macroglossia
beckwith-wiedemann syndrome
assc with wilms tumor
omphalocele
ASSC with the trisomies
bulging of stomach contents outside of the body with peritoneum covering it
Gastroschisis
like an omphalocele with no peritoneal sac covering it. looks red and angry
what are peptides cotransported with in order to get into the enterocyte
H+
what happens when H+ hits the duodenum
duodenum secretes secretin from S cells, secretin goes to pancreas to simulate bicarb secretion
consequence of CCK and secretin on stomach
inhibit gastric motility AND secretion
where is the majority of pancreatic juice secreted
ampulla vater (contains sphincter of oddi)
what cells in the pancreas secrete digestive enzymes
Acinar cells
what is the duodenal enzyme that activates the pancreas to secrete trypsinogen
enterokinase/enteropeptidase
what do you need in order for lipase to be active in the duodenum
procolipase is activated into colipase
colipase helps lipase work in the duodenum
without colipase, lipase cannot work on fat droplets because cholesterol gets in the way…
trypsin also activates procolipase
the vagus nerve secretes what neurotransmitters when you see food
ACh on the acinar cells directly
GRP on the G cells (reinforced when you actually eat)
(increase Ca in the cells which causes phosphorylation of structural and regulatory proteins with the luminal side of the acinar cell)
how does trypsin stop secretion of CCK
it actually cleaved CCK-RP (and monitor peptide), which stops the activation of CCK
(CCK also is a satiety molecule)
genetics of hereditary pancreatitis
autosomal dominant
due to mutation in the trypsinogen PRSS1 gene
causes activation of digestive enzymes inside the pancreas
intracellular mech of secretin
activates intracellular cAMP
Activation of cAMP opens up CFTR chloride channels. the chloride then goes over to another transporter on the same cell and is anti-ported for bicarbonate
all this bicarb in the blood was generated through the “alkaline tide” effect of the stomach secreting acid into the lumen
(whereas CCK operates through Ca)
GLP-`1
glucagon like peptide 1
is an incretin (means in increases insulin and decreases glucagon)
oral glucose leads to a higher insulin level than IV glucose because of GLP-1
trigger secretion of beta cells obv
decreased levels of leptin in the body mean what
you are hungry
Aniridia, genitourinary malformation, retardation
what tumor are you worried about
GI stuff you are worried about?
wilms tumor
Most common renal malignancy of early
childhood (ages 2–4). Contains embryonic
glomerular structures. Presents with huge,
palpable flank mass and/or hematuria.
(WAGR complex)
omphalocele, hyperinsulinemia, macroglossia - beckwith weidemann
mneumonic for people at greatest risk for gall stones
fair: more prevalent in Caucasian population
fat: BMI >30
female gender
fertile: one or more children
forty: age >40
ASBT
apical sodium-dependent bile salt transporter
in the ileum and colon, reuptakes conjugated bile salts (mostly ileum)
how to make conjugated bilirubin
condition in infants who cannot make it?
bilirubin is conjugated with glucuronic acid by the enzyme glucuronyltransferase
the enzyme is slow to start up in babies, leading to jaundice
Infants who have a developmental deficiency in UDP-glucuronyl transferase are unable to hepatically metabolize the antibiotic drug chloramphenicol (binds 23s of 50s and prevents peptidyl transferase) which requires glucuronidation. This leads to gray baby syndrome
Presents in early childhood with failure to
thrive, steatorrhea, acanthocytosis (spikey RBCs or burr cells), ataxia, night
blindness.
Abetalipoproteinemia
decreased synthesis of apolipoprotein B. inability
to generate chylomicrons. Decreased secretion of
cholesterol, VLDL into bloodstream. fat accumulation in enterocytes.
haematochezia
blood in stool
Ileus
failure of forward motion of intestinal contents
tenesmus
feeling that you need to pass stool even when bowels are empty
pancreatic divisum
dorsal and ventral parts fail to fuse around 8th week
bulk of pancreatic secretions go through the minor papilla instead of the papilla of vater
mostly asymptomatic, can cause pancreatitis
how can you get hypocalcemia in pancreatitis
calcium can precipitate in areas of fat necrosis caused by pancreatitis
reye syndrome
rare, often fatal childhood hepatoencephalopathy caused by viral infection that has been treated with aspirin
aspirin metabolites decrease beta-oxidation by reversible inhibition of mitochondrial enzyme
a scorpion sting can do what to your organs
cause acute pancreatitis
what causes pancreatic pseudocysts
why are they called pseudo
acute pancreatitis, trauma
inflammatory fibrous cyst that lacks an epithelial lining
(pseudocyst)
account for 75% of cysts in the pancreas. Cyst fluid are high in amylase
serous (microcystic) cystadenoma
rare, benign neoplasm composed of glycogen rich cuboidal cells surrounding small cysts containing clear, thin, straw colored fluid
multiple tiny cysts
mucinous cystic adenoma
middle aged women (95%)
form large multiloculated cysts filled with mucin in tail or body, and do not communicate with pancreatic duct
painless slow-growing mass, can do distal pancreatectomy
benign version
looks like ovarian tissue histo
mucinous cystic adenocarcinoma
middle aged women (95%)
form large multiloculated cysts filled with mucin in tail or body, and do not communicate with pancreatic duct
painless slow-growing mass, can do distal pancreatectomy
malignant version
looks like ovarian tissue histo
weight loss with painless jaundice and elevated ALP, ALT, AST
bad sign
may be pancreatic carcinoma, bile duct carcinoma, biliary carcinoma
their biliary tract is for sure obstructed
patient comes in with redness and tenderness of extremities, and obstructive jaundice with palpable, nontender gallbladder
pancreatic carcinoma
Migratory thrombophlebitis—redness and tenderness on palpation of extremities (Trousseau syndrome) Obstructive jaundice with palpable, nontender gallbladder (Courvoisier sign)
APC gene
A Poopy Cancer - makes the colon at risk for cancer
defective in FAP
on chromosome 5 (fap with you 5 fingered hand)
the three mutations that give you colorectal carcinoma
loss of both copies of APC tumor suppressor gene on chromosome 5 - colon at risk for polyps
K-RAS mutation - allows for formation of adenomatous polyp
loss of tumor supressor genes - increased expression of COX (aspirin protects against adenoma carcinoma sequence) (p53, DCC) - carcinoma
order of CRC is AK-53
tumor marker for pancreatic adenocarcinoma
CA-19-9
inspiratory arrest on RUQ palpation due to pain
murphys sign - cholecystitis
kid with polyhydramnios and lung irritation
esophageal atresia
diaphragmatic hernia is cause by defective development of what
Pleuroperitoneal membrane
most commonly hiatal hernia
Severe jaundice in a neonate with kernicterus
most likely Crigler-Najjar syndrome (congenital unconjugated hyperbilirubinemia because of lack of UDP-glucuronyltransferase)
(gilbert is decreased activity of UDP-glucuronyltransferase)
patients die within a few years
Type II is less severe and responds to phenobarbital, which increases liver enzyme synthesis.
Celiac disease lab findings
HLA subtypes assc with it
IgA Anti-transglutaminase antibodies/anti-gliadin/IgA anti-endomysial antibodies
Small bowel begins to look like shag carpet at the beginning, then they loose their villi.
HLA DQ2/DQ8
gluten gets cleaved into gliadin molecules, which get recognized as foreign by DQ2/8 APCs. These APCs stimulate t-cells, and the t-cells tell B cells to make the antibodies listed above. T cells themselves make INF gamma and damage the enterocytes
manifests most in duodenum!
Started going to dairy queen when i was two but stopped when I was diagnosed with celiac at age 8
branches of the celiac trunk
from left to right:
left gastric
splenic
common hepatic (gives rise to hepatic proper (splits into hepatic artery proper and right gastric), also gastroduodenal (splits into right gastroepiploic and anterior superior pancreaticoduodenal)
patient has celiac like symptoms and responds to antibiotics
tropical sprue
older man comes in with diarrhea, abdominal pain, arthralgias, neurological symptoms, cardiac symptoms, and is shown to have fat in macrophages in his gut
whipple disease
caused by tropheryma whipplei, gram positive actinomycete
the macrophages are called foam cells
PASS the Foamy Whipped cream in a CAN (cardiac (endocarditis), Arthralgias, Neurological symptoms)
PAS positive
do pcr to identify
lactose intolerance test
positive if
Administration of lactose produces symptoms,
and
Glucose rises
D-xylose test
decreased excretion with intestinal mucosa defects or bacterial overgrowth, normal excretion in pancreatic insufficiency
used to distinguish the two
infant with hypoglycemia, FTT, hepatomegaly
Cori (debranching deficiency)
or
Von Gierke (glucose-6-phosphatase deficiency)
indirect vs direct bilirubin
indirect - unconjugated
direct - conjugated
krekenberg tumor
stomach cancer with bilateral metastases to ovaries. Abundant mucus, Signet ring cells.
double bubble after the stomach
assc with what condition
duodenal atresia
get polyhydramnios, bilious vomm
trisomy 21
mneumonic for crohns
FAT GRANny and an OLD CROHN SKIPPing down a COBBLESTONE road away from the WRECK
creeping fat and cobblestone mucosa on gross anatomy
granulomas
skip lesions
(w)rectal sparing
erythema nodosum assc with what GI conditions
Crohn’s and ulcerative colitis
immune cell responses in crohns vs ulcerative colitis
crohn - Th1
UC - Th2
patient has nausea, pernicious anemia and achorhydria
what condition
what assc cancer
autoimmune gastritis (chronic) - autoantibodies to parietal cells. found in fundus/body
gastric carcinoma
Rugae of the stomach are hypertrophied. patient has protein loss
menetrier disease
get parietal cell atrophy, and increase in mucous cells. Precancerous.
rugae of the stomach can look like brain gyri
ulcer that uccurs in the proximal duodenum is assc with what type of trauma
what happens to the plasma?
classically with severe burns
they are called curling ulcers (burned by the curling iron)
get decreased plasma volume with the burn
problem with excretion of conjugated bilirubin (bilirubin diglucuronide)
black liver grossly
Dubin-johnson syndrome
due to defective excretion
(rotor syndrome is similar but milder and does not cause black liver)
jaundice, RUQ pain, fever
Charcot’s triad
occurs in ascending cholangitis (common bile duct infection)
what is weird about the spleen being supplied by the celiac artery
it is part of the mesoderm, and the celiac artery normally supplies foregut structures
structures contained in the hepatoduodenal ligament
portal vein
hepatic artery proper
common bile ducts
direct inguinal vs indirect inguinal hernia - which membranes do each go through
internal - indirect
abdominal wall - direct
cyanide nitroprusside test is used to diagnose what
what is wrong
how do you treat it
cystinuria - autosomal recessive (throws the popcycle at his sister), defect of PCT and intestinal amino acid transporter for Cysteine, Ornithine,
Lysine, and Arginine (COLA).
excess cystine in the urine can lead to precipitation of hexagonal cystine stones
(Cystine is made of 2 cysteines connected by a
disulfide bond)
Treatment: urinary alkalinization (e.g.,
potassium citrate, acetazolamide) and
chelating agents increase solubility of cystine stones;
good hydration
what is decreased in wilson’s disease in the serum
what cancers are assc with wilson’s
gene?
Tx?
ceruloplasmin
hepatocellular carcinoma
Autosomal recessive inheritance (chromosome 13). Copper is normally excreted into bile by hepatocyte copper transporting ATPase (ATP7B gene).
Treat with penicillamine or trientine
change in epithelium in barrett’s esophagus
non keratinized squamous –> non ciliated columnar epithelium with goblet cells
prostaglandins in the stomach are made by what
foveolar cells
increased intracranial pressure can do what to the stomach
cause a cushing ulcer
increased intracranial pressure –> increased vagal stimulation –> ACh receptor on parietal cell is activated increasing acid production
Autoimmune gastritis
where in GI tract and caused by what what antibodies do you see with it what happens to acid levels what do the damaged cells become more like associated cancer risks?
autoimmune destruction of parietal cells in the body and the fundus by T-cells (type 4 hypersensitivity)
antibodies against parietal cells or antibodies against intrinsic factor (megaloblastic (pernicious) anemia - this is the most common cause of vit b12 def.) - this is not the cause, but a consequence of the damage
causes achlorhydria with INCREASED gastrin (g-cells are trying really hard to make that acid)
a bunch of lymphocytes in the stomach cause INTESTINAL METAPLASIA
gastric adenocarcinoma (because of the intestinal metaplasia)
Gastric ulcer
where is it usually located
rupture carries risk of bleeding from what
lesser curvature of antrum
left gastric artery
nitrosamines (in smoked foods) increases risk of what GI thing
INTESTINAL type gastric carcinoma (increased risk of stomach cancer in japan linked to this)
blood type A
increased risk of what cancer
intestinal type gastric CA
CA means carcinoma
C”A” = blood type A
acanthosis nigricans
increased risk of what
sign of gastric carcinoma
darkening and thickening of the tissues under the arm pit
a bunch of sebborheic keratosis that arise all over the skin
what is it called
increased risk of what
leser-trelat
associated with gastric carcinoma
sister mary joseph nodule - what cancer assc
krukenburg tumor - what cancer assc
SMJ - periumbilical region met. intestinal type gastric carcinoma
krukenburg tumor - bilateral mucinous ovary tumors - diffuse type gastric carcinoma
bloating, flatulence, foul-smelling fatty stools in a camper
what to look for
tx
giardia
it looks like a little face in the active stage (nuclei are eyes)
in the stool it looks like a cyst
tx metronidazole
severe diarrhea in AIDS
mild watery diarrhea in otherwise healthy patient
see oocytes - what stain did you use?
organism?
tx?
oocytes on acid fast stain
cryptosporidium
nitazoxanide
(nita is Sabs cryptic sister (she has oocytes))
see when water treatment fails like a waterpark
bloody diarrhea, liver abcess, RUQ pain in someone from tropics
entamoeba histolytica
Amebiasis: bloody diarrhea (dysentery), liver abscess (“anchovy paste” exudate), RUQ pain (histology shows flask-shaped ulcer if submucosal abscess of colon ruptures)
the trophozoites can have RBCs in their cytoplasm and their nucleus looks like a target (can have up to 4 nuclei)
metronidazole for symptomatic, iodoquinol for
asymptomatic cyst
passers
iodoquinol used for
entamoeba histolytica (for asymptomatic cyst passers)
anal pruritis and intestinal infection symptoms.
a worm - name?
Dx?
Tx?
enterobius vermicularis (pinworm)
Dx - scotch tape test
Tx - bendazoles
ancylostoma duodenale, necator americanus
how do they get in the body
Sx
Tx
AKA hookworms
larvae penetrate skin
cause intestinal infection causing anemia by sucking blood from the intestinal walls
Tx - bendazoles
strongyloides
how do they get in the body
Sx
Tx
larvae in soil penetrate the skin
respiratory phase can cause dry cough, throat irritation
intestinal infection causing vom, diarrhea, epigastric pain, (may be peptic ulcer-like)
Tx. ivermectin or albendazole
mech of bendazoles
binds to parasite beta tubulin and inhibits microtubule formation
ivermectin mech and use
used for river blindness (onchocerca volvulus), strongyloides
binds glutamate-gated chloride channels in invertebrate nerve and muscle cells, causing deactivation of channel: worm paralysis and death by starvation
ingestion of undercooked pork or eggs
get intestinal infection with cysticercosis, neurocycticercosis
taenia solium (a big ole tapeworm)
common treatment for flukes (and also tapeworms)
praziquantel
Patient from south america. liver and spleen granulomas, fibrosis, and inflammation (rash or itchy skin). something penetrated their skin and it’s not bacterial
what is it
assc. cancer?
Tx?
schistosoma
snails are hosts, cercariae penetrate skin
Liver and spleen granulomas,
fibrosis, and inflammation
Chronic infection with
S. haematobium can lead to
squamous cell carcinoma
of the bladder (painless
hematuria)
S. mansoni, and japonicum can lead to portal hypertension
Tx is prazquantel
multiple nonmalignant hamartomas throughout GI tract, along with hyperpigmented mouth, lips, hands, genitalia
Peutz-jeghers syndrome - autosomal dominant
increased risk of CRC
single colonic polyp in a kid - risk of cancer?
no risk if single juvenile polyp
Juvenile polyposis syndrome on the other hand presents with multiple juvenile polyps in GI tract, increased risk of adenocarcinoma.
most common non-neoplastic polyp in the colon
Hyperplastic polyp - serrated formation of the mid-portion of the polyp
what colonic polyps are more likely to be malignant - tubular or villous
villous are more likely to be adenomatous
hypertrophy of pigmented retinal epithelium
what GI disease
Gardner syndrome - FAP plus osseous and soft tissue tumors
apple core lesion
annular adenocarcinoma
condyloma acuminatum
caused by what
genital warts caused by HPV
hematochezia - UC or CD
UC
can present in CD, but much less likely
tenesmus - UC or CD
UC
jaundice and sclerosing cholangitis - UC or CD
UC
perianal fistula and abscess - UC or CD
CD
abdominal pain, weight loss and FTT - UC or CD
more common in CD because CD is more agressive
serology of CD and UC
CD - ASCA - anti-saccharomyces cerevisiae antibodies
UC - pANCA - perinuclear antineutrophil cytoplasmic antibodies - can also be positive in microscopic polyangiitis, churg-strauss
ankylosing spondylitis - UC or CD
UC
patient has trouble bending over, erythema nodosum, uveitis, dry skin
what u think
UC - bending problem is ankylosing spondylitis
what IBD can lead to toxic megacolon
UC
Primary sclerosing cholangitis
what is it
assc with what disease
disease of the bile ducts that causes inflammation and obliterative fibrosis of bile ducts inside and or outside of the liver
assc with UC
mneumonic of CD
Ulcerative colitis causes ULCCCERS: Ulcers Large intestine Continuous, Colorectal carcinoma, Crypt abscesses Extends proximally Red diarrhea Sclerosing cholangitis
CYP2E1 converts this chemical found in plastics into a reactive epoxide that damages the liver, causing angiosarcoma
What other poison can cause angiosarcoma
Vinyl chloride
arsenic can also cause it
What is the metabolite that causes damage in acetaminophen overdose and how does it cause damage
what is the antidote
Overdose produces hepatic necrosis; acetaminophen metabolite (NAPQI) depletes glutathione AND
forms toxic tissue adducts (binds to proteins and fucks them up) in liver. N-acetylcysteine is antidote—regenerates glutathione.
primary hemochromatosis due to what mutation
assc with what HLA
C282y (worse) or H63D (more mild) on HFE gene
HLA-A3
cirrhosis, diabetes, skin pigmentation
what disease
what labs
hemochromatosis
can also present with arthralgia, lethargy, hypogonadism, abdominal pain, CHF
elevated serum iron, elevated serum ferritin, high transferrin saturation
a person has hepatotox from eating a mushroom stew they made
what enzyme is inhibited
what shroom
RNA pol II Amanita phalloides (death cap)
hepatomegaly, ascities, abdominal pain, abdominal varices
also patient is at risk for clotting
Budd-chiari syndrome - occlusion of IVC or hepatic veins with centrilobular congestion and necrosis
severe preeclampsia can lead to this liver thing
HELLP syndrome
Hemolysis, Elevated Liver enzymes,
Low Platelets. A manifestation of severe
preeclampsia, although may occur without
hypertension
Treatment: immediate delivery.
AST:ALT ratio in alcoholic liver disease
greater than 2
80% of AST is found in mitochondria, and EtOH is a mitochondrial toxin
seen these on liver biopsy - what are you thinking
Ground glass hepatocytes plasma cells lymphocytic/granulomatous cholangitis Fibrous obliterative cholangitis periportal hepatitis with mild steatosis globular hepatocyte inclusions and PAS positive
Ground glass hepatocytes - chronic viral hep B
plasma cells - autoimmune hep, primary biliary cirrhosis
lymphocytic/granulomatous cholangitis - primary biliary cirrhosis
Fibrous obliterative cholangitis - primary sclerosing cholangitis
periportal hepatitis with mild steatosis - chronic viral hepatitis C
globular hepatocyte inclusions - A1AT deficiency
lab tests for
viral hep autoimmune hep wilson's A!AT hemochromatosis primary biliary cirrhosis
viral hep - serology, nuclear testing (HBsAg, anti-HBc (total), HBV DNA, anti-HCV, HCV RNA)
autoimmune hep - ANA, anti-smooth muscle antibodies
wilson’s - ceruloplasmin
A1AT - A1AT level, phenotype
hemochromatosis - Fe, TIBC, Transferrin sat, genetics
primary biliary cirrhosis - anti-mitochondrial antibodies
antimitochondrial antibodies
what disease?
typical pt profile?
primary biliary cirrhosis
usually middle aged female
biliary tract disease assc with hypergammaglobulinemia
primary sclerosing cholangitis (IgM)
primary biliary cirrhosis can also cause increased IgM, but it is classically assc with increased serum mitochondrial antibodies.
what is found in sea food that you should avoid if you have hep A, B, or cirrhosis
vibrio
what drug blocks histamine release in the gut
octreotide (somatostatin analog - can be used to treat pituitary adenomas, gastrinoma (carcinoid tumors), esophageal varicies)
most common cause of intussusception in kiddos? Adults?
lymphoid hyperplasia (usually due to viral infection)
tumor in adults
things that cause a thrombosis of the mesenteric vein
polycythemia vera, lupus anticoagulant
things that make the blood thicker
abdominal pain, bloody diarrhea and decreased bowel sounds
infarcted bowel -
transmural damage = complete infarct.
Mucosal damage = hypotension
how is gliadin toxic in celiacs
gliadin is deamidated by tissue transglutaminase. Deamidated gliadin is presented by APCs vie MHC II. Helper T cells then mediate tissue damage
Dermatitis herpetiformins
pruritic papules, vesicles, and bullae often found on elbows. Deposits of IgA at the tips of dermal papillae. Associated with celiac disease.
looks like hepes
resolves with gluten free diet
patient with celiacs has been uncer control for years, never eats gluten, but suddenly develops disease
what u thinknig
small bowel carcinoma
t-cell lymphoma (or EATL - enteropathy associated T cell lymphoma)
patient from warm area develops diarrhea and bloating after an infectious diarrhea.
responded to antibiotics
what disease
where in the GI tract
tropical sprue
damage more in the jejunum and ileum (whereas in celiac, its the duodenum)
where is the key place we absorb folic acid?
b12?
folic acid - jejunum
b12 - ileum
macrophages loaded with PAS positive staining material in lamina propria of small bowel
whipple disease - results in fat malabsorption and steatorrhea because the macrophages get really big and compress the lacteals
abetalipoproteinemia
what dont you have
apoB48 (to make chylomicrons) and 100 (to make VLDL, LDL)
positive for chromogranin - what u think
what cancer
what is found in urine
carcinoid tumors (and all neuroendocrine tumors) - secrete serotonin which is normally broken down to 5-HIAA by MAO in the liver, which you can look for in the urine
if it’s metastatic to the liver, it can dump serotonin into the hepatic vein and go systemic. serotonin then can hit lung and skin (cause carcinoid syndrome - bronchospasm, diarrhea, flushing)
when it hits the right heart, it causes fibrosis of the heart (carcinoid heart disease) - lung has MAO so you don’t get left heart disease
ETOH can cause release of serotonin from the tumor
colonic crypt abscess with neutrophils
ulcerative cholitis
primary sclerosing cholangitis is assc with what ibd
ulcerative cholitis
calcium oxalate stones are assc with what GI thing
Crohns
the fat in the lumen binds to calcium, which oxalate normally binds to to be excreted. so you get increased oxalate absorption
what is diagnosic for hirschsprung
Rectal suction biopsy
normal biopsy doesn’t cut it because it only goes to the mucosa
you need to be able to see the absence of ganglion cells
colonic diverticula - what layers are herniated
the mucosa and submucosa herniate through the muscularis propria (it is a false diverticulum)
happens because of wall stress
arise where vasa recta traverse muscularis propria (weak point in colonic wall)
most common cause of ischemic colitis
atherosclerosis of SMA
damage occurs mostly in splenic flexure
hyperplastic polyp
where mostly
appearance on microscopy
malignant?
left colon
serrated appearance on microscopy
benign
most common type of polyp
second most common type of polyp that has the ability to become cancer if unresected
adenomatous polyp
parasite associations
Biliary tract disease, cholangiocarcinoma
Brain cysts, seizures
Hematuria, bladder cancer
Liver (hydatid) cysts
Microcytic anemia
Perianal pruritus
Portal hypertension
Vitamin B
12 deficiency
Biliary tract disease, cholangiocarcinoma Clonorchis sinensis
Brain cysts, seizures Taenia solium (cysticercosis)
Hematuria, bladder cancer Schistosoma haematobium
Liver (hydatid) cysts Echinococcus granulosus
Microcytic anemia Ancylostoma, Necator
Perianal pruritus Enterobius
Portal hypertension Schistosoma mansoni, Schistosoma japonicum
Vitamin B
12 deficiency Diphyllobothrium latum
fungus and toxin assc with hepatocellular carinoma
aspergillus
aflatoxins
presentation of aldolase B deficiency or uridyl transferease deficiency in a kid
when do each present
vomiting
FAB GUT
FAB - fructose gets phosphorylated and trapped in liver - presents when weaned (about a year)
GUT - galactose gets phosphorylated and trapped in liver - presents at birth
kid is on theophylline for asthma - common SE?
heartburn
rice water diarrhea
cholera
overactivation of adenylate cyclase permanently activates Gs, causing increased Cl secretion in the gut and H2O efflux
common causes of bloody diarrhea
CASES
Campylobacter entAmoeba Salmonella Enterohemorrhagic E. coli Salmonella
non blanching rash on lower extremities in a 12 year old. abdominal pain and low urine output
HSP
abnormal gene in hirschsprung
RET
prostaglandins/misoprostol acts on what g protein receptors in the stomach
Gi
just like somatostatin
histamine acts through which g-protein receptors in the stomach
Gs
gastrin acts through which g-protein receptors in the stomach
Gq
ACh acts on which g-protein receptors in the stomach
Gq
What is the mechanism of metronidazole
classic treatment for what?
The nitro group on metronidazole is reduced in anaerobic organisms to a product that can interrupt the helical structure of DNA, inhibiting nucleic acid synthesis.
Tx for C. Diff, Tx for some protazoans like entamoeba, trichomonas, giardia, bacterial vaginosis like gardonella, part of triple therapy for h. pylori
most common complication of acute pancreatitis resulting from bouts of heavy drinking
pancreatic pseudocyst
patient is on a drug to treat gastroparesis and has diabetes
what is the mech of the drug and some SE
metoclopramide
D2 antagonist
increases resting tone of the GI tract
parkinsonian like side effects (“extrapyramidal”)
infliximab is what
used to treat what
monoclonal antibody to tumor necrosis factor-alpha. used to treat crohn disease, second line to aminosalicylates (eg, sulfasalazine) in ulcerative colitis
sulfasalazine is what
used to treat what
combination of sulfapyridine and 5-aminosalicylic acid. activated by colonic bacteria
first like for UC, used for crohn as well
patient presents with flushing, chronic diarrhea, SOB, valve issues
what do you give for Sx
octreotide will bind to the somatostatin receptors on the carcinoid tumor and stop serotonin release
where in the GI tract is bile reabsorbed (and intrinsic factor coupled to b12)
terminal ileum
ulcers
silver stain +
what is causing
what do ulcers look like
h. pylori
Small, sharply demarcated erosions filled with nonspecific inflammatory infiltrate
mutations of tumor suppressor genes are associated with what type of hereditary colon cancer?
mutations of DNA repair genes are associated with what type of hereditary colon cancer?
FAP - tumor suppressor (APC, chromosome 5)
hereditary nonpolyposis colorectal cancer - DNA repair genes (MSH2, MLH1)
painful hemorrhoids - what arteries and veins supply this area?
inferior rectal artery, which branches from the internal pudendal and is drained by the inferior rectal vein
(superior rectal artery (branch of inferior mesenteric) is above pectinate line, and not painful unless necrosed or thrombosed)
treatment for Sx of diarrhea in someone with ibs
loperamide or diphenoxylate
renal calculi are assc with what IBD
crohns
medication someone could be taking for gerd that causes volume depletion
milk of magnesia (magnesium hydroxide) due to diarrhea
person with nontyphoidal salmonellosis
Tx?
don’t give antibiotics for nontyphoidal (salmonella typhimurium and salmonella enteritidis) because symptoms can be prolonged with antibiotic treatment.
dehydration due to diarrhea should be treated with fluid and electrolyte replacement
jaundice, hypercholesterolemia, pruritis with elevated alkaline phosphatase
what are you thinking
Primary biliary cirrhosis
antimitochondrial antibodies
tenofovir
used for
SE
first line therapy for chronic hep b
a nucleotide reverse transcriptase inhibitor
renal insufficiency in adults, decreased bone density in kids
patient is on a cholesterol drug and gets myalgias
what is it
Statin
HMG coa reductase inhibitor
something is wrong with the pancreas and you have watery diarrhea, hypokalemia, hypochlorhydria
VIPoma
pacreatic tail tumor secreting vasoactive intestinal peptide
