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Year 2 > Case 11 > Flashcards

Case 11 Flashcards

1
Q

What are the layers of the duodenal wall from lumen outward?

A

Mucosa - epithelium, lamina propria, muscularis mucosa
Submucosa - contains Brunner’s glands (only present in duodenum)
Muscularis propria/ externa - inner circular, outer longitudinal muscle
Serosa

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2
Q

What are villi made of?

A

Epithelia and lamina propria (do not contain muscular is mucosa)

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3
Q

What are plicae circulares/ valvular conniventes made of?

A

Mucosa and submucosa (do not contain muscularis propria/ externa)

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4
Q

Where are Brunner’s glands found and what do they do?

A

Brunner’s glands are in submucosa of duodenum

Secrete alkaline mucus

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5
Q

What do enterocytes do in the small intestine?

A

Produce and excrete digestive enzymes that bind and help the brush border to break down sugars and proteins

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6
Q

What do enterocytes do in the large intestine?

A

Absorb water and electrolytes

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7
Q

Where are plicae circulares/ valvular conniventes most extensive?

A

Jejunum

Less extensive in duodenum and ileum

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8
Q 
What are the differences between jejunum and ileum in terms of:
Bore 
Wall thickness
Plicae circulares/ valvular conniventes
Arcades 
Vasa recta 
Villi
Crypts
A 
(jejunum, ileum)
Bore: wide, narrow  
Wall thickness: thick, thin 
Plicae circulares/ valvular conniventes: extensive, less
Arcades: sparse, multiple  
Vasa recta: long, short
Villi: tall, short 
Crypts: long, short
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9
Q

Where are Peyer’s patches found and what do they do?

A

Submucosa of ileum

Lymphoid tissue that play an important immunological role in sampling the contents of the tract

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10
Q

Describe the histology of the large intestine.

A

No villi but crypts
Many goblet cells
Lamina propria has many macrophages, plasma cells, eosinophils, and lymphoid nodules

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11
Q

Where are bile salts and vit B12 absorbed?

A

Terminal ileum

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12
Q

Where is ethanol absorbed?

A

Stomach

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13
Q

Where is cholesterol absorbed?

A

Duodenum, jejunum and ileum

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14
Q

Where is water absorbed?

A

Duodenum, jejunum, ileum and large intestine

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15
Q

Where is vit C absorbed?

A

Ileum

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16
Q

Where are sugars, fatty acids, Fe2+, fat and water soluble vitamins absorbed?

A

Duodenum, jejunum and ileum

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17
Q

What histological changes can be observed in Coeliac disease?

A 
Flat mucosa 
Crypt hyperplasia 
Villous atrophy
Intraepithelial lymphocytes and in lamina propria 
Enterocytes become cuboidal
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18
Q

Which area of the GI tract is primarily affected in Coeliac disease and therefore what may need replacing with initial treatment?

A

Proximal small intestine

Minerals and vitamines e.g. iron, folic acid, calcium, vit D

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19
Q

Why is there fat malabsorption in Coeliac disease and why is the absorption of fat soluble vitamins more affected than water soluble?

A

Brush border enzymes do not contain lipases so fats not broken down
Surface area for absorption of fat reduced

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20
Q

Why is B12 deficiency anaemia less likely than iron and folate deficiency in Coeliac disease?

A

Duodenum and jejunum primarily affected in Coeliac - where iron and folate are absorbed
Ileum less affected - terminal ileum is where B12 is absorbed

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21
Q

What’s the link between osteomalacia/ porosis and Coeliac disease?

A

Coeliac = malabsorption of calcium/ vitamin D

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22
Q

What is a right hemicolectomy?

A 
Removal of part of ileum 
Caecum 
Ascending colon
Hepatic flexure 
1st 1/3 of transverse colon
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23
Q

Which GI tract areas does Crohn’s disease have a particular tendency to affect?

A

Terminal ileum

Ascending colon

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24
Q

What changes to the GIT are seen in Crohn’s disease?

A

Bowel thickening and narrowing
Deep ulcers and fissures in mucosa - cobble stoning
Transmural inflammation

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25
Q

What is the serious complication of ulcerative colitis?

A

Toxic megacolon as can lead to perforation

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26
Q

What are the colonoscopy changes seen in UC?

A 
Redness
Inflammation 
Friability - bleeds easily 
Mucosal ulceration 
If ulceration severe enough, inflammatory pseudopolyps may be seen
Thinning of wall
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27
Q

What are the histological changes seen in UC?

A

Goblet cell depletion

Crypt abscesses

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28
Q

What is mild - moderate pseudomembranous colitis treated with?

A

Metronidazole

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29
Q

What is severe or relapsing pseudomembranous colitis treated with?

A

Vancomycin

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30
Q

What are the most common bacterial causes of gastroenteritis in the UK?

A

Campylobacter jejuni
then Salmonella
(local outbreaks of E. coli and Staphylococcus)

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31
Q

What is diverticulosis and diverticulitis?

A

Diverticulosis: diverticula present
Diverticulitis: inflamed diverticula

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32
Q

What are the complications of diverticular disease?

A

Perforation
Inflammation and infection
Stricture
Bleeding that can lead to generalised peritonitis or paracolic/ pelvic abscess
Fistulae (passage) into bladder causing dysuria/ pneumaturia (passage of gas/ air from the urethra during or after urination)
Fistulae into vagina causing discharge

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33
Q

What are the symptoms of diverticular disease?

A

L iliac fossa pain
Erratic bowel habit
Severe pain/ constipation from luminal narrowing

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34
Q

What changes occur in pseudomembranous colitis caused by C. diff in term of:
GI wall
Crypts
Lamina propria

A

Wall - inflamed and ulcerated
Lamina propria - neutrophils and capillary fibrin thrombi present
Crypt - necrosis and dilation, release mucopurulent exudate that neutrophils adhere to

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35
Q

How would you differentiate between histology slides from duodenum, jejunum, ileum and large intestine?

A

Duodenum - Brunner’s glands
Jejunum - plicae circuleras
Ileum - Peyer’s patches
Large intestine - no villi

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36
Q

What are Lynch syndrome patients more susceptible to?

A 
Colorectal cancer 
occurs at a younger in age in LS
can occur more than once 
40-70% LS carriers get it by 70
LS Colorectal cancer grows quicker than sporadic CRC
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37
Q

When should lynch syndrome patients start to get colonoscopies and how often?

A

Start at 20-25

Every one to two years

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38
Q

How can Colorectal cancer be prevented in lynch syndrome?

A

Long-term aspirin
Smoking cessation
Healthy diet

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39
Q

Other than crohn’s and ulcerative colitis what else can cause inflammation of the colon?

A 
Radiation injury 
Mesenteric ischeamia 
Infections/ infestations
Antibiotic effects 
NSAID toxicity 
Massed diverticulosis 
Diversion of fecal stream
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40
Q

What type of inflammation is there in UC and where?

A

Mucosal inflammation

Only in colon - almost always affects rectum

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41
Q

What are the symptoms of UC?

A

Bleeding
Diarrhoea
When limited to the rectum (proctitis) - constipation, passing blood/ mucus separate to stool, urgency, abdominal pain

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42
Q

How would you see toxic megacolon on investigation?

A

Early radiological sign - accumulation of gas over long segment, lumen may be narrowed with oedema/ spasm
Later - dilatation, maximal in transverse colon as air collects in most superior segment
Protrusion of soft tissue densities into lumen - pseudopolyps, submucosal oedema

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43
Q

What can cause benign stricture in UC?

A

Muscle hypertrophy
Muscle spasm
Fibrosis (less commonly)

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44
Q

How can UC be differentiated from infectious colitis?

A

UC is a more chronic inflammatory process - anaemia and thrombocytosis

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45
Q

What skin lesion associated with colitis is most commonly seen in Crohn’s disease?

A

Erythema nodosum

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46
Q

What skin lesion associated with colitis is most commonly seen in UC?

A

Pyoderma gangrenosum

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47
Q

What is the most common extracolonic manifestation of colitis?

A

Peripheral arthritis

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48
Q

How does inflammation from Crohn’s usually present?

A 
R lower quadrant abdo pain 
Tenderness 
Diarrhoea 
Low-grade fever 
Anorexia
Weight loss
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49
Q

What causes lumen narrowing in Crohn’s and how does it present?

A

Transmural inflammation causes fibromuscular proliferation and collagen deposition in the intestinal wall
Partial obstruction - luminal distention after meals causes cramps
High grade obstruction - vomiting

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50
Q

How might Crohn’s disease be misinterpreted as appendicitis?

A

Acute R lower quadrant pain - from ileocaecal microperforation

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51
Q

How might Crohn’s disease be misinterpreted as diverticulitis?

A

Acute L lower quadrant pain - from sigmoid microperforation

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52
Q 
What are the differences between Crohn's and UC in:
blood in stools
lesions
fistulas 
smoking
A

Blood - almost always in UC, hardly ever noticed in Crohn’s
Lesions - segmental and asymmetric in Crohn’s that usually involve the small bowel and relatively sparing of rectum, diffuse and continuous in UC, almost always affects rectum
Fistula - only in Crohn’s
Smoking - positively associated with Crohn’s, negatively correlated with UC

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53
Q

Has antibiotic use been associated with Crohn’s?

A

Multiple courses of antibiotics in childhood increases the risk of developing Crohn’s

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54
Q

What is dysbiosis?

A

Altered balance of protective bacteria (lactobacillus and bifidobacterium species) and aggressive commensal organisms (bacteroides, enterococcus and E.coli)

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55
Q

What is the proper name for Lynch syndrome and what kind of inheritance is it?

A

Hereditary nin-polyposis colon cancer (HNPCC)

Autosomal dominant inheritance

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56
Q

What is the first line therapy for inflammatory bowel disease?

A

Aminosalicylates e.g. sulfasalazine, mesalamine, olsalazine, balsalazide

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57
Q

What is the only type of study design that can determine cause and effect?

A

Random controlled trial

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58
Q

What are the 6 steps involved in randomised controlled trials?

A
  1. Hypothesis (and null hypothesis)
  2. Primary and secondary outcome measures
  3. Appropriate, representative sample of population
  4. Randomise - patient/ clinician do not know specific treatment assignment
  5. Perform intervention/ control
  6. Compare findings between each group
59
Q

What is the use of antibiotics in IBD?

A

To induce and maintain remission

In Crohn’s disease

60
Q

What treatment is given to induce remission in moderate to severe IBD?

A

Corticosteroids

61
Q

What treatment is given when patients are refractory to treatment of IBD or have developed steroid dependency?

A

Immunomodulators e.g. 6-mercaptopurine, azathioprine, methotrexate
Cyclosporine if severely ill/ unresponsive to corticosteroids and non-operative UC
Anti-TNF

62
Q

What are the surgical options for UC?

A

Curative surgery - Brooke ileostomy - ileum brought to surface of R lower quadrant
Ileal puch-anal anastomosis - sphincter sparing but may get anatomic leaks, strictures, pouchitis, partial incontinence

63
Q

What are the surgical options for Crohn’s?

A

Resection of involved area and anastomosis

Stricuroplasty for strictures - longitudinal incision made that is sutured transversely

64
Q

3 examples of sulphonylureas treatment for diabetes

A

Gliclazide
Glipizide
Glibenclamide

65
Q

How do sulphonylureas work as diabetes treatment?

A

Stimulate cells in the pancreas to make more insulin

Help insulin work more effectively

66
Q

What is the only biguanide used in the UK?

A

Metformin

67
Q

How does Metformin (a biguanide) work?

A

Helps stop the liver produce new glucose
Enables insulin to carry glucose into muscle/ fat cells
Aid weight loss

68
Q

What is the first line of treatment in diabetes? especially if overweight

A

Metformin

69
Q

What is the thiazolidinedione called? (diabetes treatment)

A

Pioglitazone

70
Q

How does Pioglitazone work?

A

Helps overcome insulin resistance

Body uses own natural insulin more effectively

71
Q

Examples of prandial glucose regulators that work rapidly and are short acting

A

Repaglinide

Nateglinide

72
Q

What are exenatide and liraglutide examples of?

A

Incretin mimetics

73
Q

What non-insulin diabetes treatment is there?

A

Incretin mimetics

74
Q

How do Incretin mimetics work?

A 
Increase incretin levels
So more insulin is produced as needed
Glucose production is reduced when not needed 
Rate of stomach digestion is reduced 
Reduces appetite
75
Q

What are sitagliptin, vildagliptin and saxagliptin and what do they do?

A

DPP-4 inhibitors

Block DPP-4 enzyme action that would destroy incretin hormone

76
Q

What is the only SGLT2 inhibitor called?

A

Dapagliflozin

77
Q

How does Dapagliflozin (SGLT2 inhibitor) work? What are the negatives?

A

Reduces amount of glucose absorbed by kidney
Glucose passed out in urine reduced blood glucose
Greater risk of genital/ urinary tract infections

78
Q

What is the only a-glucosidase inhibitor used?

A

Acarbose

79
Q

How does Acarbose (a-glucosidase inhibitor) work?

A

Slows down absorption of starchy food from intestine

Slowing the rise in blood glucose after a meal

80
Q

What are the retroperitoneal organs?

A 
Suprarenal gland
Aorta and IVC
Duodenum - except 1st part 
Pancreas - except tail 
Ureter
Colon - except transverse and loop of sigmoid  
Kidney 
oEsophagus 
Rectum
81
Q

What does the hepatoduodenal ligament contain?

A

Portal triad:
Common bile duct
Hepatic artery
Portal vein

82
Q

What is the name of the passage between the greater and lesser sacs?

A

Epiploic/ omental foramen

83
Q

What are the boundaries of the epiploic/ mental foramen?

A

Superior: Peritoneum covering caudate lobe
Inferior: Peritoneum covering duodenum
Anterior: Hepatoduodenal ligament
Posterior: Peritoneum covering IVC

84
Q

Which 2 organs are connected by the lesser omentum?

A

Liver

Stomach

85
Q

What is the greater momentum suspended from?

A

Stomach

86
Q

What problem may arise with a perforating ulcer of the posterior wall of the stomach?

A

May bleed directly into lesser sac
Drainage of fluid from lesser sac cannot be done by paracentesis (anterior abdominal wall) as compartment is too deep and occluded by greater omentum

87
Q

What does the coeliac trunk divide into?

A

Hepatic artery
Gastric artery
Splenic artery

88
Q

Which 2 (unpaired) branches of the abdominal aorta supply the duodenum?

A

COELIAC TRUNK - Hepatic artery - Pancreaticoduodenal branch

SUPERIOR MESENTERIC ARTERY - Inferior pancreaticoduodenal branch

89
Q

What is the name of the muscular/ fibrous structure attached to the 4th part of duodenum and duodeno-jejunal flexure that acts as a suspensory ligament?

A

Ligament of Treitz

90
Q

What is intussusception and how is it characterised on radiograph?

A

Part of the intestine slides into the adjacent region causing blockage and potential vascular obstruction
Donut sign

91
Q

What are the sings/ symptoms of intussusception?

A

Abdo swelling
Vomiting
Currant jelly stool - blood and mucus
Grunting in pain

92
Q

What does Meckel’s Diverticulum (congenital abnormality) represent?

A

Remnant of vitelline/ omphalo-mesenteric duct

The duct between umbilical vesicle and alimentary canal in early foetal life

93
Q

In appendicitis, when only the appendix and visceral peritoneum is involved, what sort of pain does the patient experience?

A

Ill-defined, generalised abdo pain in the umbilical region

pain typical for structures innervated by ANS

94
Q

In appendicitis, when the parietal peritoneum also becomes involved, what sort of pain does the patient experience?

A

Severe, highly localised, sharp pain in the R lower quadrant
(pain typical for structures innervated by somatic, segmental nerves)

95
Q

Why can pain from appendicitis be referred to the umbilicus?

A

Afferent fibres concerned with visceral pain from appendix enter the spinal cord at T10 segment
Umbilicus is supplied by T10 spinal segment

96
Q

What do nociceptive nerve fibres from abdominal viscera travel with?

A

Sympathetic fibres

97
Q

What do general sensory nerve fibres from abdominal viscera travel with?

A

Parasympathetic fibres

98
Q

Which artery supplies the appendix and what does it arise from?

A

Appendicular artery
from posterior caecal branch of ileocolic artery
of SMA

99
Q

What are the differences between small and large intestine?

A

Lare intestine is/ has:
Larger
More fixed position
Sacculated form - haustra
Omental/ epiploic appendages (small fatty projections)
Teniae coli - longitudinal muscular fibres in 3 longitudinal bands

100
Q

What separates the upper 2/3 of the anal canal from the lower 1/3?

A

Pectinate/ dentate line

101
Q

How can you differentiate between superior and inferior to pectinate line?

A

(above, below)
Epithelium: columnar, stratified squamous
Embryological origin: endoderm, ectoderm
Arterial supply: superior rectal, middle and inferior rectal
Venous drainage: superior rectal, middle and inferior rectal
Lymph drainage: internal iliac, superior inguinal
Haemorrhoids: non painful internal, painful external
Nerves: inferior hypogastric plexus, inferior rectal

102
Q

What are haemorrhoids?

A

Swollen veins in anal region

103
Q

Explain the difference between internal and external haemorrhoids

A

Internal - superior rectal veins swollen, not painful as inferior hypogastric plexus (autonomic) contain visceral afferent pain fibres (triggered more by smooth muscle distension/ contraction, stretching of the capsule surrounding an organ, ischaemia and necrosis, or irritation by chemicals produced during inflammatory processes)
External - thrombosis in inferior rectal veins, painful as inferior rectal nerves contain somatic sensory fibres

104
Q

What makes up the superficial fascia of the abdomen?

A

Camper’s fascia (outer)

Scarpa’s fascia (inner)

105
Q

What lies beneath the transversus abdominis muscle but on top of the parietal peritoneum?

A

Transversalis fascia

Extraperitoneal fat

106
Q

What is an adenoma?

A

Relatively common
Neoplastic polyps
Arise from glandular epithelium of GIT
Precursors of carcinoma

107
Q

What types of polyps are there?

A

Pedunculated (with a stalk)

Sessile (without stalk)

108
Q

What type of hernia is medial to the inferior epigastric vessels?

A

Direct (protrude through abdominal wall)

109
Q

What type of hernia is lateral to the inferior epigastric vessels?

A

Indirect - pass through deep inguinal ring

110
Q

What is Hirschprung’s disease?

A

Congenital megacolon
Failure of parasympathetic ganglia to migrate into wall of gut
Auerbach and Meissner’s plexuses fail to form = paralysis of gut wall = sever constipation

111
Q

Where to enteric autonomic ganglia originate from?

A

Ectoderm - neural crest

112
Q

About 15% with Hirschprung’s disease also have..?

A

Down syndrome

113
Q

What ligaments is the greater omentum subdivided into?

A

Gastrocolic
Gastrosplenic
Gastrophrenic

114
Q

What ligaments is the lesser omentum subdivided into?

A

Hepatoduodenal - portal triad

Gastrohepatic

115
Q

How many layers of peritoneum makes up the greater omentum?

A

4

116
Q

Where does pain from foregut structures (oesophagus/ stomach/ liver/ gallbladder/ spleen/ parts of pancreas and duodenum) get referred to?

A

Epigastric region

117
Q

Where does pain from midgut (distal duodenum/ small intestine/ caecum/ appendix/ ascending colon/ proximal 2/3 transverse colon/ part of pancreas) structures get referred to?

A

Umbilical region

118
Q

Where does pain from hindgut (distal 1/3 transverse colon/ descending/ sigmoid colon/ proximal anal canal) structures get referred to?

A

Pubic region

119
Q

Where is the most Na+ absorbed in GIT and how?

A

Jejunum
Co-transport with e.g. glucose
or exchanged with e.g. H+

120
Q

What happens to K+ in GIT?

A

Absorbed most by jejunum by paracellular pathway

Secreted by large intestine

121
Q

How is Ca2+ absorbed from ileum and jejunum?

A

Passive - paracellular

122
Q

How is Ca2+ absorbed from the duodenum?

A 
Active uptake (transcellular) 
Via transient receptor potential vanilloid (TRPV) channels that are activated by heat and capsaicin
123
Q

What can stimulate Cl- secretion?

A

VIP released from enteric neurones
Serotonin released from EC cells
Cholera toxin
Histamine released from mast cells

124
Q

What can somatostatin from D cells, enkephalins and aldosterone stimulate?

A

Absorption

125
Q

Name 2 excitatory neurotransmitters of the enteric NS

A

ACh

Substance P

126
Q

Name 2 inhibitory neurotransmitters of the enteric NS

A

VIP

Nitric oxide

127
Q

Where is the myenteric plexus and what is its primary function?

A

Between the circular and longitudinal smooth muscle of the gut
Motor function

128
Q

Where is the submucosal plexus and what is its primary function?

A

Between the submucosa and muscularis externa
Sensory
Also affects secretory activity

129
Q

What is the general autonomic input on the GIT?

A

Parasympathetic - increases motility

Sympathetic - decreases motility

130
Q

What are the 4 basic types of movement in the small intestine?

A

Villi
Mixing: pendular and segmentation
Peristaltic waves
Migrating motility complex - in fasting

131
Q

What happens to the longitudinal and circular smooth muscle during peristalsis?

A

Longitudinal muscle contracts in front of bolus to shorten the GIT ahead
Circular muscle contracts behind bolus to propel it along

132
Q

What are the gut smooth muscles doing in segmentation?

A

Circular muscle contracting and relaxing

133
Q

What are the gut smooth muscles doing in pendular mixing?

A

Circular muscle relaxes as longitudinal contracts

Circular muscle contracts as longitudinal relaxes

134
Q

What is the effect of VIP on smooth muscle of gut?

A

VIP relaxes the smooth muscle

135
Q

What do N cells in ileum release in response to fat?

A

Neurotensin - decreases motility

136
Q

What to L cells in distal ileum release in response to glucose and fat?

A

Enteroglucan - decreases motility

137
Q

What to M cells in duodenum release in response to acid and fat?

A

Motilin - increases sensitivity of smooth muscle to intrinsic nervous activity, stimulating gastric emptying and migrating motility complex
Cyclic release during fasting

138
Q

What types of movements occur in the large intestine?

A

Segmental mixing

Propulsive mass movement

139
Q

What initiates large intestine propulsive mass movement?

A

Intrinsic reflex pathways
Enhanced by vagal neurones
Gastrin and CCK increase large intestine excitability

140
Q

What holds the anal canal upright?

A

Puborectalis muscle

141
Q

What allows the rectum to straighten during defecation?

A

Relaxation of pelvic floor muscles

142
Q

What causes the walls of the sigmoid colon and rectum to contract during defecation?

A

Parasympathetic stimulation

143
Q

What is McBurneys point and its significance?

A

Point over appendix in R lower quadrant
1/3 of the way from anterior superior iliac spine (ASIS) to umbilicus
Pressure on the point elicits severe pain in acute appendicitis

Year 2 (13 decks)

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