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Step 1 > Digestion and Metabolism > Flashcards

Digestion and Metabolism Flashcards

1
Q

Cells that secrete gastric acid

A

parietal cells

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2
Q

Cells that secrete intrinsic factor. What is the role of intrinsic factor?

A

Parietal cells.

Intrinsic factor allows for the absorption of vitamin B12 (cobalamin) by the ielum. 
Pernicious anemia (type II hypersensitivity) production of autoantibodies that dec intrinsic factor
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3
Q

Gastrin

A

Released by G cells of the stomach antrum

Increases H+ secretion, inc growth of gastric mucosa, inc gastric motility

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4
Q

What causes gallbladder contraction?

A

Release of CCK by I cells of the duodenum – allows for secretion of bile into the duodenum

Stimulated by fatty foods

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5
Q

What increases secretion of pancreatic HCO3-?

A

Secretin: released by S cells of the duodenum in response to acidic chyme
Allows for functioning of pancreatic enzymes

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6
Q

Chief cells of the stomach

A

Release pepsinogen

Pepsinogen –> pepsin in acidic environment

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7
Q

What activates trypsinogen (into trypsin)? What happens if there is a deficiency in this?

A

Enterokinase/enteropeptidase (from intestinal cells)?

Deficiency leads to malabsorption and steatorrhea

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8
Q

Deficiency in which pancreatic enzyme will cause steatorrhea?

A

Pancreatic lipase

Pancreatic lipase is normally inhibited by bile acids, but colipase helps overcome this – anchors lipase to triacylglycerol and stabilizes the active conformation

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9
Q

Kupffer cells

A

specialized macrophages of the liver that form the lining of sinusoids

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10
Q

Lab values in alcoholic hepatitis

A

AST>ALT

make a toAST with alcohol

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11
Q

Lab values in nonalcoholic hepatitis

A

ALT>AST

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12
Q

Patient presents with cirrhosis, diabetes mellitus, and skin pigmentation

A

Hemochromatosis

Iron overload leading to deposition in organs (AR mutation in HFE gene)

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13
Q

What can hemochromatosis do to the heart?

A

Reversible dialted cardiomypathy

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14
Q

Histology of the liver shows finely granular inclusions that are pale and eosinophilic

A

Characteristic of Hep B infection

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15
Q

Histology of the liver shows lymphoid aggregates within the portal tracts and focal areas of macrovesicular steatosis

A

Characteristic of Hep C infection

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16
Q

Meckel diverticulum

A

Partial closure of the vitelline duct, with the patent portion attached to the ileum – may be asymptomatic or present with rectal bleeding or obstruction

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17
Q

Ingestion of wild toxic mushrooms has what effect?

A

Binds to and inhibits RNA pol II – halts mRNA synthesis, resulting in apoptosis

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18
Q

What are people with Celiac disease intolerant to?

A

Gliadin (a component of gluten)

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19
Q

What are the lab findings in a patient with Celiac disease?

A

IgA anti-tissue transglutaminase, anti endomysial, and anti-deamidated gliadin peptide antibodies

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20
Q

What parts of the small intestine are affected by Celiac disease? What does histology show?

A

Distal duodenum and/or proximal jejunum

Will see villous atrophy, crypt hyperplasia, and intraepithelial lymphocytosis

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21
Q

VIP (Vasoactive intestinal polypeptide)

A

Secreted by the pancreas

Causes increased water and electrolyte secretion

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22
Q

Patient presents with watery diarrhea, hypokalemia, and achlorhydria (no HCl in gastric secretions)

A

WDHA syndrome = VIPoma

A pancreatic islet cell tumor that secretes VIP

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23
Q

1 g protein = ? calories
1 g carbs = ? calories
1 g fat = ? calories

A

1 g protein = 4 calories
1 g carbs = 4 calories
1 g fat = 9 calories

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24
Q

Hirschsprung disease

A

congenital megacolon caused by absence of ganglion cells in the colonic wall – affected area is narrowed and there is compensatory dilation of proximal areas

Due to failure of neural crest cell migration

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25
Q

Mutation in Lynch syndrome leading to colorectal carcinoma?

What else is this associated with?

A

Mutation of DNA mismatch repair genes (MSH2 and MLH1)

Also associated with ovarian, endometrial, and skin cancers

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26
Q

Where are dietary lipids absorbed?

A

Jejunum

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27
Q

Risk factors for gallbladder disease

A

Four F’s

Fat
Female
Forty
Fertile (pregnant)

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28
Q

What do brown gallstones suggest?

A

Infection

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29
Q

Patient presents with fever, jaundice, and RUQ pain

A

Charcot’s triad – cholangitis

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30
Q

Wilson disease

A

An AR mutation that results in impaired cellular transport of copper – causes copper accumulation in the liver, brain, and eye

Present with hepatitis, depression, impulsivity, basal ganglia injury (ataxia, parkinsonism, tremor), Kayser Fleischer rings seen on ophthalmalogic exam

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31
Q

What happens if you give Aspirin to a child with a viral infection?

A

Reye syndrome: mitochondrial dysfunction (decrease in B oxidation by reversible inhibition of mitochondrial enzymes) leading to hepatic encephalopathy –> death

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32
Q

Direct hernia

A

Medial to inferior epigastric

Tears through abdominal fascia and passes through the superficial inguinal ring

Most common in adult men

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33
Q

Indirect hernia

A

Lateral to inferior epigastric

Passes through deep inguinal ring and superficial inguinal ring –> scrotum

Covered by all three layers of spermatic fascia

Most common in male infants – Due to failure of processus vaginalis to close (can lead to hydrocele formation)

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34
Q

Femoral hernia

A

Protrudes below the inguinal ligament and lateral to the pubic tubercle – enters the femoral ring (where the lymphatics run through)

Most common in females

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35
Q

What bug causes chronic otitis media in diabetics

A

Pseudomonas

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36
Q

Round, pearly mass behind the TM in the middle ear (abnormal finding)

A

Cholesteatoma: collection of squamous cell debris

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37
Q

What lies within the hepatoduodenal ligament?

A

The portal triad: hepatic artery, portal vein, and common bile duct

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38
Q

Plummer Vinson Syndrome

A

Dysphagia
Iron deficiency anemia (microcytic)
Esophageal webs

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39
Q

Boerhaave Syndrome

A

Transmural rupture of the esophagus due to violent retching

Seen in bulimia

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40
Q

Punched out ulcers in esophagus

A

HSV1 infection

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41
Q

Linear ulcers in esophagus

A

CMV infection

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42
Q

White pseudomembrane covering esophagus

A

Candidiasis

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43
Q

Where is iron absorbed?

A

Duodenum

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44
Q

Where is folate absorbed?

A

Jejunum

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45
Q

Where is cobalamin (B12) absorbed?

A

Ileum

Needs intrinsic factor (from parietal cells)

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46
Q

Fates of short, medium, and long chain fatty acids?

A

Short and medium chain FFA are absorbed by enterocytes and pass directly into capillaries without modification –> Reach liver directly via portal blood

Long chain FFA enter the enterocytes and are made into chylomicrons which enter lymphatics –> capillaries

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47
Q

fat soluble vitamins

A

A, D, E, K

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48
Q

Role of apoE in chylomicrons

A

Allows for uptake of chylomicron remnants by the liver

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49
Q

Role of apoCII in chylomicrons

A

Activates lipoprotein lipase (found on vascular endothelium by non hepatic tissues) which allows for the release of FFA from chylomicrons

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50
Q

What do nascent chylomicrons have on them?

A

apoB48

they become mature chylomicrons by acquiring apoE and apoCII from HDL

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51
Q

Absorption of:
glucose
galactose
fructose

A

Glucose and galactose are absorbed by SGLT1 (Na dependent)

Fructose is absorbed by GLUT-5

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52
Q

Treatment of portal HTN

A

Transjugular intrahepatic portosystemic shunt (TIPS) between the portal vein and hepatic vein shunts blood to the systemic circulation and bypasses the liver

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53
Q

Enzyme in cholesterol stone formation

A

due to reduced 7a hydroxylase activity (decreased bile acid production and increased excretion of cholesterol → stones)

54
Q

Enzyme in pigmented stone formation

A

Beta glucuronidase – after infection, beta glucuronidase released by injured hepatocytes and bacteria hydrolyzes bilirubin glucronides to unconjugated bilirubin

55
Q

Medical management of cholesterol stones

A

administration of hydrophilic bile acids to reduce biliary cholesterol secretion and increase biliary bile acid concentration – promotes gallstone dissolution by improving cholesterol solubility

56
Q

Patient with a known history of liver disease prevents with a hand flapping tremor. What has accumulated and what has decreased in this patient?

A

Excess NH3 causes a depletion of a-ketoglutarate, which leads to inhibition of the TCA cycle

(The liver disease makes the pt unable to metabolize waste products)

57
Q

Which hereditary hyperbilirubinemia is most severe and leads to death within a few years of life?

A

Crigler-Najjar syndrome: absent UDP-glucuronosyltransferase (liver is unable to conjugate bilirubin)

58
Q

Patient presents with conjugated hyperbilirubinemia and a grossly black liver

A

Dubin Johnson syndrome: unable to excrete conjugated bilirubin from the liver

59
Q

4 year old child presents with numerous hamartomatous polyps in the GI tract

A

Juvenile polyposis syndrome
AD
Associated with inc risk of colorectal carcinoma

60
Q

Teenager presents with hyperpigmented oral mucosa and lips, and has numerous hamartomas throughout the GI tract

A

Peutz-Jeghers syndrome

AD
Inc risk of breast and GI cancers at a young age

61
Q

Your patient hits puberty and develops thousands of colonic polyps that also involve the rectum. What is the mutation and what is the treatment?

A

Familial adenomatous polyposis

AD mutation of APC tumor suppressor gene on chromosome 5 (5 letters in “polyp”)

Prophylactic colectomy or else 100% progress to colorectal carcinoma

62
Q

Inc alpha fetoprotein

A

HCC

63
Q

Positive anti-mitochondrial antibodies

A

Primary biliary cirrhosis

64
Q

Positive anti-smooth muscle antibodies

A

Primary sclerosing cholangitis

65
Q

Why are some babies yellow when they are born? what is the treatment?

A

They have an immature UDP-glucuronosyltransferase enzyme so there is a buildup of unconjugated bilirubin

Phototherapy isomerizes unconjugated bilirubin to water soluble form

66
Q

In patients with a1 antitrypsin deficiency, where does the misfolded protein aggregate?

A

In the ER of hepatocytes –> leads to cirrhosis

67
Q

What causes hemochromatosis?

A

Mutation in HFE- causes increased intestinal absorption of iron leading to iron overload

68
Q

Immune cells involved in Crohn vs Ulcerative Colitis

A

Crohn: Th1

Ulcerative colitis: Th2

69
Q

Patient injured her knee and was given a medication for the pain. She soon developed colicky RUQ abdominal pain. What medication was she given that caused these symptoms?

A

Opioid (morphine)

Can cause contraction of the sphincter of Oddi – leading to inc common bile duct pressures and biliary colic

70
Q

How does malabsorption contribute to gallstone formation? (eg Crohns disease)

A

Decreased absorption of bile acids (inc bile acid wasting) from the ileum means that there are less bile acids available for bile formation and the ratio of cholesterol to bile acids increases – causes cholesterol to precipitate and form stones

71
Q

Esophageal cancer differences

A

Squamous cell: upper 2/3 – due to alcohol, smoking, and hot liquids

Adenocarcinoma: lower 1/3 – due to GERD, barrett esophagus, obesity

72
Q

Effect of phosphatidylcholine on cholesterol and gallstones

A

Increase solubility of cholesterol and decrease the risk of gallstones

73
Q

Noncaseating granulomas seen in colonoscopy of a patient with bloody diarrhea

A

Crohns disease

74
Q

Histo shows microvesicular steatosis without inflammation in a recently sick child

A

Reye Syndrome - given ASA

75
Q

Histamine effects on GI

A

Causes increased gastric acid release from parietal cells that can lead to gastric ulceration
The excess acid inactivated pancreatic and intestinal enzymes, leading to diarrhea

76
Q

Ondansetron: mechanism and toxic effects

A

Anti emetic that blocks serotonin (5HT receptors and causes dec vagal stimulation)

Can cause constipation, headache, dizziness, long QT, and serotonin syndrome

77
Q

Patient presents with several months of pain after eating which has caused him to decrease his food intake and has led to weight loss

A

Chronic Mesenteric Ischemia: atherosclerosis of the celiac a., SMA, or IMA that leads to intestinal hypoperfusion (GI angina)

78
Q

Mallory Weiss Syndrome

A

Longitudinal mucosal tears at the gastroesophageal junction that occur due to rapid increase in intra-abdominal pressure, usually due to vomiting (seen in alcoholics and bulimia)

79
Q

Retroperitoneal organs

A

SADPUCKER

  • Suprarenal glands
  • Aorta and IVC
  • Duodenum (except 1st part)
  • Pancreas (head and body)
  • Ureters and bladder
  • Colon (ascending and descending)
  • Kidneys
  • Esophagus
  • Rectum
80
Q

Sequelae of anterior vs posterior duodenal ulcers

A

Anterior: cause perforation
Posterior: cause hemorrhage (gastroduodenal artery)

81
Q

Sudan III stain

A

Identifies unabsorbed fat and confirms malaborption

82
Q

Colonoscopy shows Flask shaped ulcerative lesions

A

Entamoeba histolytica

83
Q

Colonoscopy shows Spindle shaped tumor cells with small vessel proliferation

A

Kaposi’s sarcoma

84
Q

Zollinger Ellison Syndrome

What is it associated with?

A

Gastrin secreting tumor of the pancreas or duodenum that causes ulcers in duodenum and jejunum

Associated with MEN1

85
Q

Diagnosis of Zollinger Ellison Syndrome

A

Patient presents with diarrhea and abdominal pain

Positive secretin stimulation test: gastrin levels stay high after administration of secretin, which normally inhibits gastrin release

86
Q

Treatment of carcinoid syndrome

A

Octreotide: synthetic analog of somatostatin

87
Q

When does carcinoid syndrome occur?

A

When a carcinoid tumor of the GI tract metastasizes to the liver

88
Q

Patient presents with flushing, watery diarrhea, and telangiectasias

A

Carcinoid syndrome: release of vasoactive substances (serotonin, bradykinin, and prostaglandins)

89
Q

Neonate presents with drooling, choking, and vomiting with first feeding. XR shows gasless abdomen and the doctor is unable to pass NG tube into stomach

A

Tracheoesophageal abnormality

90
Q

Aflatoxins

A

Produced by Aspergillus – cause a p53 mutation (classically G;C –> T;A) which can lead to hepatocellular carcinoma

91
Q

Porcelain gallbladder

A

calcified gallbladder seen on imaging with a thickened gallbladder wall – need to perform prophylactic cholecystectomy because of high rates of gallbladder cancer

92
Q

Progression of mutations in colon cancer

A

AK-53

APC
KRAS
p53

93
Q

Treatment of hepatic encephalopathy

A

Lactulose – dec the pH of the intestinal lumen which then causes ammonia to be changed into ammonium, which is excreted

Rifaximin – a non absorbable antibiotic that kills the intestinal bacteria that produce ammonia

94
Q

Elderly patient presents with oropharyngeal dysphagia, halitosis, regurgitation, and recurrent aspiration. What is this and what causes it?

A

Zenker diverticulum
Diminished relaxation of cricopharyngeal muscles during swallowing results in increased intraluminal pressure of the oropharynx –> causes a zone of muscle weakness in the posterior hypopharynx forming a false diverticulum.

95
Q

Gallstone ileus

A

when a large gallstone causes formation of a cholecystenteric fistula between the gallbladder and adjoining gut → usually the duodenum. It then travels to the ileocecal valve, which is the narrowest portion of the intestine causing obstruction

96
Q

Internal vs external anal sphincter

A

o Internal sphincter: involuntary, parasympathetic pelvic splanchnic nerves (relaxes in response to pressure – gas or feces- descending the rectal ampulla)
o External sphincter: voluntary, inferior rectal nerve

97
Q

Mallory bodies

A

Intacytoplasmic eosinophilic inclusions of damaged keratin filaments

Seen in alcoholic hepatitis (AST>ALT)

98
Q

Wilson disease vs Hemochromatosis

Mechanism:
Inheritance:
Parts affected:
Treatment:

A

Wilson disease:

  • accumulation of copper due to impaired excretion
  • autosomal recessive
  • Liver, eyes, brain, kidney, joints
  • chelation with penicillamine

Hemochromatosis:

  • accumulation of iron due to inc intestinal absorption
  • autosomal recessive
  • liver, heart, joints, skin, pancreas
  • repeated phlebotomy, chelation with deferasirox
99
Q

What drugs should not be taken with antacids like calcium carbonate?

A

Tetracylines or Fluoroquinolones – can lead to chelation of the drug and decreased effectiveness

100
Q

Bilious vs nonbilious vomiting in a neonate?

What causes these?

A

Nonbilious = pyloric stenosis
Due to exposure to macrolides

Bilious = intestinal atresia
Duodenal is a failure to recanalize
Jejunum/Ileum is due to vascular injury

Bilious = annular pancreas
Due to abnormal migration of the ventral pancreatic bud

101
Q

What is the hepatic portal vein made up of?

A

The splenic vein and the superior mesenteric vein

*the inferior mesenteric vein joins either the splenic or the superior mesenteric vein or the junction of these two veins

102
Q 
Large intestine blood supply:
Cecum 
Ascending colon 
Transverse colon 
Descending colon 
Sigmoid colon
A

Cecum = ileocolic artery (SMA)
Ascending colon = right colic artery (SMA)
Transverse colon = middle colic artery (SMA)
Descending colon = Left colic artery (IMA)
Sigmoid colon = sigmoid arteries (IMA)

103
Q

Pancreatic tumors that arise in the head of the pancreas cause obstruction of what?

A

Common bile duct

104
Q

Superior Mesenteric Artery Syndrome

What is this?
What is it associated with?

A

when the transverse duodenum is compressed between the SMA and aorta.

S/S: postprandial pain

Typically associated with conditions with diminished mesenteric fat (low body weight/malnutrition)

105
Q

Arterial and nervous supply above vs below pectinate

A

Above:

  • Superior rectal artery (IMA)
  • Visceral innervation (no pain!)

Below:

  • Inferior rectal artery (internal pudendal artery)
  • Inferior rectal branch of pudendal nerve – (painful!!)
106
Q

Where are peyers patches?

A

Ileum

107
Q

Angiodysplasia

A

tortuous dilation of vessels → hematochezia

Most often found in cecum, terminal ileum, ascending colon

More common in older patients

108
Q

Colorectal cancer presentation in ascending colon vs descending colon

Where is the most common area of colorectal cancer?

A

Rectosigmoid>ascending>descending

Ascending- exophytic mass, iron deficiency anemia, weight loss

Descending- infiltrating mass, partial obstruction, colicky pain, hematochezia

109
Q

What can exposure to arsenic or vinyl chloride cause?

A

Angiosarcoma of the liver

Arsenic can also cause skin SCC

110
Q

What zone of the liver does yellow fever affect?

A

Zone II

yellow = II

111
Q

What zone of the liver does ingested toxins affect?

A

Zone I: periportal zone

112
Q

What zone of the liver is affected first by ischemia?

A

Zone III: centrilobular zone

113
Q

What zone of the liver contains cytochrome P450 system?

A

Zone III: centrilobular zone

114
Q

What zone of the liver is damaged by ingested toxins?

A

Zone 1: periportal zone

115
Q

What causes umbilical hernia and what is this associated with?

A

defect at the linea alba covered by skin – caused by incomplete closure of the umbilical ring, which allows protrusion of the bowel through the abdominal musculature

Associated with Down Syndrome and congenital hypothyroidism

116
Q

Patient presents with abdominal pain and diarrhea for several weeks. He now has a skin lesion over the abdomen and bowel contents appear to be draining to the surface of the skin in the RLQ of the abdomen. What condition does he likely have?

A

Crohn Disease

Fistula formed between the bowel and the skin of the abdominal wall (enterocutaneous fistula)

117
Q

What section of the GI system is always involved in Hirschsprung’s disease? Why?

A

Neural crest cells mmove caudally, so the rectum is ALWAYS involved

118
Q

In hepatic encephalopathy, what accumulates in the astrocytes of the CNS?

A

Accumulation of glutamine in the CNS astrocytes: when excess ammonia is in the blood, it crosses the BBB and is taken up by astrocytes, increasing glutamine production → causes astrocyte swelling and impaired glutamine release.

Hyperammonemia consequently decreases the amount of glutamine available for conversion to glutamate in neurons, resulting in disruption of excitatory neurotransmission

119
Q

Mechanism of chronic vs acute mesenteric ischemia?

A

Chronic: atherosclerosis

Acute: embolism

120
Q

Histo of liver shows spotty necrosis with ballooning degeneration (haptocyte swelling), Councilman bodies (eosinophilic apoptotic hepatocytes), and mononuclear cell infiltrates

A

Hepatitis A

121
Q

Abetalipoproteinemia

A

Impaired formation of apoB-containing lipoproteins (chylomicrons and VLDLs)

o Lipids absorbed by the small intestine cannot be transported into the blood and accumulate in the intestinal epithelium

o Histo: normal intestinal mucosal architecture but the enterocytes contain clear or foamy cytoplasm which is more prominent at the tips of the villi

o RBCs show acanthocytes (spur cells

122
Q

How can Aspirin reduce risk of colon cancer?

A

Increased activity of COX2 has been found in many forms of colon adenocarcinoma and in inherited polyposis syndromes.

123
Q

Pancreatic pseudocyst

A

Complication of acute pancreatitis

Lined by granulation tissue

124
Q

Stomach wall is grossly thickened and leathery

A

Diffuse signet cell carcinoma of the stomach – Often infiltrate large areas of the stomach walls causing a “leather-bottle stomach” (linitis plastic)
consist of cells that do not form glands – cells often contain abundant mucin droplets that push the nucleus to one side and lead to the characteristic appearance of a signet ring

125
Q

Metoclopramide

A

antagonizes D2 receptors in the area postrema to prevent chemotherapy induced vomiting
o Upper GI prokinetic effects: inc resting tone, contractility, LES tone, and motility – useful in treatment of delayed gastric emptying due to post surgical disorders and diabetic gastroparesis
o Due to D2 blockade, can cause extrapyramidal effects – dystonia, parkinsonian features, tardive dyskinesia

126
Q

Lactase deficiency testing

A

Deficiency: stool will have dec pH and breath will have inc hydrogen content

Bacterial fermentation of lactose produces short chain fatty acids (acetate, butyrate, and propionate) which lower stool pH and produces hydrogen gas → flatulance

127
Q

Acalculus cholecystitis
What is this?
Who is this most often seen in?

A

acute inflammation of the glallbladder in the absence of gallstones. – Thought to arise from gallbladder stasis and ischemia, which cause inflammation of and injury to the gallbladder wall

Most commonly occurs in critically ill patients (those with sepsis, severe, burns, trauma, immunosuppression) and is associated with high mortality

128
Q

Patient presents with 2 year hx of abdominal discomfort, greasy stool and weight loss. He has also been experiencing joint pain. An intestinal biopsy reveals multiple macrophages loaded with PAS positive granules in the lamina propria. What is this and how should the patient be treated?

A

Whipple disease: infection with Tropheryma whipplei (intracellular gram positive) causes malabsorption, cardiac symptoms, arthralgias, and neurologic symptoms – treat with antibiotics

Proliferate only within macrophages – Foamy macrophages in intestinal lamina propria that are PAS positive (presence of glycoprotein) and contain the rod shaped bacilli

Decreased lipid transport across enterocyte – lymphatics become blocked with fat

129
Q

What is the pathogenesis of Reye syndrome?

A

Mitochondrial dysfunction: Aspirin causes uncoupling of the electron transport chain

130
Q

Most common causes of acute pancreatitis?

A
  1. Alcohol
  2. gallstones
  3. hypertriglyceridemia

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