EXAM #1: REVIEW Flashcards
What is the staining method that is used to diagnose Barrett’s Esophagus?
Alcain Blue, which stains mucous secreting goblet cells blue
What third of the esophagus is more likely to harbor a squamous cell carcinoma?
Middle 1/3
At what vertebral level is the esophageal hiatus located?
T10
What lymph nodes are most likely to be affected by metastasis from the inferior esophagus?
Celiac trunk
What two surgical procedures can be done for refractory PUD?
1) Surgical excision of the pylorus
2) Selective vagotomy
Outline the borders of the Gastrinoma Triangle.
1) Junction of the cystic duct and common hepatic duct
2) Junction of the neck and body of the pancreas
3) Junction between 2nd and 3rd part of the duodenum
What gross change of the stomach is seen in Zollinger-Ellison Syndrome?
Prominent rugae due to increased parietal cell mass
List the four histologic features of Gluten Enteropathy.
1) Disarrayed enterocytes
2) Villous atrophy
3) Crypt hyperplasia
4) Inflammation of the lamina propria
What two structures may be damaged if their perforation of a posterior duodenal ulcer?
1) Pancreas
2) Gastroduodenal a.
What is the result of an anterior duodenal ulcer perforation?
Air accumulation between the diaphragm and anterior wall of the liver
What is the eponym of the watershed area of the colon that is most prone to ischemia?
“Critical Point of Griffiths”
What are the three mechanisms that cause esophageal stenosis?
1) Sequestration of respiratory tissue elements
2) Myenteric plexus damage that causes hypertrophy
3) Mucosal diaphragm
What vascular anomaly can cause esophageal stenosis?
Lusorian a.
- 4th brach on the left side of the aortic arch
- Retroesophageal course to become the RIGHT subclavian a.
What nerve supplies the rectum inferior to the pectinate line?
Inferior rectal n.
What is amylopectin?
Plant starch with alpha-1,4 glycosidic bonds and alpha-1,6 branches
What are the specific oligosaccharides that are the end products of pancreatic alpha-amylase?
1) Maltose
2) Maltotriose
3) Alpha-limit dextrins
What prevents pancreatic lipase from being denatured by bile acids?
Colipase
What are the four physical mechanisms that prevent infection of the GI tract?
1) Acidity of the stomach
2) Peristalsis
3) Detergent action of bile
4) Mucus secretion
List the four major locations of GALT.
1) Peyer’s patches
2) Appendix
3) Lymphoid aggregates in the large intestine
4) Lamina propria
What are the two important functions that IgA plays in immunity?
1) Opzonization
2) Anti-parasite immunity–facilitates eosinophil degranulation
What two malignancies are patients with Celiac Disease at risk for?
1) GI Lymphoma
2) GI Carcinoma
What drug can be used to treat Crohn’s Disease?
Infliximab, an anti-TNF-a monoclonal antibody
When do the symptoms of Botulism start?
12-36 hours post ingestion
What are the essential identifying characteristics of C. botulinum?
Gram positive bacillus (rod) that is:
- Anaerobic
- Spore-forming
Do the major characteristics of C. diff differ from C. botulinum?
No
Aside from supportive therapy and stopping the offending agent, how is C. diff colitis treated?
Oral metronidazole or vanomycin
Note that metronidazole is preferred*
What kind of diarrhea is associated with Shigellosis?
Bloody
What are the identifying characteristics of Shigella dysenteraie?
Gram negative bacillus that is:
- Non-lactose fermenting
What are the 3x characteristics that distinguish Shigella from Salmonella?
1) Non-glucose fermenting
2) No H2S production
3) Non-motile
I.e. Salmonella ferments glucose (not lactose), produces H2S, and is motile
What is the preferred treatment for Shigellosis?
A fluoroquinolone i.e. CIPROFLOXACIN
What is the preferred treatment for Shigellosis in children?
TMP-SMX (bactrim)
Note that cipro is not used in kids b/c of an increased risk of tendonitis and achilles tendon rupture
What are the 4x infections that can be caused by Salmonella?
1) Enterocolitis
2) Typhoid fever
3) Osteomyelitis
4) Sepsis
What is the most important host defense against Salmonella typhimurium?
Gastric acid
Where does Salmonella typhi replicate?
Mononuclear phagocytes i.e. monocytes and macrophages in Peyer’s Patches
What organ is associated with the carrier state of Salmonella typhi?
Gallbladder
What are the symptoms of Typhoid Fever?
1) Flu
2) Fever/ constipation
3) Bacteremia
4) Rose-spots
What are the drugs of choice in treating patients with Salmonella enterocolitis?
1) Ceftriaxone
2) Ciprofloaxcin
List the major identifiable characteristics of E. coli.
Gram negative bacillus (rod) that:
- Facultative anaerobe
- Ferments lactose
What strain of E. coli most commonly causes traveler’s diarrhea?
ETEC
What is the MOA of the ETEC toxin?
Similar MOA to cholera toxin:
- AB toxin
1) B= binds
2) A= activates Gs–> increases cAMP
Causing a watery diarrhea
What type of diarrhea is seen with EIEC?
Bloody/ mucous
What is EPEC most commonly associated with?
Chronic diarrhea in infants
What type of diarrhea is associated with EPEC?
Mucous
What toxins are associated with EHEC?
Shiga-like Toxins i.e. SLT-1 and SLT-2
What is a major complication of EHEC infection?
Hemolytic Uremic Syndrome that is characterized by:
1) Microangiopathic hemolytic anemia
2) Thrombocytopenia
3) Acute kidney injury
Note that this is the leading cause of renal failure in children worldwide*
What antibiotics are used to treat E. coli infection in children?
Gentamicin
Polymyxin
What antibiotics are used to treat severe Campylobacter jejuni infections?
1) Erythromycin
2) Ciprofloaxcin
What neurologic disorder can be part of the sequelae of C. jejuni infection?
Gullian Barre Syndrome
What are the identifying characteristics of H. pylori?
Gram negative SPIRAL shaped bacteria that is:
- Microaerophilic
- Contain a polar flagella (motile)
What should you think when a patient complains of odonphasia?
Infectious esophagitis i.e. esophagitis caused by:
1) C. albicans
2) HSV
3) CMV
What five complications are patients with Achalasia at risk for?
1) Obstruction
2) Aspiration
3) Esophagitis
4) Diverticula formation
5) Squamous cell carcinoma (SCC)
What is the primary presenting symptom of an esophageal diverticula?
Halatosis
What is the most common infectious cause of esophageal varices?
Schistosomiasis–parasite released from freshwater snails that can cause liver damage and portal HTN similar to chronic alcoholism
List four symptoms seen with esophagitis.
1) GERD
2) Dysphagia
3) Hematemesis
4) Melena
List six risk factors for GERD.
1) Alcohol use
2) Tobacco use
3) Caffeine
4) Fat-rich diet
5) Obesity
6) Hiatal hernia
Outline the histologic progression seen in reflux esophagitis.
1) Eosinophilia
2) Basal zone hyperplasia
3) Elongation of lamina propria papillae
4) Ulceration and superficial necrosis
What is the buzzword for low-grade dysplasia seen in Barett’s Esophagus?
Picket-fence nuclei
What esophageal pathology is Scleroderma associated with?
Fibrosis of smooth muscle leading to stricture formation and dysphagia
What is the most common benign tumor of the esophagus?
Leiomyoma
List six risk factors for Squamous Cell Carcinoma of the esophagus.
1) Alcohol
2) Tobacco
3) Nitrosamines in food (smoked)
4) Chronic esophagitis
5) Achalasia
6) HPV
What are the three types of SCC seen in the esophagus?
1) Protruding
2) Flat
3) Ulcerated
What are the two lab markers of cholestatic injury?
1) Alkaline phosphatase (ALP)
2) Bilirubin
What are three causes of APL elevation?
1) Stretch or inflammation of the biliary tree
2) Bone disease
3) 3rd trimester pregnancy
What is LKM?
Anti-Liver/Kidney miroscomal antibody
What lab and what antibody are associated with Primary Biliary Cirrhosis?
- Elevated ALP
- ANA
What are the red flags for Primary Sclerosing Cholangitis on lab evaluation?
1) Elevated ALP
2) Beads on a string bile duct
3) Onion skin bile duct
What antibodies are associated with autoimmune hepatitis?
ANA
ASMA
List six causes of acute gastritis.
1) NSAIDs
2) Alcohol
3) Chemotherapy
4) Severe burn (Curling)
5) Increased ICP (Cushing)
6) Shock (Stress)
Histologically, how will mild acute gastritis appear?
- Hyperemia (increased blood)
- Edema
- Neutrophils above the basement membrane
Histologically, how will severe acute gastritis appear?
- Erosion of entire mucosal thickness
- Hemorrhage
Histologically, what will chronic gastritis lead to?
- Mucosal atrophy
- Intestinal metaplasia
What characteristic of H. pylori facilitates binding to the gastric mucosas?
Adhesins
What is the most common site of H.pylori infection in the stoamch?
Antrum
What are the two types of gastric carcinoma?
1) Intestinal-type
2) Diffuse-type
What are the characteristics of an intestinal-type gastric carcinoma?
- Large
- Irregular
- Heaped-up margins
Where are intestinal-type gastric carcinomas typically found?
Lesser curvature of the stomach in the anturm
List four risk factors for gastric carcinoma.
1) H. pylori
2) Autoimmune gastritis
3) Nitrosamines
4) Blood Type A
What are the symptoms of gastric carcinoma?
- Abdominal pain
- Early satiety
- Anemia
- Weight loss
What cell-type undergoes neoplastic proliferation in a GIST?
Mesenchymal “Cells of Cajal”
What are the histologic markers for a GIST?
- CD117
- c-KIT
What is the typical clinical presentation of Crohn’s Disease?
- Intermittent non-bloody diarrhea
- RLQ pain
- Fever
List the major complications associated with Crohn’s Disease.
1) Malabsorption
2) Calcium oxalate nephorlithiasis
3) Fistula formation
4) Carcinoma
What is the typical clinical presentation in Ulcerative Colitis?
- Bloody diarrhea
- LLQ pain
What are the major complications associated with Ulcerative Colitis?
1) Toxic megacolon
2) Perforation
3) Carcinoma
What are the two classic morphologic features of Ulcerative Colitis?
1) Loss of haustra
2) Pseudopolyps
How is the inflammation in Ulcerative Colitis described?
Crypt abscess formation
What is the typical complication of chronic bowel ischemia?
Stricture leading to obstruction
Where are most diverticula located?
Sigmoid colon
List five potential complications of diverticular disease.
1) Inflammation and diverticulitis
2) Perforation
3) Abscess formation
4) Rupture (of the abscess)
5) Fistula tract formation
What is the classic presentation of diverticulitis?
- Cramping abdominal pain
- LLQ pain
- Sensation of being unable to empty rectum
List the symptoms of an intestinal obstruction.
- Abdominal pain
- Abdominal distension
- Vomiting
- Constipation
- Inability to pass gas
What is the mnemonic to remember the difference between indirect and direct inguinal hernias?
MDs don’t LIe
- Medial to inferior epigastric= direct
- Lateral to inferior epigastric= indirect
What type of inguinal hernia will result in bowel in the scrotum?
Indirect
What are the two most common causes of intussception in kids?
1) Secondary Lymphoid Hyperplasia
2) Rotavirus
Name two secondary causes of bowel obstruction.
1) Foreign body e.g. “drug mule”
2) Carcinoma
What are the three most common malabsorptive disorders in the US?
1) Celiac spure
2) Chronic pancreatitis
3) Crohn’s Disease
What is the cause of Whipple Disease?
Tropheryma whipplei
What is the hallmark of Whipple Disease?
Macrophages stuffed with PAS+ granules in multiple organ systems
What are the clinical features of Whipple Disease?
Fat malabsorption and steatorrhea
- Macrophages block the lacteals
- Chylomicrons cannot be transferred from enterocytes to lymphatics
What are the two most common tumors of the small bowel?
1) Adenomas
2) Mesenchymal tumors i.e. GISTS
What are the two most common malignant tumors of the small bowel?
1) Adenocarcinoma
2) Carcinoid
What specific location in the small bowel harbors the most adenomas?
Ampulla of Vater i.e. the union of the pancreatic duct and common bile duct
Where do most hyperplastic polyps occur?
Rectosigmoid region
What are patients with Peutz-Jegher’s Syndrome at risk for?
- Intussusception
- Cancer i.e.
1) Colorectal
2) Breast
3) GYN
What is the classic presentation of a villous polyp?
- Overt rectal bleeding
- Hyponatremia
- Hypokalemia
List four risk factors for colorectal carcinoma.
1) Increased age
2) Prior colorectal cancer or polyps
3) Ulcerative Colitis or Crohn’s Disease
4) Poor diet
What is the inheritance pattern of FAP?
Autosomal Dominant
What is the average age of onset in FAP?
25 years old
What is the hallmark of Mediterranean Lymphoma?
Abnormal IgA heavy chain
List the causes of extrinsic neuropathy leading to dysmotility.
1) DM
2) Trauma
3) PD
4) Amyloidosis
5) Paraneoplastic Syndrome
What causes enteric neuropathy?
1) Idiopathic degeneration
2) Inflammatory/infiltrative processes
What are the two most common causes of GI dysmotility?
Gastroparesis
Pseudo-obstruction
List the differential diagnosis for a GI dysmotility disorder.
1) Mechanical obstruction
2) Crohn’s Disease/ IBD
3) Autonomic neuropathy
4) Functional GI Disorder
5) Eating disorder
What labs can you order to rule out organic disorders that may mimic IBS?
1) Celiac antibodies
2) TSH
3) CRP/ESR
4) Stool studies
5) Imaging
What are the mixed neural and muscle causes of dysmotility?
1) Amyloidosis
2) Mitochondrial cytopathies
3) Sclerderma
List the four “other” minor diseases associated with IBD.
1) Microscopic colitis
2) Diversion colitis
3) Diverticular colitis
4) Pouchitis
Outline the four pathogenic mechanisms that lead to the development of IBD.
1) Persistent infection
2) Defective mucosal integrity
3) Dysbiosis
4) Dysregulated immune response
List the symptoms that are classic for UC.
- Bloody diarrhea*
- Rectal discomfort
- Fecal urgency
- Abdominal cramping
List the symptoms that are classic for CD.
- Abdominal pain
- Diarrhea
- Low grade fever
- Anorexia
Which has a higher associated with perianal disease, Ulcerative Colitis or Crohn’s Disease?
Crohn’s Disease
What are the drug classes used to treat IBD.?
1) Aminosalicylates
2) Corticosteroids
3) Immunomodulators
4) Antibiotics
5) Supportive agents
How is remission induced in UC? How it maintained?
- Aminosalicylates*
- 6MP/Azathoprine*
- Corticosteroids
- Cyclosporine
Used for both induction and remission.
What are the adverse effects of Metronidazole?
- Nausea
- Metallic taste
- Furry tongue
- Candidiasis
- Peripheral neuropathy
What are the indications for topical corticosteroids?
- Proctitis
- Left-sided colitis
What are the adverse effects associated with 6MP/ Azathioprine?
- Hypersensitivity
- Bone marrow suppression
- Opportunistic infection
- Lymphoma risk
What are the indications for surgery is Ulcerative Colitis?
1) Severe bleeding
2) Perforation
3) Cancer or dysplasia
4) Unresponsive acute disease
What surgical procedure is the standard of care for UC?
Ileal pouch-anal anastamosis
What are the indications for surgery in Crohn’s Disease?
1) Severe bleeding
2) Perforation
3) Cancer or dysplasia
4) High grade obstruction
(vs. unresponsive acute disease in UC)
