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Gastrointestinal Flashcards

1
Q

Functions of the pharynx

A

respiratory and digestive functions
circular mm. - constrictions that help push food down the esophagus, prevent air from being swallowed

longitudinal mm. - lift walls during swallowing

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2
Q

Nerves associated with swallowing

A

Oral - CN V, VII, XII - pre-hend food and form bolus which moves to end of tongue
pharyngeal - CN IX, XII - propel bolus along pharynx, closure of larynx by epiglottis + inhibition of breathing
Esophageal - CN IX, X, SNS - bolus moves esophagus into stomach

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3
Q 
Which is not a nerve associated with the oral aspect of swallowing?
A) CN V
B) CN VII
C) CN X
D) CN XII
A

C - CN X

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4
Q

T/F: CN X is associated with all aspects of swallowing (oral, pharyngeal, esophageal)

A

False, it is only esophageal

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5
Q

Causes of dysphagia

A

congenital - cricopharyngealachalasia, esophageal dysmotility

neuromuscular dz - myasthenia gravis, brainstem lesions
myopathy, myositis, neoplastic or paraneoplastic
infectious uncommon

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6
Q

Diagnostic approach to pharyngeal disease

A

PE - watch the animal eat and drink
sedated oropharyngeal exam
look at pulmonary status, muscling, nutrition status
do bloods, rads of head + neck, fluoroscopy, acetylcholinesterase receptor antibody tiger, 2M antibody assay, upper GI endoscopy, MRI for brain stem lesion

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7
Q

Which is true about the esophagus?
A) The dog and cat esophagus has striated muscle the entire length
B) the dog and cat esophagus have smooth muscle the entire length
C) The dog esophagus has smooth muscle in the distal aspect while the cat esophagus is entirely striated muscle
D) The cat esophagus has smooth muscle in the distal aspect while the dog esophagus is entirely striated muscle

A

D is correct

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8
Q

What parasite can cause a mass lesion in the esophagus?

A

Spirocerca lupi

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9
Q

Diagnostic modalities of esophageal disease (in general)

A

sedated oropharyngeal exam + rads w/ contrast (Barium w/ food or water but careful of aspiration or Iohexol)
systemic evaluation, thyroid levels, eval for pneumonia, eval for compressive lesions, fluoroscopy to eval peristalsis + swallowing phases, endoscopy - balloon if stricture seen, Bx if mass, remove FB

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10
Q

Esophagitis

A

inflammation of mucosa
secondary to meds (Doxy), FB, toxins, reflux, etc
Dx: rads = unremarkable endoscopy - see erythema +/- edematous mucosa, ulcers, erosions
Tx: pain management, topical anesthetic (magical mouthwash - buprenorphine, codeine), mucosal protection (sucralfate/carafate), antacid (PPI omeprazole)
monitor for strictures, ID underlying dz

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11
Q 
Which is not a risk factor (discussed in class) for esophageal strictures?
A) Anesthesia
B) trauma
C) neoplasia
D) LARPAR
A

D - I made this up

post anesthesia is a big one, dont forget

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12
Q

Esophageal diverticulae

A

secondary to trauma or congenital abnormality (PRAA)
if small no CS
if large - impactions, esophagitis, can rupture + pyothorax
Dx: rads or fluoroscopy, both w/ contrast
Tx: clear impactions, Sx when necessary

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13
Q

Megaesophagus

A

congenital - <6m, shar pei, fox terrier, GSD, lab, siamese cat, abnormal NM innervation, may improve w/ time

acquired - idiopathic, primary CNS (brainstem lesion), primary neuromuscular dz (MG), neoplastic syndrome, endocrine, lead toxicity, strictures
Tx: underlying dz, nutritional support, decrease risk of aspiration pneumonia, small frequent meals, elevate food
Px: good if patient tolerates interventions, guarded/poor if fulminant MG crisis, severe aspiration pneumonia or intractable regurgitation

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14
Q

Describe the layers of the stomach

A

submucosa - dense connective tissues, structural support, blood vessels + lymphatics
- Meissner’s plexus
muscularis - layers of smooth muscle perpendicular to each other
- Auerbach’s (myenteric) plexus
serosa - connective tissue layer

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15
Q

Enteric nervous system (ENS)

A

= brain of the gut
functions autonomously but communicates w/ CNS
cross connections so gut can provide info to CNS and CNS can affect GI function

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16
Q

Stomach secretions and functions

A

gastric juice - muscular walls churn food into chyme, stored food for 2-6h, absorbs glucose + alcohol
HCl - acidic medium (pH 1) for enzyme action, kills bacteria
Water - solvent and for hydrolysis
mucus - protects stomach wall from acidic gastric juice, lubricant for movement of food in stomach
pepsin - proteins to polypeptides
rennin - converts protein into insoluble curds (coagulate milk) for hydrolysis of pepsin

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17
Q

Gastrin localization and main physiologic actions

A

gastric antrum, duodenum (G cells), pancreas

stimulate secretion of gastric acid + IF from parietal cells
stimulate secretion of pepsinogen from chief cells

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18
Q

Physiological action of Cholecystikinin (CCK)

A

stimulate gallbladder contraction, stimulate release of pancreatic enzymes, relaxes sphincter of Oddi for release of bile and enzymes

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19
Q

physiological action of secretin

A

stimulate secretion of HCO3 from pancreas

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20
Q

Physiological action of vasoactive intestinal peptide (VIP)

A

increases water + electrolyte secretion from pancreas + gut

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21
Q

Physiologic action of Motilin

A

increases small bowel motility and gastric emptying

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22
Q

Somatostatin localization + physiological action

A

stomach, SI, pancreas (D cells)

inhibits secretion and action of many hormones

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23
Q

Mucosa of the stomach

A

superficial epithelium
lamina propria (below epithelium) - loose connective tissue, immune system cells, nutritional support
gastric glands - mucus neck cells, parietal cells (H/K ATPase pump - HCl), chief cells (digestion)
Neuroendocrine cells - enterocromafin - serotonin _ histamine, somatostatin, gastrin
muscularis mucosa - thin muscle layer

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24
Q 
Most intrinsic factor in the dog comes from:
A) liver
B) kidney
C) pancreas
D) heart
A

C - pancreas

IF is vital for B12 (cobalamin) absorption

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25
Stomach physiology
reservoir for food + starts digestion - protein (pepsin) + fat digestion (gastric lipase) - vitamin + mineral absorption - some IF in dogs motility - migrating motility complex, neural and hormonal stimulus, pressure/distension - mechanoreceptors, nutritional content of food (fat slows movement)
26
Clinical signs associated with the stomach
vomiting, hematemesis, melena, retching, burping, ptyalism, weight loss, abdominal distension + pain
27
Acute Gastritis
inflammation of stomach, sudden onset of CS, symptomatic + supportive care Bx diagnosis but we often presume Dx: based on Hx + CS, trial response to symptomatic care if not systemically ill, if persistent CS or patient systemically ill, systematic dx + supportive care - fluids, antacids, anti-emetics (once FB r/o, vomiting protracted or severe enough to cause dehydration + electrolyte imbalances), pain meds, water + bland diet reintroduced
28
Gastric Foreign body
``` Dx + Tx based on Hx + CS - obstructive lesion has intermittent or persistent CS MC in young r/o other causes and systemic illness Sx or endoscope ```
29
Stomach food bloat
acute vomiting or retching w/ abdominal distension + discomfort at least 24-36h, fluids but withhold food, walk frequently, pain management +/- lavage +/- Sx
30
Gastric erosions + ulcers
mucosal barrier injury (disruption of normal gastroprotection, decreased blood flow, hyper secretion of acid, decreased mucous or bicarb) secondary to neoplasia, trauma, meds, uremic gastritis CS/Dx: vomiting, hematemesis, melena, retch, inappetence, weak, anything assoc w/ underlying dz, anemia, BUN endoscopy best for visual confirmation + Bx Tx: tx primary dz, mucosal protection --> sucralfate, PPI (omeprazole), pain management, blood transfusion, nutrition
31
Helicobacter Gastritis
acute or chronic vomiting spiral gram neg bacteria, can be present normally, pathogenicity assessed based on correlation to inflammatory infiltrates, based on pathology assessment of infiltrative nature into crypts/pits Tx: triple therapy - amoxicillin, tetracycline, pepto-bismol, flatly, omeprazole, Pepcid AC, clarithromycin, azithromycin, erythromycin
32
Gastric roundworms
toxocara canis/cati visual or fecal dx tx - fenbendazle or pyrantel pamoate
33
gastric physalloptera
canine and feline, 2-6cm worms may see on endoscope, hard to see in fecal Tx: pyrantel pamoate
34
Ollulanus tricuspsi in stomach
feline, <1mm, seen on biopsy, gastric juice evaluation, vomitus evaluation tx fenbendazole
35
Gastric pythiosis
chronic vomiting oomycete - P. insidiosum, tropical dz, standing water, thickened gastric outflow tract pyogranulomatous inflammation, high fatality rate, pythiosis vaccine terbinafine + itraconazole (antifungals) +/- Sx
36
Gastroesophageal reflux (GERD)
chronic vomiting or regurgitation lip licking, hard swallow, ptyalism, halitosis, esophagitis secondary to primary gastric or small intestinal dz Dx: CS + Hx Tx: PPI (omeprazole) + sucralfate (gastropretactant) find and Tx primary dz
37
Inflammatory gastritis
chronic vomiting inciting cause rarely Idd, other causes r/o endoscopy or Sx Bx Dx: infiltrate of inflammatory cells in mucosa + lamina propria #1 lymphoplasmacytic infiltrate, also eosinophilic, mast cells Prior to Bx: Tx, symptomatic, antacid/gastroprotectants, antiemetics, empiric deworming (fenbendazole, pyrantel), diet trial w/ hypoallergenic or novel protein diet After Bx: immune modulation, prednisone (dog), prednisolone (cat), mycophenolate, azathioprine, chlorambucil
38
What happens if you don't treat inflammatory gastritis?
Atrophic gastritis chronic vomiting, marked mononuclear cell infiltrate, thinning of gastric mucosa, atrophy of gastric glands Tx inflammation and helicobacter if present
39
Hypertrophic gastropathy
chronic projectile vomit hours after eating, diffuse or focal hypertrophy or mucosa, muscularis or both inflammatory infiltrates assoc w/ hypergastrinemic conditions dec clearance from renal or liver dz gastrin excreting tumor, pronounced in pyloric outflow region older small breeds Tx underlying dz +/- surgical resection of thickened tissue
40
Congenital pyloric stenosis/hypertrophy
boxers, Boston terriers, English bulldogs, siamese cats muscular thickening of pyloric sphincter delayed gastric emptying - vomiting several hours after meal CS: poor weight gain, aspiration pneumonia, depression, dehydration medically tx systemic effects of dehydration + acid/base, Sx
41
Acquired pyloric stenosis
inflammation, neoplasia, Sx correction
42
Gastrinoma
Zollinger Ellison syndrome, gastrin secreting tumor chronic vomiting, thickened gastric wall, hypertrophy of pylorus, gastric ulceration - effects of high gastrin reflux esophagitis +/- diarrhea neuroendocrine, tumor usually in pancreas Dx: gastrin levels - TAMU, fasted +frozen serum, low pH of gastric juice, US, CT, scintigraphy, Bx Tx: Sx, PPI, octreotide (inhibits gastrin), guarded to poor Bx
43
70% of all malignant canine stomach tumors
adenocarcinoma
44
MC malignant feline stomach tumor
lymphosarcoma
45
Bilious vomiting syndrome (BVS)
Dx: early morning vomiting of bile, usually young dogs reflux of duodenal fluid into stomach + irritation of gastric mucosa Tx: frequent small feedings, pro kinetics, gastroprotectants, novel protein diet
46
Histology of small intestine
single columnar epithelium + lamina propria form villi w/ crypts of Lieberkuhn between central lymph vessel in each villus absorptive enterocytes w/ microvilli + goblet cells dispersed jejunum villi = tall, ileum = short, histo identical except presence of paneth cells paneth cells = eosinophilic cytoplasmic granules in clusters at base of crypts
47
Physiology of SI
digestive enzymes - peptidases - nucleases - disaccharidases - utilizes bile acids + pancreatic enzymes - absorption of nutrients - barrier to infection - complex immunologic organ
48
Brush border enzymes + absorption
active transport: glucose, galactose facilitated diffusion: fructose diffusion: SCFA long chain FA + f soluble vitamins - diffusion (+ micelles) _ exocytosis to chylomicrons formed in ER, moved to lacteals
49
Energy requirement for enterocytes
glutamine
50
Hemorrhagic gastroenteritis (HGE)/ acute hemorrhagic diarrhea syndrome
acute onset of profuse hemorrhagic diarrhea (raspberry jam) small/toy breeds general GI CS Dx: hypovolemic shock, PCV >60% Tx: fluids, antibiotics (Unasyn +/- metronidazole), gastroprotectants, antiemetics, nutrition Px: good w/ aggressive support
51
A client comes in because her toy yorkie has been feeling unwell. She explains he has been lethargic, vomiting, not eating, and cries when she touches his belly. This morning she noticed his poop looked like raspberry jam. what do you suspect?
HGE - hemorrhagic gastroenteritis aka acute hemorrhagic diarrhea syndrome
52
Diplydium canis
SI ingestion of fleas, shed proglottids Tx: praziquantel + fenbendazole
53
Toxocara canis/cati
whipworms, SI | ingestion of eggs or maternal transmission
54
Giardia duodenalis
SI Dx: trophozoites on direct smear, cysts on fecal float, ELISA (1st time only) Tx: fenbendazole + metronidazole + bathing dont confuse w/ tritrichomonas fetus (cat), large bowel, also trophozoites
55
Coccidia
SI, fecal oral or predation, sporozoites infect enterocytes worse in immunocompromised/young Dx: direct smear or fecal float Tx: sulfadimethoxine, support
56
Cryptosporidium parvum
SI species specific but not zoonotic, fecal oral, contaminated food/water self limiting SI diarrhea, life threatening if immunocompromised Tx: paromomycin, Tylosin
57
Toxoplasma gondii
SI zoonotic, oocysts require 1-5d to be infectious after passed - clean litter daily predation - bradyzoites in muscle, fecal contamination CS: Gi signs uncommon, pneumonitis Dx: antibody tigers - IgG + IgM useful when assoc w/ sick pet, positive titer doesnt mean shedding or clinical dz Tx: TMS every 12h for 4 weeks, clindamycin
58
Histoplasmosis
SI Mississippi + Ohio river aerosols into lungs + thoracic LN, disseminated by blood CS: cats show no GI signs, dogs do Dx: Bx abnormal tissue, ELISA antigen (may cross react w/ blastomycosis) Tx: prolonged medical tx - itraconozole or amphotericin B
59
Phythiosis
SI aquatic oomycete, gulf states, exposure to free standing water, penetration of skin/mucosa by motile zoospores CS: GI, derm (non healing skin lesions) - do not occur together, ulcerative nodules, draining tracts +/- LN enlargement Dx: eosinophilia, severe transmural thickening, pyogranulomatous + eosinophilic inflammation, GMS to stain Tx: removal Sx, meds - 2-3m of itraconaole or terbinafine, , immunotherapy if non resectable
60
Candidiasis
opportunistic, associated w/ disruption of mucosal integrity | dogs - perforating intestinal lesions after Sx
61
top 3 bacterial causes of intestinal dz
Salmonella (SI) E. Coli (SI) Campylobacter (LI)
62
Salmonella
``` gram -, facultative anaerobe S. typhimurium zoonotic! destroys villi Tx: supportive, fluids, fluoroquinolone, chloramphenicol, TMS, amoxicillin ```
63
Salmon poisoning dz (SI)
dog, salmon, fluke (nanophyteus salmincola), bacteria (neorickettsia helminthoeca) Pacific Northwest, acute dz Dx: fluke eggs in feces, inclusions in macrophages (bacteria) hospitalize, oxytetracycline, doxy, praziquantel (flukes) Px: good, death in 90% if untreated
64
Canine parvovirus (SI)
type 2, fecal oral, shed while sick >10d after, in environment for months, very contagious, ill w/in 4-7d infection young <6m likes rapidly dividing cells Dx: electrolyte shift, SNAP test, PCR to confirm Tx; supportive care
65
Feline panleukopenia (SI)
closely related to Parvo, 50-90% fatal w/o aggressive support cerebellar hypoplasia w/ perinatal infection
66
Small intestinal neoplasia
lymphoma cats > dogs infiltrative diffuse dz, thickening of SI on US Tx: chlorambucil + prednisolone
67
Antibiotic responsive diarrhea (ARD) (SI)
SI bacterial overgrowth, no reliable test to prove abnormal host bacterial interactions, competition for nutrients, malabsorption, diarrhea assess pancreatic function CS: diarrhea, GI signs Dx: response to Tx Tx: 4-5w of metronidazole or Tyllosin SIBO - small intestinal bacterial overgrowth -- can be clinical sign or secondary pathogenetic mechanism
68
Describe cobalamin + folate absorption
Cobalamin (vit B12) -absorbed in distal SI - values below normal range seen with EPI, bacterial overgrowth in upper SI or dz affecting lower SI Folate - absorbed in proximal SI values above normal range seen with bacterial overgrowth in upper SI below normal - disease of upper SI
69
High folate and low cobalamin levels are suggestive of
bacterial overgrowth in upper SI
70
Food allergy hypersensitivity
resolves w/ diet change HS type 1, 2, or 4 hydrolyzed diets with novel proteins, proteins ideally 1KD but bitter so settle for 7-10kD
71
Inflammatory Bowel disease
idiopathic, chronic inflammation specific dx criteria multifactorial causes Tx: regardless of cause, diet modification (based on nutrient content + digestibility) +/- immunosuppressive tx (most important) - prednisone or prednisolone, can use azathioprine (dog) and chlorambucil (cat) to spare steroids
72
Dx criteria of IBD
chronic GI signs histopath evidence of mucosal inflammation inability to document other cause inadequate response to tx trials clinical response to anti-inflammatories + immunosuppressive agents histopath changes in absence of criteria doesnt allow Dx to be made
73
Protein losing enteropathy
MC cause = lymphoma, IBD, lymphangiectasis CS: hypocholesterolemia, hypoCa, hypoMg, lymphopenia Can be d/t erosive or ulcerative lesions, lymphatic dysfunction, mucosal changes low serum cobalamin common, hypercoagulabiltity
74
Lymphangiectasia
dilation + dysfunction intestinal lymphatics, abnormal lacteals rupture, lymph leaks into lumen PLE --> hypoproteinemia, loss of lymphocytes = immunodeficiency ascites or SQ edema Dx: nodular masses around lymphatics (lipogranulomas) Tx: resolve inflammation, fat restricted, calorie dense, highly digestible diet (weight reduction diet not good), diuretics + taps to manage effusions
75
Histology of the colon
lack large villi, invaginations of surface epithelium = intestinal crypts of lieberkuhn, tubular crypts extend entire thickness of mucosa high mitotic index many more goblet cells vs SI
76
Colonic microbiome
interacts w. mucosal immune system, provide energy for colonocytes, synthesize AA + its colon has highest [] of bacteria in gut metabolize carbs, proteins, lipids into SCFAs acetate, propionate, butyrate, by-products = H, methane, sulpha compounds, CO2
77
chronic LI inflammation
colitis
78
Clinical signs of colonic disease
A#1 diarrhea #2 constipation unique to colonic dz: frank blood, mucus, tenesmus, dyschezia, urgency no weight loss or vomiting
79
Acute colitis
sudden onset, self limiting, withheld food, give low fat/highly digestible diet Kaolin based antidiarrheals may bind toxins + produce firmer stools, diphenoxylate or loperamide can reduce tenesmus
80
Chronic colitis
acute that doesnt resolve w/in 3weeks
81
Trichuris vulpis (whipworm)
LI hyper K and hypo N - pseudo-Addison's dz, ACTH stim will be normal dog > cat, acute or chronic LI diarrhea, fecal oral
82
Heterobilharzia Americana
LI schistosomiasis, trematodes, gulf states racoons = reservoir need praziquantel to fix hyperCa
83
Tritrichomonas fetus
LI protozoa young cats in crowded housing ID in fresh feces, too motile trophozoites, PCR more sensitive
84
Campylobacter
LI | gram -, motile, spiral
85
Clostridium difficile
LI gram +, anaerobic, spore forming bacillus 2 toxins: A (enterotoxin) and B (cyanotoxin)
86
Clostridium perfringens
LI gram +, anaerobe, spore forming bacillus causes acute colitis + hemorrhagic gastroenteritis (HGE) type A toxins inc major toxin A (enterotoxin) = clostridium perfringens enterotoxin (CPE) Tx: metronidazole, amoxicillin, erythromycin, tylosin resistance to tetracyclines common
87
E.Coli
commensal unless carries specific pathogenic plasmid gene ETEC - SI EPEC - SI + LI EHEC - LI, produces shiva like toxins that kill colonocytes by inhibition of protein synthesis, results in hemorrhagic diarrhea PCR to isolate pathogenic genes
88
Granulomatous colitis
intracellular E. coli infection young boxers + frenchies macrophages full of PAS staining material underlying an ulcerated colonic mucosa immunosuppressives dont work, tx w/ enrofloxacin
89
Constipation + obstipation
obstipation = permanent loss of function dilated megacolon = end stage of colonic dysfunction CS: dyschezia, vomiting, anorexia, dehydration Tx: mild - warm water enemas, laxatives, prokinetics Severe - correct dehydration + metabolic abnormalities, remove impacted feces, warm water enema + manual extraction
90
megacolon
dilation - secondary to electrolyte abnormalities, neuromuscular disorders or idiopathic hypertrophy - consequence of obstructive lesions
91
Feline idiopathic megacolon
middle aged male DSH absent or painful defecation permanent loss of colonic structure + function medical tx then colectomy
92
Vomit reflex
visceral receptors - abdominal viscera, acute distension, erosions, ulceration, inflammation, irritation vagal + sympathetic afferent neurons - entire GIT + peritoneal cavity CRTZ - mediates vomiting assoc w/ drugs, toxemias, metabolic dz emetic center - all emetic stimuli converge in emetic center, vomiting stimuli travel directly or indirectly via CRTZ
93
test of choice to Dx exocrine pancreas insufficiency
trypsin like immunoreactivity (TLI) | <2.5ug/L dogs, <8ug/L cats
94
Anatomy of pancreas
L + R lobes w/ small central body cat - pancreatic duct fuses w/ bile duct before opening on major duodenal papilla each lobule = acinar cells, branching duct system, Langerhans cells
95
Physiology of pancreas
acinar cells secrete fluid rich in enzymes, pancreatic juice secreted into duodenum in presence + absence of food, secretion in response to cephalic stim + GI stim (secretin + cholecystokinin)
96
what is a zymogen
an inactive form of an enzyme, this is how it is stored so it is safe in pancreas
97
digestive enzymes from pancreas
protein - trypsin, chymotrypsin, carboxypeptidase carbs - amylase fats - lipase, cholesterol lipase, phospholipase
98
Pancreatitis
pancreatic auto digestion (activation of enzymes in the gland)
99
Pathophysiology of pancreatitis
unopposed free radicals cause increased capillary permeability d/t endothelial cell damage with resultant edema plasma protease inhibitors consumed (a-macroglobulin)
100
Acute vs chronic pancreatitis
acute - fully reversible inflammation, history presence of edema, neut infiltrates + necrosis chronic - continuing inflammation (lymphocytic or lymphoplasmacytic) w/ irreversible changes like fibrosis can be subclinical or recurrent w/ episodes of severe illness (acute on chronic)
101
Clinical signs of pancreatitis
dogs - anorexia, vomiting, weakness, abdominal pain, dehydration, diarrhea cats - anorexia + lethargy mc
102
pancreatic lipase immunoactivity
canine - decreased in dogs w/ EPI vs healthy, increases w/ pancreatitis + renal dysfunction feline - may be more specific to dx EPI vs TLI or US
103
Test of choice for exocrine pancreatic insufficiency
TLI - trypsin like immunoreactivity
104
Tests of the pancreas
TLI used to Dx EPI PLI researched - may be good for cats US - valuable see non-homogenous masses, loss of echo density, cystic masses, biliary obstruction Bx - most definitive dx but many risks + complications
105
Treating pancreatitis
dogs - feed whenever possible, ultra low fat diet, if not hungry use NG tube or esophagostomy, jejunostomy if relentless vomiting, supportive tx, antivomit meds, analgesia, tx underlying dz cats - DONT restrict fat
106
MC disorder of feline exocrine pancreas
pancreatitis
107
Exocrine Pancreatic insufficiency
90% secretory ability lost = maldigestion pancreatic acinar atrophy - genetic or immune mediated GSD, collie, eurasians CS: weight loss, steatorrhea, poor hair coat TLI levels - species specific B12 - often low and needs supplement Tx: give animal IF + 12, abs (tylosin or metronidazole)
108
T/F: liver specific signs show rapidly when liver is dz
false, only w/ end stage
109
what lobe is gall bladder in?
quadrate

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