GI Flashcards
0
Q
What is gastroschisis?
A
Congenital malformation of the anterior abdominal wall causing extrusion of abdominal contents.
Not covered by peritoneum
1
Q
What is derived from the foregut?
Midgut?
Hindgut?
A
Foregut - Pharynx to duodenum, liver, gallbladder, pancreas
Midgut - Duodenum to transverse colon
Hindgut - Distal transverse colon to rectum
2
Q
What is an omphalocele?
A
Failure of intestines to return to body cavity after herniation into the umbilical cord. Covered by peritoneum
3
Q
What causes intestinal atresia?
A
Duodenal atresia - failure to recanalize
Jejunal, ileal, colonic atresia - vascular accident in-utero
Vascular accident can cause apple peel syndrome where distal atrophic gut is wrapped around an artery.
4
Q
When does midgut rotation occur?
A
6th week –> midgut herniates through umbilical ring
10th week –> abdominal cavity is large enough & midgut returns to it & rotates around SMA
Failure can cause malrotation of midgut or omphalocele
5
Q
What are the possible types of tracheoesophageal abnormalities?
Which is most common?
A
Most common is EA with distal TEF
Others:
Pure EA
Pure TEF (H-type; fistula present but esophagus still patent)
6
Q
What is seen with EA+TEF?
A
Drooling Choking with first feeding Cyanosis (laryngospasm to prevent reflux aspiration) Air in the stomach on CXR Failure to pass NG tube into stomach
7
Q
What can result from malformation of the pancreas?
A
Annular pancreas - ventral pancreatic bud encircles 2nd part of duodenum & may cause narrowing. Due to failure of migration.
Pancreas divisum - Common; dorsal & ventral buds fail to fuse so that most pancreatic acini drain to minor sphincter. Predisposes to chronic pancreatitis.
8
Q
From where does the spleen arise?
A
Arises from mesoderm but is supplied by foregut (celiac artery)
The other gut structures are all endodermal.
9
Q
What are the retroperitoneal structures?
A
SAD PUCKER
Suprarenal glands Aorta & IVC Duodenum (2nd & 3rd parts) Pancreas (except tail) Ureters Colon (ascending & descending) Kidneys Esophagus (lower 2/3) Rectum (lower 2/3)
10
Q
What is the falciform ligament?
A
Connects the liver to the anterior abdominal wall
Contains ligamentum teres (derivative of fetal umbilical vein)
11
Q
What ligament contains the portal triad?
A
Hepatoduodenal ligament
Portal triad = hepatic artery, portal vein, common bile duct
12
Q
What is the difference between an erosion and an ulcer?
A
Erosion = mucosa only
Ulcer = submucosa or deeper
13
Q
What is the frequency of electrical rhythm along the GI tract?
A
Stomach = 3 waves/min
Duodenum = 12 waves/min
Ileum = 8 waves/min
14
Q
What are the layers of the gut wall?
A
1) Mucosa (epithelium, lamina propria, muscularis mucosa)
2) Submucosa (includes Submucosal/Meissner’s plexus)
3) Muscularis externa (includes Myenteric/Auerbach’s plexus)
4) Serosa (intraperitoneal) or Adventitia (retroperitoneal)
15
Q
What is the duodenum composed of histologically?
A
Villi & microvilli
Brunner’s glands (unique to duodenum; HCO3-)
Crypts of Lieberkuhn (throughout small & large intestine)
16
Q
What is the histology of the ileum?
A
Peyer’s patches (unique to ileum)
Largest # of goblet cells in SI
Plicae circularis (along with jejunum)
Crypts of Lieberkuhn
17
Q
What can result from failure of the vitelline (omphalomesenteric) duct to obliterate?
When should it obliterate?
A
Meckel diverticulum
Persistent vitelline duct
Vitelline cyst
Vitelline sinus
Should obliterate during the 7th week
18
Q
What does an acid fast stain bind to?
A
Mycolic acid (TB, Nocardia)
19
Q
What can cause papillary necrosis?
A
Sickle cell disease or trait
Analgesic use
Diabetes
Acute pyelonephritis
20
Q
When is a child at risk for hemolytic disease of the newborn?
A
Anti-A or Anti-B Ig’s are formed early in life. If a mother is A or B, she will form IgM (cannot cross placenta). If she is O, she will form IgG (can cross placenta). Thus, even her first child is at risk.
Mothers must be inoculated (with the first birth) against Rh. Subsequent births are at risk.
21
Q
What is the difference in mechanism between unfractionated heparin and LMW heparin?
A
Unfractionated heparin binds Xa & IIa equally
LMW heparin preferentially binds Xa
*Antithrombin is needed in both cases to form the ternary inactive complex (heparin, AT, Xa/IIa)
22
Q
What is the function of human Placental Lactogen (hPL)?
A
Insulin resistance –> fetus gets more of the glucose
^Lipolysis, proteolysis –> energy for both mom & fetus
hPL levels rise throughout gestation to support a growing fetus
23
Q
What can be seen as a side effect of massive amounts of blood transfusions?
A
If a patient gets an entire body content of blood (5L) in under 24h, citrate from the blood products (additive) can accumulate and chelate the blood calcium causing hypocalcemia.
24
Where do the nitrogen atoms in urea come from?
```
Free NH3 (alanine cycle)
Aspartate (added into the urea cycle)
```
25
How id carbamoyl phosphate synthetase I regulated?
Rate-limiting enzyme in the urea cycle
It is activated by N-acetylglutamate
26
What physical exam findings are more specific for iron deficiency anemia?
```
Dysphagia
Spoon nails (koilonychia)
```
27
What growth factors are responsible for angiogenesis?
FGF
VEGF
This is true both in granulation tissue & in tumorgenesis
28
What is the receptor for rabies virus in the body?
Nicotinic ACh receptor
29
What is the cellular receptor for CMV?
Cellular integrins
30
What is the cellular receptor for Rhinovirus?
ICAM1
31
What murmurs can be heard better with the patient leaning forward?
Aortic murmurs
It brings the valve close to the chest wall
32
What can cause Pure Red Cell Aplasia?
```
Thymoma (auto-Ab's)
Lymphocytic leukemia (auto-Ab's)
Parvovirus infection
```
PRCA is selective aplastic anemia seen with erythroblasts but sparing granulopoiesis & thrombopoiesis.
33
What are the effects of dobutamine?
Selective B1 agonist
Inotropy > Chronotropy
^Contractility
^Cardiac conduction velocity (proarrhythmic)
^Myocardial O2 consumption
34
What drains the lower limbs & male genitalia?
Testis --> para-aortic
Penis & cutaneous calf --> deep inguinal
Scrotum & rest of leg --> superficial inguinal
35
Where does HBV acquire its envelope?
Endoplasmic reticulum
36
How does HBV use its reverse transcriptase?
The viral mRNA transcript is packaged into a capsid & RT acts on it to produce circular DNA that is partially ds. This is the infective form of HBV.
37
What toxicity is seen with Vincristin/Vinblastine?
Neurotoxicity
They inhibit MT assembly & thus axonal transport in neurons.
38
What are the vegetations of bacterial endocarditis composed of?
Platelets
Fibrin
Bacteria
39
What causes bronchiolitis?
Bronchiolitis is viral
It is inflammation of the bronchioles (smallest air passageways).
40
What is the DDx for absent thymic shadow?
SCID
| DiGeorge syndrome
41
What is the cause of Leukocyte Adhesion Deficiency 1 (LAD1)?
Absence of LFA-1 (CD18), an integrin required for leukocyte tight adhesion.
42
What is the cause of Leukocyte Adhesion Deficiency 2 (LAD2)?
Impaired formation of Sialyl-Lewis carbohydrate ligands on leukocytes, leading to impaired selectin binding.
It is a milder form of LAD than LAD1 & LAD3. No delayed separation of the umbilical cord.
43
What is seen with leukocyte adhesion deficiency 3 (LAD3)?
Delayed separation of the umbilical cord (Types 1 & 3)
Recurrent skin infections without pus formation
Bleeding complications
44
What is the blood supply to the lesser curvature of the stomach?
Greater curvature?
Lesser curvature:
Proximal - Left gastric
Distal - Right gastric
Greater curvature:
Proximal - Left gastroepiploic
Distal - Right gastroepiploic
45
What are the GI watershed zones?
Splenic flexure
| Sigmoid colon/rectum
46
What are the sites of porto-systemic venous anastomoses?
Portal-->Systemic:
Left gastric-->Esophageal
Paraumbilical--> Epigastric & lateral thoracic
Superior rectal-->Middle & inferior rectal
Together cause esophageal varices, caput medusae, & hemorrhoids
47
What are means of drug administration that bypass 1st pass metabolism?
IV
SubQ
Sublingual
Rectal suppository
48
What is the blood supply to/from the anus?
Above pectinate: Superior rectal (IMA)-->Superior rectal (portal)
Below pectinate: Inferior rectal (int. pudendal)-->Inf. rectal (IVC)
49
What is the lymphatic drainage of the anus?
Above pectinate line - deep nodes
Below pectinate line - superficial inguinal nodes
50
Where is the most common location of an anal fissure?
On the midline posterior wall of the anus, below the pectinate line
Presents with BRBPR & pain w/ defecation
51
What are the zones of a hepatic lobule?
| Which are affected first by insults?
Zone 1 = periportal - affected 1st by viral hepatitis
Zone 2
Zone 3 = centrilobular - affected 1st by ischemia, EtOH, drugs
Just remember periportal is affected by (zone) 1 thing - viruses
52
What is the organization of the femoral region?
Going from lateral-->medial: NAVL
Nerve
Artery
Vein
Lymphatics
53
What is contained in the femoral sheath?
| Femoral triangle?
Femoral sheath: Femoral artery, vein, & deep inguinal LN's
(not the nerve)
Femoral triangle: Femoral nerve, artery, vein (not the femoral canal)
54
What are the types of diaphragmatic hernias?
Sliding hiatal hernia:
Most common
GE junction displaced upward
"Hourglass stomach"
Paraesophageal hernia:
Fundus protrudes into thorax next to esophagus
Both can cause GERD
55
What patient populations are the various abdominal hernias associated with?
Indirect - male infants (patent processus vaginalis)
Direct - older males (weakened abdominal wall)
Femoral - women
56
Where is an indirect hernia located?
| What layers cover it?
Lateral to inferior epigastric artery. Goes through deep inguinal ring --> superficial inguinal ring --> scrotum
Covered by all 3 layers of spermatic fascia.
57
Where is a direct hernia located?
| What layers cover it?
Medial to inferior epigastric artery.
Protrudes through Hasselbach's triangle (through abd wall) --> superficial inguinal ring --> can extend into scrotum
Covered by external spermatic fascia only.
58
Where is a femoral hernia located?
Below inguinal ligament & lateral to pubic tubercle.
The leading cause of bowel incarceration (smaller hole)
More common in women.
59
What form the borders of Hasselbach's triangle?
Rectus abdominus
Inguinal ligament
Inferior epigastric vessels
This is the site of a direct inguinal hernia.
60
Gastrin
Secreted by:
Effects:
Regulation:
Secreted by: G cells in gastric antrum
Effects: ^acid secretion, motility, growth of gastric mucosa
Regulation: ^ by amino acids, vagal stim, stomach distention, ^pH
Can be ^ with chronic PPI use. Phenylalanine & tryptophan are the strongest stimulators.
61
Cholecystokinin
Secreted by:
Effects:
Regulation:
Secreted by: I cells of duodenum/jejunum
Effects: ^pancreatic secretion, GB contraction, spincter of Oddi relaxation, decreases gastric emptying
Regulation: ^ by fatty acids & amino acids
62
Secretin
Secreted by:
Effects:
Regulation:
Secreted by: S cells in duodenum
Effects: ^pancreatic HCO3- secretion, ^bile secretion, inhibits gastric acid secretion
Regulation: ^by acid, ^by FA's in duodenum
63
Somatostatin
Secreted by:
Effects:
Regulation:
Secreted by: D cells of pancreatic islets & GI mucosa
Effects: Inhibits secretion of gastric acid & pancreatic secretion, inhibits GB contraction, inhibits insulin & glucagon release
Regulation: ^ by acid, inhibited by vagal stimulation
64
Glucose-dependent insulinotropic peptide (GIP)
Secreted by:
Effects:
Regulation:
Secreted by: K cells of duodenum & jejunum
Effects: decreases gastric acid secretion, ^insulin release
Regulation: ^by fatty acids, amino acids, oral glucose
65
Vasoactive Intestinal Peptide (VIP)
Secreted by:
Effects:
Regulation:
Secreted by: Parasympathetic ganglia
Effects: ^intestinal water & electrolyte secretion, ^relaxation of smooth muscle & sphincters
Regulation: ^by vagal stimulation, decreased by adrenergics
66
What is seen with a VIPoma?
WDHA syndrome:
Watery Diarrhea
Hypokalemia
Achlorhydria
Seen as a non-alpha/non-beta pancreatic cell tumor.
67
Motilin
Secreted by:
Effects:
Regulation:
Secreted by: Small intestine
Effects: Produces migrating motor complexes (MMC's)
Regulation: ^during fasting state, stimulated by erythromycin
68
How is B12 absorbed?
Binds Haptocorrin (R-factor) in saliva --> binds intrinsic factor (parietal cells) --> absorbed in TERMINAL ILEUM
69
What is secreted by parietal cells of the stomach?
| Chief cells?
Parietal cells - Gastric acid, intrinsic factor
Chief cells - Pepsinogen (activated to pepsin by acid)
70
How is salivation regulated?
Salivation is increased by both sympathetic & parasympathetic activity
71
How does vagal stimulation cause gastric acid secretion?
1) GRP synapse on G cells --> Gastrin in circulation --> ECL cells release histamine --> parietal cells respond
(most important mechanism)
2) GRP synapse on G cells --> Gastrin stimulates parietal cells
3) Direct ACh synapse on parietal cells
72
What type of pump is located on the gastric parietal cell membrane?
H+/K+ ATPase exchanger
73
What substances act on the parietal cell to modulate gastric acid secretion?
Stimulate:
ACh (M3)
Gastrin (Gq)
Histamine (H2)
Inhibit (Gi):
Prostaglandins
Somatostatin
74
What is responsible for the activation of trypsinogen?
Duodenal mucosa --> Enterokinase/Enteropeptidase --> Activated trypsin --> can cleave other trypsin molecules to activate
75
How does flow rate affect pancreatic secretion ionic composition?
Low flow rate --> ^Cl-
| High flow rate --> ^HCO3-
76
What molecules are responsible for carbohydrate digestion & absorption in the GI tract?
Salivary/Pancreatic amylases --> oligosaccharides
Brush border oligosaccharide hydrolases --> monosaccharides
Transporters:
SGLT1 = Glucose & Galactose (Na+ dependent)
GLUT-5 = Fructose (facilitated diffusion)
77
Where in the GI tract is iron absorbed?
Duodenum
Absorbed as Fe2+
"Iron Fist Bro"
78
Where is Folate absorbed in the GI tract?
Duodenum
"Iron Fist Bro"
79
Where is B12 absorbed in the GI tract?
Terminal ileum along with bile acids (requires intrinsic factor)
"Iron Fist Bro"
80
What is the oxidation state of body iron?
Fe2+ absorbed
Fe3+ when bound to transferrin/ferritin
Fe2+ in heme
81
What is the rate-limiting step in bile acid synthesis?
Cholesterol 7-alpha-hydroxylase
82
What are the functions of bile?
1) Digestion/absorption of lipids & ADEK
2) Cholesterol excretion (body's only means of doing so)
3) Antimicrobial activity (membrane disruption)
83
How is heme broken down within macrophages?
Heme --(Heme oxygenase)--> Biliverdin
| --(Biliverdin reductase) --> Unconjugated bilirubin
84
How is bilirubin handled following its release from macrophages?
Transported to liver on albumin --(UDP glucuronosyltransferase)--> Conjugated bilirubin released in bile --(gut bacteria)--> Urobilinogen
85
Why is urine yellow?
| Why is poop brown?
Urine - urobilin
| Poop - stercobilin
86
What causes Behcet syndrome?
| What is seen?
Immune complex vasculitis involving small blood vessels
Triad of:
Recurrent aphthous ulcers (canker sores)
Genital ulcers
Uveitis
87
What is the lymphatic drainage of the esophagus?
Upper 1/3 - Cervical nodes
Middle 1/3 - Mediastinal or tracheobronchial nodes
Lower 1/3 - Celiac & gastric nodes
88
What are the 3 types of salivary gland tumors & their presentations?
Pleomorphic adenoma - painless mobile mass composed of cartilage & epithelium; recur frequently
Warthin's tumor - benign cystic tumor with germinal centers
Mucoepidermoid carcinoma - painful mass with occasional facial nerve palsy; mucinous & squamous components
89
What is seen with achalasia?
^LES tone due to loss of Auerbach's plexus (Chagas; idiopathic)
Dysphagia to solids AND liquids
"Bird's beak" on barium swallow
^risk of esophageal SCC
90
What is seen on manometry of achalasia & CREST/Scleroderma?
Achalasia = high LES pressure
CREST/Scl = low LES pressure
Both cause esophageal dysmotility
91
What causes GERD?
| How does GERD present?
Impaired LES tone --> GERD
Heartburn & regurgitation while lying down
Nocturnal cough & dyspnea
Adult-onset asthma
92
What is the venous drainage of the esophagus?
Upper 2/3 = Azygous (systemic)
| Lower 1/3 = Left gastric (portal)
93
What can cause esophageal stricture?
Lye ingestion
| GERD
94
What is seen on histology in Barrett's esophagus?
Intestinal metaplasia:
| Nonciliated columnar epithelium with goblet cells
95
What type of esophageal cancers are caused by smoking?
| Alcohol?
Smoking - both
| Alcohol - just squamous
96
What GI abnormalities are seen with Down's syndrome?
Duodenal atresia
| Hirschsprung's disease
97
What causes Hirschsprung's disease?
Failure of neural crest cell migration --> aganglionic colon (missing both Meissner's & Auerbach's plexuses) --> functional obstruction w/ proximal dilation
98
What is seen in Ogilvie's syndrome?
aka Acute Colonic Pseudo-obstruction
Obstruction of the cecum & right hemicolon without an identifiable obstruction
99
What causes duodenal atresia?
| What is seen?
Failure of recanalization of the small bowel
Associated w/ Down syndrome
Presents with:
Early bilious vomiting
"Double bubble" on x-ray
100
What is seen with ischemic colitis?
Pain after eating (like angina in the heart)
| Commonly occur at the splenic flexure or sigmoid colon
101
What is the most common cause of small bowel obstruction?
Adhesion (commonly following surgery)
102
What histologic factors increase an adenomatous polyp's chances of becoming malignant?
^Size
Villous histology
Dysplasia
103
What is the most common type of polyp in the colon?
Hyperplastic polyps
104
Are juvenile polyps premalignant?
Single polyp = no malignant potential
Juvenile polyposis syndrome = ^risk of adenocarcinoma
105
What is seen in Peutz-Jeghers syndrome?
Nonmalignant hamartomas throughout GI tract
Hyperpigmented mucous membranes
^risk of CRC, breast, & gynecological cancers
106
What mutation causes FAP?
APC gene on chromosome 5
When it is mutated, beta-catenin is free to act as a transcription factor --> ^proliferation and impaired cell adhesion
107
What are the variants of FAP?
| What is seen?
Gardner's syndrome --> FAP + fibromatosis & osteomas
Turcot's syndrome --> FAP + malignant CNS tumors
108
What causes HNPCC?
| What is seen?
Aut. dominant mutation in DNA mismatch repair
^risk of CRC, ovarian, & endometrial cancers
Right colon is affected
109
Strep bovis
CRC
Get a colonoscopy
110
What tumor marker is used for CRC?
CEA
Only used to monitor recurrence, not a good screening tool
111
What are the most common sites of a carcinoid tumor?
Appendix
Ileum
Rectum
It is the most common malignancy in the small intestine
112
What is seen with carcinoid syndrome?
Wheezing
Diarrhea
Flushing
R. sided carcinoid heart disease (valvular fibrosis --> murmur)
It is right sided only because lung contains MAO (like liver) which can metabolize 5-HT --> 5-HIAA so serotonin never hits LA/LV.
113
What can be used to confirm liver/bile duct disease when alkaline phosphatase is elevated?
Gamma-glutamyl transferase (GGT)
114
What can cause an elevation in serum amylase?
| Lipase?
```
Amylase = Mumps, acute pancreatitis
Lipase = acute pancreatitis
```
115
What viruses are associated with Reye's syndrome?
VZV
Influenza B
Can be any viral infection that is treated with aspirin in a child.
116
What is seen histologically with alcoholic hepatitis?
Macrovesicular fatty change
Mallory bodies
(condensed cytoskeleton --> cytoplasmic eosinophilic inclusions)
117
What autoantibodies are seen with the liver diseases?
Autoimmune hepatitis = Anti-smooth muscle
PBC = Anti-Mitochondrial
PSC = p-ANCA's
118
What GI abnormalities are seen with Down's syndrome?
Duodenal atresia
| Hirschsprung's disease
119
What causes Hirschsprung's disease?
Failure of neural crest cell migration --> aganglionic colon (missing both Meissner's & Auerbach's plexuses) --> functional obstruction w/ proximal dilation
120
What is seen in Ogilvie's syndrome?
aka Acute Colonic Pseudo-obstruction
Obstruction of the cecum & right hemicolon without an identifiable obstruction
121
What causes duodenal atresia?
| What is seen?
Failure of recanalization of the small bowel
Associated w/ Down syndrome
Presents with:
Early bilious vomiting
"Double bubble" on x-ray
122
What is seen with ischemic colitis?
Pain after eating (like angina in the heart)
| Commonly occur at the splenic flexure or sigmoid colon
123
What is the most common cause of small bowel obstruction?
Adhesion (commonly following surgery)
124
What histologic factors increase an adenomatous polyp's chances of becoming malignant?
^Size
Villous histology
Dysplasia
125
What is the most common type of polyp in the colon?
Hyperplastic polyps
126
Are juvenile polyps premalignant?
Single polyp = no malignant potential
Juvenile polyposis syndrome = ^risk of adenocarcinoma
127
What is seen in Peutz-Jeghers syndrome?
Nonmalignant hamartomas throughout GI tract
Hyperpigmented mucous membranes
^risk of CRC, breast, & gynecological cancers
128
What mutation causes FAP?
APC gene on chromosome 5
When it is mutated, beta-catenin is free to act as a transcription factor --> ^proliferation and impaired cell adhesion
129
What are the variants of FAP?
| What is seen?
Gardner's syndrome --> FAP + fibromatosis & osteomas
Turcot's syndrome --> FAP + malignant CNS tumors
130
What causes HNPCC?
| What is seen?
Aut. dominant mutation in DNA mismatch repair
^risk of CRC, ovarian, & endometrial cancers
Right colon is affected
131
Strep bovis
CRC
Get a colonoscopy
132
What tumor marker is used for CRC?
CEA
Only used to monitor recurrence, not a good screening tool
133
What are the most common sites of a carcinoid tumor?
Appendix
Ileum
Rectum
It is the most common malignancy in the small intestine
134
What is seen with carcinoid syndrome?
Wheezing
Diarrhea
Flushing
R. sided carcinoid heart disease (valvular fibrosis --> murmur)
It is right sided only because lung contains MAO (like liver) which can metabolize 5-HT --> 5-HIAA so serotonin never hits LA/LV.
135
What can be used to confirm liver/bile duct disease when alkaline phosphatase is elevated?
Gamma-glutamyl transferase (GGT)
136
What can cause an elevation in serum amylase?
| Lipase?
```
Amylase = Mumps, acute pancreatitis
Lipase = acute pancreatitis
```
137
What viruses are associated with Reye's syndrome?
VZV
Influenza B
Can be any viral infection that is treated with aspirin in a child.
138
What is seen histologically with alcoholic hepatitis?
Macrovesicular fatty change
Mallory bodies
(condensed cytoskeleton --> cytoplasmic eosinophilic inclusions)
139
What autoantibodies are seen with the liver diseases?
Autoimmune hepatitis = Anti-smooth muscle
PBC = Anti-Mitochondrial
PSC = p-ANCA's
140
How does gallstone ileus occur?
Fistula must be present between GB & duodenum --> obstruction of small bowel by gallstones
141
What chemical mediates the damage seen in alcoholic hepatitis?
Acetaldehyde
142
What is seen on LFT's with alcoholic hepatitis?
AST > ALT
This is because AST is within mitochondria and EtOH is a mitochondrial poison. This differentiates alcoholic hepatitis from viral hepatitis & NASH.
143
How does Reye's syndrome present?
```
Hypoglycemia
N/V
Elevated liver enzymes
Hepatomegaly
Coma, death
```
144
How does phototherapy help in neonatal hyperbilirubinemia?
Does not conjugate it, just makes it water soluble so it can be excreted in the urine
145
What cell type mediates cirrhosis?
Stellate (Ito) cells
They are located in the space of Disse & normally function to store Vitamin A. When activated, they mediate the fibrosis seen in cirrhosis.
146
What can lead to cirrhosis?
```
Alcoholic cirrhosis
HBV & HCV
Wilson's disease
Hemochromatosis
Alpha-1 Antitrypsin deficiency
Aflatoxin (Aspergillus)
```
147
What genetic disease has a high rate of HCC?
Hereditary tyrosinemia
148
What paraneoplastic syndrome is seen with HCC?
Polycythemia
149
What are the risk factors for hepatic adenoma?
OCP's
Anabolic steroids
Can rupture during pregnancy. Often regress spontaneously.
150
What cell marker can be used for angiosarcoma?
CD31 (endothelial cell marker)
151
What is seen in Bud-Chiari syndrome?
```
Absence of JVD
Hepatomegaly
Ascites
Abdominal pain
Visible abdominal/back veins
```
152
What are the causes of Bud-Chiari syndrome?
Polycythemia vera
Hypercoagulable state
Pregnancy
HCC
153
What is seen histologically in the liver with A1AT deficiency?
Cirrhosis
| PAS+ globules
154
What bilirubin levels will present as jaundice?
>2.5 mg/dL
155
What are the causes of unconjugated bilirubinemia?
Hemolytic anemia
Neonatal jaundice
Gilbert syndrome
Crigler-Najjar syndrome
156
What are the causes of conjugated hyperbilirubinemia?
Biliary tract obstruction:
Gallstones
Pancreatic/Liver cancer
Echinococcus granulosus
Biliary tract disease:
PBC
PSC
Excretion defect:
Rotor syndrome
Dubin-Johnson syndrome
157
What causes a mixed (direct & indirect) hyperbilirubinemia?
Hepatitis
| Cirrhosis
158
What causes Gilbert's syndrome?
| What is seen?
Mild deficiency in UDP-glucuronyl transferase
Mild unconjugated bilirubinemia
Triggered by fasting or stress
159
What causes Crigler-Najjar syndrome?
| What is seen?
Absent UDP-glucuronyl transferase
Presents in neonatal life --> death within a few years
Jaundice
Kernicterus (bili deposition in brain)
Unconjugated bilirubinemia
Tx: Plasmapheresis & phototherapy
160
What causes Rotor's syndrome?
| What is seen?
Defective hepatocyte excretion of bilirubin
A benign condition
Conjugated hyperbilirubinemia
Dubin-Johnson = slightly more severe form with grossly black liver
161
What is seen with Wilson's disease?
```
Decreased ceruloplasmin
Cirrhosis
Kayser-Fleisher rings
Hemolytic anemia
Basal ganglia degeneration
Asterixis
Dementia
```
162
What causes Wilson's disease?
| How is it treated?
AR defect in ATP7B gene (chrom 13) --> copper cannot be excreted into bile by hepatocytes
Tx: Penicillamine
163
What is seen in Hemochromatosis?
```
Diabetes
Bronze color to skin
Cirrhosis
CHF (dilated or restrictive)
Testicular atrophy
^risk of HCC
```
164
What causes hemochromatosis?
Primary hemochromatosis:
HFE mutation --> transferrin-Fe complex not taken up into intestinal epithelial cells --> no feedback inhibition --> excessive Fe absorption --> deposition in tissues
```
Secondary:
Chronic transfusions (beta-thalassemia, etc.)
```
Tx: Phlebotomy, deferasirox, deferoxamine
165
How does biliary tract disease present?
```
Pruritis
Jaundice
Dark urine
Light stools
HSM
```
166
What is seen hisologically with PBC & PSC?
PBC: lymphocytes & granulomas
PSC: "Onion skin" bile duct fibrosis
Beading seen on ERCP
167
What type of gallstones are radiolucent/radiopaque?
Cholesterol stones = usually radiolucent
Pigment stone = usually radiopaque
168
What are the risk factors for cholesterol gallstones?
```
Obesity
Age
Estrogens
Multiparity
Crohn's disease
Cystic fibrosis
Clofibrate
Rapid weight loss
Native American heritage
```
169
How is cholelithiasis diagnosed?
```
Ultrasound
HIDA scan (radionucleotide biliary scan)
```
170
What can cause acute pancreatitis?
```
GET SMASHED:
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmunity
Scorpion sting
Hypercalcemia/Hypertriglyceridemia
ECRP
Drugs
```
also bleeds from gastroduodenal artery (posterior duodenal ulcer)
171
What can result from acute pancreatitis?
```
DIC
ARDS
Hypocalcemia (fat necrosis)
Hemorrhage
Infection
Pseudocyst formation (which can still rupture --> hemorrhage)
```
172
What causes chronic pancreatitis?
Basically repeated bouts of acute pancreatitis:
- Alcohol abuse (adults)
- Cystic fibrosis (kids)
- Idiopathic
Amylase & lipase not as high as in acute pancreatitis. Can lead to pancreatic insufficiency.
173
What tumor marker is used for pancreatic adenocarcinoma?
CA-19-9
| 10 letters in "pancreatic"
174
From where does pancreatic adenocarcinoma arise?
Pancreatic ducts
175
What are the risk factors for pancreatic adenocarcinoma?
Smoking
Chronic pancreatitis
Age
Jewish & Black descent
176
How does pancreatic adenocarcinoma present?
Abdominal pain radiating to the back
Weight loss
Trousseau's sign - migratory thrombophlebitis
Obstructive jaundice (tumor in head of pancreas; most common)
Tx: Whipple procedue, chemo, radiation
177
What are the H2 blockers?
What is their use?
Toxicities?
Cimetidine, Ranitidine, Famotidine, Nizatidine
Take them before you DINE --> impairs gastric acid secretion
Used for PUD, gastritis, GERD
Toxicities:
Cimetidine - CYP450 inhibitor, antiandrogen, HA, ^creatinine
178
What are the PPI's?
What are their uses?
Toxicities?
Omeprazole, Lansoprazole, Pantoprazole, Dexlansoprazole
Irreversibly bind H+/K+ ATPase in parietal cells
Used for PUD, GERD, ZES
```
Toxicities:
C. diff infection
Pneumonia
Hip fractures
Hypomagnesemia w/ long term use
```
179
What is Misoprostol?
| What is it used for?
PGE1 analog --> ^gastric mucous barrier & less acid production
Uses:
Prevent NSAID-induced ulcers
Keep PDA open
Induction of labor
Contraindicated in women of childbearing age (abortifacient)
180
What is Sulfasalazine?
What are its uses?
Toxicities?
Sulfapyridine (abx) + 5-aminosalicylic acis (anti-inflammatory)
Activates by colonic bacteria
Used for Crohn's & UC
Toxicities:
Reversible oligospermia
181
What is Ondansetron?
| What are its uses?
5-HT3 antagonist --> powerful central antiemetic
Used to control postop & chemo-induced vomiting
182
What is Metaclopramide
What are its uses?
Toxicities?
D2 receptor antagonist --> ^LES tone & gut motility (except colon)
Used for postop & diabetic gastroparesis; also antiemetic
Toxicities:
Parkinsonism
Interaction with digoxin & diabetic agents
183
What is the lymphatic drainage of the colon?
Para-aortic
The sigmoid colon drains to the inferior mesenteric
184
What are the appropriate ages for Tanner development?
```
Females:
II = 11
III = 12
IV = 13
V = 14
```
```
Males:
II = 12
III = 13
IV = 14
V = 15
```
185
What is precocious puberty?
Puberty beginning before age 8 in girls or 9 in boys.
186
Aneurysm of what cerebral artery can lead to a blown pupil?
PCA
