GI Flashcards
1
Q
Why is a pancreatic pseudocyst called a “pseudo”cyst?
A
Lined by granulation tissue and fibrosis not epithelium. Filled with enzymes and inflammatory debris
2
Q
pancrease lesion shows glycogen rich cuboidal epithelium
A
serous pancreatic neoplasm
3
Q
pancreatic lesion with columnar mucinous epithelium
A
mucinous cystic neoplasm of pancreas
4
Q
What causes fatty liver (mechanism) of alcoholics?
A
Excess NADH (from alch dehydrogenase and aldehyde dehydrogense) -->decrease in fatty acid oxidation
5
Q
What do you see on histology of kaposi’s sarcoma? Macroscopically?
A
- Spindle shaped tumor cells with angiogenesis
2. red/violat flat lesions or hemorrhagic nodules
6
Q
Histology of cryptosporidium
A
Basophilic clusters on surface of intestinal mucosal cells
7
Q
tx: wilson’s dz
A
lactulose to treat the cirrhosis
penicillamine to remove the excess copper
8
Q
tx: hemachromatosis
A
defuroxamine
9
Q
Sequelae/complications of ulcerative colitis
A
toxic megacolon
10
Q
Main clinical manifestation of crohn’s
A
abdominal pain
11
Q
main clinical manifestation of UC
A
bloody diarrhea
12
Q
Skip lesions
A
Crohns. terminal ileum usually but lesions ANYWHERE form mouth to anus.
13
Q
Granulomas in intestine
A
Crohns
14
Q
Rectum is always involved in which IBD
A
Ulcerative colitis
15
Q
mesenteric adenitis in children with abd pain, fever, nausea
A
Yersinia enterocolitica
16
Q
Describe the schilling test
A
Give oral labeled B12 and IM b12 and measure excretion in urine. If normal urinary excretion of radiolabeled B12, this means normal absorption
- -Administer with intrinsic factor to see if pernicious anemia or malabsorption
- -If celiac/diphyllobothrium, no correction with intrinsic factor
17
Q
Drugs causing esophagitis
A
tetracycline
potassium chloride
bisphosphonates
18
Q
What do patients on opioid NOT develop tolerance to?
A
constipation
19
Q
histology findings in alcoholic hep
A
hepatocellular swelling/necrosis
20
Q
Hist: Acetaminophen tox
A
centrilobular necrosis
21
Q
His: reye’s syndrome
A
microvesicular steatosis of the liver
22
Q
Hist: Primary biliary cirrhosis
A
granulomatous bile duct destruction with lots of lymphocytes “florid ducts”
23
Q
What are the four types of non-neoplastic polyps?
A
- hyperplastic polyps: from mucosal gland/crypt cells
- hamartomatous polyps: from smooth muscle/CT. Seen in juvenile polyposis and peutz-jegers
- inflammatory polyps: UC and Crohns
- lymphoid polyps: children
24
Q
What factors tell you malignant potential of polyps?
A
- degree of dysplasia, sessile (not pedunculated)
- villous vs tubular
- size: adenomas < 2 cm usually benign.
25
Secretin is produced by
duodenum.
26
Action of secretin
increased bicarbonate secretion from exocrine pancreas
27
What stimulates secretin release?
HCl in the duodenum
28
Sx: PBC
pruritis
fatigue
xanthomas, hepatosplenomegally leading to jaundice
29
Labs: PBC
Elevated alkaline phosphatase, elevated IgM
| -anti-mitochondrial antibodies
30
PBC associated with
```
Sjogren''s
raynaud's
scleroderma
hypothyroid
celiacs
BASICALLY AUTOIMMUNITY
```
31
Budd chiari
thrombosis of hepatic veins/IVC
--Portal HTN
ascites
hepatosplenomegaly
32
OATP (organic anion transporting polypeptide)
Used to take up indirect (unconjugated bilirubin). Passive process
33
Organic anion transporter (MRP2)
energy dependent transporter for excreting conjugated bilirubin. Without this, will have elevated direct hemoglobin which is excreted in urine
34
PSC associated with
Ulcerative colitis. Will have a high Alk Phos
35
Cobblestone colonoscopy
Crohn's
36
string sign
colonal stricture on barium swallow seen in Crohn's
37
Cause of duodenal atresia:
failure of recanalization--congenital defect
38
Cause of jejunal, ileal, and colonic atresia in newborn:
Vascular ischemia causing necrosis. Gives "appeal peel" appearance.
39
sternal defects in baby=
problem with rostral abdominal fold closure
40
bladder exstrophy caused by
failure of caudal abdominal wall to fold
41
duodenal atresia caused by
failure to recanalize
42
when does the midgut herniate through the umbilical ring
6th week
43
When does the midgut return to the abdominal cavity and rotate around the SMA?
10th week
44
malrotation of gut, volvulus arise from
pathology of midgut herniation/rotation
45
What is gastroschisis
extrusion of abdominal contents through abdominal folds, not covered by peritonium
46
what is omphalocele
persistence of herniation of abdominal contents into umbilical cord, not covered by peritoneum
47
Most common type of tracheoesophageal anomaly
esophageal atresia with distal tracheoesophageal fistula.
48
sx of EA with distal TEF
chocking
Air in stomach,
failure to pass NG tube into stomach
49
H type TE anomaly
Normal except with a fistula only
50
Pure EA
atresia or stenosus of esophagus alone
51
CSR of pure esophageal atresia
No gas in abdomen
52
olive like mass in epigastric region with projectile vomiting (nonbilius) at 2 weeks
congenital pyloric stenosis
53
congenital pyloric stenosis occurs in
first born males.
54
Tx: cong pyloric stenosis
surgery
55
Annular pancreas causes narrowing of
duodenum
56
Ventral pancreatic bud makes
pancreatic head, main pancreatic duct and uncinate process
57
GI retroperitoneal structures. These can cause blood or gas accumulation in retroperitoneal space
```
Suprarenal
Aorta and IVC
Duodenum (2nd and third parts)
Pancreas
Ureters
Colon (ascending, descending)
Kidneys
Esophagus (lower 2/3)
Rectum (lower 2/3)
```
58
falciform ligament connects
liver to anterior abdominal wall
59
falciform contains
ligamentum teres hepatis
60
hepatoduodenal ligament connects
liver to duodenum
| --also connects greater and lesser sacs
61
hepatoduodenal ligament contains
portal triad: hep arter, portal vein, common bile
62
Gastrohepatic ligament connects
Liver to lesser curvature of stomach
63
gastrohepatic contains
gastric arteries
64
You need to cut this during surgery to access the lesser sac
gastrohepatic ligament
65
You can use the pringle maneuver to compress this ligament to control bleeding in the omental foramen
hepatoduodenal
66
gastrocolic connects
greater curvature to transverse colon
67
gastrocolic contains
gastroepiploic arteries
68
gastroplenic connects
greater curvature and spleen
69
structures inside gastrosplenic
short gastrics, left gastroepiploic vessles
70
separates greater and lesser sacs on the left
gastrosplenic
71
splenorenal lig contains
splenic artery+V, tail of pancreas
72
erosions of digestive tract only extend to
mucosa
73
submucosa contains
meissner's plexus
74
muscularis externa contains
myenteric nerve plexus
75
How fast do stomach/duodenum/ileum contract?
stomach: 3 waves/min
duodenum: 12 waves/min
ileum: 8-9 waves/min
76
where do you see crypts of liberkuhn
duodenum, jejunum, and ileum
77
where do you see peyer's patches?
ileum
78
where do you see brunner's glands
duodenum
79
where do you see the largest number of goblet cells in the small intestine?
ileum
80
what do you see in the colon?
no villi, numerous goblet cells
81
When the third part of the duodenum is entrapped between SMA and aorta, causing intestinal obstruction in females
Superior mesenteric artery syndrome
82
parasympathetic innervation of hindgut
pelvic (errything else is vagus)
83
celiac artery exits at
T12/L1
84
SMA artery exits at
L1
85
IMA artery exists at
L3
86
supplies distal duodenum to prox 2/3 or transverse colon
SMA
87
supplies stomach, prox duodenum, liver, gallbladder, pancreas, spleen (mesoderm)
Celiac artery
88
Branches of the celiac trunk
common hepatic
splenic
left gastric
89
Which arteries do not have good anastamoses?
```
short gastrics (splenic artery blockage)
However, left and right gastrics and epiploics have good anastamoses
```
90
branches of the common hepatic
hepatic artery proper
-->right gastric
gastroduodenal
-->right gastroepiploic
91
branches of the splenic
L gastroepiploic
| short gastric arteries
92
branches of the L gastric
esophageal branches
93
anastamoses between external iliac and internal thoracic
superior/inferior epigastric
94
anastamoses between celiac trunk and SMA
superior/inferior pancreaticoduodenal
95
anastamoses between SMA and IMA
middle/left colic
96
anastamoses between IMA and internal iliac
superior rectal/middle and inferior rectal
97
Name the three portosystemic shunt systems
1. left gastric(portal)-->esophageal(systemic)
2. paraumbilical-->epigastric veins (systemic)
3. superior rectal (portal)-->middle and inferior rectal (systemic)
98
How do the three portosystemic shunt explain portal HTN findings?
1. esophageal varices
2. caput medusa
3. internal hemorroids
99
rectal adenocarcinoma
above pectinate line
100
rectal squamous cell carcinoma
below pectinate
101
rectal internal hemorrhoids vs external
internal: above pectinate
external: below
102
blood supply above pectinate
superior rectal (IMA)
103
blood supply below pectinate
inferior rectal (internal pudendal)
104
venous drainage above pectinate line
superior rectal-->inferior mesenteric-->portal system
105
venous drainage below pectinate line
inferior rectal-->internal pudendal vein-->internal iliac vein-->IVC
106
innervation below pectinate
painful external hemorrhoids
| --inferior rectal branch of pudendal nerve
107
lymphatic drainage above pectinate line
deep nodes
108
lymphatic drainage below pectinate line
superficial inguinal nodes
109
which liver zone affected first by viral hepatitis?
Zone 1 (periportal)
110
Which liver zone affected first by ischemia and alcoholic hepatitis?
Zone 3 (central vein)
111
which liver zone has the P450 system
Zone 3
112
Order of structures in femoral region
nerve, artery, vein, empty space, lymph (from lateral to medial)
113
femoral triangle
femoral vein, artery, nerve
114
femoral sheath
femoral vein, artery, and canal with deep inguinal nodes
| NO NERVE
115
External spermatic cord
external oblique
116
cremaster muscle and fascia made of
internal oblique
117
internal spermatic fascia made of
transversalis fascia
118
Why doesn't the spermatic cord have transversus abdominis muscle?
There's a hole in the muscle where it passes through. The normal order is
1. transversalis
2. transversus abdominis
3. internal oblique
4. external oblique
119
GE junction is displaced upwards through diaphragm=hourglass stomach
sliding hiatal hernia
120
fundus of stomach protrudes into thorax, although GE junction is normal
paraesophageal hernia. bowel sounds in the lung fields
121
This type of hernia passes lateral to the inferior epigastric artery
indirect inguinal hernia
122
cause of indirect inguinal hernia
failure of processus vaginalis to close. Occurs in infants
123
this inguinal hernia passes medial to inferior epigastric
direct inguinal hernia. passes through hesselbach's triangle
124
Indirect hernias are covered by
all three layers of spermatic fascia
125
direct hernias are covered by
only external spermatic fascia. usually happens in old men
126
which Amino acids are potent stimulators of gastrin
phenylalanine
| tryptophan
127
what produces cholecystokinin?
I cells
128
Where are I cells found
duodenum/jejunum
129
Action: CCK
```
pancreatic secretions
gallbladder contractions
sphincter of oddi relaxation
decreased gastric emptying
THINK: RELEASE OF PANCREATIC ENZYMES
```
130
stimulant: CCK
fatty acids/amino acids
131
where do you find S cells?
duodenum
132
action: secretin
pancreatic HCO3
decrease gastric acid
increase bile secretion
THINK: DECREASING ACIDITY
133
How is secretin regulated?
Increased by acid, fatty acids in lumen of duodenum
134
action: somatostatin
decreases gastric acid secretion
decreases pancreatic secretions
decreases gallbladder
decreases insulin/glucaton
135
regulation: somatostatin
Increased by acid
| decreased by vagal stimulation
136
which cells release somatostatin?
D cells of pancreas, GI mucosa
137
glucose dependent insulinotropic peptide (GIP) effects
decrease gastric acid
| Increase insulin release
138
which cells release GIP?
K cells of duodenum/jejunum
139
source: vasoactive intestinal polypeptide (VIP)
parasympathetic ganglia
140
Action: VIP
increase water/electrolyte secretion
| relaxation of intestinal smooth muscle
141
Stimulation: VIP
vagal stimulation and distention
| inhibited by adrenergics (duh)
142
copious watery diarrhea, hypokalemia, and achlorhydria (little to no stomach acid)
VIPoma
143
Nitric oxide's role in GI
relaxes GEJ sphincter
144
motilin action
migrating motor complexes for peristalsis in small intestin
145
when is motilin high
fasting state
146
which drugs work as motilin agonists
erythromycin
147
How do you regulate gastric acid?
Increase: histamine, ACh, gastrin
Decrease: somatostatin, GIP, prostaglandin, secretin
148
which cells secrete pepsin
chief cells
149
what stimulates pepsin release
vagal stimulation, acid
150
What secretes HCO3
Mucosal cells and brunner's glands
151
Stimulation: HCO3
increased pancreatic/biliary secretion
152
is saliva stimulated by sympathetic or parasympathetic activity?
Both. Note that it is hypotonic with low flow rates but isotonic at high flow rates
153
vagus nerve stimulates
Parietal cells and G cells
154
what happens in stomach when you give atropine?
Mild decrease in stomach acid.
- vagus nerve releases ACh on parietal cells
- vagus nerve releases GRP on G cells-->gastrin-->ECL cells-->histamine-->parietal cells
The pathway through GRP and histamine is much stronger stimulator
155
brunner gland hypertrophy
peptic ulcer disease. Because working overtime to secrete alkaline mucus
156
How else can gastrin release acid?
binds to CCK receptor and upregulates H/K ATPase
157
intracellular signaling of H2 receptor:
cAMP increases-->H/KATPase
158
intracelular signalling of Ach and Gastrin
Gq
159
intracellular signaling of somatostatin
Gi
160
Describe the flow of pancreatic secretions
low flow=high Cl-
| high flow=high HCO3-
161
Pancreatic acid secretions
alpha-amylase
Lipases (phospholipase A, colipase)
Proteases (trypsin, chymotrypsin, elastase)
trypsinogen
162
salivary amylase hydrolyzes
alpha 1,4 linkages-->disaccharides
163
glucose/galactose transporter
SGLT1 (sodium dependent)
164
fructose transporter
GLUT-5 (facilitate difusion)
165
GLUT2
transports monosaccharides to gut
166
iron absorbed in
duodenum
167
folate absorbed in
jejunum
168
D xylose tells you
integrity of gastric mucosa in absorption.
D xylose requires NO breakdown! If problem is with breakdown (i.e. no secretions) then D xylose should be normal
169
Maltose is made of
glucose+glucose
170
lactose is made of
glucose+galactose
171
where are lipids digested/absorbed?
digested in duodenum, absorbed in jejunum
172
special cells in peyer's patches that take up antigen
M cells
173
what happens when B cells in peyer's patches are stimulated?
differentiate into IgA secreting plasma cells
174
difference between bile acids vs salts?
bile acids are conjugated to glycine/taurine
175
rate limiting step of bile acid secretion
cholesterol 7a-hydroxylase
176
What carries bilirubin in blood?
albumin
177
urobilinogen
conjugated bilirubin that has been processed by the gut bacteria
178
how much of urobilinogen is reabsorbed?
20%. Of that, 10% is excreted in urine and 90% goes back to liver
179
painless mobile mass in neck made of cartilage and epithelium and recurs frequently. A salivary tumor
pleomorphic adenoma. Most common!
180
salivary tumor: A benign cystic tumor in germinal centers
warthin's tumor
181
salivary gland: mucinous and squamous components. presents as a PAINFUL mass
mucoepidermoid carcinoma
182
achalasia=increased risk for
esophageal squamous cell carcinoma
183
secondary achalasia
chagas, CREST
184
pts with achalasia have problems swallowing
BOTH solids in liquids!
| If obstructive mass, liquids are fine
185
Can also present as nocturnal cough/dyspnea or adult onset asthma
GERD
186
causes of esophagitis
reflux
infections (like candida etc)
chemical ingestion
187
punched out ulcers in esophagus
HSV-1
188
linear ulcers in the esophagus
CMV
189
mucosal lacerations at the GEJ from severe vomiting
mallory weiss syndrome
190
who is at risk of mallory weiss?
alcoholics/bulimics
191
transmural esophageal rupture from violent retching
boerhaave syndrome. May have crackling beneath skin from air in mediastinum
192
esophageal strictures associated with
lye ingestion and acid reflux
193
Plummer vinson syndrome
dysphagia
glossitis
iron deficiency anemia
194
barrett's esophagus predisposes to what cancer
esophageal ADENOcarcinoma (not squamous)
195
which esophageal cancer is most common worldwide?
squamous
196
alcohol=type of esophageal cancer?
squamous
197
cigarettes=type of esophageal cancer?
both
198
diverticula=type of esophageal cancer?
squamous
199
esophagela web=type of esophageal cancer?
squamous
200
fat=type of esophageal cancer?
adeno
201
GERD=type of esophageal cancer?
adeno
202
hot liquids=type of esophageal cancer?
squamous
203
How to treat tropical sprue?
antibiotics. We don't understand the cause! but it looks similar to celiac's
- -AFFECTS JEJUNUM AND ILEUM not duodenum
204
PAS positive foamy macrophages in intestine and mesenteric nodes
Whipple's disease
205
Presentation: Whipple's disease
cardiac symptoms
arthralgias
neuro sx
-->usually presents in older men
206
Which part of the intestine is affected in celiac's
distal duodenum
- -LESS so jejunum/ileum
- -hyperplasia of crypts seen
207
histology of lactose intolerant peeps
normal villi!!!!
208
lactose tolerance test
1. symptomatic
| 2. glucose rises t absorbing that milk!)
209
child presents with malabsorption and neuro deficits, biopsy shows fat accumulation within enterocytes. Also no VLDL or LDL
abetalipoproteinemia. Missing B48 and B100
210
Three causes of pancreatic insufficiency
1. cystic fibrosis
2. cancer
3. chronic pancreatitis
211
Celiac HLA predisposition
HLA-DQ2, HLA-DQ8
212
Antibodies in celiac sprue?
anti-TTG
anti-endomysial
anti-gliadin
213
histology findings in celiacs
blunting of villi
| lymphocytes in lamina propria
214
skin condition associated with celiac's
dermatitis herpetiformis
215
celiac malignancy
T cell lymphoma. Think about refractory celiacs that has been well controlled
216
Gastric ulcer in burn victim
curling's ulcer. Happens cuz low plasma volume allows sloughing of mucosa
217
gastric ulcer in pt with TBI
cushing's ulcer
| -->increased vagal sitmulation increases acid production
218
Type A chronic gastritis
pernicious anemia
219
pernicious anemia affects which part of the stomach?
fundus/body
220
Type B chronic gastritis
H pylori.
221
H pylori affects which part of stomach?
antrum
222
Gastric hypertrophy with protein loss, parietal cell atrophy and lots of mucous cells. Rugae look like brain gyri
Menetrier's disease
223
what are you worried about with menetrier's?
gastric cancer
224
skin findings in stomach cancer
acanthosis nigracans
| LOTS of seborrheic keratoses (leser-Trelat sign)
225
possible nodal spread of stomach cancer
1. virchow's node
2. krukenberg's tumor: bilateral metastases to ovaries
3. sister mary joseph's nodule: periumbilical metastasis
226
histology findings of krukenberg tumor
mucus and signet ring cells
227
Intestinal stomach cancer associated with
```
H pylori
nitrosamines (smoked food)
achlorhydria
chronic gastritis
TYPE A BLOOD?! weird!
```
228
what does intestinal stomach cancer look like?
ulcer with raised margins
229
Appearance of diffuse stomach cancer
thick and leathery stomach (linitis plastica)
230
histology of diffuse stomach cancer
signet cell rings
231
which type of ulcer has more pain with meals? less pain with meals?
gastric: more pain
duodenal: less pain
232
which ulcer is more associated with H pylori?
duodenal ulcers almost always H pylori
| gastric ulcer 70%
233
zollinger ellison causes which type of ulcer
duodenal. caused by increased acid secretion
Note that increased acid secretion does not cause gastric ulcers! The stomach is prepared to handle acidity. usually caused by a problem with mucosal barrier.
234
Which type of ulcer is associated with carcinomas?
gastric ulcer.
-->duodenal ulcers are more benign
235
Which type of ulcer can hemorrhage?
Both!
236
You find a duodenal ulcer that is hemorrhaging. is it more likely to bleed from the posterior or anterior wall?
posterior--from gastroduodenal artery
237
You find a duodenal ulcer that is perforated. Is it more likely to perforate on the posterior or anterior wall?
anterior
238
etiology of crohn's disease
disordered response to intestinal bacteria
239
which IBD is Th1 mediated? Th2?
Th1=crohn's
| Th2=UC
240
IBD: pyoderma gangrenosum
UC
241
IBD: erythema nodosum
Crohn's
242
IBD: primary sclerosing cholangitis
UC
243
IBD: migratory polyarthritis and calcium oxalate stones
Crohn's
244
IBD: histology shows crypt abscesses and ulcers
UC
245
IBD: "lead pipe appearance" on imaging
UC
| --from loss of haustra in the colon
246
IBD: creeping fat (fat growing out closer to serosa)
Crohn's
247
IBD: friable mucosal pseudopolyps with freely hanging mesentary
UC
248
IBD treatment: steroidx, TNF-alpha inhibitors, azathioprine, methotrexate
crohn's
249
IBD tx: sulfazalazine, 6MP, TNF-alpha inhibitors, colectomy
UC
250
Sx of IBS
1. pain improves with defecation
2. change in stool frequency
3. change in appearance of stool
251
Causes of appendicitis in kids
fecalith in adults
| lymphoid hyperplasia in kids
252
false diverticula are missing
muscularis externa. Only mucosa and submucosa
253
diverticulosis
many false diverticulae in elderly from weakness of colonic walls
254
diverticulosis associated with
low fiber diets
255
sx of diverticulosis
hematochezia
256
LLQ pain, fever, leukocytosis
diverticulitis
257
complication of diverticulitis
fistula with bladder forms.
| --pneumaturia: gas or air in the urine
258
Zencker's occurs btw which muscles
thyropharyngeal and cricopharyngeal portions of the inferior pharyngeal constrictor
259
Meckel's diverticulum caused by
persistence of vitelline (omphalomesenteric) duct
260
The five 2's of meck
2 inches long, 2 feet from ileocecal valve, 2% of population, presents in first 2 years of life
261
Dx: meckel's
pertechnetate study for ectopic uptake (gastric/pancreatic mucosa)
262
complications of meckel's
intussusception
volvulus
obstruction
263
currant jelly stools
intussusception
264
Volvulus usually occurs in what age group
Elderly.
265
which section of colon susceptible to volvulus?
cecum/sigmoid colon
266
vitelline sinus vs vitelline cyst etiology
Same as meckels, only varying degrees of malformation.
vitelline sinus--just a small string of mesentery connecting to umbilicus.
vitelline cyst has a small area of dilation outside of intestine
267
chronic constipation early in life with a congenital megacolon
hirschsprung
268
Dx: hirschsprung's
rectal suction biopsy. treat with resection
269
who is at risk for hirschsprungs
down's syndrome
270
bilious vomiting
duodenal atresia
271
double bubble on X ray
duodenal atresia
| --proximal stomach distention
272
meconium ileus common in
cystic fibrosis
| --meconium plug blocks intestine
273
neonate with necrosis of intestinal mucosa
necrotizing enterocolitis
274
extreme pain after eating and weight loss but normal abdominal exam in an elderly patient
ischemic colitis
275
which areas of colon most susceptible to ischemic colitis?
splenic flexure and distal colon. USUALLY ATHEROSCLEROSIS OF SMA.
276
most common cause of small bowel obstruction
adhesion
277
tortuous dilation of vessels and hematochezia in an older adult located in CECUM terminal ileum, and ascending colon (right side)
angiodysplazia
278
malignancy risk in adenomatous polyp
size > 1cm
villous
epithelial dysplasia
279
most common type of non-neoplastic polyp?
hyperplastic
280
juvenil polyps occur in
rectum
281
a 4 yr old child presents with a single juvenile polyp. Does he have increased cancer risk?
No. However, if he has juvenile polyposis syndrome, he IS at increased risk of adenocarcinoma
282
inheritance of peutz-Jeghers
autosomal dominant
283
associated sx of peutz-jeghers
hyperpigmented mouth, lips, hands, genitalia
284
pts with peutz jegers SYNDROME (not single polyp) are at risk for
CRC and other visceral malignancies
285
Third most common cancer in US and third most deadly
CRC
286
APC gene chromosome #
5q
287
FAP+osseous and soft tissue tumors AND congenital hypertrophy of retinal pigment epithelium
Gardner's syndrome
288
FAP + malignant CNS tumor
Turcot's syndrome
289
CRC caused by DNA mismatch repair genes
HNPCC (aka lynch)
| --Causes microsatellite instability
290
inheritance of HNPCC
Autosomal dominant
291
HNPCC usually involves which part of colon?
proximal. Also at risk for ovarian and endometrial carcinoma.
292
FAP usually involves which part of colon?
rectum and the entire colon
293
CRC usually affects which parts of colon?
rectosigmoid>ascending>descending
294
CRC with exophytic mass, iron deficiency anemia, weight loss
ascending colon. Usually with HNPCC
295
CRC with infiltrating mass, partial obstruction, hematochezia.
napkin ring lesion with decreased stool caliber
descending colon
296
apple core lesion on barium enema
THINK CRC!!
297
amrker for CRC
CEA
298
APC gene codes for
beta catenin which is important for chromosomal stability
299
Progression of CRC mutations
1. APC=formation of polyp
2. Kras=growth of polyp
3. p53 and DCC=adenoma and carcinoma
300
most common malignancy in the small intestine
carcinoid tumors
301
pt presents with wheezing, diarrhea, flushing and right sided heart murmurs.
carcinoid syndrome
302
dense core bodies on EM of small intestine
carcinoid
303
pt has 5-HIAA in urine
Dx: carcinoid tumor!
304
pt has 5-HIAA in urine but no carcinoid sx. What does this tell you?
The tumor is confined to the GI. All of the serotonin product is brought through portal vein to the liver, which breaks down serotonin
305
Tx: carcinoid tumor
resection
octreotide
somatostatin
306
breath smells musty and asterixis
liver failure
307
uncommon causes of liver failure
hemachromatosis and biliary disease
308
LFTs with viral hepatitis
ALT>AST
309
Alkaline phosphatase tells you presence of:
1. obstructive liver disease
2. bone disease
3. bile duct disease
310
Alkaline phosphatase is elevated. What other test do you need to make sure caused by hepatic system and not by bone disease?
Get a gamma-glutamyl transpeptidase (GGT)
| --will not be elevated in bone disease
311
elevated amylase
pancreatitis
| mumps
312
decreased ceruloplasmin
wilson's disease
313
Hist: reye's syndrome
microvesicular fatty change
314
Sx: reye's
hypoglycemia
vomiting
hepatomegaly
coma
315
Mech: reye's
aspirin inhibits enzyme causing beta oxidation of fat in mitochondria
316
Hist: alcoholic hepatitis
swollen and necrotic hepatocytes with neutrophilic infiltration
-mallory bodies
317
Hist: alcoholic cirrhosis
sclerosis around central vein (zone III)
318
uncommon causes of HCC
wilson's
hemachromatosis
a1-AT deficiency
aflatoxin exposure from aspergillus
319
which marker is elevated in hepatocellular carcinoma?
alpha-fetoprotein
320
common benign liver tumor in peeps age 30-50.
cavernous hemangioma
321
what is contraindicated in cavernous hemangioma?
biopsy--hemorrhage risk
322
liver tumor: malignant tumor of endothelial origin
angiosarcoma
323
benign liver tumor associated with oral contraceptive use
hepatic adenoma
324
associated with arsenic and polyvinylchloride
angiosarcoma
325
Pt with signs of liver failure (ascites, hepatomegaly) with prominent abdominal and back veins and an absent JVD
Budd chiari syndrome. Caused by occlusion of IVC or hepatic veins
326
Cause of budd chiari
hypercoagulable state
polycythemia vera
pregnancy
HCC
327
PAS positive globules in liver with cirrhosis
alpha-1AT
328
inheritance of a1AT
codominant
329
Urine bilirubin is increased:
Heptaocellular and obstructive jaundice (none in hemolytic)
330
urine urobilinogen is decreased
obstructive jaundice
331
urine urobilinogen is increased
hemolytic jaundice
332
labs: hepatocellular jaundice
direct/indirect bilirubin increased
increased urine bilirubin
normal or decrease urobilinogen (may not be secreting enough to GI tract)
333
Pathophysiology of neonatal jaundice
immature UDP glucuronyltransferase
| -->causes unconjugated hyperbilirubinemia
334
Tx of neonatal jaundice
phototherapy
| --converts unconjugated bilirubin to a soluble form
335
Asymptomatic patient with high unconjugated bilirubin but not hemolysis. Labs are higher when pt is fasting or stressed
gilbert's (mild decrease in UDP glucuronyltransferase)
336
Tx: gilbert's
none!
337
Baby has jaundice. Labs show high levels of unconjugated bilirubin. Despite phototherapy, she still dies. Autopsy finds kernicterus.
Dx? how should she have been treated?
Crigler Najjer TYPE I. pts die in a few days. CANNOT conjugate ANY bilirubin!!
Tx: plasmapheresis and phototherapy
338
Type II crigler-Najjar tx?
Less severe form
| Tx: phenobarbital, which increases liver enzyme synthesis
339
Asymptomatic patient presents with elevated direct bilirubin and jaundice. gross examination of liver biopsy shows a black liver
Dubin Johnson
340
Tx: dubin johnson?
nothing. it's benign.
341
Rotor's vs dubin johnson?
Rotor's syndrome is milder and does not have a back liver
342
inheritance of wilson's disease
autosomal recessive
343
chromosome wilson's
13
344
gene wilson's
ATP7B
345
Presentation of wilson's
```
Cirrhosis
hemolytic anemia
basal ganglia--parkinsonian sx
asterixis
dementia, dyskinesia, dysarthria
```
346
pt has cirrhosis, diabetes, and bronze skin
hemochromatosis
347
hemochromatosis mutation
C282Y
H63D
-->ON HFE gene
348
HLA association hemochrom
HLA-A3
349
Tx of hemochrom
1. phlebotomy
| defersirox/defuroxamine
350
hemochromatosis risk:
CHF, HCC, testicular atrophy
351
cause of 2ndary hemochromatosis
chronic transfusions (beta-thalassemia major)
352
Labs: biliary cirrhosis
Increased conjugated bili
Increased cholesterol
Increased alkaline phosphatase
353
Pathophys: Primary biliary cirrhosis
autoimmune rxn
354
Hist: PBC
lymphocytic infiltrate and granulomas of the biliary tree
355
Pathophys: primary sclerosing cholangitis
Unknown
356
histology: PSC
onion skin bile duct fibrosis
- -"beading" of bile ducts on ERCP
- -alternate stricture and dilation
357
antibodies in PBC
mitochondrial antibodies and IgM
358
PBC associated with
Other autoimmune conditions (Crest, RA etc)
359
PSC antibodies
hypergaammaglobulinemia IgM
360
PSC associated with
UC
361
Radiolucent gallstones
cholesterol. 80% of stones
362
cholesterol stones associated with
```
Crohn's
CF
rapid weight loss, clofibrate (Fat)
Age (forties)
Native Americans
estrogens (female)
multiparity (fertile)
```
363
air in biliary tree
gallstone fistula with small intestine
364
gallstone ileus: presentation
elderly female with a history of gallstone disease presents with recurrent bowel obstructions. Usually examination of nidus will show cholesterol
365
Dx of gallstone
ultrasound, radionuclide biliary scan (HIDA scan). HIDA is definitive
366
pigment stone: causes
```
chronic hemolysis (black)
alcoholic cirrhosis
biliary infection (brown)
```
367
Causes of acute pancreatitis
GET SMASHED
1. gallstone
2. ethanol
3. trauma
4. steroids
5. mumps
6. autoimmune
7. scorpion sting
8. hypercalcemia/hypertriglyceridemia
9. ERCP
10. Drugs (sulfa)
368
Complications of acute pancreatitis
```
DIC
ARDS
fat necrosis
hypocalcemia
pseudocyst
multiorgan failure
```
369
why r u worried about a pancreatic pseudocyst?
Can rupture=hemorrhage
370
do gallstones cause chronic pancreatitis?
NO!
371
major causes of chronic pancreatitis
alcohol and idiopathic
372
Marker for pancreatic carcinoma
CA-19-9
373
most common site of pancreatic adenocarcinoma
pancreatic head--usually in ducts
374
risk factors for pancreatic adenocarcinoma
tobacco
chronic pancreatitis
age>50
Jewish and AA males
375
Sx of pancreatic cancer
weightloss
abdominal pain-->back
redness and tenderness on palpitation of extremities (migratory thrombophlebitis)
obstructive jaundice with NONTENDER gallbladder
376
which h2 blocker inhibits CytoP450?
cimetidine
377
side effects cimetidine
anti-androgenic effects
| Dizziness (crosses BBB)
378
Pt comes in with GERD. doc prescribes an H2 blocker. Follow up shows an increased creatinine level, pt has never had an history of renal disease. Which drug did the doc prescribe?
cimetidine or ranitidine
379
Mechanism PPI
irreversibly inhibit H/K ATPase
380
Tox: PPI
C. diff
pneumonia
hip fracture
decreased Mg2+
381
mech: bismuth/sucralfate
bind to ulcer base, protects
382
misoprostol mech
PGE1 analog. Increases production and secretion of gastric mucous. Decreases acid production
383
Indications misoprostol
1. prevention of NSAID INDUCED ulcers
2. maintenance of patent ductus
3. Induce labor
384
tox: misoprostol
diarrhea
| women who are trying to conceive!! (abortion)
385
Mechanism: octreotide
Long-acting somatostatin analog
386
Indications: octreotide
somatostatin analog
387
Indications for octreotide
1. VIPoma/carcinoid tumors
2. acute variceal bleeds
3. acromegaly
388
Tox of antacids
hypokalemia
389
Tox aluminum hydroxide
constipation (aluminimum amount of feces)
hypophosphatemia
osteodystrophy
muscle weakness
390
Tox: mg OH
diarrhea (Mg must go to the bathroom)
cardiac arrest
hyporeflexia/hypotension
391
Tox: Calcium carbonate
Hypercalcemia
Rebound acidemia
Can decrease effectiveness of other drugs like Tetracycline
392
Osmotic laxatives
magnesium hydroxide, magnesium citrate
393
which laxative can treat hepatic encephalopathy (ammonia in the brain)?
lactulose. Lactic acid promotes nitrogen excretion
394
Tox of infliximab
TB reactivation, fever, hypotension
395
Infliximab indications
Crohns
| UC
396
Sulfasalazine indications
UC
| Crohns
397
Tox: sulfasalazine
sulfonamide
oligospermia
malaise/nausea
398
Ondansetron mechanism
5-HT3 antagonist. good for chemo pts
399
mech: metoclopramide:
D2 antagonist
Increases gastric resting tone/motility/contractility
LES tone
400
Indications for metoclopramide
Diabetic and post surgical gastroparesis
401
Tox: metoclopramide
Parkinsons (Duh duz it's a D2 antagonist!)
| Interacts with digoxin and diabetic agents
402
Metoclopramide is contraindicated in
pts with small bowel obstruction/parkinson's
403
Recurrent aphthous ulcer, genital ulcers, and uveitis
behcet syndrome. Aphthous is grey.
404
Oral SCC risk factors
tobacco and alcohol
405
hairy leukoplakis caused by
EBV in immunocompomised. NO dysplasia, only squamous hyperplasia.
Occurs on side of tongue!
406
what virus can cause pancreatitis?
mumps
407
which gland affected by pleomorphic adenoma?
parotid. high rate of recurrence. irregular margins.
408
how do you know if pleomorphic adenoma has become cancerous?
facial nerve damage (pain)
409
warthin tumor histology
lymphocytes and germinal centers in parotid
410
where does esophagus spread (lymph nodes?)
upper 1/3: cervical
middle 1/3: mediastinal
lower 1/3: celiac/gastric nodes
411
how do you make sure H pylori is gone?
urea breath test and stool antigen
412
duodenal ulcer histology
hypertorphy of brunner's glands
413
intestinal gastric adeno distant metastases
periumbilical
414
diffuse gastric adeno distant metastases
krukenberg
415
Double bubble sign
duodenal atresia (bubble on either side of the atresed area)
416
elderly volvulus vs teenage volulus
elderly=sigmoid
| teen=cecum
417
cause of intussusception in an adult
tumor
418
transmural vs mucosal infarction
mucosa: hypotension
transmural: thrombosis
419
Cause of dermatitis herpetiformis
deposition of IgA at dermal papillae. SHould resolve with a gluten free diet
420
why test for IgG antibodies as well in celiacs?
Because many celiac patients also have IgA deficiency.
421
carcinoid tumors stain positive with
chromogranin. Most common site is in the small bowel!! This is the only carcinoma in the small bowel.
422
why does carinoid tumor only cause right sided valvular fibrosis?
lung also has monoamine oxidase to break down serotonin
423
p-ANCA positive IBD
Ulcerative colitis
424
smoking is protective against what type of IBD
UC
425
Crohn's disease in terminal ileum--risk for CRC?
NO-only if inflammation occurs in colon
426
most common type of polyp
hyperplastic polyp. Serrated apperance.
427
Enzymes that shut down trypsin
SPINK1
Trypsin also cleaves itself
-->without these, recurrent pancreatitis
