GI: 349 - 353 Flashcards
1
Q
Bilirubin is a product of the metabolism of what?
A
Heme
2
Q
What is another name for unconjugated bilirubin?
A
Indirect
3
Q
Direct vs. indirect bilirubin - which one is water soluble?
A
Conjugated - water soluble; Unconjugated - water insoluble
4
Q
What is bilirubin conjugated with to make it water soluble?
A
Glucuronic acid
5
Q
What organ removes bilirubin from the blood?
A
Liver
6
Q
Where is heme broken down into bilirubin?
A
Macrophages
7
Q
How does bilirubin get to the liver?
A
Travels in the bloodstream bound to albumin
8
Q
Where does bilirubin get conjugated?
A
Liver
9
Q
What enzyme conjugates bilirubin?
A
UDP-glucuronosyl-transferase
10
Q
Where does conjugated bilirubin go and what does it become?
A
To the gut where it becomes urobilinogen
11
Q
80% of urobilinogen does what?
A
Excreted into the feces as stercobilin which gives feces its brown color
12
Q
20% of urobilinogen does what (2 possible fates)?
A
- 90% (of this 20%) reenters enterohepatic circulation and goes back to the liver.
- 10% (of this 20%) is excreted in urine which gives urine its yellow color
13
Q
Are salivary gland tumors generallly benign or malignant?
A
Benign
14
Q
Which salivary gland is most likely to have a tumor?
A
Parotid gland
15
Q
What are 3 types of salivary gland tumors?
A
- Pleomorphic adenoma
- Warthrin tumor
- Mucoepidermoid carcinoma
16
Q
Which is the most common salivary gland tumor?
A
Pleomorphic adenoma
17
Q
What is a pleomorphic adenoma composed of?
A
Benign mixed tumor - made of chondromyxoid stroma and epithelium
18
Q
How does pleomorphic adenoma present?
A
Painless mobile mass
19
Q
When does pleomorphic adenoma recur?
A
Incomplete excision or intraoperative rupture
20
Q
Describe a warthrin tumor.
A
Papillary cystadenoma lymphomatosum - a benign cystic tumor with germinal centers
21
Q
What is the most common malignant salivary gland tumor?
A
Mucoepidermoid carcinoma
22
Q
Describe a mucoepidermoid carcinoma
A
Has mucinous and squamous components that typically presents as a painless slow-growing mass
23
Q
What is achalasia?
A
Failure of relaxation of LES due to loss of myenteric (Auerbach) plexus
24
Q
What happens in achalasia?
A
High LES opening pressure and uncoordinated peristalsis leads to progressive dysphagia to solids and liquids
25
How is achalasia different from obstruction?
Achalasia is dysphagia of solids and liquids while obstruction is just dysphagia of solids
26
What test can we use to check for achalasia and what will it show?
Barium swallow shows dilated esophagus with an area of distal stenosis - "Bird's beak"
27
Achalasia is associated with an increased risk of what cancer?
Esophageal squamous cell carcinoma
28
Achalasia maybe be secondary to what other disease?
Chagas
29
What is Boerhaave syndrome?
Transmural, usually distal esophageal rupture due to violent retching
30
How should Boerhaave syndrome be treated?
Surgical emergency
31
What is eosinophilic esophagitis?
Infiltration of eosinophils in the esophagus in atopic patients (food allergy)
32
What are 3 characteristics of eosinophilic esophagitis?
Dysphagia, heartburn, strictures
33
Can eosinophilic esophagitis be treated with GERD therapy?
No
34
Characterize esophageal varices.
Painless bleeding of dilated submucosal veins in the lower 1/3 of esophagus
35
What are esophageal varices secondary to?
Portal hypertension
36
What are 3 associations of esophagitis?
1. Reflux
2. Infection in immunocompromised
3. Chemical ingestion
37
What are 3 infections that are associated with esophagitis and how do you differentiate between them?
1. Candida - white pseudomembrane
2. HSV-1 - punched out ulcers
3. CMV - linear ulcers
38
How does GERD typically present?
Heartburn, regurgitation upon lying down, nocturnal cough and dyspnea, adult-onset asthma
39
GERD involves decreased tone of which sphincter?
LES
40
What is Mallory-Weiss syndrome?
Mucosal lacerations at the GE junction due to severe vomiting
41
What is a key presenting symptom of Mallory-Weiss syndrome?
Hematemesis
42
What 2 groups are especially prone to Mallory-Weiss syndrome?
Bulimics and alcoholics
43
What is the triad of Plummer-Vinson syndrome?
Mnemonic: DIG
| Dysphagia (due to esophageal webs), Iron deficiency anemia, Glossitis
44
Describe the pathophysiology of sclerodermal esophageal dysmotility.
Esophageal smooth muscle atrophy leads to decreased LES pressure and dysmotility leads to acid reflux and dysphagia leads to stricture, Barrett esophagus, and aspiration
45
What syndrome is sclerodermal esophageal dysmotility a part of?
CREST
46
What is Barrett esophagus?
Glandular metaplasia - replacement of nonkeratinized (stratifeid) squamous epithelium with intestinal epithelium (nonciliated columnar with goblet cells) in the distal esophagus
47
What causes Barrett esophagus?
Chronic GERD
48
What are 3 things associated with Barrett esophagus?
Esophagitis, esophageal ulcers, and increased risk of esophageal adenocarcinoma
49
What are the 2 types of esophageal cancer?
Squamous cell and adenocarcinoma
50
How does esophageal cancer typically present?
Progressive dysphagia and weight loss
51
Does esophageal cancer have a good prognosis?
No
52
Contrast the incidence of the 2 types of esophageal cancer as well as where they tend to occur in the esophagus.
1. Squamous cell - more common worldwide (makes sense since this is the one linked to EtOH and Asian flush), upper 2/3 of esophagus
2. Adenocarcinoma - more common in the U.S., lower 1/3
53
What are the risk factors for esophageal cancer?
```
Mnemonic: AABCDEFFGH
Achalasia
Alcohol - squamous
Barrett esophagus - adeno
Cigarettes - both
Diverticula (e.g. Zenker) - squamous
Esophageal web - squamous
Familial
Fat (obesity) - adeno
GERD - adeno
Hot liquids - squamous
```
54
Gastritis can broadly be broken up into what 2 groups?
Acute (erosive) vs. chronic (nonerosive)
55
Describe what happens in acute gastritis.
Disruption of mucosal barrier leads to inflammation
56
What can cause acute gastritis?
Stress, NSAIDs, EtOH, uremia, burns, brain injury
57
Why do NSAIDs cause acute gastritis?
Decreased PGE2 leads to decreased gastric mucosa production
58
What's the difference between a curling ulcer vs. cushing ulcer?
Mnemonic: Burned by the curling iron and always cushion the brain
1. Curling ulcer is associated with burns - decreased plasma volume causes sloughing of gastric mucosa
2. Cushing ulcer is associated with brain injury - increased vagal stimulation causes increased ACh causes increased H+ production
59
What are the 2 types of chronic gastritis?
Mnemonic: A before B
| Type A - fundus/body vs. Type B - antrum
60
Which is more common Type A or Type B chronic gastritis?
Type B
61
What causes Type A chronic gastritis?
Autoimmune disorder characterized by autoantibodies to parietal cells, pernicious anemia, achlorhydia
62
What causes Type B chronic gastritis?
H. pylori infection
63
Type B chronic gastritis is associated with increased risk of?
MALT lymphoma and gastric adenocarcinoma
64
What is Menetrier disease?
Gastric hypertrophy with protein loss, parietal cell atrophy, and increased mucous cells
65
What does gross inspection of Menetrier disease reveal?
Rugae of stomach are so hypertrophied that they look like brain gyri
66
How does Menetrier disease relate to cancer?
It is a precancerous condition
67
Stomach cancer is almost always what type?
Adenocarcinoma
68
What paraneoplastic syndrome often presents with stomach cancer?
Acanthosis nigricans
69
Describe the course of stomach cancer.
Early aggressive local spread and node/liver metastases
70
How can you break down the different presentations of stomach cancer?
Intestinal vs. diffuse
71
Is intestinal or diffuse stomach cancer associated with H. pylori?
Intestinal
72
Aside from H. pylori what are other causes of intestinal stomach cancer?
Dietary nitrosamines, tobacco smoking, achlorhydia, chronic gastritis
73
Describe what you would see with intestinal stomach cancer.
Commonly on the lesser curvature - looks like ulcer with raised margins
74
Describe what you would see with diffuse stomach cancer.
Signet ring cells and the stomach wall is grossly thickened and leathery (linitis plastica)
75
What is Virchow node?
Involvement of left supraclavicular node by metastasis from the stomach
76
What is a Krukenberg tumor?
Bilateral metastases to ovaries of stomach cancer; marked by abundant mucus and signet ring cells
77
Subcutaneous periumbilical metastasis from stomach cancer is called what?
Sister Mary Joseph nodule
78
Pain decreasing with meals - gastric or duodenal ulcer?
Duodenal
79
Weight gain - gastric or duodenal ulcer?
Duodenal
80
Which one is more strongly associated with H. pylori infection - gastric or duodenal ulcer?
Duodenal (almost 100%) vs. gastric (70%)
81
Aside from H. pylori infection what are other causes of ulcers?
NSAIDs - gastric, Zollinger-Ellison - duodenal
82
Are gastric or duodenal ulcers associated with increased risk of carcinoma?
Gastric
83
Which ulcer often occurs in older patients?
Gastric
84
What do we see histologically for duodenal ulcers?
Hypertrophy of Brunner glands
85
What are 2 complications of ulcers?
Hemorrhage and perforation
86
Where do we tend to see hemorrhage as a complication of ulcer?
1. Ruptured gastric ulcer on the lesser curvature of the stomach - bleeding from the left gastric artery
2. Ulcer on the posterior wall of the duodenum - bleeding from gastroduodenal artery
87
Where do we tend to see perforation as a complication of ulcer?
Anterior wall of the duodenum
88
Chest radiograph shows what with perforation of an ulcer?
Free air under the diaphragm
89
A patient with a perforated ulcer may have referred pain to where?
Shoulder
90
Tropical sprue, whipple disease, celiac sprue, disaccharidase deficiency, abetalipoproteinemia, pancreatic insufficiency are all examples of what?
Malabsorption syndromes
91
Malabsorption syndromes can cause what symptoms?
Diarrhea, steatorrhea, weight loss, weakness, vitamin and mineral deficiencies
92
What is the difference between tropical and celiac sprue?
Tropical sprue responds to antibiotics - cause is unknown but tropical sprue is seen in residents of or recent visitors to the tropics
93
What causes Whipple disease?
Tropheryma whipplei infection
94
Is tropheryma whipplei gram positive or negative?
Gram positive
95
What do you see on histology with Whipple disease?
PAS + foamy macrophages in intestinal lamina propria, mesenteric nodes
96
What demographic tends to get Whipple disease more often?
Older men
97
What are 3 characteristic symptoms (aside from GI) of Whipple disease?
Mnemonic: Whipped cream in a CAN
Cardiac symptoms, Athralgia, Neurological symptoms
98
What is celiac sprue?
Autoimmune-mediated intolerance of gliadin (wheat) leading to malabsorption and steatorrhea
99
What are three things (2 genetic, 1 demographic) associated with celiac sprue?
1. HLA-DQ2
2. HLA-DQ8
3. Northern European descent
100
Name 3 antibodies found in celiac sprue.
1. Antiendomysial
2. Anti-tissue transglutaminase
3. Anti-gliadin
101
What happens to villi in celiac sprue?
Blunting
102
Where do you see lymphocytes in celiac sprue?
Lamina propria
103
Decreased mucosal absorption in celiac sprue primarily affects what parts of the GI tract?
Distal duodenum and/or proximal jejunum
104
What is used to diagnose celiac sprue?
Serum levels of tissue transglutaminase antibodies
105
What other condition is celiac sprue associated with?
Dermatitis herpetiformis
106
Does celiac sprue increase your risk of cancer?
Moderately (e.g. T cell lymphoma)
107
How is celiac sprue treated?
Gluten-free diet
108
What is the most common disaccharidase deficiency?
Lactase deficiency
109
What happens to the villi in disaccharidase deficiency?
Nothing - they look normal
110
What symptoms characterizes disaccharidase deficiency?
Osmotic diarrhea
111
When do you see self-limited lactase deficiency and why?
Following injury (e.g. virus) to the tips of the villi which is where lactase is located
112
What marks a positive lactose tolerance test for deficiency of lactase?
1. Administration of lactose produces symptoms
| 2. Glucose rises < 20 mg/dL
113
Describe the pathophysiology in abetalipoproteinemia.
Decreased synthesis of apolipoprotein B leads to inability to generate chylomicrons leads to decreased secretion of cholesterol and VLDL into the bloodstream leads to fat accumulation in enterocytes
114
When does abetalipoproteinemia present?
Early childhood
115
What are 5 symptoms in abetalipoproteinemia?
1. Failure to thrive
2. Steatorrhea
3. Acanthocytosis
4. Ataxia
5. Night blindness
116
What are 3 causes of pancreatic insufficiency?
1. Cystic fibrosis
2. Obstructing cancer
3. Chronic pancreatitis
117
Pancreatic insufficiency causes malabsorption of what?
Fat and fat-soluble vitamins (A, D, E, K)
118
What happens to stool in pancreatic insufficiency?
Increase in neutral fat
119
Describe what we use a D-xylose absorption test for.
Normal urinary excretion in pancreatic insufficiency vs. decreased excretion with intestinal mucosa defects or bacterial overgrowth
