GI Flashcards
1
Q
What do rostral and caudal mean?
A
Rostral: head
Caudal: tail
2
Q
What does failure of caudal wall lead to?
A
Bladder exstrophy
3
Q
What does failure of caudal wall =?
A
Sternal defects
4
Q
What does failure of lateral wall =?
A
Gastroschisis
5
Q
3 arterial supplies to gut and what do they supply?
A
Celiac: foregut
SMA: Midgut
IMA: hindgut
6
Q
What does the foregut become and what supplies it?
A
- Pharynx -> duodenum
- Liver
- Gallbladder
- Distal stomach
- Pancreas
- Supplied by celiac
7
Q
Organ supplied by celiac that is not derived from foregut?
A
Spleen: derived from mesoderm, NOT endoderm
8
Q
What layer makes most GI tract?
A
Endoderm
9
Q
What does the hindgut become?
A
Distal 1/3 gut -> internal anus
- supplied by IMA
10
Q
What does the midgut become? What supplies it?
A
- Jejunum -> proximal 2/3 colon
- Supplied by SMA
11
Q
How does midgut develop?
A
Needs more space so from week 6 - 10 develops outside of abdomen
- Must rotate 270 degrees around SMA before can move back in
12
Q
What is omphalocele?
A
- Failure of gut to rotate around SMA and reduce into abdomen at week 10
- Left stuck outside body with peritoneal covering
- Associated with trisomies
13
Q
Difference between gastroschisis and omphalocele?
A
Gastroschisis does not have peritoneal covering and is adjacent to belly button
14
Q
Presentation of esophageal atresia with TE fistula?
A
- Polyhydramnios as fetus cannot swallow
- Vomit / regurg on first feeding
- Drooling choking
- Gastric air bubbles on CXR
15
Q
What is associated with duodenal atresia?
A
Down syndrome
16
Q
What does double bubble sign mean?
A
Duodenal atresia
- Air is stuck in stomach and again in duodenum below pyloric sphincter
17
Q
What does triple bubble sign mean?
A
Jejunal or ileal atresia
- Ligament of treitz is separating air into third bubble
18
Q
Signs of duodenal atresia?
A
- Polyhydramnios
2. Bilious emesis (green)
19
Q
How to tell duodenal from esophageal atresia?
A
There is not bilious emesis seen in in esophageal as atretic lumen is before bile is secreted in SI
20
Q
What is sphincter of Oddi?
A
Where bile enters duodenum from common bile duct
21
Q
What is hypertrophic pyloric spincter?
A
- Slow hypertrophy of sphincter AFTER birth
- Presents 1 month AFTER birth in contrast to atresias
1. Palpable olive shaped mass
2. Projectile vomiting
3. Non bilious vomit
22
Q
What are the retroperitoneal structures?
A
“SAD PUCKER”
Suprarenal glands
Aorta / IVC
Duodenum 2 - 4th parts
Pancreas - except tail Ureters Colon (ascending and descending) Kidneys Esophagus Rectum
23
Q
Which ligament does the portal triad travel through? What makes up the triad?
A
Hepatoduodenal ligament
- Common bile duct
- Hepatic artery
- Portal vein
24
Q
What is the pringle maneuver?
A
Getting the liver to stop bleeding by compressing the hepatoduodenal ligament: the hepatic artery is found in here as well as rest of portal triad
25
First branch of aorta and where does it branch?
Common iliac arteries at L4
26
Where is IVC relative to aorta?
- To the right
- Anterior to renal / adrenal A
- Posterior to right gonadal A.
27
Left abdominal venous drainage to IVC?
- Renal vein is only vein that makes it to IVC
| - Both gonadal and adrenal vein merge with renal then ride over
28
What is SMA syndrome?
- Normally, SMA travels in mesentery of fat over curvature of duodenum which give it cushion
- In malnourished folks, mesentery is lost and duodenum compressed between SMA and aorta = obstruction
1. Postprandial pain
2. Nausea / vomiting
29
Innervation of celiac / SMA area?
Greater and lesser splanchnic nerves T5-T12
30
Innervation of IMA area?
Lumbar splanchnic nerves L1 - L2
31
What does celiac arterial branch into?
1. Left gastric: lesser curvature of stomach
2. Common hepatic
3. Splenic
32
What does left gastric artery do?
1. Small branch to esophagus
| 2. Anastomosis on lesser curvature of stomach
33
What does splenic artery do?
1. Body and tail pancreas
2. Spleen
* **Short gastric artery: supplies fundus
34
What does hepatic artery do?
1. Gastroduodenal:
2. Proper hepatic: part of portal triad to liver
* *Also branches into Right gastric which anastomoses with left
35
Main blood supply to liver?
Portal vein: 80% volume, 50% oxygen
36
Venous blood to liver?
Portal to liver, hepatic veins to IVC
| - Splanchnic, IMV, SMV feed liver
37
What is the ligamentum teres?
Used to be umbilical vein: if pressure in portal vein too high, recanalized and blood flows through it to umbilical area where cutaneous veins head back to VCs
**Caput medusae in portal HTN
38
Left gastric anastomoses from portal vein?
Left gastric -> esophageal veins -> Azygos vein - > SVC
39
IMV anastomosis from portal?
Rectal veins -> IVC - > heart
| ***This is why rectal absorption of drugs is better than liver as it bypasses liver
40
What does TIPS connect?
Hepatic vein to portal vein to bypass increased pressure
| - However, the liver is no longer filtering
41
What is pectinate line?
Where the endoderm and ectoderm met at the anus
42
Venous drainage above pectinate line? Lymph? Cell type? Nervous?
1. Superior rectal
2. IMV
3. Portal vein
Lymph: internal iliac
Histo: simple columnar
Nerves: Visceral pelvic splanchnic
43
Venous drainage below pectinate line? Lymph? Nervous?
```
Bypasses liver:
1. Middle / inferior rectal veins
2. Internal pudendal
3. Internal iliac
4. IVC
Lymph: superficial inguinal
Histo: Stratified squamous
Nerves Pudendal
```
44
Which hemmorhoids are painful?
- External
| - Internal = visceral innervation = non specific and dull `
45
Presentation of anal fissures?
Caused by constipation
1. Painful defecation
2. Blood on TP
46
What is central vein?
Found at center of hepatic lobules: drains blood from hepatic a. and portal vein to carry blood to hepatic veins and IVC
47
What are Kupffer cells? What are the important in?
Macrophages that line hepatic sinusoids
- Break down RBCs to make heme which makes bilirubin
- Hepatocytes accept the bilirubin to conjugate and excrete it
48
Where are Zone 1/3?
Zone 1: closest to triad, metabolizes and does O2 intensive tasks
Zone 3: Closest to central vein: CYP450 metabolism
49
Which zone of liver most susceptible to ischemia?
Zone 3, furthest from triad which has higher O2
50
Which zone most susceptible to toxins?
Zone 1: has not yet hit cyp450 which is in liver
51
What is toxic to zone III?
Alcohol and tylenol: both need to be metabolized before they become toxic
52
Which zone susceptible to hepatitis?
Zone 1
53
What is zone 2 susceptible to?
Yellow fever
54
Flow of bile from liver?
1. Hepatic duct: drains bile from liver to sphincter of oddi to duodenum
2. As oddi is usually closed, refluxes up cystic duct into gallbladder
3. Common bile duct is distal to cystic and hepatic duct
55
What is the ampulla of vater?
Where common bile duct and pancreatic ducts meet
56
What are cholelithialsis?
Gallstones
57
What is cholecystitis?
Inflammation of gallbladder resulting from cholelithiasis
58
What is choledocolythiasis? Presentation?
Stone that has migrated down to common bile duct
1. Jaundice: bile buildup in body
2. Pale stools: bile colors stools
3. Liver inflammation
59
Where would stone need to be to obstruct bile flow completely?
Common bile duct "choledocolithiasis"
| - If only obstructing cystic duct, liver can still drain some of content town towards oddi
60
Where does stone need to be to cause inflammation of both bile duct and pancreas?
Confluence of pancreatic duct and common bile duct "ampulla of vater"
61
What else can obstruct the bile duct?
Pancreatic cancer
62
How to tell bile obstruction from stone and cancer?
Cancer usually presents with palpable, PAINLESS gallbladder
63
What hernia is more common in women?
Femoral
64
3 layers of inguinal canal?
1. Transversalis fascia (NOT muscle)
2. Internal oblique
3. External oblique
65
What does the cremaster do?
Moves testis up and down to adjust for temperature
66
What does remnant of distal process vaginalis cause? Proximal?
Distal: Hydrocele
Proximal: indirect inguinal hernia, comes through deep inguinal ring to inguinal canal
67
What do direct and indirect hernias pop through?
Indirect: deep inguinal ring
Direct: superficial ring from abdominal wall
68
Indirect or direct hernal more common in elderly?
Direct as it needs to plow through a week abdominal wall
69
Which hernia covered by all 3 layers of inguinal canal?
Indirect
| Direct: only covered by external spermatic fascia
70
Landmark for direct and indirect hernias?
Indirect: lateral to inferior epigastric vessels
Direct: Medial to inferior epigastric vessels
71
What occurs in hesselbach's triangle?
Direct inguinal hernias
72
Which hernias are almost all male?
Indirect
73
What is sliding hiatal hernia?
Stomach pops up through diaphragm
74
What is paraesophageal hernia?
Fundus of stomach passes through diaphragm to side of esophagus
75
Presentation of diaphragmatic hernia?
1. Asymptomatic
| 2. Reflux
76
Risk of congenital diaphragmatic hernia?
1. Deadly lung HYPOplasia as lungs have nowhere to go
| 2. Causes pulmonary HTN and right HF
77
Where is gastrin produced and what does it do?
G cells of stomach antrum:
1. Stimulates ECL to secrete histamine (endocrine)
2. Stimulates parietal HCL
3. Promotes growth of gastric mucosa
4. Increases gastric motility
78
Regulation of gastrin?
```
Increased:
1. Stomach distension
2. AAs / peptides in stomach
3. Vagal release of GRP
4. Alkalinization
5. PPIs
6. ZE syndrome
7. Chronic gastritis
Decreased:
1. PH
```
79
What is Zollinger ellison syndrome?
Gastrinoma
| - Pancreatic tumor secreting gastrin
80
What occurs in chronic gastritis?
Parietal cells are destroyed, G cells keep secreted gastrin as not receiving negative feedback
81
Where is somatostatin made and what does it do?
D cells of pancreas:
1. Stops secretions of pretty much everything
2. Decreased gallbladder contraction: increased risk gallstones from stasis
82
What does somatostatin do in brain?
Released by hypothalamus to reduce GH secretion
83
What is octreotide? Side effect?
Somatostatin analogue: side effect of gallstones as it stops gallbladder contractions
84
Stimulation of somatostatin?
Increase:
1. Acid
Decrease:
1. Vagas
85
What does cck do? Where is it made? What increases?
"Cholecystokinin" ***Think CHOLE = gall bladder
- Made by I cells in SI
1. Increase pancreatic secretions
2. Contract gallbladder
3. Increase pyloric emptying
4. Relax oddi: bile secretion
* **Increased by fat in duodenum
86
Main purpose of bile?
Help emulsify fats from food
87
Where is secretin made? What does it do?
- Increases secretions
- Made by S cells of duodenum
1. Increased bicarb
2. Increased bile
3. Decreased gastric emptying
88
What is GIP?
"Glucose-dependent insulinotropic peptide" aka "gastric inhibitory peptide"
- Increases insulin when glucose in duodenum
- Decreases gastric acid secretion: slows food coming down for insulin to take effect
* ***Much more highly stimulated with oral glucose than IV
89
Why is more insulin released in oral admin than IV?
GIP
90
What is motilin?
- Produced by M cells in SI
- Responsible for migratory motor complexes
- More prevalent in fasted state as we want to slow food down in fed for absorption
91
What drug is a motilin agonist?
Erythromycin
92
What does VIP do?
1. Smooth muscle relaxation of sphincters
2. Increased water / electrolyte secretion
* Increased by vagal stimulation
* Decreased by adrenergic NE
93
Presentation of VIPoma?
- Watery diarrhea from excess water / electrolyte secretion
94
NO roll in stomach?
1. LES relaxation
95
What is loss of NO implicated in?
Achalasia
96
What is ghrelin?
- Produced by stomach in fasting state to remind you to eat
97
Disease in which ghrelin is increased?
- Prader willi syndrome from Chromosome 15 anomaly
| - Causes overeating
98
What is IF?
"Intrinsic factor"
- Made my parietal cells in stomach and necessary for B12 absorption
- Allows for its absorption in terminal ileum
99
What is pernicious anemia?
- Destruction of parietal cells = decreased IF and macrocytic anemia
100
How does vagal stimulate parietal cells?
- ACH
101
3 Stimulators of Parietal cell?
1. ACH: vagal binding M3 receptor
2. Histamine: ECL cells via gastrin
3. Gastrin
102
What does cimetidine do?
Block H secretion by blocking histamine receptor
103
How does H leave parietal cell?
H/K ATPase which is stimulated via ACH on M3 Gq via I# Ca cascade
104
How does histamine signal on parietal?
Via H2 receptor increasing cAMP which stimulates H/K ATPase
105
How do somatostatin and PGs signal on parietal cell?
Decreased cAMP decreasing H secretion
106
What do chief cells do?
Secrete pepsin: enzyme that aids in protein digestion
107
What do brunner glands secrete?
Bicarb into SI
108
Effects of PGs on GI?
Protect mucosa via increased bicarb and decreased H
109
What triggers CCK secretion?
Fats entering SI: think CCK increases bile and bile helps emulsify fats so this makes sense
110
What stimulates secretin?
Acid
111
What do D cells secrete?
Somatostatin
112
What releases GIP?
K cells
113
How is pancreatic bicarb secreted?
- Via pancreatic Cl / bicarb exchanger in pancreatic ducats cells
- Secretin increases this action
114
Flow dependency of pancreatic secretions?
Low flow: Cl high
| High flow: bicarb high
115
What does alpha amylase do?
Starch digestion from pancreas
116
Why is trypsinogen?
Enzyme that activates all the zymogens secreted by pancreas
| ***Needs to first be activated by brush border enzyme enterokinase
117
What is enterokinase?
Brush border enzyme of SI that activates trypsinogen
118
Does stomach secrete anything for starch digestion?
No, only proteins and fats
119
What are the 3 major monosaccharides?
1. Glucose
2. Galactose
3. Fructose
120
How are glucose and galactose taken up in stomach?
SGLT1 - uses Na gradient
121
How is fructose taken up on GI?
Glut-5
122
What is D xylose test?
- D xylose does not require pancreatic enzymes to be absorbed
- If problem with brush border enzymes: will not appear in bloodstream
- If problem with pancreatic enzymes: will appear in bloodstream
123
Where are Fe, B12, and folate absorbed?
"Iron First Bro"
Iron: duodenum
Folate: Jejunum / ileum
B12: distal ileum, needs IF
124
Where are bile acids absorbed?
Terminal ileum
125
Where are peyer's patches found? What are they?
Lamina propria of and submucosa of illeum
- Lymphoid patches that can present antigens from GI tract
- Patches respond to antigens by secreting secretory IgA
126
Where are breuners glands found?
Duodenum
127
What can and cannot be absorbed by GLUT2?
Cannot: lactose (not a monosaccharide)
Can: Glucose, galactose, fructose
128
Composition of bile?
1. Bile salts
2. Phospholipids
3. Cholesterol
4. Bilirubin
5. Water / ions
129
Rate limiting step in bile synthesis?
Cholesterol synthesis via 7-a-hydroxylase
130
What is a bile salt?
Bile acid conjugated with glycine or taurine to make water soluble
131
What is 7-a-hydroxylase?
Rate limiting step in bile synthesis that makes cholesterol
132
What is only way body can get rid of cholesterol?
In the bile
133
How is bilirubin made?
1. Macs eat RBCs makin heme
2. Heme oxygenase makes biliverdin -> unconjugated bilirubin
3. Binds albumin to make blood soluble
4. UDP-glucuronyltransferase conjugates in liver
5. Excreted as bile in duodenum
134
Another name for unconjugated bilirubin?
Indirect
| *** Both are water insoluble
135
Important train in unconjugated bilirubin?
Water insoluble
136
What happens to bile in gut?
1. Gut bacteria convert to urobilinogen
2. 80% excreted in stool as stercobilin = brown color
3. 20% urobilinogen reabsorbed at terminal ileum
3a. 10% leaves urine as urobilin = yellow color
3b. 90% returned to liver
137
What does heme oxygenase do?
Makes indirect bilirubin
138
Cause of cleft lip and palate?
Failure of facial prominences to fuse
139
What is an aphthous ulcer?
Painful superficial ulcer on oral mucosa
- Arises from stress and spontaneously resolves
- Gray base surrounded by erythema
140
What is behcet syndrome?
1. Aphthous ulcers
2. Genital ulcers
3. Uveitis
* from small vessel IC vasculitis
141
Cause of oral herpes?
HSV1
142
Where is HSV1 latent?
Ganglia of trigeminal nerve
143
What causes hairy leukoplakia?
EBV
144
What is bilateral inflamed parotids indicative of?
Mumps
145
What causes elevated amylase in mumps?
1. Parotitis
| 2. Pancreatitis
146
What is a fistula?
Abnormal connection between 2 tubes
147
4 signs of TE fistula?
1. Vomit
2. Polyhydramnios
3. Air in GI - distension
4. Aspiration
148
What is an esophageal web?
- Protrusion of upper esophageal mucosa into lumen = obstruction
1. Presents with dysphagia for poorly chewed food
2. Risk of SCC
149
What is plummer vinson syndrome?
1. Severe Fe anemia "Iron pipes / plumber"
2. Esophageal web "Web / vines / vinson"
3. Beefy red tongue "Jake plummer is a beefy guy"
150
What is zenker diverticulum?
- Outpouching of pharyngeal mucosa through muscle
- Occurs above UES at junction of esophagus and pharynx
- Caused by increased swallowing pressure in pharynx
1. Dysphagia
2. Obstruction
3. Halitosis
151
Is zenker true of false diverticulum?
False
152
What is mallory weiss?
1. LONGITUDINAL laceration of mucosa at GE junctions
2. Seen in severe vomit
3. PAINFUL hematemesis vs. varices which is no pain
153
What is boerhaave syndrome?
- Rupture of esophagus = air in mediastinum
- Creates air bubbles in skin that make crackling noise
* Can be caused by mallory weiss tear
154
2 drainages of esophagus?
1. Azygous to SVC
| 2. Esophageal veins -> Left gastric -> portal vein: risk of varices is here
155
What is achalasia?
"Without relaxation"
- Disordered esophageal motility / cannot relax LES
- Caused by damaged ganglion cells in myenteric plexus
1. Dysphagia for both solids and liquids
2. Esophageal dilation with bird beak on CXR
3. High LES pressure
4. Bad breath
* Seen in chagas
156
What is bird beak on CXR indicative of?
Achalasia
157
What cells line esophagus?
Non keratinizing, squamous epithelium
158
When is hourglass appearance of stomach seen?
Sliding hiatal hernia
159
GERD presentation?
1. Adult onset asthma
2. Cough
3. Heartburn
4. Damage teeth enamel
160
What happens in barrett's esophagus?
Metaplasia from non keratinizing squamous epithelium to non ciliated columnar epithelium with goblet cells
161
Facts for esophageal adenocarcinoma?
- Most common esophageal carcinoma
- Lower 1/3 esophagus
- Usually from barrett's
162
Squamous cell carcinoma of esophagus facts?
1. Middle to upper 1/3 esophagus
| 2. Most common worldwide
163
Where does cancer from esophagus spread?
Upper 1/3: cervical nodes
Middle 1/3: tracheobronchial or mediastinal nodes
Lower 1/3: Celiac / gastric nodes
164
What is gastroschisis?
Congenital exposure of abdominal wall usually on right side and not covered with peritoneum
- From lateral wall
165
Causes of acute and chronic gastritis?
```
Acute: burning of stomach by acid
1. Increased acid production
2. Decreased protection
Chronic:
1. Autoimmune
2. H Pylori
```
166
Risks for acute gastritis?
1. NSAIDs - GPs were protective
2. Severe burn (curling ulcer) - decreased blood flow
3. Booze
4. Chemo
5. Increased ICP - Cushing ulcer
167
How are prostaglandins protective to stomach?
1. Decreased Acid
2. Increased mucus
3. Increased bicarb
4. Increased ICP - Cushing ulcer
168
What is a cushing ulcer?
- Increased ICP = acute gastritis
- Increased vagal stimulation = increased ACH
- ACH = more acid from parietal cell
169
Difference between ulcer and erosion?
Erosion: loss of epithelium
Ulcer: loss of mucosa
170
What happens in autoimmune gastritis?
1. Autoimmune destruction of parietal cells in body fundus
2. Achlorhydria - decreased acid
3. Increased Gastrin / G cell hyperplasia
4. Megaloblastic anemia
5. Intestinal metaplasia
171
Where are parietal cells found?
Fundus and body of stomach
172
What is intestinal metaplasia?
- Chronic gastritis leads to increased inflammatory cells in gastric lining which are not normally seen here but are seen in peyer's patches of intestine
173
How does H. pylori cause gastritis? Where does it impact?
- Create ureases and proteases that damage defenses
| - Antrum is most common site
174
Location breakout of peptic ulcer?
Proximal duodenum: 90%
| Distal stomach: 10%
175
Causes of duodenal ulcer?
1. H. Pylori, almost always
| 2. ZE syndrome
176
Which ulcer improves with meals?
Duodenum, this is because it is preparing itself for the meal and extra acid to arrive so it gets better
177
What happens on anterior and posterior duodenal wall rupture?
```
Anterior wall:
- More common
Posterior wall:
1. Rupture form gastroduodenal artery
2. Acute pancreatitis
```
178
Main cause of gastric ulcer?
1. H Pylori 70%
2. NSAIDs 20%
3. Bile reflux
179
What ulcer worsens with meals and why?
Gastric: stomach secretes more acid to prepare for meal
180
Where is gastric ulcer usually found and what is risk?
- Found on lesser curvature of antrum
| - Can lead to left gastric artery bleeding
181
Duodenal or gastric ulcer more likely malignant?
Gastric
182
2 types gastric carcinoma?
1. Intestinal type: large irregular ulcer with heaped margins in antrum
2. Diffuse type
183
What do nitrosamines in smoked foods give risk for?
- Intestinal type gastric carcinoma
184
Characteristics of diffuse gastric carcinoma?
1. Signet rings cells infiltrate wall resulting in:
| 2. Desmoplasia causing thickening and linitis plastica
185
When are signet ring cells seen?
Diffuse type gastric carcinoma
186
What is linitis plastica indicative of?
Diffuse type gastric carcinoma
187
When is ulcer see in gastric cancer?
Intestinal type
188
Signs of gastric carcinoma?
1. Acanthosis nigricans
| 2. Leser trelat sign
189
What is lesser trelat sign?
Dozens of seborrheic keratosis on skin
| - Sign of gastric carcinoma
190
What is virchow node?
- Left supraclavicular node that drains stomach where cancer often spreads
191
Type of cancer causing krukenberg?
Diffuse type: signet ring cells seen
192
Type of cancer causing sister mary joseph?
Intestinal type
193
Association with duodenal atresia?
Down syndrome
194
What is meckels diverticulum?
- True diverticulum (all 3 layers) of bowel wall
| - Failure of vitelline duct to involute
195
What does vitelline duct to?
- Nutrients from yolk sac to midgut early in fetus
- Forms in 4th week, gone by 7th
- Persistence = diverticulum
196
What does passing meconium through belly button at birth mean?
Failure of vitelline duct to close
197
What is being able to feel stool in belly button area indicative of?
Meckel's diverticulum
198
Presentation of meckel's diverticulum"?
1. Bleeding: from heterotopic gastric mucosa that produces acid
2. Volvulus
3. Intussusception
4. Obstruction
199
What is volvulus?
- Twisting of bowel along mesentery
- Obstructs blood supply = infarct
- Usually at sigmoid or cecum
200
Presentation of intussusception?
1. Obstruction
| 2. Infarction - currant jelly stools
201
Causes of intussusception?
Adults: tumor
Kids: lymphoid hyperplasia of peyer's patches
- Terminal illeum gets dragged into cecum
202
Presentation of small bowel ischemia?
1. Abdominal pain
2. Bloody diarrhea
3. Decreased bowel sounds
203
Associations of celiacs?
HLA-DQ-2/8
204
Process of gluten?
- Most pathogenic form is gliadin
- Deamidated by tTG then presented to APCs via MHCII
- Helper Ts cause tissue damage
205
Celiacs presentation in kids?
1. Abdominal distention
2. Diarrhea
3. Failure to thrive
4. Dermatitis herpetiformis - IgA deposition in dermal papillae
206
Lab findings in celiacs?
IgA against:
1. Endomysium
2. tTG - (transglutaminase)
3. Gliadin
207
Histo in celiacs?
1. Flat villi
2. Crypt hyperplasia
3. Lymphocytic infiltrate
208
What is tropical sprue? Main characteristics?
Damage to small bowel villi by unknown org = malabsorption
1. In tropical regions
2. After infectious diarrhea
3. Responds to antibiotics
* **Normally seen in jejunum and ileum
209
Main thing absorbed in jejunum?
Folic acid
210
What is whipple disease?
- Systemic tissue damage with macs loaded with whipple
- Partially destroyed orgs found in lysosomes with PAS +
- Usually in small bowel lamina propria
211
Presentation of whipple disease?
1. Fat malabsorption
| 2. Steatorrhea
212
What are lacteals?
- Areas for absorption of chylomicrons found in lamina propria of SI villi
- Drain to lymphatics
- Chylomicrons made in enterocytes surrounding LP
213
What is lamina propria of of SI loaded with macs indicative of?
Whipple disease
214
What is abetalipoproteinemia?
- AR deficiency of apolipoprotein B48/100
215
What is B 48 required for?
Creation of chylomicron
216
What is B100 required for?
LDL / VLDL
217
What is positivity for chromogranin indicative of?
Carcinoid tumor
218
Most common site of carcinoid tumor?
Small bowel: chromogranin positive
219
What does carcinoid tumor usually secrete?
1. Serotonin: only presents in liver because otherwise 5HT is draining to liver which just metabolizes it
220
What breaks down 5HT in liver?
MAO: breaks it down into 5-HIAA which is seen in urine
221
What is 5-HIAA in urine indicative of?
Carcinoid tumor
222
Presentation of carcinoid syndrome?
1. Bronchospasm
2. Diarrhea
3. Flushing of skin
4. Right sided fibrosis of heart valves: deposition of collagen = pulmonary stenosis and tricuspid regurg
223
Why doesn't carcinoid tumor cause left sided fibrosis?
Lungs have MOA which breaks down MAO so fibrosis is not seen on the left side
224
Cause of appendicitis?
Obstruction of appendix by lymphoid hyperplasia or fecalith
225
Wall involvement in IBD?
Ulcerative: mucosal/submucosal ulcers
| Crohn's: full thickness with knife like fissures
226
Location in IBD?
Ulcerative: Continuous from rectum to colon
| Crohn's: Mouth to anus with skip lesions, ileum most common
227
Symptoms of IBD?
Ulcerative: left pain with blood diarrhea
| Crohn's: right pain, non bloody diarrhea
228
Inflammation in IBD?
Ulcerative: Crypt abscesses with neuts
| Crohn's: Lymphoid aggregates with granulomas
229
Gross appearance of IBD?
Ulcerative: Pseudopolyps, loss of haustra, lead pipe
| Crohn's: Cobblestone mucosa, creeping fat, strictures, string sign
230
What are crypt abscesses with neuts indicative of?
Ulcerative colitis
231
IBD complications?
Ulcerative: toxic megacolon, carcinoma
| Crohn's: Malabsorption, calcium ox stones
232
What is smoking protective against?
Ulcerative colitis
233
When is P-anca seen in stomach?
1. Ulcerative colitis
2. Churg strauss
3. Microscopic polyangiitis
234
What is hirschsprung? Association?
- Defective relaxation and peristalsis of rectum and distal sigmoid
- Congenital failure of ganglion cells to descend
- Associated with Downs
235
Presentation of Hirschsprung?
1. Failure to pass meconium
2. Empty rectum on DRE
3. Bowel dilation
4. Rectal suction with lack of ganglion cells
236
What are colonic diverticula?
- Outpouching of mucosa and submucosa through muscular layer
- Caused by increased wall stress usually occurring where vasa recta cross
237
Complications of diverticula?
1. BRBPR
2. Fistula
3. Diverticulitis
238
What is angiodysplasia?
- Acquired malformation of mucosal / submucosal capillary beds
- Usually in right colon and cecum due to high wall tension
- Presents as hematochezia
239
What do high stress in left and right colon caus?
Both present with hematochezia
Left: Diverticula
Right: angiodysplasia
240
What is hereditary hemorrhagic telangiectasia?
- Genetic thin walled vessels in GI and nasopharynx
241
Cause and location of ischemic colitis?
- Splenic flexure due to atherosclerosis of SMA
242
What is a hyperplastic polyp?
- Hyperplastic glands with serrated appearance
- Left colon
- Benign with no malignant potential
243
What is serrated appearance indicative of?
Hyperplastic polyp - benign left colon
244
What is adenoma carcinoma pathway?
1. APC mutation = polyp (tumor suppressor)
2. KRAS
3. a P53 mutation
3. b increased COX expression
245
What protects against gastric adenocarcinoma?
Aspirin - COX is part of pathway and aspirin inhibits this
246
What are sessile and pedunculated polyps and risk?
Sessile: flat growth, higher risk
Pedunculated: like mushroom
247
Histology in adenocarcinoma and risk?
Villous: high risk (villous = villain)
Tubular: low risk
248
What is FAP?
"Familial adenomatous polyposis"
- Inherited APC mutation on chromosome 5
- 1000s of colonic polyps
- Prophylactic colon resection
249
What is gardner syndrome?
1. FAP
2. Osteomas
3. Fibromatosis
250
What is turcott syndrome?
1. FAB
2. Glial tumors
3. Meduloblastomas
251
What is peutz jeghers syndrome?
1. Hamartomatous GI polyps
2. Mutocutasenous hyperpigment on lips, oral, genitals
3. Increased risk for many cancers
252
What is MSI pathway?
"Microsatellite instability pathway"
| - Instability seen in DNA replication that can lead to cancer
253
What is HNPCC?
"Hereditary non polyposis colorectal carcinoma"
- Inherited mutations in DNA repair
- Carcinomas arise de novo
254
Presentation of left sided GI carcinoma?
"Napkin ring lesion"
- Decreased tool caliber
- LLQ pain
- Blood in stool
* *Adenoma carcinoma sequence
255
Right sided GI carcinoma presentation?
"Raised lesion"
- Fe deficiency anemia
* Microsatellite sequence
256
WHat is CEA tumor marker for?
Progress / response of colon cancer
257
What is finely granular, large, hepatocytes with pale pink cytoplasm indicative of?
HBV
258
What does ventral pancreatic bud become?
1. Main pancreatic duct
| 2. Uncinate process
259
What is adenosine demainase deficiency seen in?
SCID: Both B and T cell deficiency
260
What is deficient in SCID?
Adenosine deaminase
261
What cholesterol, bile salt, and phosphatidylcholine levels lead to gallstones?
Cholesterol: high
Bile salts: low
Phosphatidylcholine: low
262
Difference in cause of proximal and distal duodenal atresia?
Proximal: failure of recanalization
Distal: Vascular occlusion in utero
263
What does IL8 do?
- Attracts neuts and induces phagocytosis
264
What does C3a/C5a do?
C3: recruits eos/basos
C5: recruits neuts
265
What does IL3 do?
Bone marrow stimulation and growth
266
What does IL10 do?
Antiinflammatory from macs and TH2
267
Landmark for appendix?
Taenia coli
268
Risk of high triglycerides?
Acute pancreatitis
269
2 most common causes of acute pancreatitis?
1. Booze
| 2. Gallstones
270
How does staph cause food poisoning?
Preformed exotoxin
271
How does C diff toxin work?
Toxin A/enterotoxin:
Toxin B/cytotoxin:
* both enter cell and disregulated cytoskeletal stability
272
Strongyloides appearance in stool?
Rhabidiform larvae
273
Vein in gastric varices?
Short gastric / splenic
274
What bleeds in perforation of posterior duodenum?
Gastroduodenal artery
275
What is seen in cholera diarrhea?
Flecks of mucus and, sloughed epithelial cells, no leukocytes
276
Most common cancer in liver?
Metastasis
277
Chrons hypothesis?
TH1 overactivity
278
What acid base abnormality does vomit lead to?
Metabolic alkalosis
279
What does exocrine pancreas do?
Digestive enzymes
280
Etiology of acute pancreatitis?
- Premature activation of trypsin causing other enzymes to be activated and causing autodigestion of pancreatic parenchyma
281
Appearance of prancreas in acute pancreatitis?
1. Liquefactive necrosis
2. Extensive hemorrhage
3. Fat necrosis and saponification
282
2 most common causes acute pancreatitis?
1. Alcohol - contracts spincter of oddi
2. Gallstones
3. Trauma
4. Hypercalcemia
5. Hyperlipidemia
6. Drugs
7. Scorpions
8. Mumps
9. Posteriors duodenal ulcer - head of pancreas sits here
283
Presentation of acute pancreatitis?
1. Epigastric abdominal pain radiating to back
2. Nausea / vomit
3. HYPOcalcemia
4. Elevated amylase and lipase
5. Periumbilical and flank hemorrhage
284
2 things that could cause increased amylase?
1. Pancreatitis
| 2. Damage to salivary gland
285
Complications of pancreatitis?
1. Shock
2. Pancreatic pseudocyst
3. Abscess
4. DIC - enzymes eat coag factors
5. ARDS - enzymes eat alveolar lining
286
What is pancreatic pseudocyst?
- Seen in acute pancreatitis
- Fibrous tissue surrounding areas of necrosis and pancreatic enzymes to wall them off
* Presents with:
1. Abdominal mass
2. Persistence of amylase enzyme
3. Rupture
287
Causes of acute pancreatitis?
1. CF: kids
| 2. Booze
288
Signs of pancreatic insufficiency / chronic pancreatitis?
1. Malabsorption
2. Steatorrhea
3. Fat soluble vitamin deficiencies
4. TIIDM
5. Calcification
* *Amylase and lipase not elevated as pancreas is destroyed
289
What does pancreatic carcinoma arise from?
Ducts
290
Risks for pancreatic carcinoma?
1. Smoking
| 2. Chronic pancreatitis
291
Signs of pancreatic carcinoma based on location?
```
Head:
1. Obstructive jaundice
2. Pale stools
3. Palpable gall bladder
Body / Tail:
1. Secondary diabetes
```
292
Serum tumor marker for pancreatic cancer?
Ca - 199
293
What is ca 199 tumor marker for?
Pancreatic carcinoma
294
Cause of biliary atresia?
Failure to form extrahepatic bile ducts
295
Presentation of biliary atresia?
1. Biliary obstruction
296
Increase / decrease in what can cause cholelithiasis?
```
Increased:
1. Bilirubin
2. Cholesterol
Decreased:
1. Phospholipids (lecithin) (helps solubilize cholesterol)
2. Bile acids
```
297
2 types of gallstones?
1. Cholesterol stones
| 2. Bilirubin stones
298
What is cholestyramine?
- Lipid lowering agent that binds bile acids
| - Increases risk for gallstones because of this
299
How does stasis cause bili gallstones?
1. Allows bacteria to flourish
2. Bacterio unconjugated bili
3. Deconjugated is not soluble = stones
300
Cholesterol stones radiolucent or opaque? Bilirubin?
Cholesterol: Lucent
Bilirubin: Opaque
301
Risk for cholesterol stones?
1. Age
2. Estrogen - Increases HMG CoA reductase
- Increases cholesterol uptake in hepatocytes via more receptor expression
3. Cirrhosis
4. Crohn's - damages terminal ileum - decreased bile acids
5. Clofibrate
302
Risk for bili stones?
1. Extravascular hemolysis - increased unconjugated bilirubin
2. Biliary tract infection: causes deconjugation
303
Breakdown path of hemoglobin
Broken down into:
1. Heme: which is broken into
a. Iron (recycled)
b. Protoporphyrin: becomes unconjugated bili (UCB)
2. Globin
- Broken into AAs which are recycled
304
Complications of gallstones?
1. Biliary colic
2. Cholecystitis
3. Ascending cholangitis
4. Gallstone ileus
5. Gallbladder cancer
305
What is biliary colic?
- Waxing / waning RUQ pain from gallbladder contraction against stone in cystic duct
306
Acute cholecystitis presentation?
1. RUQ pain radiating to right shoulder
2. Fever / elevated WBC
3. Increased alkaline phosphatase
307
What is porcelain gallbladder complication of?
Chronic cholecystitis
308
What is RUQ pain after eating indicative of?
Acute cholecystitis: bladder is trying to contract to release bile
309
Cause of jaundice?
Serum bili >2.5
310
What is urobilinogen?
- Enteric flora in GI act on conjugated bilirubin when released in bowel
- Makes poo brown / pee yellow
311
Why does ineffective erythropoiesis cause jaundice?
Macs are destroying poorly made RBCs
312
Do hemolysis and ineffective erythropoiesis case elevated conjugated or unconjugated?
- Unconjugated as system is overwhelmed
313
Whats happening in physiologic jaundice of newborn?
- Baby has deficiency conjugating due to low UGT
314
What is kernicterus?
- UCB is fat soluble so can deposit in basal ganglia if too much seen in baby
- Causes neurologic deficits and death
315
What does phototherapy do?
Makes UCB water soluble: ISNOT conjugating
316
What is gilberts?
- Genetically low UGT = increased UCB during stress
| - Normally not clinically significant
317
Two spectrums of decreased UGT in adults?
1. Gilberts: mild
| 2. Crigler: severe
318
What is Crigler Najar?
- Absent UGT
- High UCB
- Kernicterus and death
319
What is Dubin Johnson?
Dubin "think dubin = dumpin" problem with dumbing bili
- Deficiency in canalicular bili transport protein
- Increase in CB as conjugating system is fine
* Liver is pitch dark
320
What is pitch dark liver indicative of?
Dubin Johnson syndrome: think that it's getting dark from all the bile that is accumulating in there
321
What is rotor syndrome?
Same as dubin Johnson but lacks black liver
322
Signs of obstructive jaundice?
1. Jaundice
2. Pruritis: bile acids leak and deposit in skin
3. Xanthomas / HYPERcholesterolemia: cholesterol is leaking from bile
4. Pale stool as bile cant get in bowel
5. Steatorrhea
6. Deficient fat soluble vitamins
7. Dark urine: CB is water soluble
323
Break out of bili in hepatitis?
- Both UCB and CB as both hepatocytes and ducts are being damaged
324
3 causes viral hepatic?
1. Hepatitis virus
2. CMV
3. EBV
325
Presentation of acute hepatitis?
1. Mixed jaundice
2. Dark urine
3. ALT > AST
326
Where is inflammation in Acute / chronic hepatitis?
```
Acute:
1. Within portal tracts
2. Between hepatocytes
Chronic:
1. Portal tracts
```
327
Mechanism of hepatocyte destruction in hepatitis?
- Viral antigens presented in MHCI
| - CD8 cells perform killing
328
Routes of HAV, HEV? What is chronic state like?
HAV: fecal oral, travelers
HEV: fecal oral, contaminated water
*No chronic state seen
329
HEV in pregnancy?
Fulminant hepatitis with liver failure / necrosis
330
Which acute hepatitis has vaccine?
HAV
331
First serum marker to rise in acute HBV?
HBsAg
- If > 6 months = chronic
- Gone if infection is resolved
332
Marker of acute HBV battle?
IgM vs. core antigen
| *If IgG, chronic
333
How to tell if resolved chronic HBV or immunized?
Resolved: IgG vs. core and surface
Vax: only surface IgG
334
What indicates HBV infectivity?
Envelop antigen
335
How to tell if HCV infx?
Viral RNA
336
HDV?
Only can occur if infected with HBV
- Acquire at later time: coinfection, less sever
- Acquire at same time: super inx, very severe
337
Histo in cirrhosis?
- Disruption of parenchyma by broad bands of cirrhosis and regenerative nodules of hepatocytes
338
What mediates fibrosis in cirrhosis?
- TGF-beta from stellate cells
| - Lies below endothelial cells that line sinusoids
339
Funny things that happens in splenomegaly?
Hypersplenism: consumes RBCs and platelets
340
Why does cirrhosis cause hyperestrinism and what are results?
* Liver is normally removing estrogen from blood:
1. Gynecomastia
2. Spider angioma
3. Palmar erythema
341
Protein impacts of cirrhosis?
1. HYPOalbuminemia
2. Coagulopathy: decreased clotting factors
- Can no longer activate vitamin K
* *Increased PT AND PTT
342
Is fatty liver reversible?
Yes
343
What mediates damage in alcoholic hepatitis?
Acetaldehyde
344
Presentation of alcoholic hepatitis?
1. Swelling / ballooning of hepatocytes
2. Necrosis and acute inflammation
3. Mallory bodies: damaged intermediate filaments in hepatocytes
345
What are mallory bodies indicative of?
Alcoholic hepatitis: from damaged intermediate filaments in hepatocytes
346
What is AST > ALT in alcoholic hepatitis?
- Acetaldehyde is mitochondrial poison
| - AST is located in mitochondria
347
What is hemochromatosis / siderosis?
Hemochromatosis: excess Fe in body
Siderosis: deposition in tissues
*Damage is being caused by free radical deposition
348
Gi handling of Fe?
- Enterocytes take up and store Fe
| - Only passes to blood if body says its needed
349
What happens in primary hemochromatosis?
- No regulation of Fe moving from enterocytes to blood
| - Excess Fe now is deposited in tissues
350
Mutation in primary hemochromatosis?
HFE gene / C282Y
351
Cuase of secondary hemochromatosis?
Transfusions: body has no way to get rid of Fe
352
Presentation of hemochromatosis?
1. Bronze skin
2. Cirrhosis
3. Secondary diabetes
4. Arrhythmia
5. Gonadal dysfunction
353
Lab values in hemochromatosis?
Ferritin: increased
TIBC: decreased
Serum Fe: increased
% Saturation: increased
354
Diagnosis of hemochromatosis?
- Liver biopsy showing brown pigment turning blue on prussian stain
- If does not turn blue, it is lipofuscin from normal damage
355
Defect in wilson's? What does it cause?
- ATP7B gene involved in ATP mediated hepatocyte copper transport
1. Decrease Cu secretion in bile
2. Decreased Cu incorporation in ceruloplasmin
356
What is ceruloplasmin?
- Molecule that carries copper in blood
| - Cannot integrate copper in wilson's disease
357
Presentation of wilson's?
Presents in childhood:
1. Variety of neurologic symptoms
2. Kayser fleischer rings in cornea
3. Hepatocellular carcinoma
358
What are kayser fleischer rings seen in?
Wilsons
359
Treatment of wilson's disease?
D-penicillamine: copper chelator
360
What is decreased serum ceruloplasmin seen in?
Wilson's
361
What is primary biliary cirrhosis?
- Autoimmune, granulomatous destruction of intrahepatic bile ducts
* Antimitochondrial Ig is diagnostic
362
What is autoimmune, granulomatous destruction of intrahepatic bile ducts?
- Primary biliary cirrhosis
363
What is antimitochondrial Ig diagnostic of?
Primary biliary cirrhosis
364
Presentation of primary biliary cirrhosis?
1. Obstructive jaundice
| 2. Liver cirrhosis
365
What is primary sclerosing cholangitis?
"Periductal fibrosis with onion skinning"
- Inflammation / fibrosis of intra/extrahepatic bile ducts
- Uninvolved areas are dilated = beaded appearance on imaging
- P-ANCA positive
- Causes conjugated jaundice
* Seen in ulcerative colitis
366
What is the following indicative of:
| "Periductal fibrosis with onion skinning"
Primary sclerosing cholangitis
367
Associations of Primary sclerosing cholangitis
Ulcerative colitis
| - p-ANCA
368
What is Reye syndrome?
- Fulminant hepatitis in child who takes aspirin with viral illness
- Likely due to mitochondrial damage
369
Reye presentation?
1. Nausea / vomit
2. Elevated liver enzymes
3. HYPOglycemia
4. Coma / death
370
Causation of hepatic adenoma?
- Oral contraceptive use: resolves on cessation `
| - Risk of rupture in pregnancy which E2 is high
371
What is aflatoxin risk for?
Hepatocellular carcinoma
| - Induces P 53 mutations
372
What is budd chiari?
- Thrombosis of hepatic vein often from tumor invasion
| - Ascites and painful hepatomegaly seen
373
Tumor marker for hepatocellular carcinoma?
AFP
374
What is AFP tumor marker for?
Hepatocellular carcinoma
375
What CN moves through parotid gland?
VII: as such tumor in parotid can = facial pain, paralysis
376
Another name for achalasia?
Megaesophagus: from chagas
377
2 instances in which eosinophils are seen?
1. Allergies
| 2. Parasitic infections
378
When is trachealization of esophagus seen?
Eosinophilic esophagitis
379
Medication causing esophagitis?
Bisphosphonates
380
Difference in HSV and CMV esophageal ulcers?
CMV: linear
HSV: punched out
381
Cancer risk in H pylori?
MALT lymphoma
382
What is menetrier disease?
Gastric hypertrophy associated with:
1. Increased mucus cells
2. Parietal atrophy
3. Protein loss
* *Rugae are so hypertrophic they look like rain
383
What to suspect if ulcers seen further down SI than in duodenum?
ZE syndrome
384
When is hypertrophy of brunner's glands seen?
Duodenal ulcers
385
Blood supply to lesser curvature of stomach?
Left gastric
386
Blood supply to greater curvature of stomach?
Gastroepiploic artery
387
Blood supply to duodenum?
Gastroduodenal artery: rungs along posterior
388
What does sudan B stain test for?
Fat in stool
389
D xylose test in celiacs?
Decreased as BB enzymes are destroyed so can't absorb as much
390
What does lactose break into?
Glucose and galactose
391
Hydrogen breath test relevance in lactose intolerance?
Large rise in these patients post lactose as they colonic bacteria ferment lactose making H and they cannot break it down
392
Folate or B12 show neuro symptoms?
B12
393
When is string sign seen?
Crohn's
394
When is cobblestone mucosa seen?
Crohn's
395
What are the extra intestinal manifestations of IBD?
1. Pyoderma gangrenosum: rash
2. Uveitis
3. Erythema nodosum
4. Oral ulcers
5. Arthritis
6. Ca / ox stones: Crohns
396
Where is mcburneys point?
1/3 way between anterior superior iliac spine and umbilicus
| - Appendicitis pain often presents here
397
Tissue often found in meckel diverticulum?
1. Gastric
| 2. Pancreatic
398
Diagnosis of Meckel's
Pertechnetate study
| - Molecules are taken up by the ectopic parietal cells in the diverticulum
399
What does pertechnetate study diagnose?
Meckel's
| - Molecules are taken up by the ectopic parietal cells in diverticulum
400
Hirschsprung presentation?
1. No stools
2. Bilious vomit
3. Distended abdomen
* *Often seen in down's syndrome
401
What is ileus? Causes?
HYPOmotility of bowel
1. Opiates
2. HYPOkalemia
3. Post opp
402
When is meconium ileus seen?
CF
403
"CLAX TPAG" mnemonic?
```
Syndrome:
Cockayne
Lynch
Ataxia Telangiectasia
Xeroderma Pigmentosum
Mutation:
Transcription coupled nucleotide excision repair
Post replicative repair
ATM gene defect
Genome wide repair
```
404
What is lynch syndrome?
aka "HNPCC"
- Defect in Post replicative mismatch repair
- Due to methylation of MHS1, 2, or 6
- Leads to colorectal carcinoma of right colon
405
Other cancers seen in lynch?
1. Endometrial
2. Skin
3. Ovarian
406
Colorectal polyp that does not have risk for cancer?
Hyperplastic
407
2 disease processes with increased alkaline phosphatase?
1. Biliary obstruction
2. Bone disease
* ***Use GGT to distinguish as is specific to alcoholic liver
408
Which zone at risk for alcoholic liver?
Zone III
409
What is a non smoker with panacinar emphysema and PAS+ liver lobules indicative of?
A1-antitrypsin deficiency
410
Type I or II crigler more serious?
Type I
411
Why is liver black in Dubin Johnson?
Buildup of epinephrine metabolites
412
Risks for cholesterol stones?
1. Obesity
2. Crohns
3. Weight loss
4. 4 Fs: fat, female, fertile, forty `
413
What is courvoisier sign?
1. Palpable non tender gallbladder
2. Obstructive jaundice
3. Cancer of pancreatic head
414
What does prazole ending indicate?
PPIs
415
What kills cells with decreased or absent MHC I?
Natural killers
416
What makes up walls of pancreatic pseudocyst?
Fibrous tissue, granulation tissue, ABSENCE of epithelial cells
417
What can't liver to with ammonia in cirrhosis?
Convert it to urea
418
Where are fats digest and absorbed?
Digested: duodenum
Absorbed: jejunum
419
Where do most anal fissures occur?
Posterior, distal to dentate
420
Another name for B12?
Cobalamin
421
What could cancer in 3rd part of duodenum compress?
SMA
422
Where in duodenum is ampulla and odi?
2nd part
423
Where would air be seen in gallstone ileus?
1. Biliary tree
| 2. SI
424
Presentation of VIPoma?
1. Secretory / watery diarrhea
2. Achlorhydria
3. HYPOkalemia
425
Lymphatic drainage proximal and distal to dentate?
Proximal: internal iliac and IMA
Distal: inguinal nodes
426
How does HBV replicate?
1. DSDNA
2. SSRNA
3. DSDNA
427
What is CREST?
```
Calcinosis
Raynauds
Esophageal dysmotility
Sclerodactyly
Telangiectasias
```
428
What is IV bioavailability?
100% normally
429
Equation for oral bioavailability?
AUC oral dose / AUC IV dose
430
What vitamins do enteric bacteria make?
1. K
| 2. Folate
431
Where is stomach attached in GI bypass?
Jejunum
432
What is SI intestine with large PAS foamy macs indicative of?
Whipple
433
Bodies protection form Giardia?
Iga and CD4+ helpers
434
Where can splenic pain refer to?
Shoulder
435
What can cause hiccups?
Phrenic nerve irritation leading to spasm of diaphragm
436
What causes secretin to be released?
Duodenal H
437
What is CA 125 marker for? 199?
125: ovarian
199: pancreatic
438
Signs of carcinoid syndrome?
1. Watery diarrhea
2. Flushing
3. Bronchospasm
4. Right sided valvular plaques
439
Treatment for carcinoid?
Octreotide: somatostatin analog
| **Also works in VIPomas
440
How is secretin used diagnostically?
Normal: decrease gastrin and increases bicarb
ZE: Increases gastrin
