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GIR Test 1 > GI Physiology: First Aid & Ninja Nerd Because That Guy Sucks > Flashcards

GI Physiology: First Aid & Ninja Nerd Because That Guy Sucks Flashcards

1
Q

secreted by G cells in the antrum of stomach, duodenum

A

gastrin

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2
Q

increases H+ secretion

A

gastrin

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3
Q

increases the growth of gastric muscosa

A

gastrin

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4
Q

increases gastric motility

A

gastrin

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5
Q

upregulated by stomach distension/alkalinization, animo acids, peptides, vagal stimulation via GRP

A

gastrin

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6
Q

down regulated by a pH less than 1.5

A

gastrin

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7
Q

upregulated by chronic proton pump inhibitor use

A

gastrin

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8
Q

secreted by D cells in pancreatic islet and GI mucosa

A

somatostatin

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9
Q

decreases gastric acid and pepsinogen secretion

A

somatostatin

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10
Q

decreases pancreatic and small intestine fluid secretion

A

somatostatin

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11
Q

decreases gallbladder contraction

A

somatostatin

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12
Q

decreases insulin and glucagon release

A

somatostatin

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13
Q

upregulated by acid

A

somatostatin

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14
Q

downregulated by vagal stimulation

A

somatostatin

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15
Q

inhibits secretion of various hormones, encourages homeostasis

A

somatostatin

(somato-stasis)

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16
Q

secreted by I cells in the duodenum and jejunum

A

cholecystokinin (CCK)

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17
Q

increases pancreatic secretion

A

CCK

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18
Q

increases gallbladder contraction

A

CCK

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19
Q

decreases gastric empyting

A

CCK

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20
Q

increases spinchter of Oddi relaxation

A

CCK

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21
Q

upregulated by fatty acids, amino acids

A

CCK

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22
Q

acts on neural muscarininc pathways to cause pancreatic secretion

A

CCK

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23
Q

secreted by S cells in the duodenum

A

secretin

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24
Q

increases pancreatic HCO3- secretion

A

secretin

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25
Q

decreases gastric acid secretion

A

secretin

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26
Q

increases bile secretion

A

secretin

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27
Q

upregulated by acid, fatty acids in lumen of duodenum

A

secretin

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28
Q

allows pancreatic enzymes to function by neutralizing the gastic acid in the duodenum via increased bicarb production

A

secretin

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29
Q

secreted by the small intestine

A

motilin

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30
Q

produces migrating motor complexes (MMCs)

A

secretin

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31
Q

upregulated in a fasting state

2

A

motilin
ghrelin*

*don’t think this has been discussed yet, FA pg 380

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32
Q

erythromycin can be used to stimulate peristalsis because it’s a […] receptor agonist

not sure if he discussed this, but useful clinical correlation i think

A

motilin

FA pg 380

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33
Q

increases smooth muscle relaxation and spinchter relaxation

A

NO and VIP

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34
Q

secreted from parasympathetic ganglia in spinchters, gallbladder, small intestine

A

VIP

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35
Q

increases intestinal water and electrolyte secretion

A

VIP

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36
Q

secreted by parietal cells of stomach

2

A

gastric acid
intrinsic factor

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37
Q

upregulated by histamine, gastrin, and vagal stimulation

2

A

gastric acid
intrinsic factor

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38
Q

downregulated by somatostatin, GIP, prostaglandin, and secretin

2

A

gastric acid and intrinsic factor

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39
Q

vitamin B12 binding protein

A

intrinsic factor

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40
Q

secreted by chief cells of stomach

A

pepsin

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41
Q

digests proteins

A

pepsin

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42
Q

upregulated by vagal stimulation (Ach), local acid

A

pepsin

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43
Q

pepsinogen is converted to pepsin in the presence of

A

H+

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44
Q

secreted by muscosal cells in the stomach, duodenum, salivary glands, and pancreas
and Brunner glands in the duodenum

A

bicarbonate

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45
Q

neutralizes acid

A

bicarb

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46
Q

upregulated by pancreatic and biliary secretion with secretin

A

bicarb

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47
Q

trapped in the mucus that covers the gastric epithelium

A

bicarb

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48
Q

autoimmune destruction of parietal cells can cause

A

chronic gastritis and pernicious anemia

(lack of gastric acid and intrinsic factor to bind B12)

FA pq 381

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49
Q

somatostatin analog used to treat acromegaly, carcinoid syndrome, VIPoma, and variceal bleeding

A

octreotide

throwing it back to RC haha

FA pg 380

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50
Q

secreted by K cells in duodenum and jejunum

A

glucose dependent insulinotropic peptide

GIP

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51
Q

exocrine: decreases gastric H+ concentration
endocrine: increases insulin release

A

glucose dependent insulinotropic peptide

GIP

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52
Q

upregulated by fatty acids, amino acids, and oral glucose

A

glucose dependent insulinotropic peptide

GIP

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53
Q

gastin increases acid production primarily through its effects on […] cells, leading to histamine release

A

enterochromaffin like cells (ECL)

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54
Q

what layer of the alimentary canal contains the myenteric plexus?

A

muscularis externa

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55
Q

what layer of the alimentary canal contains the submucosal plexus?

A

submucosa

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56
Q

if a structure has serosa it is

intra or retroperitoneal

A

intraperitoneal

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57
Q

if a structure has adventitia it is

intra or retro peritoneal

A

retroperitoneal

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58
Q

for food to move down the gut, the circular muscles need to […] and the longitudinal muscles need to […]

contract/relax

A
  1. contract
  2. relax
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59
Q

ascending fibers in the myenteric plexus work on the […] side of the bolus to push it forward

oral or aboral

A

oral

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60
Q

what neurotransmitters cause the circular muscles to contract

A

Ach

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61
Q

what neurotransmitters cause the longitudinal muscles to relax?

A

NO and VIP

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62
Q

the descending fibers work on the […] side of the bolus to open and relax the next segment

oral/aboral

A

aboral

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63
Q

what neurotransmitters relax the circular muscles?

A

NO and VIP

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64
Q

what neurotransmitters contract the longitudinal muscle fibers?

A

Ach

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65
Q

chemoreceptors are located in the […] plexus

submucosal or myenteric

A

submucosal

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66
Q

how to chemoreceptors stimulate blood vessels?

A

cause dilation, more blood flow, increased absorption of nutrients

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67
Q

how to chemoreceptors stimulate the glands in the submucosal plexus?

A

stimulates glands to secrete secretions into lumen to help digest food

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68
Q

foods rich in fatty acids and H+ stimulate the release os secretin. what 2 functions does secretin have?

A
  1. stimulates hepatocytes to produce bile
  2. stimulates duct cells in acini of pancreas to release bicarb to neutralize acid
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69
Q

food rich in protein stimulates the I cells to produce CCK. what are the 4 functions of CCK?

A
  1. gall bladder contractions
  2. potentiate secretins action on liver
  3. stimulates pancreatic ductal cells to produce proteases, lipases, and amylase
  4. relaxes spinchter of Oddi to allow more bile and pancreatic juices into duodenum
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70
Q

food rich in glucose activates K cells to procude GIP. what is the function of GIP?

A

stimulates pancreas to produce insulin, inhibiting gastric motility

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71
Q

how does the sympathetic nervous system effect the process of the GI tract?

A

overall: inhibits
decreases motility, blood flow, secretions, absorption

however, contracts spinchters

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72
Q

how does the parasympathetic nervous system effect the process of the GI tract?

A

overall, induces it
increases motility, secretions, and absorption

however, relaxes spinchters

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73
Q

GLP is secreted by what cells?

A

L cells in the ileum and large intestine

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74
Q

effects of GLP-1 on stomach

A

reduces gastric empyting, acid secretion, and motility

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75
Q

describe the vagovagal reflex

A
  • chemoreceptor/stretch receptors transmist signal via afferent fibers to DNV of PNS
  • stimulates DNV, sends signal via efferent fibers to activate submucosal and myenteric plexus

parasympathetic response

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76
Q

the vagovagal reflex allows for […] of the stomach

A

compensation

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77
Q

describe the entero-gastric reflex

A
  • chemo/stretch receptors send signal to prevertebral ganglion (SNS)
  • inhibits secretions, dilation, constriction of pyloric spinchter

sympathetic response

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78
Q

the entero-gastric in an inhibitory reflex triggered by what 2 things?

A
  • too much acid in intestines
  • too much distension of stomach
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79
Q

describe the defecation reflex

A
  • distension of colon activates chemo/stretch receptors, send signal to sacral plexus (S2-S4)
  • sacral plexus sends signal to pelvic splanchinic nerves, which innervate the submucosal and myenteric plexus
  • submucosal and myenteric plexus intiate peristaltic waves in descending colon, sigmoid, and rectum
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80
Q

list the layers of the alimentary canal

4

A

mucosa, submucosa, muscularis externa, serosa

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81
Q

where is the Auerbach plexus located?

myenteric

A

muscularis externa

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82
Q

where is the Meissner’s plexus found?

A

submucosa

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83
Q

ascending fibers cause the contraction of the […] and the relaxation of the […] to push food forward

muscle types

A
  1. circular muscles
  2. longitudinal muscles
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84
Q

what receptor is the most powerful stimulator of the submucosal plexus?

A

chemoreceptors

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85
Q

what is the postganglionic cells bodies of the parasympathetic nervous system?

A

submucosal and myenteric plexus

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86
Q

which long reflex is activated when there is a high amount of acid in the intestines?

A

entero-gastric reflex

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87
Q

cells located in the antrum of the stomach

2

A

D cells
G cells

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88
Q

the vagus nerve can act directly on what cells in the stomach?

A

D cells and G cells

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89
Q

Ach binds to an M3 receptor on antral D cells, inhibiting the release of

A

somatostatin

results in an increase of pepsin and HCl secretion

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90
Q

GRP released by the vagus nerve binds to receptors on the G cells to stimulate the release of

A

gastrin

results in increase of pepsin and HCl secretion

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91
Q

gastrin binds to CCK2 receptors on parietal cells, resulting in

A
  • increased intracellular Ca++
  • stimulates proton pump, pushing H+ ions out into lumen and brings K+ in

increases concentration of H+ in lumen

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92
Q

Ach binds to M3 receptors on parietal cells resulting in

A
  • increased intracellular Ca++
  • stimulates proton pumps
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93
Q

Histamine binds to the H2 receptor on parietal cells to stimulate

A

HCl secretion

94
Q

prostaglandin binds to PGE2 receptors on parietal cells to inhibit

A

inhibits HCl production

95
Q

somatostatin binds to SST receptors on parietal cells to inhibit

A

proton pumps

96
Q

parietal cells are stimulated by

3

A

gastrin
Ach
histamine

all end result in increased HCl

97
Q

parietal cells are inhibited by

2

A

prostaglandin
somatostatin

inhibit HCl production/proton pumps

98
Q

chief cells are stimulated by

4

A

gastrin
histamin
Ach
secretin

stimulate release of pepsinogen

99
Q

stimulate enterochromaffin like cells (ECL)

2

A

Ach
gastrin

stimulates release of histamin

100
Q

inhibit ECLs

1

A

somatostatin

inhibit release of histamine

101
Q

the secretion of gastrin stops when the pH of gastric content is below

A

2

102
Q

is released as a result of contact of acidic chyme with the duodenmal mucosa

A

secretin

103
Q

stimulated by gastric distension and inhibited by presences of excess acid in pyloric antrum

A

gastrin

104
Q

stimulates insulin secretion from pancreas

A

gastrin

105
Q

the cephalic phase of gastric secretion is controlled by the […] nerves

A

vagus

106
Q

3 phases of gastric secretion

A
  • cephalic (1/3 of secretions)
  • gastric (2/3)
  • intestinal (very little)
107
Q

describe how contraction moves through the stomach

A

starts at cardia -> fundus -> antrum -> pylorus

108
Q

what is it called when 25% of the chyme is pushed back into the corpus of the stomach to continue mixing?

A

retropulsion

109
Q

secrete intrinsic factor important for absorbing vitamin B12

A

parietal cells

110
Q

when high peptone concentration are sensed by duodenal G cells, the release gastrin into the blood to the parietal cells in the corpus, stimulating the release of

A

more H+ ions into lumen

peptones are basic

111
Q

endocrine secretions of the pancreas

A

insulin
glucagon

112
Q

exocrine secretions of the pancreas

general

A
  • fluid: bicarb, H20, elctrolytes
  • digestive enzymes

secretions that aid in digestion

113
Q

pancreatic cells that secrete enzymes, Na, Cl and some fluids

A

acinar

114
Q

pancreatic cells that modify the fluid secreted by acinar cells, secrete bicarb, and add water to pancreatic juice

A

ductal cells

115
Q

fluid secreted by the pancreas contains […] to neutralize the acidic fluid from the stomach

A

bicarb

116
Q

describe the flow rate of pancreatic fluid in a fasted state

A

low flow
* high Cl-
* low bicarb

117
Q

describe the flow rate of pancreatic fluid in a fed state

A

high flow
* low Cl-
* high bicarb

118
Q

the Na and K concentrations of pancreatic fluid are always

isotonic, hypotonic, hypertonic

A

isotonic

same as plasma

119
Q

why is bicarb higher in high flow states?

A
  • bicarb is secreted in the small ducts and reabsored in the large ducts
  • reabsorption is ineffective at high flow rates
120
Q

what hormone is the main stimulus for HCO3- release by the pancreas?

A

secretin

released in response to increased H+ in duodenum

121
Q

secreted by S cells in duodenum

A

secretin

122
Q

major stimuli for release of pancreatic enzymes from acinar cells

A

CCK

also Ach via vagovagal reflex

123
Q
  • local GI tract reflex circuit
  • both afferent and efferent fibers found within the vagus nerve
A

vagovagal reflex

124
Q

H+, amino acids, and fats in the duodenum activate the […] reflex and stimulate pancreas to release enzymes

A

vagovagal

125
Q

pancreatic enzyme that digests starch

A

a-amylase

126
Q

hydrolyzes starch at a1-4 linkages

A

a-amylase

127
Q
  • secreted by the pancreas in the active form
  • functional in small intestine
  • elevated in acute pancreatitis
A

a-amylase

128
Q

breaks down amylopectin and amylose

A

a-amylase

129
Q

what is different about salivary amylase vs. pancreatic?

A

salivary amylase has an optimal pH of 6 and is inactivated in the stomach

130
Q

only […] are absorbed by the intestine

carbohydrate form

A

monosaccarides

131
Q

after amylase intital breaks down amylopectin and amylose, further digestion occurs at

A

intestinal brush border by oligosaccharide hydrolases

maltase, sucrase, lastase, etc

132
Q

rate limiting step of carbohydrate digestion

A

breakdown at the intestinal brush border

133
Q

glucose
fructose
galactose

are all…

A

monosaccharides

134
Q

hydrolyzes 1 and 3 bonds of triglycerides into fatty acids and monoglycerides

A

pancreatic lipase

135
Q

pancreatic enzymes for fat digestion

3

A

colipase
lipase
phospholipase

136
Q

assists pancreatic lipase

A

colipase

137
Q
  • secreted as inactive pro-phospholipase A2
  • activated by trypsin
A

phospholipase A2

138
Q

pancreatic enzymes that aid in protein digestion

4 big ones

A
  • trypsin
  • chymotrypsin
  • elastase
  • carboxypeptidases
139
Q

pancreatic enzymes that aid in protein digestion are all secreted as

A

zymogens

inactive proenzymes

140
Q

trypsin is secreted as inactive trypsinogen and activated by […]

A

enterokinase

brush border enzyme

141
Q

once activated by enterokinase, […] activates all other protein enzymes

A

trypsin

142
Q

when pancreatic secretion is blocked, auto-activation of trypsin leads to auto-digestion of pancreatic enzymes causing

clinical correlate

A

acute pancreatitis

increased amylase and lipase

143
Q
  • found in the gastric glands
  • secrete HCl (gastric acid)
A

parietal cells

144
Q
  • maintains very low pH in stomach
  • provides protection against infectious agents
  • denatures proteins for breakdown/absorption
A

gastric acid

145
Q

stomach cells are protected from gastric acid by

A

mucous and bicarb secreted by neck cells

146
Q

hormone from G cells in antrum of stomach

A

gastrin

147
Q

binds to CCKb receptor on parietal cells to trigger them to release HCl

A

gastrin

148
Q

activates ECL cells which produce histamine to stimulate parietal cells to release more HCl

A

gastrin

149
Q

activates G cells to produce gastrin via binding on M3 receptors

A

Ach

from vagus

150
Q

the vagus can release […] to stimulate G cells to produce gastrin

A

GRP

151
Q

3 stimuli for acid procdution

A
  1. direct gastrin
  2. indirect gastrin (histamine mediated)
  3. vagus nerve (Ach and GRP)
152
Q
  • muscarinic blocker
  • blunts parietal cells stimulation by Ach
  • but does not block GRP so not great for acid control
A

atropine

153
Q
  • necessary for B12 absorption
  • released by parietal cells
A

intrinsic factor

154
Q

block H+ secretion by parietal cells

A

proton pump inhibitors

omeprazole, pantoprazole

155
Q

H+ that is pumped out of parietal cells is formed from what enzyme?

A

carbonic anhydrase

156
Q

H+ formed by carbonic anhydrase causes HCO3- to be pumped out of the cell. The increased serum HCO3- after meals if referred to as the

A

alkaline tide

157
Q

how does vomiting cause metabolic alkalosis?

A
  • increased production of HCl
  • more HCO3- is generated during the production of HCl

hypochloremia as well

158
Q

a low urinary chloride indicates

A

vomiting

loss of Cl- in gastric secretions

159
Q

stimulate secretion of HCl by parietal cells

3

A

Ach
gastrin
histamine

160
Q

inhibit secretion of H+ by parietal cells

2

A

somatostatin
prostaglandins

161
Q

work via Gq proteins with IP3/Ca second messenger system

2

A

Ach
Gastrin

162
Q

work via Gs/i and cAMP second messenger system

A

histamine, somatostatin, PGs

163
Q

Gq proteins

2

A

Ach
Gastrin

164
Q

Gs/i proteins

3

A

histamin
prostaglandins
somatostatin

165
Q

H2 blockers

A
  • cimetidine
  • ranitidine
  • fomotidine
  • nizatidine

decrease HCl production

166
Q

PGE1 analog that blunts acid production

A

misoprostol

167
Q

released by chief cells to digest proteins

A

pepsin

168
Q

chief cells release pepsinogen, it is activated to pepsin by

A

H+

169
Q

works best at a pH of 1-3

A

pepsin

170
Q

what stimulates the release of pepsin?

A

vagus nerve

171
Q
  • major hormone that stimulates acid secretion in stomach
  • produced by antral G cells
A

gastrin

172
Q

gastrin is secreted into the […] vein blood and takes physiologic action on […] cells

A

portal vein
parietal

173
Q

found in glands of lamina propria in the mucosa layer in antrum

cell type

A

G cells

174
Q

found in glands of lamina propria in the mucosa layer in body

cells type

A

parietal cells

175
Q

stimulates H+ secretion by parietal cells

A

gastrin

176
Q

effects of gastrin

3

A
  • stimulates H+ secretion by parietal cells
  • stimulates growth of gastric mucosa
  • increases gastric motility

gets stomach ready for digestion

177
Q

gastrin stimulates […] cells to release histamine, which stimulates parietal cell

A

ECLs

178
Q

parietal cell receptors

3

A
  • histamine (most important)
  • gastrin
  • Ach (vagus)
179
Q

most important way by which HCl secretion is stimulated

A

indirect gastrin pathway

gastrin -> ECL -> histamine -> parietal cells

180
Q

stimuli for increased gastrin secretion

4

A
  • stomach distension
  • alkalinazation
  • amino acids
  • vagal stimulation (GRP)
181
Q

gastrin secretion is inhibited by

A
  • low pH
  • somatostatin
182
Q

atropine does not block […] mediated gastrin release

A

GRP

183
Q

phenylalanine and tryptophan are potent stimuli for […] release

A

gastrin

184
Q
  • tumors that occur in duodenum or pancreas
  • cause excessive acid secretion
  • cause hypertrophy/hyperplasia of mucosa

clinical correlate

A

gastrinoma

gastrin secreting tumors

185
Q
  • abdominal pain that improves with food
  • chronic diarrhea
  • ulcers in distal duodenum refractory to PPI therapy
  • heartburn

clinical correlate

A

zollinger-ellison syndrome
from gastrinoma

186
Q
  • extremely high gastrin levels
  • increased gastrin after secretin administration

would indicated what disease?

A

gastrinoma

187
Q

elevated […] levels are a typical finding of pernicious anemia

A

gastrin

188
Q
  • hormone for gallbladder contraction
  • stimulates secretion of pancreatic enzymes
A

CCK

189
Q

released by I cells in the duodenum and jejunum

A

CCK

190
Q

how does CCK stimulate pancreatic enzyme secretion?

A
  • CCK receptors in vagus nerves
  • CCK stimulates vagus -> Ach -> pancreas
191
Q
  • relaxes spinchter of Oddi
  • inhibits gastric empyting
A

CCK

192
Q

major stimuli for CCK release

3

A
  • fatty acids
  • monoglycerides
  • amino acids

not triglycerides

193
Q

hormone to raise pH in small intestine

A

secretin

194
Q

released by S cells of duodenum

A

secretin

195
Q

released in response to H+ in duodenum and fatty acids in duodenum

A

secretin

196
Q

increases HCO3- secretion by pancreatic duct cells

A

secretin

neutralizes gastric acid, allows pancretic enzymes to function

197
Q

inhibits gastic H+ secretion by inhibiting gastrin release

A

secretin

198
Q

increases bile production

A

secretin

199
Q
  • promotes pancreatic flow
  • water secreted with bicarb and flushes pancreatic enzymes into intestines
A

secretin

200
Q

inhibits most GI hormones

A

somatostatin

201
Q

released by D cells throughout GI tract

A

somatostatin

202
Q

major stimuli for somatostatin release

A

low pH

203
Q

major inhibitor for somatostatin release

A

vagus nerve

thinking about eating decreases somatostatin to prepare digestive tract

204
Q

how does somatostatin regulate digestion/acid secretion

describe both fed and fasted states

A

fed: food in stomach -> decreases somatostatin -> hormones are released

fasted: acid in stomach -> increases somatostatin -> hormones inhibited

205
Q

analog of somatostain used in upper GI varices bleeding

A

octreotide

reduces splanchnic blood flow

206
Q

used to treat carcinoid syndrome,
acromegaly,
gastrinoma

A

octreotide

207
Q
  • stimulates insulin release from pancreas
  • blunts H+ secretion
A

GIP

208
Q

released by K cells of duodenum/jejunum

A

GIP

209
Q

what stimulates the release of GIP?

3

A

glucose
fatty acids
amino acids

only hormone released in response to fats, protein, and carbs

210
Q

why is oral glucose metabolized faster than IV glucose?

A

IV glucose does not stimulate GIP release

211
Q
  • synthesized in neurons
  • released in response to action potential onto target cells
A

VIP

212
Q
  • causes relaxation of the smooth muscle
  • raises pH
  • inhibits gastric H+ secretion
A

VIP

similar to secretin

213
Q

how does VIP raise pH?

A

stimulates pancreatic HCO3- secretion

214
Q

important for relaxation of lower esophageal spinchter

A

VIP

215
Q
  • watery diarrhea (tea colored, odorless)
  • hypokalemia
  • achlorhydria

clinical correlate

A

VIPoma

WDHA syndome

216
Q

rare VIP secreting tumors in pancreatic islet cells

A

VIPoma

217
Q
  • adult 30-50 years old
  • long standing watery diarrhea without blood or pus
  • no response to diet change
  • high pH in stomach on EGD
  • elevated VIP on serum testing

clinical correlate

A

VIPoma

218
Q
  • released by cells in stomach, intestines, and colon
  • promotes motility in fasting state
A

motilin

219
Q

highest levels of motilin are found

fed/fasted state

A

between meals

fasted

220
Q

binds motilin receptors and used to treat gastroparesis

A

erythromycin

221
Q

secreted in antrum

A

gastrin

222
Q

secreted in duodenum and jejunum

3

A

CCK
secretin
GIP

223
Q

secreted throughout GI tract

3

A

motilin
VIP
somatostatin

224
Q

major player in cephalic phase of digestion

A

vagus nerve

225
Q

stimulated by thought, sight, and smell of food

A

vagus

226
Q

in the cephalic phase, the vagus nerve primarily stimulates

A

acid secretion by triggering gastrin release

227
Q

major player in gastric phase

A

stomach

228
Q

how does the stomach trigger acid secretion in the gastric phase?

A

gastric distension, increased gastric pH and amino acids trigger gastrin release

229
Q

major player in intestinal phase of digestion

A

small intestine

230
Q

how does the small intestine trigger CCK, secretin, and GIP release in the intestinal phase?

A

presence of fatty acids, amino acids, and H+ trigger this release

231
Q

what does CCK do during the intestinal phase?

3

A
  • gallbladder contraction
  • release of pancreatic enzymes
  • relax spinchter of Oddi
232
Q

what does secretin do during the intestinal phase?

2

A
  • release bicarb
  • inhibit H+ secretion

GIR Test 1 (16 decks)

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