GIGU Flashcards
1
Q
Liver Cirrhosis
A
- fatty changes, diffuse bridging fibrosis (via stellate cells) and regenerative nodules disrupting the normal architecture of liver - inc. risk for hepatocellular carcinoma - Etiologies: alcohol (most common), nonalcoholic steatohepatitis, chronic viral hepatitis, autoimmune hepatitis, biliary disease, genetic/metabolic disorders - hapatomegaly and “hobnail” appearance on surface
2
Q
Pneumomediastinum
A
- abnormal pressure pf air or gas in the mediastinum - may interfere w/ respiration and circulation - may lead to pneumothorax or pneumopericardium - occurs spontaneously or as a result of trauma or pathology after a procedure
3
Q
Migrating myoelectric complex and bacterial overgrowth
A
- small intestine bacterial overgrowth (SIBO): colonic bacterial over abundance in SI - MMC important for cleansing mechanism and prevention of SIBO - BO can disturb SI motility, cause N&V, anorexia, and bloating
4
Q
LH and Spermatogenesis
A
- secreted by the anterior pituitary - stimulates Leydig cells to secrete T
5
Q
Non-rotation of midgut loop
A
- completes first 90* rotation but not the following 180* rotation - results in left-sided colon and right sided small intestines - 1:500 births - higher risk of Volvulus
6
Q
Gilbert Syndrome
A
- mildly dec. UDP-glucuronosyltransferase conjugation and impaired bilirubin uptake - usually asymptomatic: stress, illness, or fasting can create episodes of hyperbilirubinemia w/ mild jaundice - inc. unconjugated bilirubin w/o overt hemolysis - mutation in UGTA1 (activity ~30% of normal) : gene coding for UDP-glucuronosyltransferase - relatively common and benign
7
Q
Secondarily retroperitoneal
A
- organs initially suspended in mesentery that later fused with posterior body wall - ex: ascending/descending colon, duodenum, and the bulk of pancreas
8
Q
Pancreatic Secretions
A
Characteristics: - High HCO3- - isotonic - pancreatic lipase, amylase, and proteases Factors INC. secretion - Secretin (only for HCO3-) -CCK (potentiates secretin) - PNS
9
Q
Gastrosplenic Ligament:
A
- connects: greater curvature of stomach to spleen - contains: short gastric a.s, left gastroepiploic vessels - derivative of dorsal mesentery
10
Q
Perforated Gastric Ulcer
A
- foregut chronic visceral pain - sudden severe pain spreading all over abdomen - sign of generalized peritonitis
11
Q
Defects due to Abnormal Urorectal Septum
A
- Females: - Rectovaginal: rectum empties into vagina (meconium in vagina) - Rectovestibular: rectum empties in to vaginal vestibule with vagina and urethra - Rectoperineal: empties through perineum in front of anus - In Males: - Rectovesical: rectum empties into bladder (meconium in urine) - Recto-urethral: rectum empties into urethra in penis (meconium in urine) - Rectoperineal: empties through perineum in front of anus
12
Q
Actions of androgens
A
- RBC production - sebaceous gland secretion - nitrogen retention - linear body growth, bone growth & closure of the epiphyses - ABP synthesis - secretion of sex glands - libido - regulation of behavior
13
Q
Persistent Processus Vaginalis and Hydroceles
A
- patent connection between tunica vaginalis and abdomen - Hydrocele: peritoneal fluid accumulation within tunica vaginalis - more common in babies - adults: inflammation or injury in scrotum, testis, or epididymis - communicating and non-communicating types - Hematocele: accumulation of blood in tunica vaginalis - Presentation: scrutinize swollen due to accumulation of peritoneal serous fluid - detected trans-illumination: tell difference between blood and serous fluid - 10% males born w/ this, most self-rectify
14
Q
Medial umbilical fold
A
- due to obliterated umbilical arteries
15
Q
Ruptured Ectopic Pregnancy
A
- woman of childbearing age - missed last period - sudden onset of severe pain in hypogastric area radiating to sacral area - afebrile - localized peritonitis in hypogastric area - tenderness in rectouterine pouch upon DRE (digital rectal exam) or vaginal exam
16
Q
Diff Dx for Upper GI bleed
A
- PUD - Erosive gastritis - Arteriovenous malformations/agioectasias - Mallory-Weiss tear - Esophageal varices
17
Q
Gastroschisis
A
-1:10,000 live births - herniation of bowel without peritoneal covering
18
Q
Alcoholic Cirrhosis
A
- final and usually irreversible - sclerosis around central vein —> may be seen early - regenerative nodules and fibrotic bands in response to chronic liver injury - portal hypertension and end-stage liver disease
19
Q
Male pattern baldness
A
- caused by DHT excess - 5a-reductase inhibitor
20
Q
Ventral Mesentery
A
- between ventral wall and foregut running from septum transversum to umbilical vein - Adult derivatives: - lesser omentum: hepatoduodenal & hepatogastric ligaments - falciform ligament of liver - coronary ligament of liver - triangular ligaments of liver
21
Q
Hematochezia
A
- passage of bright red blood or maroon stools - lower GI bleed usually
22
Q
Pancreatic Polypeptide
A
- secreted from PP cells in islets of pancreas - dec. food intake directly through Y4R in the brainstem and hypothalamus - possible vagal anorectic effect - secreted in response to carbs, proteins, and lipids - inhibits pancreatic secretion of HC03- and enzymes
23
Q
- testicular cancer
A
- interstitial cell tumors - produce large amounts of testosterone
24
Q
Lactose Intolerance
A
- no brush border lactase enzyme - lactose not broken down to glucose and galactose - broken down to: SCFAs and H2 gas: acetate, butrate, and propionate - remains in lumen creating osmotic diarrhea - ferments into methane and H+ gas
25
Melena
- dark-colored stool consistent with broken down hemosiderin in bowel - typically malodorous (unpleasant smell), sticky, thick lick paste, "tarry"
26
GERD
- Transient decrease in LES tone - motor abnormalities result in lower pressures in LES - intragastric pressure increases: pregnancy, after large meal, and during heavy lifting, bending over - presentation: heartburn, regurgitation, dysphasia, ulceration, chronic inflammation; backwash of acid, pepsin, and bile - less common presentation: chronic cough, hoarseness (laryngopharyngeal reflux) - associated w/ Asthma -if chronic can lead to Barrett’s Esophagus, gastrointestinal bleeding, esophagitis, scar tissue in esophagus (Stricture of esophagus) -Diagnostics: usually off symptoms alone, might need Upper Endoscopy if alarm features present - Tx: lifestyle modification, antacids, H2 blockers, Proton Pump inhibitors
27
Indirect Inguinal Hernia
- enters deep Inguinal ring - Peritoneum w/in spermatic cord with internal spermatic fascia
28
Liver Waste Management
- the primary site of conversion and or degradation metabolites and xenobiotics - metabolites: intermediates or end products of metabolism - xenobiotics: compounds ingested from outside (no nutritional value, potentially toxic): pharmacological agents, rec. drugs, food additives and preservatives - 2 phase reaction: increase polarity, conjugation for safe excretion - phase 1 catalyzed by CYP450 enzymes
29
Type 2 DM
- insulin resistance: progressive exhaustion of B-cells due to environmental factors - sedentary lifestyle, malnutrition, or obesity - histology: islet amyloid polypeptide (IAPP) deposits - pt. produces insulin but needs more and more - 95% of diabetes cases - reactive hyperinsulinemia - obesity-induced insulin resistance - dec. GLUT4 uptake of glucose in response to insulin - decreased ability of insulin to repress increased hepatic glucose production (earliest response) - the inability of insulin to repress adipose tissue of uptake (via LPL) nad lipolysis (via HSL) - mechanisms still not well understood - strongly hereditary - not as prone to DKA - hyperglucagonemia - higher risk for Non-alcoholic fatty liver disease/ hepatic steatosis, PCOS, lipid abnormalities, and obesity Treatment: - caloric restriction, weight reduction, exercise - insulin secretagogues: sulfonylurea drugs, incretin analog GLP-1 (exenatide) - slow absorption of CHO: a-glucosidase inhibitors (acarbose, miglitol), Amylin analogs (pramlintide) - insulin sensitizers: Biguanide drugs (Metformin) - better insulin receptor trafficking - Bariatric surgery
30
Hirschsprung’s Disease
- 1:500 live births - absence of ganglionic plexuses (Auerbach and Meissner plexuses) due to absence of NC cell migration - loss of function mutations in RET gene - increased wall thickness due to hypertrophy in intestine proximal to aganglionic segment - lack of peristalsis (colon fails to relax) - Vasoactive intestinal peptide (VIP) low levels —\> SM contraction - abnormal colonic dilation (area above aganglionic portion: transition zone) or distinction (megacolon) - surgical removal of constrained distal segment - risk inc. in Down Syndrome -presentation: bilious emesis, abdominal distention, & failure to pass meconium w/in 48 hrs (chronic constipation), poor feeding - explosive expulsion of feces (squirt sign) —\> empty rectum on digital exam - RET mutation in REcTum - short segment disease: 85% of cases —\> confined to rectosigmoid region - long-segment disease: 10% of cases —\> extends to sigmoid flexure - total colonic aganglionosis: 5% of cases: entire colon affected
31
Pneumoperitoneum
- abnormal presence of air or gas in the peritoneal cavity
32
Glucagon actions
- major actions on the liver - increases blood glucose - increased gluconeogenesis - increased glucogenolysis - inhibits glycogen synthesis - actions elsewhere - stimulates lipolysis- in adipose tissue and skeletal muscle - keto acids produced from fatty acids
33
Camper’s Fascia
- fatty layer of superficial fascia directly under integument
34
Dysphagia
- difficulty in swallowing
35
Nutcracker Syndrome
- best viewed in mid-sagittal CT - compression of left renal V. between SMA and Aorta - leads to renal venous hypertension and disruption of thin veins in the collecting system of kidney leading to hematuria
36
Medial Inguinal Fossa
- gutter lateral to medial umbilical folds
37
Brush Border Enterocyte functions
- Maltose --\> 2 glucose - Trehalose --\> 2 glucose - Lactose --\> glucose and galactose - Sucrose --\> glucose and fructose - starch --\> a-dextrine, maltose, Maltrotriose --\> 2 glucose
38
Transtubercle Plane
- between iliac tubercles - level of iliocecal junction
39
Hepatoduodenal Ligament
- connects: liver to duodenum - contains: portal triad —\> proper hepatic artery, portal veins, common bile duct - derivative of enteral mesentery - borders the Epiploic foramen which connects the greater and lesser sacs - part of lesser omentum - Pringle Maneuver: compression of ligament w/ a vascular clam in mental foramen to control bleeding from hepatic inflow source
40
Physiology of Achalasia
- impaired peristalsis - incomplete LES relaxation during swallowing - stays closed —\> back up of food - elevation of resting LES pressure -Causes: - decreased # of ganglion cells in myenteric plexus - preferential degeneration of inhibitory cells - no production of NO/VIP - nerve damage in esophagus —\> cant force food to stomach - results in back flow of food into throat (regurgitation), dysphasia of liquids and solids, heartburn, chest pain - Dx: Barium swallow or Esophageal motility study -Tx: Botox Injection, dilation, surgery
41
Omphalocele
- 2.5 in 10,000 live births - herniation through umbilicus - peritoneal covering around the intestines outside the umbilicus - increased risk with Trisomy 13 or 18 - Etiologies: - herniated bowl not fully retracted during development - abnormal lateral body folding creating body wall weakness - Faulty formation of CT of skin and hypaxial musculature
42
Interspinous plane
- between ASIS - level of Appendix, sigmoid colon
43
Somatic Pain
- irritation of parietal peritoneum: diseased organ rubs/irritates the peritoneal lining 1. Acute: severe pain detected at specific anatomical location 2. Pain travels through somatic afferent fibers to SC (T7-12) to brain 3. Sensitive to stretching of parietal peritoneum or “rebound tenderness”
44
Fluid in Omental Bursa
- perforated posterior stomach wall - pancreatitis - trauma to pancreas (which is behind lesser sac)
45
Tropical Sprue
- cause unknown - reduced microvilli S.A. - steatorrhea: fat malabsorption - folate and B12 deficiency - diarrhea, cramps, nausea, weight loss, gas, indigestion - Tx: tetracycline and folate for 6 mo
46
Left upper Quadrant
- left lobe of liver - spleen - Stomach - Jejunum and proximal ileum - pancreatic body and tail - left kidney and adrenal gland - splenic flexure - left 1/2 transverse colon - superior descending colon
47
Rotor Syndrome
- increase in conjugated \> unconjugated - similar to Dubin-Johnson - gene mutation: abnormally short or absent OATP1B1 and OATP1B3 proteins - can not be transported from blood into liver to be cleared from body - not pigmentation in liver cells
48
Pernicious Anemia
- not enough IF from stomach --\> decreased Vitamin B12 Common causes: - atrophic gastritis: chronic inflammation of stomach mucosa leads to loss of parietal cells (no IF secreted) - Autoimmune metaplastic atrophic gastritis - immune system attacks IF proteins or gastic parietal cells - Gastrectomy: removal of part or whole stomach (loss of parietal cells - Gastric bypass: exclusion f the stomach, duodenum, and proximal jejunum alters the absorption - determine if dietary insufficiency or no IF by doing the Schilling's test - must be given injections of B12 to get enough
49
Slow Gastric Emptying
- Symptoms: fullness, loss of appetite, N&;V - causes: gastric ulcer, cancer, eating disorders, Vagotomy - Tx: pyloroplasty, balloon dilation
50
Gastritis
- inflammation of stomach with distinctive histological and endoscopic features
51
Vaso-vagaries reflex
- long reflex - generally stimulatory: increases motility, secretomotor activities, vasodilatory activities - vagus carries both afferents (75%) and efferents (25%)
52
Chagas Disease
- secondary achalasia - esophageal dysfunction indistinguishable from primary idiopathic achalasia - patients from endemic regions: the south - caused by parasite Trypanosoma cruzi: protozoan disease - causes other systemic symptoms
53
ERCP
- endoscopic retrograde cholangiopancreatography - diagnosing and treatment of problems in the bile and pancreatic duct - ultrasound used more for gallstones
54
Median Arcuate ligament
- tendinous arch of the crura of the diaphragm: unites right and left crura
55
Liver Synthesis of Blood Proteins
- Albumin, IgGs (antibodies), Apoproteins (lipid transport proteins), Fibrinogen, Prothrombin, Blood Coagulation Factors V, VII, IX, and X - acute phase response proteins (APRP): encompass all systemic changs in response to infection or inflammation - synthesizes APRP such as C-reactive protein and protease inhibitors such as a-1 Antitrypsin and a-1 Antichymotrypsin
56
Leptin or Leptin receptor gene deficiency
- early-onset severe obesity - infertility (hypogonadotropic hypogonadism) - hyperphagia - infections - mutation in leptin or leptin receptor
57
Transtubercular plane
- passes through iliac tubercles (L5) - right around the appendix
58
Coffee-ground emesis
- blood congealed and separated within gastric contents - due to contact w/ acidic environment - usually Upper GI bleed
59
Liver Carbohydrate Metabolism
- Glucostasis: maintains optimal levels of circulating glucose under fed, fasting, and starvation states - glycogen synthesis - glycogenolysis: releases glucose when BGL are low - has glucose 6 phosphatase which permits the release of free glucose unlike muscles which keep G6P for its own use - gluconeogenesis: synthesizes glucose from non-carbohydrate sources (mostly body's protein) - starvation: makes keytone bodies fro energy source
60
PCOS
- Polycystic ovarian syndrome - 5-10% of women in repro years - most common cause of infertility - frequently manifests in adolescence - unexplained hyperandrogenism, anovulation, and polycystic ovaries - abnormal ovarian steroidogenesis & folliculogenesis - Elevated LH, low GSH, elevated testosterone - promotion of atresia and disruption of feedback relationships - increased DHEA - presentation: young, obese, hirsute females or repro age, oligomenorrhea or secondary amenorrhea, infertility
61
Quadratus Lumborum
- Origin: iliolumbra lig and lip or iliac crest - inserton: medial 1/2 of inferior surface of 12th rib and tip or lumbar TPs - Innervation: anterior rami of T12-L4
62
Supravesicular fossa
- gutter on either side of upper bladder
63
Clinical Manifestations of Liver disease
- steatohepatitis: fatty liver accompanied by inflammation --\> scarring of liver & cirrhosis - portal hypertension causes changes in the venous circulation - esophageal varices: swollen connection between systemic and portal system at inferior end of esophagus - caput medusae: swollen connections between systemic and portal systems around the umbilicus - Hepatic encephalopathy: decreased hepatic urea cycle leads to NH3 accumulation - NH3 readily crosses BBB and alters brain function
64
Lateral Inguinal fossa
- gutter lateral to lateral umbilical folds
65
Virchow's node
- palpable mass, lymph node, in the left supraclavicular/sternoclavicular fossa
66
Gastric Vagotomy
- truncal vagotomy: enervates nerves supply to all of the stomach & some of the GI tract and liver - Proximal Gastric Vagotomy: enervates branches of vagus nerve going only to the stomach - Selective proximal vagotomy: specifically enervates area of stomach in which parietal cells are located (fundus or cardia) - done to decrease the amount of HCl present in pots with history of peptic ulcers
67
Colic (GI reference)
- acute paroxymal abdomina pain
68
Inhibitory factors for insulin
- dec. blood glucose - fasting - exercise - somatostatin - a-adrenergic agonists; norepinephrine - diazoxide (K+ channel activator, relaxes smooth muscle, vasodilator) - used to treat hypoglycemia
69
Type 1 DM
- Inadequate insulin secretion - Autoimmune T-cell mediated destruction of B-cells - presence of glutamic acid decarboxylase antibodies - histology: islet leukocytic infiltrate - symptoms not evident until \> 80% of cells destroyed - inc. blood glucose, fatty acids, keto acids, A.A.s, increased conversion of fatty acids to keto acids - associated with HLA-D4 and HLA-D3 (4-3=1) - resulting DKA: decreased utilization of keto acids - Hyperkalemia: shift K+ out of cells - intracellular K+ conc. low - lack of insulin effect on NA/K+ ATPase - plasma levels may be normal but total levels low due to polyuria and dehydration - Osmotic diuresis/ Glucosuria - inc. filtered load of glucose exceeds reabsorptive capacity of proximal tubule - water and electrolyte reabsorption blunted - polyuria: inc. excretion of Na & K+ even though urine electrolytes are low - polydipsia (thirst) - Tx: insulin replacement - drawbacks: painful and time-consuming, lag between glucose measurement and insulin dosing, delayed absorption following s.c. injections, poor BG control (prolonged hyperglycemia) - insulin pumps have advantages - transplants are a possibility - comorbidities: Autoimmune Thyroiditis, Celiac Disease, Addison's Disease
70
Defecation reflex (rectosphincteric)
- rectal distention initiates defecation - when rectum is distended by feces, internal sphincter relaxes
71
Celica Sprue
- Autoimmune disorder - Abs for gluten component- gliadin - destruction of SI villi and hyperplasia of crypts - malabsorption of folate, iron, calcium, Vit. A & B12 & D - most common in Caucasian women - Symptoms: abdominal pain, constipation, diarrhea, unexplained weight loss, N&V, steatorrhea, tingling numbness in extremities, seizures, easy bruising, fractures, itchy skin w/rash - Tx: gluten-free diet
72
Testosterone action at puberty
- increased muscle mass - Pubertal growth spurts - closure of epiphyseal plate (actually estrogen but in men it is converted from T) - growth of penis and seminal vesicles -deepening of voice - spermatogenesis - Libido
73
Visceral Pain
- organic pain varies from dull to severe - poorly localized - radiated to dermatology level receiving visceral afferent fibers from diseased organ ( based on embryologic origin of organ involved) - Foregut organs: produce pain in the epigastric region - stomach, duodenum, biliary tract - Midgut organs: cause periumbilical pain - most SI, appendix, cecum - Hind Gut: cause initial pain in the suprapubic or hypogastric area - most of colon, 1/2 of sigmoid, intraperitoneal portions of the genitourinary tract
74
Cryptochid Testis
- undescended testis - increased risk of developing testicular cancer
75
Cystic Fibrosis and the pancreas
- mutations in CFTR: regulate CL- channel in the apical surface of the ductal cells - pancreas 1 of first organs to fain in CF - mutations may be associated with loss of HCO3- secretion - ability to flush active enzymes out of duct lost - may lead to recurrent acute and chronic pancreatitis
76
Subcostal Plane
- passes inferior border 10th costal cartilage - level of transverse colon
77
Prader-Willi Syndrome
- Neonatal hypotonia - slow infant growth - small hands and feet - mental retardation - hypogonadism - hyperphagia leading to severe obesity - paradoxically elevated ghrelin - due to partial deletion of chromosome 15 or loss of paternally expressed genes
78
Rectus Abdominis M.
- Paired muscles of anterior abdominal wall: wider at top - Origin: pubis symphysis and pubic crest - Insertion: xiphoid process and outer surface of 5-7th intercostal cartilages - tendinous intersections form part of rectus sheath at umbilical, xipoid, and midway levels - Innervation: T7- T12 - Action: flex abdomen and compress it - Linea semilunaris: lateral border of m. - Pyramidis M. (Extension from very bottom RA M.) absent in 20%
79
Ulcerative Colitis
- location: Colitis: colon inflammation, continuous colonic lesions always w/ rectal involvement - gross morphology: mucosal and submucosal inflammation only, friable mucosa w/ ulcerations; loss of haustra --\> "lead pipe" - microscopic morphology: crypt abscesses and ulcers, bleeding, no granulomas. Th2 mediated - complications: malabsorption/ malnutrition, colorectal cancer, fulminant colitis, toxic megacolon, perforation - intestinal manifestations: bloody diarrhea - extraintestinal Manifestations: 1\* sclerosing cholangitis, rash, eye inflammation, oral ulcerations, arthritis - Treatment: colectomy
80
Accessory Pancreatic duct
- 33% of population - the dorsal pancreas’ duct joins with the ventral pancreas’ duct to form one - the dorsal duct does not regress - there are two insertion sites into the duodenum
81
UGIB
-upper GI bleed: proximal to ligament of Treitz - esophagus, stomach, duodenum Pearls of UGIB: - past aortic graft: aortoenteric fistula - liver disease: portal htn causing varices - ETOH abuse: varices, erosive esophagitis/gastritis, PUD - Aortic Stenosis, renal disease, telangiectasias: angiodysplasia - Heliobacter pylori, NSAID use, smoking: PUD, malignancy - significant ENT bleed can mimic UGIB
82
Gastric Secretions
Characteristics: - HCL - pepsinogen - IF Factors INC. Secretion - Gastrin - ACh - Histamine - PNS (not for HCL) Factors DEC. Secretion - H+ in the stomach - Chyme in the duodenum - Somatostatin - Atropine - Cimetidine - Omeprazole
83
Intestinal Stenosis and Atresia
- 5-6th month: lumen is obliterated due to epithelial proliferation - recanalization (by end of embryonic period): vacuoles form as epithelial cells degenerate opening the lumen and forming villi - commonly associated with Trisomy 21 - stenosis: partial occlusion due to ineffective recanalization - usually horizontal or ascending parts - atresia: complete occlusion of lumen - surgery required
84
Scarpa’s fascia
- membranous layer underlying the CT layer of superficial fascia - continuous with Colle’s fascia of perineum (scrotum/labia) but fused with fascia lata of lower limb - fluid can not go from abdominal cavity into leg b/c of fascial fusion but can flow into or out of the superficial perineum
85
Hiatal Hernias
- Para-esophageal Hiatal Hernia: - cardia of stomach in normal position - peritoneum and fundus of stomach are anterior to esophagus - Sliding Hiatal Hernia: - esophagus, cardia & fundus protrude through esophageal hiatus - more common to cut when bent over @ waist vs. sitting/standing
86
GI Red Flag Symptoms and Signs
- Dysphagia: difficulty swallowing - Odynophegia- painful swallowing - Hematemesis - Melena - Unintentional weightloss - persistent vomiting - constant/severe pain - unexplained Iron deficiency - palpable mass - lymphadenopathy - FH of upper GI cancer
87
Structures at T12 level
- pancreas - spleen - kidneys (particularly left) - gallbladder and portal triad - SMA - aorta - IVC - small bowel
88
Gastroparesis
- slow emptying of stomach/ paralysis of stomach in absence of mechanical obstruction - T1DM common cause: 20% pts are affected ( some T2) - injury to vagus n. Can also result - symptoms: N&;V, early fullness when eating, weight loss, abdominal bloating, abdominal discomfort
89
Causes of pain in the Hypogastic of suprapelvic area
- Testicular torsion - urinary retention - cystitis - placental abruption - UTI - appendicitis - Diverticular disease - IBS - pelvic pain (Gynae)
90
Dorsal Mesentery
- connects organs to dorsal body wall - runs along entire GI tract - Adult Derivatives: - greater omentum: gastrosplenic, gastrocolic, and splenorenal ligaments - SI mesentery - Mesoappendix - Transverse Mesocolon - Sigmoid mesocolon
91
Adhesive Small Bowel obstruction
- history of previous abdominal surgery (to get adhesions) - midgut visceral colicky pain - vomiting - no flats or bowel actions - possible dehydration - distended soft abdomen; non-tender - increased bowl sounds (proximal to obstruction likely)
92
Illiacus
- Origin: 2/3s iliac fossa, ala, anterior sacro-iliac ligaments - insertion: lesser trochanter and shaft below - innervation: femoral nerve (L2-4)
93
Structures at T11 Level
- spleen - stomach - liver - aorta - IVC - diaphragm and inferior lungs
94
Personalized Medicine with CYPs
- allelic variation and polymorphisms exist in individuals - influences CYP catalytic activity - influences drug metabolism - Genotyping CYPs to personalize individual's response to a particular drug
95
Neonatal Physiological Jaundice
- immature UDP-glucuronosyltransferase leads to unconjugated hyperbilirubinemia --\> jaundiced and kernicterus - occurs after 24 hrs of life and usually resolves w/o treatment in 1-2 weeks - phototherapy (non-UV) isomerizes unconjugated bilirubin to a water-soluble form - done in any newborn w/ bilirubin \> 21 mg/dL
96
Gastroileal Reflex (gastroenteric)
- gastric distention relaxes ilececal sphincter
97
Duodenal PUD
- pain: Decreased with meals - weight gain - H. Pylori infection: ~ 90% - Mechanism: decreased mucosal protection or increased gastric acid secretion - Other causes: Zollinger- Ellison syndrome - Cancer risk: generally benign - more common than gastric ulcers - baseline gastrin levels may be normal but secretion levels after eating are increased - increase in parietal cell mass b/c of inc gastrin levels - Dx: EGD, check for H. pylori - Tx: H2 blocker, proton inhibitor, eradicate H pylori, stop smoking
98
Internal Oblique M.
- runs 90\* from External Oblique M. - origin: iliac crest and thoracolumbar fascia - insertion: lower 10-12 ribs, aponeurosis, linea alba and pubic crest - some fibers follow spermatic cord to make Cremasteric M. - aponeurosis splits to encompass rectum abdominis m. In upper 3/4s and all go in front in lower 1/4 - Innervation: T7-12 and L1 - Action: compresses and support viscera, lateral flexes and rotates - opposite external and internal m.s work together as a digastric belly to laterally flex and rotate at same time
99
Benign Prostatic hyperplasia (BPH)
- by 80, over 80% of men will have BPH - symptoms: urinary frequency & urgency, nocturia, difficulty initiating & maintaining a stream, feeling of postvoid fullness in the bladder, dribbling - might have more DHT receptors in their prostates than normal
100
Germinal epithelial tumors
- produce no hormones
101
Cystinuria
- 1:7,000 live births - defect in transport (SLC3A1) or absence of dibasic AA transporter (SLC7A9) - cysteine, lysine, arginine, ornithine not absorbed - make stones - AAs secreted in feces
102
Andropause
- gonadal sensitivity to LH decrease & androgen production drops - FSH\>LH rise - T decreases slowly after 40: decreased bone formation, muscle mass, facial hair, appetite, libido - loss of sexual activity around 68-70
103
Right Lower Quadrant Contents
- Cecum - appendix - Most of Ileum - Inferior Ascending Colon - right ovary - right uterine tube - right ureter: abdominal part - right spermatic cord: abdominal part - uterus (if enlarged) - urinary bladder if very full
104
Causes of Pain in the Umbilical area
- appendicitis (early) - Mesenteries adenitis: swelling of lymph nodes in abdomen - Meckel’s Diverticulum - stomach ulcers - pancreatitis - IBS - umbilical hernias - Lymphomas
105
Salivary Secretions
Characteristics: - High HCO3- - High K+ - Hypotonic - a-amylase, lingual lipase Factors INC. secretion - PNS (prominent) -SNS Factors DEC. secretion - Sleep - Dehydration - Atropine
106
Insulin actions of Adipose Tissue
- increased glucose uptake - increased glycolysis - decreased lipolysis --\> decreases keto acids in blood - promotes the uptake of fatty acids
107
Gallstone Pancreatitis
- gallstone stuck in pancreatic duct - elevated lipase and amylase and LFT
108
actions of DHT
- fetal differentiation of the external male genitalia (penis, scrotum, & prostate) - male hair distribution and male pattern baldness - Sebaceous gland activity - prostate growth
109
Passage of Kidney stone
- sudden pain of very severe colicky pain from loin to groin - severe back pain - pt writhing w/pain and pacing about - possible hematuria - afebrile - soft abdomen - tender real angle
110
Transpyloric plane
- L1 level - level of gallbladder fundus, pylorus, pancreatic neck, SMA origin, hepatic portal vein, root of transverse mesocolon, and hilarious of kidneys
111
Assessment of Liver Function/metabolic panel
- albumin: decreases as the synthetic function of liver decreases, not enough leads to edema - TransaminaseeL ALT and AST --\> convert A.A.s to keto acids: elevated in hepstocyte injury - alkaline phosphatase: increased in bile duct injury (cholestasis) - Prothrombin Time (PT): reflects the degree of hepatic synthetic dysfunction --\> increases with worsening coagulopathy in severe hepatic damage - bilirubin ( important to distinguish conjugated vs. unconjugated): measures liver's ability to detoxify metabolites - Urea (BUN) - Glucose - Triacylglycerol - Cholesterol: total, VLDL, HDL, LDL
112
kernicterus
- deposition of unconjugated, lipid-soluble, bilirubin in the brain - particularly the basal ganglia, sometimes hippocampus - major clinical features: cerebral palsy, sensorineural hearing loss, and gaze abnormalities
113
Acute Abdomen
- any serious scute intraabdominal condition (appendicitis) attended by pain, tenderness, muscular rigidity - emergency surgery must occur
114
Annular Pancreas
- 1:12,000-15,000 - there are two ventral pancreas lobes, one rotates behind the duodenum and one in front of duodenum to join the dorsal lobe - duodenal obstruction or stenosis - bilious omitting if the annulus develops inferior to the bile duct - low birth weight
115
Glucagon
- secreted by a cells in islets of pancreas - increases BG levels and insulin secretion - reduces food intake
116
Dubin-Johnson
- increased conjugated bilirubin - Mutation in the gene encoding for multidrug resistance-associated protein 2 (MRP2) in the canalicular membrane - hepatocyte cant secrete conjugated bilirubin into bile - mild jaundice throughout life - may appear in puberty or adulthood - usually only symptom - exacerbated by alcohol, birth control pills, infection, pregnancy - liver has black pigmentation: intracellular melanin-like substance but is otherwise histologically normal
117
Causes of pain in the flank or lumbar areas (right and left)
- ureteric colic- urinary stone - pyelonephritis- kidney infection from UTI - renal colic- kidney stones - UTI - lumbar hernia - constipation - IBS (mostly left) - diverticular disease (left)
118
Diaphragm
- Muscular portion - seternal part: attaches to xiphoid process (might be present) - costal part: attaches to inferior 6 costal cartilages - central tendon - Crura (lumbar portion) - right crus: larger & longer (extends to L3-4) - some fibers cross and run on left side of aortic hiatus - left crus: extends to L2-3 - Superior Arterial Supply: - musculophrenic and pericardiophrenic a. (off internal thoracic a.) - superior phrenic a. (off thoracic aorta) -Inferior Arterial Supply: - inferior phrenic a. (off abdominal aorta) - intercostal branches for peripheral diaphragm
119
Causes of pain in the Right Inguinal area
- appendicitis ( late) - Crohn’s disease - cecum obstruction - ovarian cyst - ectopic pregnancies - Inguinal and femoral hernias - constipation - pelvic pain (Gynae)
120
Dyspepsia
- postprandial epigastric pain
121
Protective Factors on Gastric Mucosa
- HCO3- and mucus - prostaglandins - mucosal blood flow, - growth flow
122
Gastrocolic Ligament
- Connects: greater curvature of stomach and transverse colon - contains: gastroepiploic arteries - part of greater omentum - part of dorsal mesentery
123
Hemolytic Anemia
- due to hemolysis - lead to an increase in bilirubin - inc. bilirubin overwhelms the liver's capacity to conjugate and leads to unconjugated bilirubin
124
Femoral Hernia
- Below Inguinal Ligament - more common in women -40% present as emergencies with incarceration (can’t be easily moved back into place) or strangulation (can lead to obstruction of bowel)
125
Falciform Ligament
- connects: liver to anterior abdominal wall - contains: ligamentum teres hepatis (derivative of fetal umbilical vein), patent paraumbilical veins - derivative of ventral mesentery
126
Psoas Abscess
- not super common - back or flank pain, fever, limp, Inguinal mass - Causes: - disease of organs: TB spread to abdomen - cancers: adenocarcinomas - infections deep to psoas fascia - psoas sign: pain exacerbated by extending thigh
127
Rectus Sheath
- fascia and aponeurosis of encompassing m.s - EO aponeurosis: always anterior - IO aponeurosis: splits in upper 3/4 and all anterior in lower 1/4 - TA aponeurosis: posterior except in lower 1/4 wen all fascia moves anteriorly of RA - Arcuate Line: sharp transition where all aponeurosis become anterior to RA m. - below line RA is in contact with transversalis fascia
128
Gastro- & Deodeno-colic reflexes
- distention in stomach/ duodenum initiates mass movements - transmitted by ANS
129
Causes of pain in the Left Inguinal area
- Inguinal and femoral hernias - pelvic pain (Gynae) - Diverticulitis (diverticular disease) - ulcerative colitis - constipation - ovarian cyst
130
Alcoholic Stools
- white clay-colored stools - b/c no bile secreted into GI tract
131
Function of Sertoli cells
- blood-testis barrier - Phagocytosis - nutrients for sperm - receptors for hormones and paracrine (ABP, T, and FSH) - production of fluid - production of ABP - determination of the release of sperm from seminiferous tubules - Production of AMH - Aromatization of T to estradiol -17B - production of inhibin to regulate FSH levels
132
Esophagitis
inflammation of esophagus
133
Testosterone and Spermatogenesis
- secreted by Leydig cells - essential for growth and division of germ cells
134
Viewing Abdominal Aortic Vasculature
- digital subtraction arteriography: take the first picture then inject contrast dye and take another, subtract the first pic from one with contrast
135
Diseases of the liver cause:
- leaky basement membrane replaced by a high-density membrane containing fibrillar collagen - spaces between endothelial cells and fenestrations lost - increased resistance in vascular channels, increased pressure leading to portal hypertension - impairment of free exchange of material between hepatocytes and blood
136
Causes of Pain in the Left Hypochondriac area
-spleen abscess - Acute Splenomegaly - Spleen rupture - stomach ulcer - duodenal ulcer - pancreatitis - biliary colic
137
Leaking Aortic Aneurism
- elderly male w/Hx of atherosclerotic disease ( HTN or cardiac disease) - severe onset of severe back pain (typical could be leg pain too) - pale and shocked - hypotensive - tender epigastrium - palpable impulse from aneurysm in epigastrium
138
Drug Metabolism
- most metabolized in liver - metabolism increases hydrophilicity and ability to be excreted - metabolites usually less pharmacologically active than parent drugs - some inactive upon administration and converted to active form in liver (prodrugs) - metabolic enzymes have low substrate specificity
139
Congenital trypsin absence
- protein absorption problem - all pancreatic enzymes gone b/c trypsin cleaves them all into active form
140
Liver central receiving, distribution, and recycling center
- major role is monitoring, synthesizing, recycling, distributing, and modifying metabolites - any useful products in the body are retrieved by the liver and converted into the active form - harmful products are converted into safe products and excreted
141
Transversus Abdominis M.
- runs transverso-medially except for some running toward pubic crest (contribute to conjoint tendon) - Origin: ribs 7-12, thoracolumbar fascia, iliac crest, some off upper Inguinal ligament - Insertion: linea alba, pecten pubis and pubic crest - aponeurosis contributes to rectum sheath - Innervation: T7-L1 - Action: compresses and supports viscera
142
Anorexia Nervosa (AN)
- self-starvation and excessive weight loss - severely malnourished and emaciated - endocrine and cardiovascular dysfunctions - abnormalities w/digestive, skeletal, and reproductive systems WHY? - polymorphism in ArGP pathway - basal and pulsatile of Leptin dec. w/ fat mass dec. - Ghrelin resistance = possible restrictive diet habits - elevated PPY levels: dec. nutrient intake and disordered eating pathology
143
LGIB
- lower GI bleed anything distal to ligament of Treitz - jejunum, ileum, colon, rectum Causes: - Diverticulosis - vascular anomalies - Malignancy - IBS (Crohn's or Ulcerative Colitis) - Anorectal disease: hemorrhoids, anal fissures - Colitis: ischemic or infectious
144
Causes of pain in the Right Hypochondriac area
-gallstones - cholangitis - Hepatitis - liver abscess - stomach ulcer - pancreatitis
145
Ilioinguinal N.
- L1 - motor to lower IO and TA - sensory to owner Inguinal, anterior scrotum/labia, near middle thigh
146
Retroperitoneal organs
- organs that are excluded from the peritoneal cavity
147
GH and Spermatogenesis
- maintain background metabolic functions of testes - promotes early division of the sperm - w/o --\> pituitary dwarfs: inhibited = infertile
148
Oxyntomodulin
- proglucagon derived peptide - released from L cells in SI - secreted in response to food in proportion with caloric intake - Anorectic effect
149
Pneumobilia
- abnormal pressure of gas in the biliary system/ ducts
150
CCK
- I cells in duodenum - acts on vagal afferents - decrease appetite - decrease gastric emptying
151
Transpyloric Plane
- passes through pyloric sphincter (L1) - passes through part 1 of duodenum
152
Testosterone deficiency
- 2-3 mo gestation: Male Pseudohermaphrodism - Puberty: poor 2\* sex characteristics, eunuchoidism - Post puberty: decreased libido, ED, decreased facial and body hair, low energy & infertility
153
Median Umbilical Fold
- fold due to obliterated urachus
154
Pancreatic Divisum
- 4% of population - patients prone to pancreatitis - dorsal pancreatic duct empties into the duodenum - ventral pancreatic duct does not join the dorsal duct - ventral duct is small and empties at normal anatomical location at the Major papillae
155
Guarding
- protective response in muscle resulting from pain or fear of movement, voluntary versus involuntary
156
Functions of Peritoneum
1. Produce peritoneal fluid ( clear plasma filtrate) which lubricates the peritoneum 2. Minimize friction between abdominal organs 3. Resist infection: peritoneal fluid - produces antibodies - produces leukocytes - peritoneum localizes infection
157
Crigler-Najjar Syndrome Type 2
- starts later in life - mutation in UGT1A1: \<20% activity of UDP-glucuronosyltransferase - less likely to develop kernicterus - most pts survive into adulthood Treatments - phototherapy: must be done throughout pts life: works in babies, not as well after age 4 due to thicker skin - blood transfusions: helps control amount of bilirubin in the blood - oral calcium phosphate and carbonate: forms complexes w/ bilirubin - Phenobarbitol: aids in the conjugation of bilirubin
158
Damaging Factors on Gastric Mucosa
- H+ and pepsin - H. pylori - NSAIDS - Stress - Smoking - Alcohol
159
Gastrohepatic Ligament
- Connects: liver to lesser curvature of stomach - contains: gastric vessels - derivative of enteral mesentery - separates greater and lesser sacs on the right - may be cut during surgery to access the lesser sac - part of lesser omentum
160
Vomiting Reflex
- coordinated by medulla - vagus and sympathetic afferent to multiple brain stem nuclei -Events: - reverse peristalsis in SI (wretching) - stomach and pyloric relaxation - forced inspiration due to inc. abdominal pressure - mov’t of larynx - LES relaxation - glottis closes (avoid aspiration) - forceful expulsion of gastric contents
161
Stimulatory Factors of Insulin
- inc. glucose concentration - inc. A.A. concentration - Inc. fatty acid and keto acid concentration - glucagon - cortisol - glucose-dependent insulinotropic peptide (GIP) - Vagal stimulation (ACh) - sulfonylurea drugs (tolbutamide, glyburide) - obesity
162
Glucagon-like peptide-1 (GLP-1)
- secreted by L cells in SI - proglucagon derived peptide - co-secreted with PYY - incretin: promotes insulin secretion - levels rise after meal and fall during fasting - reduces food intake, suppresses glucagon secretion, and delays gastric emptying
163
Imperforated Anus
- persistent anal membrane - 1: 5000 births - low, intermediate, or ugh malformation relative to leaver ani and pelvic bony landmarks - can also have atresia of rectum with a normal anus
164
Liver Lipid Metabolism
- biosynthesis of TAG, phospholipids, steroids (cholesterol, bile acids, and bile salts), lipoproteins (VLDL, LDL, HDL) - degradation of TAG a plasma lipoproteins - regulation of free fatty acid (FFA) metabolism - breakdown of FFA via beta-oxidation to release energy
165
Subcostal N.
- T12 - runs along inferior 12th rib for motor - sensory component is superior to iliac crest (lateral and Anterior cutaneous branches)
166
Subcostal Plane
- passes inferior to costal margin (L2-3)
167
Prostate cancer
- treated with androgen receptor antagonist, radiotherapy, radical prostatectomy
168
Bile Secretion
Characteristics - Bile salts - bilirubin - phospholipids - cholesterol Factors INC. secretion - CCK (contraction of gallbladder & relaxation of Sphincter of Oddi) Factors DEC. secretion - Illeal resection
169
Incretin Hormones
- promote insulin secretion (glucose-dependent) - Intestine derived hormones - GLP-1, GIP - short half-life - secreted in response to GI glucose and fat - inhibit glucagon secretion - slows gastric emptying - reduced incretin effects in diabetic patients
170
Esophageal and Gastric Varices
- dilated submucosal veins resulting from portal HTN - most often the result of alcoholic liver disease - small % of UGIB - prone to rebleed - high mortality rate
171
Acute Appendicitis signs
- ill looking pt, low grade fever - cough may cause increased pain (Dunphy’s sign) - McBurney’s point tenderness, involuntary guarding - site of tenderness may vary depending on pt positioning - somatic pain in RLQ upon palpating in LLQ (Rovsing’s sign) - Perforated Appendicitis: more severe and diffuse abdominal pain, tenderness and abdominal wall rigidity, will have signs of localized peritonitis - midgut visceral pain - N & V
172
Menopause
- 12 months after last menstrual period - ~52 yrs old - due to reduction in estrogen and inhibin levels - no negative feedback = high LH and FSH - occurs naturally, due to surgery, or chemotherapy - symptoms: irregular periods, vaginal dryness, hot flashes, night sweats, sleep problems, mood changes, weight gain, thinning hair and dry skin, loss of breast fullness - Tx: relieving symptoms: estrogen therapy, vaginal estrogen, low dose antidepressants, gabapentin (for hot flashes)
173
Ureterolithiasis
- stone from kidney making its way through ureter to bladder - UA will show hematuria
174
Gastric PUD
- pain: can be Greater with meals --\> weight loss - H. Pylori infection: ~ 70% - Mechanism: decreased mucosal protection against gastric acid - Other causes: NSAIDs - Cancer risk: increased - other: biopsy margins to rule out malignancy - decreased H+ secretion and a resulting increase in gastrin levels - Dx: EGD (esophagoduodenoscopy), check for H. pylori - Tx: H2 blocker, proton inhibitor, eradicate H pylori, stop smoking
175
Crigler-Najjar syndrome type 1
- starts earlier in life, jaundice apparent @ birth or in infancy - no function of UDP-glucuronosyltransferase - increased unconjugated bilirubin - mutations in UGT1A1: no function - severe kernicterus Treatments - phototherapy: must be done throughout pts life: works in babies, not as well after age 4 due to thicker skin - blood transfusions: helps control amount of bilirubin in the blood - oral calcium phosphate and carbonate: forms complexes w/ bilirubin - liver transplant
176
Medial Arcuate lig.
- fascial thickening of the psoas fascia - spanning the lumbar body and tip of L1 TP - lateral to median accurate lig.
177
Cryptorchidism
- lack of testicular descent into scrotum - due to no testosterone during last 2-3 mo of pregnancy
178
Small Intestine Bacterial Overgrowth (SBIO)
- bacteria deconjugate bile salts, impairing micelle formation - damages the intestinal mucosa - removes guanine and taurine from bile salts making them less water-soluble - pain, bloating, gas, diarrhea/constipation - malabsorption, steatorrhea, vit. deficiencies - lowers pH = inactivating pancreatic enzymes - Dx: methane breath test
179
Melanocortin 4 receptor gene mutation
- early-onset severe obesity - increased linear growth - hyperphagia - hyperinsulinemia - most common known genetic cause of obesity - homozygous worse than heterozygous - MC4R mutation
180
Hematemesis
- vomiting blood
181
Gastric ulcers
- foregut visceral pain - worse on eating - pt. tend to skip meals
182
Crohn's Disease
- location: any part of GI tract --\> usually terminal ileum, and colon. skip lesions, rectal sparing - gross morphology: transmural inflammation --\> fistulas, cobblestone mucosa, creeping fat, bowel wall thickening ( "string sign" on barium swallow x-ray), linear ulcers, fissures - microscopic morphology: noncaseating granulomas and lymphoid aggregates, Th1 mediated - complications: malabsorption/ malnutrition, colorectal cancer, fistulas (can cause recurrent UTIs), strictures (causing obstruction), perianal disease - intestinal manifestations: diarrhea (possibly bloody) - extraintestinal Manifestations: kidney stones (Ca), gallstones, rash, eye inflammation, oral ulcerations, arthritis - Treatment: corticosteroids, antibiotics, biologics, azathioprine
183
Abdominal Lymph Drainage
- superficial vessels superior to umbilicus drain to auxiliary nodes w/ few going to parasternal nodes - Superficial Vessels below umbilicus drain to superficial Inguinal nodes - Deep vessels accompany deep veins of abdominal wall (ex and int iliac)
184
Helicobacter Pylori
- cause of PUD - releases cytotoxins that break down the mucosal barrier and underlying cells - urease activity allows it to colonize in the mucosa - converts urea to ammonia (NH3) alkalinizes the environment - NH3--\> NH4 (toxic) damages epithelial cells and breaks down barrier - diagnostics based on urase activity - inhibits somatostatin release = inc. H+ gastric secretion - inhibits HCO3- secretion in duodenum = less buffering capacity Dx: urea breath test, fecal antigen test (used to confirm eradication) - Abs in serum (not good for confirming eradication) - Upper endoscopy w/ gastric biopsy
185
Proopiomelanocortin (POMC) deficiency
- loss-of-function mutations in POMC gene - obesity - red hair - adrenal insufficiency due to ACTH deficiency - hyperproinsulinemia - hyperphagia - pale skin - cholestatic jaundice
186
Flattus
- gas or air in GI tract expelled through anus
187
Testicular Varicocele
- Varicosities of pampiniform plexus ( veins surrounding testicular A.) - swelling in scrotum w/ dull and recurring pain in scrotum
188
Causes of Gallstones
- too much absorption of water from bile - too much absorption of bile acids from bile - too much cholesterol in bile - inflammation of epithelium
189
Enterogastric Reflex
- negative feedback from duodenum will slow down rate of gastric emptying
190
Leptin
- fat cells and endocrine cells of the stomach - acts on hypothalamus - dec. NPY, AgRP system - inc. POMC system - acts on vagal afferents - decreases appetite - increases metabolism - decrease Ghrelin secretion
191
Insulin actions on Skeletal Muscle
- increased glucose uptake --\> decreased blood glucose levels - increased glycogen synthesis - increased glycolysis and CHO oxidation - increased protein synthesis --\> decreases A.As in blood - decreased protein breakdown - increased K+ uptake into cells --\> decreased blood K+
192
Cholelithiasis
- gallstones: could be in gallbladder, cystic duct, hepatic duct, or hepatopancreatic ampulla -crystals: bile supersaturated with cholesterol - insufficient secretion of bile salts or phospholipids into the gallbladder or excess cholesterol secretion into bile - Calculous: most common type, gallstone impaction resulting in inflammation and thickening of gallbladder wall, can cause 2\* infection - Acalculous: due to gallbladder stasis, hypoperfusion, or infection, seen in critically ill patients - Dx: with ultrasound or HIDA scan (failure to view suggests obstruction) - Murphy Sign: inspiratory arrest upon RUQ palpation due to pain - pain may radiate to right shoulder - risk factors: females \>males (2:1), obesity, 40’s, fertile (pre-menopausal), pregnancy, ethnicity (Am Indians and Mexicans), diabetes, estrogen replacement therapy - can cause obstructive jaundice - chronic disturbance in bile salt metabolism leads to malabsorption syndromes (steatorrhea), and deficiency in fat-soluble vitamins
193
ALT and AST
- Alanine amino Transferase - Aspartate Amino Transferase - convert AA to keto acids - required for protein and carbohydrate metabolism - both in mito. ALT also in cytosol - levels increase in liver disease as they are released from damaged hepatocytes - ALT more sensitive since cytosolic
194
Thoraco-abdominal N.
- T7-11 - continuation of intercostal N.s - both motor a sensory innervation - runs between TA and IO m.
195
Volvulus
- rolled up, twisted intestines - symptoms: acute abdominal pain, vomiting, GI bleeding - increased risk with gut rotation anomalies - obstipation and ischemia of looped segment
196
Cachexia
- profound constitutional disorder - general ill health and malnutrition
197
Intraperitoneal organs
- suspended on all sides by mesentery
198
External Oblique M.
- Runs in downward medial direction - interdigitates with Serratus Anterior - Origin: outer surface of ribs 7-12 - insertion: aponeurosis and linea alba, anterior iliac crest and pubic tubercle - lower portion rolled under to make Inguinal ligament, makes opening of superficial Inguinal ring, some reflected fibers make Lacunar ligament, contributes to conjoint ligament - Innervation: ventral rami T7-12 of intercostal N.s - Action: completes abdomen, increase intra-abdominal pressure, move trunk to retain posture
199
Right Upper Quadrant Contents
- liver: right lobe - gallbladder -Stomach: pylorus - Duodenum: parts 1-3 - Pancreatic head - right adrenal gland - right kidney - hepatic flexure - superior Ascending colon - right half of transverse colon
200
Left lower Quadrant Contents
- sigmoid colon - inferior descending colon - left ovary - left uterine tube - left ureter: abdominal part - left spermatic cord: abdominal part - uterus- if enlaged - urinary bladder: if very full
201
Direct Inguinal Hernia
- medial to inferior epigastric A. - peritoneum and transversalis fascia alongside the spermatic cord
202
Drug Hepatotoxicity
- drug can be toxic in excess - in some people and not others b/c of genetic or immunologic causes Acetaminophen Poisoning - conjugated with glucuronic acid or sulfates to be excreted via kidney - in overdose capacity for conjugation is overwhelmed - oxidized in liver by CYP3A4 to NABQ1 - NABQ1 causes damage to hepatocytes: free radical-mediated peroxidation of memb. lipids - could lead to hepatic failure and death - NABQ1 detoxified by glutathione, in overdose stores are depleted - N-acetyl cysteine is the antidote given
203
Causes of pain in the Epigastric area
- Esophagitis - peptic ulcer - perforated ulcer - pancreatitis - heartburn/indigestion (GERD) - Epigastric Hiatal Hernia - gallstones - functional dyspepsia --\> no organic reason - food poisoning - biliary tract disease - viral gastroenteritis - gastric cancer
204
Ascites
- collection of fluid in the peritoneal cavity - causes: - salt and water retention - liver cirrhosis: portal hypertension - cancer - CHF - TB - End stage renal failure: Dialysis - Pancreatic disease - other - maybe accompanied by pain or feeling of bloating - diuretics and therapeutic paracentesis can treat
205
Splenorenal Ligament
- connects: spleen to left pararenal space - contains: splenic a. & v., tail of pancreas - derivative of dorsal mesentery
206
Colicky Pain
- intermittent cramp-like pain - obstruction of hollow muscular viscus - Ex: bowl obstruction from adhesions, ureteric colic, cholelithiasis (gallstone) - GI tract: foregut, digit or hind gut - GU system: loin to groin - in 3 midline areas
207
Biliary Atresia
- fetal and perinatal forms - defined as obliterations of extrahepatic or intraheptaic ducts - decks replaced by fibrotic tissue due to acute or chronic inflammation - Symptoms: - neonatal jaundice soon after birth: low activity of UDP glucuronyl transferase and short lifespan of fetal erythrocytes - white clay colored stool - dark colored urine - 12-19 month average survival time - can be treated with liver transplant: only option for intrahepatic -extrahepatic can be fixed by using a small part of the jujenum to make a new bile duct sometimes
208
Hartnup Disease
- no absorption of neutral AA - resembles pellagra (niacin deficiency) - SLC6A19 gene, sodium-dependent neutral amino acid transporter B0AT1 - symptoms: diarrhea, mood changes, neuro changes, red scaly skin rash, photosensitivity, short stature, UA shows neutral AA (try) and byproducts (serotonin)
209
UGIB
- upper GI bleeding
210
Meckel’s Diverticulum
- Failure of the yolk stalk connection (Vitelline duct)to the midgut to regress - may contain acid-secreting gastric mucosa and/or pancreatic tissue - most common GI abnormality - Rule of Twos - 2% incidence - 2X’s more common in males - 2% have medical symptoms - usually 2 ft. Proximal to terminal ileum - usually 2 inches long - usually presents in first 2 years of life - may have 2 types of epithelia (gastric/pancreatic) - abdominal swelling, intestinal obstruction near terminal ileum, bowel sepsis, and GI bleeding, RLQ pain, Volvulus, intrussusception (telescoping of bowel segments to cause obstruction), hematochezia (fresh blood in anus) or melena (dark bloody stool) - can mimic pain of appendicitis - there are other pathologies involving the yolk sac connection to the midgut - differential Dx: omphalomesenteric cyst (cystic dilation of vitelline duct) - diagnosis: 99mTc-pertechnetate scan (aka Mekel scan) for uptake by heterotopic gastric mucosa
211
Insulin Actions on liver
- promotes glycogen synthesis - increases glycolysis and CHO oxidation - decreased gluconeogenesis - increased hexose monophosphate shunt - increased pyruvate oxidation - increased lipid synthesis and decreased protein breakdown - increased K+ uptake into cells --\> decreased blood K+
212
Acute Cholecystitis
- foregut visceral pain - somatic pain in RUQ - referee pain to right shoulder - nausea and vomiting - fever - Positive Murphy’s sign: inspiratory arrest upon RUQ palpation
213
Hypertrophic Pyloric Stenosis
- narrowing of pyloric lumen: obstructing food passage - Muscularis externa hypertrophies forming a palpable mass @ right costal margin - faulty migration of NC cells so no innervation of ENS (ganglion cells not populated) - fewer and smaller stools - projective non-bilious vomiting after feeding - failure to thrive
214
Abdominal Wall and Groin Hernia Sites
- Umbilical - Epigastric: weakness in wall at midline fusion point - Spigelian: through fascia between the abdominal muscles but along the semilunar line of the rectum abdominus M. (More common in obese population) - Inguinal - femoral Flank (lumbar): defects in the posterolateral abdominal wall allowing the tissues insides the abdomen to protrude
215
Lateral umbilical fold
- fold due to inferior epigastric a.
216
CYP450 Enzymes
- protein superfamily - heme-containing - present in the ER - detoxify pharmacological agents - co-localize with NADPH: cytochrome P450 reductase (CYPR) --\> CYP:CYPR = 4:1 (CYPR rate-limiting enzyme) - metabolism of hydrophobic compounds - operate via electron transfer system - inhibitors of CYP: cause an increase in drug levels - ex: citrus juice, grapefruit juice (will increase statin levels in plasma) - stimulators of CYP: cause a decrease in drug levels in plasma - Ex: St. John Wort --\> mood stabilizer that decreases statin levels in plasma - may lead to toxic side effects
217
Structures at T12-L1
- kidneys - gallbladder and Biliary tree - SMA, Left Renal V., Aorta, IVC - small bowel and colon
218
Kallman's Syndrome
- GnRH neurons fail to migrate to the hypothalamus in embryo development - delayed or absent puberty - impaired sense of smell - males\>\>females - form of hypogonadotropic hypogonadism
219
PYY
- L cells in the ileum and colon - acts on hypothalamus - dec. NPY, AgRP system - inc. POMC system - acts on stomach - Dec. appetite - inc. metabolism - dec. gastric emptying
220
Peritonitis
- inflamed peritoneum - causes include 1. Burned viscera (ruptured appendix) 2. Perforated viscera ( perforated gastric ulcer) 3. Penetration trauma to viscera ( knife wound or bullet wound)
221
Pancreatitis
- 4.9-35/100000 - inflammation of pancreas w/ abdominal pain and elevated enzymes in blood - problems with protein, carb, and lipid digestion - impaired HCO3- and enzyme secretion - pancreatic enzymes become activated and self-digest the pancreas - Dx: CBC, CMP, lipase, UA, preg test - Tx: varies on disease severity - IV fluids, pain and nausea meds - NPO or clear liquids
222
Interspinous plane
- passes through ASIS (S2)
223
Follicle-Stimulating Hormone and Spermatogenesis
- secreted by the anterior pituitary - stimulated Sertoli cells to make sperm - spermatogenesis would not occur without
224
Zenker's Diverticulum
- false diverticulum: herniation in the esophageal wall between the thyropharyngeal and the cricopharyngeal parts of the inferior pharyngeal constrictor - symptoms: dysphagia, obstruction, gurgling, aspiration, foul breath, neck mass - Elder MIKE has bad breath - elderly - Males - Inferior Pharyngeal constrictor - Killian triangle - Esophageal dysmotility - Halitosis: bad breath - stapling it closed is usually better than surgical removal
225
Klinefelter Syndrome
- seminiferous tubular dysgenesis - 47, XXY - phenotypically male, appears male at birth - puberty: increased levels of gonadotropins fail to induce normal testicular growth and spermatogenesis - 1\* hypogonadism: androgens low, gonadotropins high - seminiferous tubules are largely destroyed - infertile
226
Superior Mesenteric Artery Syndrome
- mid-sagittal CT view is best to view - digestive condition - 3rd part of the duodenum is compressed between aorta and SMA - due to loss of mesenteric fat - partial or complete blockage of duodenum - symptoms: abdominal pain, fullness, N&V, and or weight loss - surgery possibly needed
227
Barrett’s Esophagus
- specialized intestinal metaplasia - nonkeratinized stratified squamous epithelium of the esophagus —\> nonciliated columnar epithelium w/goblet cells (intestinal epithelium) - so the esophagus can withstand the stomach acid during reflux - due to chronic GERD - inc. risk of esophageal adenocarcinoma
228
Ghrelin
- from endocrine cells of the stomach, hypothalamus, large and small intestine - acts on hypothalamus - INC. NPY, AgRP system - inc. appetite - dec. metabolism - dec. Leptin release
229
Obstructing Cancer of descending colon
- older age pt - weight loss - Hindgut visceral colicky pain - no flats or feces - distended abdomen - possible palpable mass in LLQ - increased bowel sounds
230
Wilson's disease
- free copper accumulation in brain, liver, cornea, joints - mutation in ATP7B: transports copper across plasma membrane using ATP - inadequate copper excretion by liver - failure of CU to enter circulation bound to ceruloplasmin - generate free radicals --\> tissue damage - AR inheritance Symptoms: Parkinson-like symptoms (putamen accumulation), Hemiballismus [flailing, ballistic undesired mov'ts of limbs] (accumulation in subthalamic nucleus, dementia (cerebral cortex), Keyser-Fleischer rings in eyues, cirrhosis - Tx: Ammonium Tetrathiomolybdate (urinary excretion), Penicillamine (chelating agent), Trientine (chelating agents), liver transplantation
231
Intestino-Intestinal Reflex
- depends on extrinsic neural connections - inhibitory - if an area of bowel is grossly distended the rest of the bowel’s contractile activity is inhibited
232
Cholesterol-lowering drugs: bile acid-binding resins
- use instead of statins - 20-30 g of bile acids enter enterohepatic circulation every day - ~ 95% reabsorbed and 5% excreted out - cholestyramine: non-absorbable bile-acid binding resins cause large excretion of bile acids - bile acid synthesis increases by induction of 7-a-hydroxylase - depletion of liver cholesterol pool - receptor-mediated and receptor-independent mechanism of LDL uptake - lower plasma cholesterol levels
233
Structures at L3-L4
- right kidney - small bowel, ascending and descending colon - abdominal musculature (psoas M)
234
Iliohypogastric N.
- L1 - runs between IO and TA layers - motor innervation to IO and TA - sensory to upper Inguinal and hypogastric region
235
Zollinger- Ellison Syndrome
-large secretion of gastrin by duodenal or pancreatic tumors (gastrinomas) - H+ increases from parietal cell secretion - gastric hypertrophy in parietal cells - secretory diarrhea: inhibits the absorption of Na and water by SI - increased H+ in duodenum overwhelms buffering capacity of HCO3- resulting in ulcer Acidification of SI: - inactivates pancreatic enzymes (lipase) - no emulsification of lipids by bile salts - damage to Intestinal epithelial cells and villi - maldigestion and malabsorption leading to steatorrhea - symptoms: diarrhea, N&V, PUD, inc. resting gastric disease, weight loss, GERD, epigastric pain, hematochezia, hematemesis, melena, ulcers in unusual locations (Proximal jejunum) - Tx: H2 receptor blocking drugs (cimetidine), H-pump inhibitors (omeprazole), removal of tumor, gastric resection
236
Peptic Ulcer disease
- H. Pylori and NSAID leading causes in US - result of: - loss of protective mucosal barrier: contains HCO3- to neutralize pepsin - excessive H+ or pepsin secretions - or combination of the 2 - 2 types: gastric or duodenal
237
Functions of Liver
- primary receiving, distribution, and recycling center - carbohydrate metabolism - lipid metabolism - nucleotide biosynthesis - protein and amino acid metabolism - removal of nitrogen generated by amino acid metabolism via the urea cycle - impaired clearance of ammonia causes brain damage - synthesis of blood proteins - bilirubin metabolism - waste management
238
Amylin
- stored and released with insulin in response to food - Anorectic effect (inhibits NPY release)
239
Turner Syndrome
- most common cause of congenital hypogonadism - 50% = 45X genotype - internal and external genitalia are female - 1\* hypogonadism: germ cells don't develop, gonad = CT filled streak - because of ovary failure = high serum FSH - presentation: short stature, delayed puberty, infertility, webbed neck, lymphedema of hands & feet, skeletal abnormalities, learning disabilities
240
Incisions
- Subcostal: 2.5 cm inferior from margin, access to gallbladder and biliary tract and spleen - Midline: can be made quickly, doesn’t heal quickly, few BVs and N.s - Paramedian: open anterior sheath, push rectus M. Aside laterally and enter perineum - Gridline (McBurney’s Point): muscle splitting; typical of appendectomy - Suprapubic: used most in GYOBN surgeries
241
Reverse Gut Rotation
- completes initial 90\* rotation and then rotates 180\* in the opposite direction than it should (clockwise not counterclockwise) - transverse colon ends up posterior to duodenum - when the duodenum is pulled back to become retroperitoneal organ this pulls the transverse colon with it and results in obstruction or stenosis - at higher risk of Volvulus
242
Lateral Arcuate Lig.
- fascial thickening of quadratus lumborum m. - runs from L1 TP to tip of 12th rib
243
Estrogens and Spermatogenesis
- may have role - formed from testosterone
244
Shatzki Ring
- narrowing or esophagus caused by ring of mucosal tissue or muscular tissue lining the esophagus - can cause difficulty in passing liquids and food - use balloons to expand the area and meds to keep it from recurring
245
Psoas Major and Minor
- 40% of people don’t have minor - origin: TP, IV disks and bodies of T12-L5 - Insertion: - major: lesser trochanter of femur - minor: near pectinate line - Innervation: anterior rami L1-3
246
Insulin
- pancreatic beta cells - acts on hypothalamus to dec. appetite and inc. metabolism
247
Causes of Male Impotence
- Nerve damage tp prostatic nerve plexus - Atherosclerosis decreases blood supply to penis - T2DM - spinal cord injury - hormonal disorders - psychological disorders
248
Lymphatic drainage of Perineum
- Superficial Perineal space: distal portions of the vagina and anal canal (inferior to pectinate line) drains to superficial inguinal nodes - Deep perineal space: proximal vagina, proximal anal canal (superior to pectinate line) drains to internal iliac nodes
249
Episiotomy
- surgical incision between vagina and anus to prevent tearing during delivery - 4 types - most common is medio-lateral incision - incision through posterior vaginal wall, bulbospongiosus m., superficial transverse perineus m., skin and associated fascia - repair: sutures through muscle layer, subcutaneous fascia layer, and skin - most likely muscle of levator ani to tear during childbirth is Pubococcygeus M.
250
Perineal Blood Supply
External Pudendal A. --\> scrotum and penis, or labia majora and clitoris Internal Pudendal A. --\> passes through greater and lesser sciatic foramena, enters the pudendal canal, supples all perineal structures
251
Pudendal N.
- preganglionic parasympathetic fibers - somatic motor fibers - somatic sensory fibers - postganglionic sympathetic fibers - inferior rectal nerve: external anal sphincter and anal skin, travels through ischiorectal fossa - Perineal N. --\> scrotum/labia majora, urethra/labia minora, ischiocavernosus, bulbospongiosus, deep transverse perineal m., sphincter urethrae - Dorsal N. of the penis/clitoris: penis/clitoris
252
Female Superficial Perineal Space
Contents: - bulbs of the vestibule (erectile tissue) - bulbospongiosus m (bulbocavernosus m) - Greater vestibular (Bartholin's) glands: releases mucous into vestibule during intercourse, deep to labia minora - Superficial transverse perineus m. - clitoris - ischiocavernosus m.
253
clitoris
- bilateral crura covered bi ischiocavernosus m. - bilateral corpus cavernosus in the body of the clitoris - glans clitoris (visible externally)
254
Perineal Blood Supply
External Pudendal A. --\> scrotum and penis, or labia majora and clitoris Internal Pudendal A. --\> passes through greater and lesser sciatic foramena, enters the pudendal canal, supples all perineal structures
255
Pudendal N.
- preganglionic parasympathetic fibers - somatic motor fibers - somatic sensory fibers - postganglionic sympathetic fibers - inferior rectal nerve: external anal sphincter and anal skin - Perineal N. --\> scrotum/labia majora, urethra/labia minora, ischiocavernosus, bulbospongiosus, deep transverse perineal m., sphincter urethrae - Dorsal N. of the penis/clitoris: penis/clitoris
256
Female Superficial Perineal Space
Contents: - bulbs of the vestibule (erectile tissue) - bulbospongiosus m (bulbocavernosus m) - Greater vestibular (Bartholin's) glands: releases mucous into vestibule during intercourse - Superficial transverse perineus m. - clitoris - ischiocavernosus m.
257
Female Urogenital Diaphram (deep perineal space)
- Superior fascia - inferior fascia or perineal membrane - deep transverse perineus m. - external urethral sphincter surrounds urethra - compressor urethrae (not in males) - vagina
258
Perineal Blood Supply
External Pudendal A. --\> scrotum and penis, or labia majora and clitoris Internal Pudendal A. --\> passes through greater and lesser sciatic foramena, enters the pudendal canal, supples all perineal structures
259
Pudendal N.
- preganglionic parasympathetic fibers - somatic motor fibers - somatic sensory fibers - postganglionic sympathetic fibers - inferior rectal nerve: external anal sphincter and anal skin - Perineal N. --\> scrotum/labia majora, urethra/labia minora, ischiocavernosus, bulbospongiosus, deep transverse perineal m., sphincter urethrae - Dorsal N. of the penis/clitoris: penis/clitoris
260
Female Superficial Perineal Space
Contents: - bulbs of the vestibule (erectile tissue) - bulbospongiosus m (bulbocavernosus m) - Greater vestibular (Bartholin's) glands: releases mucous into vestibule during intercourse - Superficial transverse perineus m. - clitoris - ischiocavernosus m.
261
clitoris
- bilateral crura covered bi ischiocavernosus m. -
262
Perineal Blood Supply
External Pudendal A. --\> scrotum and penis, or labia majora and clitoris Internal Pudendal A. --\> passes through greater and lesser sciatic foramena, enters the pudendal canal, supples all perineal structures
263
Pudendal N.
- preganglionic parasympathetic fibers - somatic motor fibers - somatic sensory fibers - postganglionic sympathetic fibers - inferior rectal nerve: external anal sphincter and anal skin - Perineal N. --\> scrotum/labia majora, urethra/labia minora, ischiocavernosus, bulbospongiosus, deep transverse perineal m., sphincter urethrae - Dorsal N. of the penis/clitoris: penis/clitoris
264
Female Superficial Perineal Space
Contents: - bulbs of the vestibule (erectile tissue) - bulbospongiosus m (bulbocavernosus m) - Greater vestibular (Bartholin's) glands: releases mucous into vestibule during intercourse - Superficial transverse perineus m. - clitoris - ischiocavernosus m.
265
clitoris
- bilateral crura covered bi ischiocavernosus m. -
266
Vestibule of Vagina
- surrounded by labia majora Contents: - external urethral orifice - vaginal orifice - paraurethral glands orifices - greater vestibular glands orifices
267
Vestibule of Vagina
- surrounded by labia majora Contents: - external urethral orifice - vaginal orifice - paraurethral glands orifices - greater vestibular glands orifices
268
Body (shaft) of penis
- skin - subcutaneous tissue (no fat) - corpus cavernosus (bilateral and contain deep a. of penis) - corpus spongiosum: contains spongy (penile) urethra - dorsal a., v., and n. of penis (on top of shaft)
269
Male Superficial Perineal Space
Root of Penis - two crura - bulb of penis - ischiocavernosus m. --\> helps maintain erection - bulbospongiosus m. --\> contraction assisting in keeping an erection Spongy or penile urethra Superficial transverse perineus m.
270
Urogenital Diaphram (deep perineal space)
- Superior fascia - inferior fascia or perineal membrane - deep transverse perineus m. - external urethral sphincter surrounds urethra - compressor urethrae (not in males) - vagina
271
Male Superficial Perineal Space
Root of Penis - two crura - bulb of penis - ischiocavernosus m. --\> helps maintain erection - bulbospongiosus m. --\> contraction assisting in keeping an erection Spongy or penile urethra Superficial transverse perineus m.
272
Urogenital Diaphram (deep perineal space)
- Superior fascia - inferior fascia or perineal membrane - deep transverse perineus m. - external urethral sphincter surrounds urethra - compressor urethrae (not in males) - vagina
273
Male Superficial Perineal Space
Root of Penis - two crura - bulb of penis - ischiocavernosus m. --\> helps maintain erection - bulbospongiosus m. --\> contraction assisting in keeping an erection Spongy or penile urethra Superficial transverse perineus m.
274
Urogenital Diaphram (deep perineal space)
- Superior fascia - inferior fascia or perineal membrane - deep transverse perineus m. - external urethral sphincter surrounds urethra - compressor urethrae (not in males) - vagina
275
Male Urogenital Diaphragm (deep perineal space)
- superficial fascia - Inferior fascia or perineal membrane - deep transverse perineus muscle - External urethral sphincter surrounds membranous urethra - membranous urethra - Bulbourethral glands (Coulper's) - produce mucous which is secreted into the penile urethra prior to ejaculation
276
Anal Triangle of Perineum
- external anal sphincter (skeletal muscle): distal 2/3s of anal canal, attaches to levator ani m. anococcegeal lig. nd perineal body (central tendon) - internal anal sphincter: smooth muscle, proximal 2/3s of canal, continuous with rectum
277
Ischiorectal fossa
Boundaries - lateral wall- obturator internus and ischium - superiomedial: levator ani and anal canal (EAS) - base: skin Contents: fat, pudendal canal (blood vessels and nerves) - fat allows the rectum and anal canal to distend during defecation and not harm any vital organs
278
Pudendal Canal
- fascia lined space - on the medial surface of obturator internus m. Contents: - Pudendal N. - Internal Pudendal A. - Internal Pudendal N.
279
Inferior Rectal Vessels
- Inferior Rectal A. --\> branch of internal pudendal a. - Inferior rectal V. --\> tributary to internal pudendal v. - vessels travel through ischiorectal fossae
280
Inferior Rectal Vessels
- Inferior Rectal A. --\> branch of internal pudendal a. - Inferior rectal V. --\> tributary to internal pudendal v. - vessels travel through ischiorectal fossae
281
Urinary Incontinence
- Overflow: urethral blockage, bladder unable to empty fully
- Stress: relaxed pelvic floor, increased abdominal pressure (more common in F\>M)
- Urge: bladder oversensitivity from infection, neurologic disorders
Men:
- stress: after prostate gland removed
- overflow: blocked urethra in BPH (benign prostate hypertrophy)
281
What Muscles make up the pelvic floor?
Pelvic diaphragm: Levator ani and Coccygeus
Levator Ani: Iliococcygeus and Pubococcygeus (usually torn during childbirth)
Pyriformis
Obturator Internus
Urogenital Diaphragm
282
5 a-reductase Deficiency
* male DSD
* autosomal deficiency
* make AMH and T so normal testes and duct system
* cant make DHT
* underdeveloped male external genitalia
* female phenotype
283
46, XY
* male has testes but phenotype is female
* causes
* inadequate testosterone synthesis
* 17 B-hydroxysteroid dehydrogenase deficiency (no androstenedione to T)
* androgen insensitivity syndrome
* 5 a-reductase deficiency (T to DHT)
* mutations in AMH or AMH receptor
284
Androgen Insensitivity Syndrome
* x-linked recessive
* loss of functional androgen receptors
* have testes, ususally in inguinal or labial regions, but no spermatogenesis
* T may be high
* @ puberty T --\> estradiol and female secondary sex characteristics w/amenorrhea
* Produce AMH: no uterus or uterine tubes, vagina is short and ends blindly
* inc. risk of gonadal cancer
285
Female DSDs
* 46, XX genotype
* have ovaries
* fetus produces excess androgens
* masculinization of external genitalia
* fusion of labia giving scrotum appearance
286
Congenital Adrenal Hyperplasia
* most common cause of female sexual ambiguity
* mutation: deficiency in 21-hydroxylase
* excessive ACTH and androgens
287
Cervical Transformation Zone
* endocervix = simple columnar
* ectocervix = nonkeratinized stratified squamous epithelium
This is where a pap smear biopsy is performed
288
Ectopic Pregnancy
* implantation somewhere other than uterine fundus
* most common site is oviduct (tubal pregnancy) 95-98% occur here
* decidualization will not occur
* invasion is not controlled and can cause rupture of the tissue and hemorrhage
* 2% of all pregnancies
* signs
* abdominal pain
* amenorrhea
* vaginal bleeding
* rupture of the oviduct
* affected tube/conceptus usually surgically removed
* produces hCG but at slower rate than normal
289
Hydramnios
* excessive amniotic fluid
* fetal defect in CNS, genetic defect, or blockage of GI tube
* abdominal pain, significant swelling or bloating, breathlessness
* monitored via US
290
Oligohydramnios
* insufficient amniotic fluid (\<400 mL)
* renal agenesis, pulmonary hypoplasia
* placental abnormalities or maternal HBP
* decreased fluid does not provide enough cushion for fetus and umbilical cord
291
Absence of umbilical A.
* 1:100 neonates
* chromosome and fetal abnormalities associated with this
* agenesis or degeneration of one of two umbilical a.s
* detected by US
292
Placenta Previa
* implants in lower uterine segment or cervix
* serious 3rd trimester bleeding
* most common type
* 20% of all bleeding cases are this
293
Placenta Accrete/a
* partial or complete absence of decidua --\> villous chorion adheres directly to myometrium
* failure of placental separation @ birth
* severe, possibly life-threatening postpartum bleeding
294
Complete Hydatidiform Mole
* normal villi are dilated or hydropic translucent vesicles
* all/most villi are enlarged, covered w/ trophoblast invasion
* no fetal tissue
* fertilization of blighted ovum --\> all DNA paternal
* fertilized by two sperm or duplication of single sperm
* 46,XX or 46, XY
295
Partial Hydatidiform Mole
* normal villi are dilated or hydropic translucent vesicles
* a portion of villi are edematous
* capillaries can be seen in villi
* fetal tissue commonly found
* normal ovum fertilized by two sperm
* 69, XXY or 92, XXXY
296
Invasive Mole
* complete mole that penetrates or even perforates uterine wall (15%)
* persistent high hCG levels
* trophoblast invasion too deep can cause hemorrhaging
* responsive to chemotherapy
297
Gestational Choriocarcinoma
* highly invasive, metastatic tumor from trophoblast cells
* in 50% of pts w/ molar pregnancies
* increasing hCG titer w/no uterine enlargement
* Tx: combined chemotherapy usually curative
298
Dizygotic twins
* originate from 2 zygotes
* 'fraternal twins'
* separate implantations: 2 chorions and 2 amnions
* adjacent implantation: 2 amnions, 2 fused chorions, 2 placentas
299
Monozygotic Twins
* originate from one zygote
* membranes dependent of timing of division
* 2-8 cell stage: 0-72 hrs --\> diamniotic and dichorionic (fused or separated placenta)
* blastocyst: 4-8 days --\> diamniotic and monochorionic
* implanted: 9-12 days --\> monoamniotic and monochorionic
* the earlier the split --\> the more separate the membranes will be
* 65% develop from division of embryoblast of the blastocyst
* 35% develop from morula producing two identical blastocytes
300
Functions of the placenta
* fetal "gut": supplying nutrients
* fetal "lung": exchanging O2 and CO2
* fetal "kidney": regulates fluid volumes and disposing of waste metabolites
* endocrine gland: synthesizes steroids and proteins that affect both maternal and fetal metabolism
301
Functions of endocrine placenta
* Maintaining the pregnant state of uterus
* stimulating lobuloalveolar growth & fxn of breasts
* adapt maternal metabolism for growing fetus
* regulate fetal development
* regulate the timing and progression of partuition
* manufacture: steroid hormones, amines, hormones, neuropeptides, proteins/ glycoproteins
* regulate in a paracrine fashion
* release of local placental hormones
* release of hormones into fetal or maternal circulation
302
Human Chorionic Gonadotropin (hCG)
* produced by syncytiotrophoblasts
* similar to LH
* binds LH receptors in C.L
* prevent leteolysis
* glycosylation increases half life
* rapidly accumulates in maternal circulation
* nausea for morning sickness
* small amounts enter fetal circulation and stimulate Leydig cells to produce testosterone
303
Chorionic Villi
* Main Stem villi: extending from chorionic plate
* Branch Villi: extend from the main stem villus, increases S.A., main site for exchange
* Anchoring Villi: attach to maternal tissue through the cytotrophoblastic shell
304
Placental Transfer
Crosses Placenta:
* nutrients: water, glucose, electrolytes, AA, vitamins
* hormones: T, progestins, thyroxin, T3
* IgG
* waste products: urea, uric acid, conjugated bilirubin
* drugs (most): alcohol, caffeine, cocaine, heroin, labor-management drugs
* infectious agents: cytomegalovirus, rubella, varicella, measles, herpes, syphilis, Toxoplasma gondii, Listeria monocytogenes
Don't cross Placenta:
* protein hormones: insulin, pituitary hormones
* bacteria
* drugs w/AA like structures: methydopa
305
Human chorionic Somatomammotropin (hCS)
* human placental lactogen (hPL)
* related to GH and prolactin
* produced by syncytio ~ day 10
* maternal blood ~ 3 weeks
* coordinates fuel economy in fetoplacental unit
* glucose --\> fatty acids and ketones
* antagonistic action to maternal insulin --\> diabetogenicity of pregnancy
* lipolytic actions help mother shift to FFA i=use for energy
* promote development of maternal mammary glands during pregnancy
306
Progesterone
* high levels required throughout pregnancy
* implantation: increases adhesion proteins in endometrium
* stimulates endometrial glands for early nutrient delivery
* reduces uterine motility
* inhibits propagation of uterine contractions
* induces mammary growth and differentiation
307
Estrogen
* induces endometrial growth, progesterone receptor expression, LH surge
* inc. uteroplacental blood flow
* inc. LDL receptor expression in syncytium
* induce prostaglandins and oxytocin receptors necessary for parturition
* inc. growth and development of mammary glands
* placenta cannot produce cholesterol
* lacks 17 a-hydroxylase & 17,20 desmolase for estrone and estradiol
* lacks 16 a- hydroxylase for estriol
*
308
Preeclampsia
* occurs after20 wks of pregnancy
* 5-8% of pregnancies
* HBP and signs of damage to other organ systems (kidneys)
* related to # of factors
* abnormal placentation
* immunologic factors
* preexisting HTN
* obesity
* history of preeclampsia
* limited blood supply to uterine a.s
* ischemia
* endothelial damage & release of cytokines
* can lead to serious or fatal complications for M and F
* eclampsia
* HELP Syndrome
* Hemolysis, Elevated Liver enzymes, Low Platelet count
* avoided by early delivery normally
309
Hematopoiesis in fetus
in yolk sac, liver, and bone marrow
310
Fetal Blood Flow: Placenta
* shunts blood away from lower trunk
* umbilical a.s: branch repeatedly
* returns deoxy blood
* dense capillary network at terminal villi
* "legs" connected to IVC
* Umbilical V.:
* returns oxy blood to fetus from placenta
* PO2 = 30-35 mmHg
* blood enters ductus venosus
311
Fetal blood Flow: Ductus Venosus
* liver bypass or "detour"
* liver = largely nonfunctional
* direct route from umbilical v. --\> IVC
* closure: immediately after birth most portal blood flows through
* 1-3 hr: muscle wall contracts and closes
* portal venous pressure rises, forcing venous blood through liver sinuses
* rarely fails to close
312
Fetal Blood Flow: Foramen Ovale
* hole in septum dividing the atria
* R to L atrial shunt
* bypass around right ventricle
* PO2 = ~27 mmHg in IVC to left ventricle to supply carotid and brain
* of blood entering right atrium ~27% is shunted through foramen ovale
* closure:
* reversal of pressure gradient pushes the flap closed and it seals
* increased venous return to L atrium & elevated L atrial pressure
* decreased R atrial pressure
* Patent Foramen Ovale:
* 20% people by age 2 it doesn't close
* increased R atrial pressure pushes flap open
* sustained pulmonary HTN
* or transient increases: coughing, sneezing, bowel movement
313
Fetal Blood Flow: Ductus Arteriosus
* Pulmonary artery to Aorta
* R to L shunt
* a substantial amount of SM being dilated by PGF2
* Closure: aortic pressure rises above pulmonary pressure
* blood flows the wrong way --\> oxy blood flows through DA
* high PO2 --\> vasoconstriction within a few hrs
* 1-8 d: constriction sufficient
* 1-4 mo: anatomically occluded
* Patent Ductus Arteriosus
* heart problem occurs soon after birth
* Oxy blood in aorta mixes with deoxy blood in the pulmonary artery
* puts a strain on the heart and increases pulmonary pressure
314
Fetal Kidneys
* nephrogenesis begins ~ 8 weeks gestation and completed ~ 36 weeks
* urine production begins ~10-20 weeks
* fetal urine accounts for 70-80% amniotic fluid
* function matures rapidly in 3rd trimester
* functional development completes in 1st month of age
315
Fetal Liver
* poor conjugation of bilirubin
* no UDP glucosyltransferase
* deficiency in forming plasma proteins and coagulation factors
* deficient gluconeogenesis (BG could be as low as 30-40)
* infant uses stored fat and proteins for metabolism until mothers milk can provide it
316
Fetal Hemoglobin
* HbF (a2y2): major hemoglobin in fetus
* adult is a2B2
* fetal higher oxygen binding affinity
* normal adult levels achieved by ~12 weeks
317
Neonatal nutritional needs
* Ca2+ & vitamin D - rapid ossification of bones
* adequate amount can be supplied in milk
* Iron: liver has sorted enough to make blood for 6 mo
* breast milk concentration is low but highly bioavailable (reverse in formula)
* Vitamin C:
* not stored in body
* adequate amounts can be supplied in milk
318
Neonatal Immunity
* inherits a great degree of immunity from mother
* does not form Abs to a significant amount
* Abs from mother will protect for ~ 6 mo
* baby's own system begins and returns to normal by 12-20 months
319
Mammogenic Hormones
* promotes mammary cell proliferation
* Lobuloalveolar growth
* estrogen
* growth hormone (IGF-I)
* Cortisol
* Prolactin
* Relaxin?
* Ductal Growth
* Estrogen
* Growth hormone
* Cortisol
* Relaxin
320
Lactogenic Hormones
promote the initiation of milk production by alveolar cells
* Prolactin
* hCS (or hPL)
* Cortisol
* Insulin (IGF-I)
* Thyroid hormones
* Growth hormones?
* withdrawal of estrogens and progesterone
321
Galactokinetic Hormones
promote contraction of myoepithelial cells and milk ejection
* oxytocin
* Vasopressin
322
Galactopoietic Hormones
maintain milk production
* Prolactin (primary)
* cortisol and other metabolic hormones
323
Initial Reproductive Health Visit
* 13-15 years of age
* provide preventative health care services, education, and guidance
* topics:
* pubertal development
* normal menses
* timing of routine gynecological visits
* STIs
* pregnancy prevention
* sexual orientation & gender identity
* acquaintance rape prevention
* general exam
* HPV vaccine:
* 6, 11: external warts
* 16, 18: cervical cancer
324
Menarche
* median age ~ 12.5 years
* occurs 2-3 yrs after Thelarche (breast budding), @ Tanner Stage 4, rare before Tanner stage 3
* by 15, 98% will have it
* normal cycle ranges 21-45 days even in 1st gyno year
* most females bleed 2-7 days
325
Primary Amenorrhea
* absence of menarche by age 13 w/o secondary sexual development
* by age 15 with secondary sexual development
326
Secondary Amenorrhea
* absence of menstruation x 6 months
* rare for an adolescent girls to go more than 3 months
* rule out pregnancy
* may be associated with many conditions
* endocrine: poorly controlled DM, PCOS, Cushings
* acquired: exercise-induced, eating disorders
* tumors: ovarian, adrenal, prolactinomas
327
Polymenorrhea
abnormally frequent menses at \<21 days
328
Menorrhagia
excessive or prolonged menses (\>80mL and \>7 days) occurring at regular intervals
329
Metrorrhagia
irregular episodes of uterine bleeding
330
Menometrorrhagia
heavy & irregular uterine bleeding
331
Intermenstural bleeding
scant bleeding at ovulation for 1-2 days
332
Oligomenorrhea
menstrual cycles at \>35 days
333
Endometrial Polyps (AUB-P)
* form from to create soft friable protrusions into cavity
* can cause menorrhagia, spontaneous or postmenopausal bleeding
* US findings: focal thickening of endometrial stripe
* saline hystersonography & Hysteroscopy for better detection
* may evade in-office endometrial sampling
* most are benign
334
Adenomyosis (AUB-A)
* extension of endometrial glands and stroma into the unterine musculature ( \>2.5mm beneath basalis)
* 15% of patients also have endometriosis
* these areas no longer participate in the proliferative and secretory cycles
* Symptoms:
* may be asymptomatic
* severe secondary dysmenorrhea and menorrhagia
* pelvic pressure
* pain with deep intercourse
* uterus feels soft and boggy
335
Uterine Leiomyomas "Fibroids" (AUB-L)
* benign tumor from SM cells of myometrium
* most common neoplasm of uterus
* rarely malignant
* most asymptomatic
* symptoms:
* excessive uterine bleeding
* pelvic pressure
* pelvic pain (lower back) & infertility
* most common indication for hysterectomy
* frequency of urination of pressing on the bladder
* Risk Factors:
* increasing age in repro yrs
* African American 2-3 x more likely
* Nulliparity
* FH
* locations:
* subserosal (most common)
* submucosal
* interstitial
* cervical
* pathogenesis:
* factors unknown
* rarely form before menarche or enlarge after menopause
* estrogen stimulates the proliferation of SM cells
* can dramatically enlarge during pregnancy
* Characteristics:
* spherical, well-circumscribed, white firm lesion w/whorled appearance on cut sections
* may degenerate and cause pain
* may calcify in postmenopausal patients
336
Endometrial Hypoplasia (AUB-H)
* overabundant growth of endometrial lining usually because of persistent unopposed estrogen
* PCOS
* Granulosa theca cell tumor
* obesity: 2\* to peripheral conversion of androgens to estrogens in adipose tissue
* exogenous estrogens
* Tamoxifen: anti-estrogen in the breast but agonist in the uterus, giving for breast cancer
* a precursor to endometrial cancer
* simple w/o atypia: do nothing 1% risk
* complex w/o atypia: 3% risk
* simple w/atypia: 9% risk
* complex w/ atypia: 27% risk
* Type 1: endometrial adenocarcinoma: most common cancer
* Type 2: clear cell and papillary serous
* presentation:
* postmenopausal bleeding- most common
* AUB- perimenopausal women
* if cancer in more than 1/2 uterus you need adjunct therapy like radiation and chemotherapy
* if \<1/2 no adjunct therapy
337
Coagulopathies (AUB-C)
* associated with heavy flow
* Von Willebrand disease
* 1/6 women in ER for vaginal bleeding
338
Ovulatory Dysfunction (AUB-O)
* associated with unpredictable menses w/variable flow
* PCOS
339
Endometrial Causes (AUB-E)
infection
340
Iatrogenic (AUB-I)
IUD, IUS, exogenous hormones, birth control
341
Not Yet classified (AUB-N)
reserved for entities that are poorly defined &/or not well examined
* arteriovenous malformation
342
Laboratory Testing for AUB
* Pregnancy test: blood or urine
* CBC (anemia)
* targeted screening for bleeding disorders
* Von Willebrands profile
* PT and PTT
* TSH
* Chlamydia trachomatis
* Transvaginal US
* Saline infusion sonohysterography
* MRI
* Hysteroscopy
* Tissue sampling methods
* office endometrial biopsy
* Hysteroscopy directed endometrial sampling
343
Clinical indications for Endometrial Biopsy (EMBX)
AUB
* postmenopausal women
* sample w/ any spotting/bleeding
* endometrial lining \> 4mm
* age 45 to menopause
* any AUB, including intermenstrual bleeding, menorrhagia
* \<45 y/o
* any bleeding that occurs in the setting of unopposed estrogen exposure
* obesity
* PCOS
* prolonged amenorrhea
Cervical cytology results
* + glandular cells on cervical cytology
