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GIT Flashcards

1
Q

Normal gastrointestinal embryology

A

Foregut- esophagus to duodenum at level of pancreatic duct and common bile duct insertion (ampulla of VATER)

Midgut- lower duodenum to proximal 2/3 of transverse colon

Hindgut- distal 1/3 of transverse colon to anal canal above pectinate line

Midgut development: 6th week - physiologic herniation of midgut through umbilical ring, 10th week returns to abdominal cavity and rotates around SMA, total 270’ counterclockwise

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2
Q

Ventral wall defect

A

development defects due to failure of rostral fold closure (sternal defects (ectopia cordis), Lateral fold closure (omphalocele, gastroschisis), or caudal fold closure- bladder extrophy

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3
Q

Gastroschisis

A

Extrusion of abdominal contents through abdominal folds (typically right of umbilicus)

Not covered by peritoneum or amnion
Not associated with chromosomal abnormalities, favorable prognosis

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4
Q

Omphalocele

A

Failure of lateral walls to migrate at umbilical ring–> persistent midline herniation of abdominal contents into umbilical cord

Surrounded by peritoneum abdominal contents are sealed

Associated with congenital anomalies (trisomies 13, 18, Beckwith Wiedermann syndrome) and other structural abnormalities (cardiac GU, neural tube)

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5
Q

Tracheoesophageal anomalies

A 
Esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is the most common 85%
and often presents as polyhydramnios in utero (baby cant swallow amniotic fluid. Continue to make urine cause the umbilical blood supply

Neonates drool, choke, and vomit with first feed

TEFs allow air to enter in stomach

Cyanosis 2’ to laryngospasm (to avoid reflux related aspiration, failure to pass nasogastric tube into stomach

in H type, the fistula- like above but can get food in

pure EA - nothing gets into stomach

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6
Q

Intestinal atresia

A

presents with bilious vomiting and abdominal distension within 1st 1-2 days of life.

Duodenal atresia- failure to recanalize, abdominal xray shows double bubble (stomach pyloric sphincter dudenum and atretic portion of duodenum. Associated with Down syndrome

Jejunal/ileal astresia- disruption of mesenteric vessels (typically SMA)–> ischemic necrosis of fetal intestine –> segmental resorption –> bowel becomes discontinuous. Xray shows dilated loops of small bowel with air fluid levels

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7
Q

Hypertrophic pyloric stenosis

A

Most common cause of gastric outlet obstuction in infants (1/600)
olive shaped mass in epigastric region, visible peristaltic waves, and nonbilious projectile vomiting at 2-6 weeks old. More common in first born males, associated with exposure to macrolides

Results in hypokalemic hypochloremic metabolic alkalosis (2’ to vomiting of gastric acid and subsequent volume contraction)

treatment - pylorotomy

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8
Q

Pancreas and spleen embryology

A

Pancreas- derived from foregut. Ventral pancreatic bud contributes o uncintate process and main pancreatic duct

The dorsal pancreatic bud alone becomes body, tail, isthmus and acessory pancreatic duct, both ventral and dorsal buds contricute to pancreatic head

Annular pancreas- abnormal rotation of ventral pancreatic bud forms a ring of pancreatic tissue- encircles 2nd part of duodenum, may cause duodenal narrowing and vomiting

Pancreas divisum- ventral and dorsal parts fail to fuse at 8 weeks. common anomaly - mostly asymptomatic, but may cause abdominal pain pancreatitis

Spleen spleen is mesentery of stomach, but has foregut supply from splenic artery

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9
Q

Falciform ligament

A

Connects liver to anterior abdominal wall

Ligamentum teres hepatis- derived from fetal umbilical vein), patent paraumbilical veins

Derivative of ventral mesentery

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10
Q

Hepatoduodenal ligament

A

connects liver to duodenum

Contains portal triad : proper hepatic arter, portal vein, common bile duct

Derivative of ventral mesentery
Pringle maneuver- ligament compressed manually or with vascular clamp in omental foramen, to control bleed from hepatic inflow source

Part of lesser omentum

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11
Q

Gastrohepatic ligament

A

connects the liver to lesser curvature of stomach

contains gastric vessels

Derivative of ventral mesentery separates greater greater and lesser sacs on the right, may be cut during surgery to access lesser sac, part of lesser omentum

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12
Q

Gastrocolic ligament-

A

connects the greater curvature and transverse colon

Gastroepiploic arteries, derivative of dorsal mesentery, part of greater omentum

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13
Q

Gastrosplenic ligament

A

connects Greater curvature and spleen, short gastics, left gastroepiploic vessels

Derivative of dorsal mesentary , separates greater and lesser sacs on the left part of greater omentum

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14
Q

Digestive tract anatomy

A

Layers of gut wall inside to out

Mucosa- (epithelium, lamina propria, muscularis mucosa)
Submucosa- includes the submucosal nerve plexus (meissner), secretes fluid
Muscularis externa- includes myenteric nerve plexus (Aurebachs) for motility
Serosa- when intraperitoneal, adventitia when retroperitoneal

Ulcers can extend into submucase, inner or outer muscular layer. Erosiion is just mucosa

Frequency of basal electrical rhythms (slow waves) which originate in the intersitital cells of cajal- Stomach 3 waves a minute, duodenum (12 waves a minute), ileum (8-9 waves a minute

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15
Q

Digestive tract histology

A

esophagus- nonkeratinized stratified squamous epithelium. upper 1/3 is striated muscle, middle and lower 2/3 smooth muscle, with some overlap at transition
Stomach- gastric glands
Duodenum- contain villi, and microvili (increase absorptive surface, Brunners glands (HCO3- secreting cells of sumbucosa), crypts of lieberkuhs (contain stem cells that replace enterocytes/goblet cells and Paneth cells that secrete defensins, lysozyme, and TNF)

Jejunum- villi , crypts of lieberkuhn, and -plicae circularis
ileump- pyeyrs pathces, lymphoid aggregates in lamina propria, submucosa, plicae circulares (proximal ileum) and crypts of liberukuhns largest number of goblet cells in the small intestine

Colon- no villi, crypts of lieberkuhn with abundant goblet cells

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16
Q

nutcracker syndrome

A

compression of left renal vein between SMA and Aorta, characteristic abdominal flank pain and gross hematuria (from rupture of thin walled renal varicositeis

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17
Q

SMA syndrome

A

intermited obstruction symptoms when SMA and Aorta compress transverse compress transverse protrion of duodenum, typucally in conditions associated with deminished mesenteric fat (low body weight/ malnutrition

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18
Q

Gastrointestinal blood supply and innervation

A

Celiac and SMA get parasympathetic from vagus

IMA- gets from pelvic innervation)

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19
Q

Portosystemic anastomoses

A

Esophagus –> esophageal varices- left gastric (portal system) and esophageal (from azygous)

Umbilical–> Caput medusa (paraumbilical from portal system–> small epigastric veins of the anterior abdominal wall

Rectum-> anorectal varices Superior rectal (from portal, IMV)–> middle and inferior rectal

treat with a transjugular intra hepatic shunt (TIPS) between the portal vein and hepatic vein relieves portal hypertension by shunting blood to the systemic circulation, bypassing the liver, TIPS ccan precipitate hepatic encephalopathy due to decreased clearance of ammonia from shunting

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20
Q

Pectinate Line

A

Above: visceral innervation, IMV, IMA, lymphatics drain to internal iliac LN

Below: somatic innervation, inferior rectal arteru (branch of intern al pudendal artery. Inferior rectal vein-> pudendal, internal iliac-> common iliac -> IVC. Lymphatics–> drain to superficial inguinal lN

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21
Q

Anal fissures

A

Located posteriorly bc poor perfusion, innervated by pudendal nerve

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22
Q

Liver tissue architecture

A

functional unit is made up of hexagonal arranged lobules surrounding the central vein with portal triads on the edges (consisting of a portal vein, hepatic artery, bile ducts as well as lymphatics)

Apical surface of hepatocytes faces bile canaliculi, basolateral surface faces sinusoids

Kupffer cells (specialized macrophages) located in sinusoids clear bacteria and damaged or senescent RBCs

Hepatic Stellate (Ito) cells in space of disse store vitamin A (when quiescent) and produce extracellular matrix (when activated), responsible for hepatic fibrosis

Zone 1 (periportal zone)- affected 1st by viral hepaptitis, best oxygenated, most resisitant to circulatory compromise (ingested toxins (cocaine)

Zone 2- intermediated zone (yellow fever)

Zone 3- pericentral vein (centrilobular) zone: affected 1st by ischemia (least oxygenated), High Concentration of cyp 450, most sensitive to metabolic toxins (ethanol, CCL4, halothane, rifampin, acetaminophen). Site of alcoholic hepatitis

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23
Q

Biliary structures

A

Gallstones that reach the confluence of the common bile and pancreatic ducts at the ampulla of Vater can block both the common bile and pancreatic ducts

Tumors that arise in the head of pancreas (usually ductal adenocarcinoma) can cause obstruction of common bile duct–> enlarged gallbladder with pain jaundice (Courvoidier sign)

Cholangiography shows filling defects in gallbladderand cystic duct

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24
Q

Inguinal canal

A

Deep inguinal ring (internal- site of protrusion of indirect hernia
Abdominal wall - site of protrusion of direct hernia

Layers of abdominal wall from in to out
Parietal peritoneum> Extraperitoneal tissue> transversalis fascia>Transversus abdominus> internal oblique> aponeurosis of external oblique muscle> inguinal ligament

Spermatic cord/
ICE TIE (Internal spermatic fascia/transversalis, Cremasteric muscle/internal oblique, external spermatic fascia/external oblique
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25
Q

Hernias

A

Protrusion of peritoneum through opening usually at site of weakness, contents may be at risk for incarceration ( not reducible back into abdomen/pelvis) and strangulation(ischemia and necrosis)

tenderness, erythema, fever

26
Q

Diaphragmatic hernia

A

Abdominal structure enter the thorax

Congenital defect of pleuroperitoneal membrane or from trauma- usually occurs on left side due to relative protection of right hemidiaphragm by liver, most commonyl a hiatal hernia, in which stomach herniates upward through the esophageal hiatus of the diaphragm

Sliding hiatal hernia, paraesophageal hiatal hernia

27
Q

Indirect inguinal hernia

A

through the deep inguinal ring, external inguinal ring, and into the groin, enters internal inguinal ring lateral to the inferior epigastric vessels
Caused by failure of processus vaginalis to close ( can form hydrocele)

may be noticed in infants or discovered in adulthood

much more common in males
Follows the path of testicular descent

Covered by all 3 layer of spermatic fascia

28
Q

Direct inguinal hernia

A

protudes theough inguinal hesselbach triangle , bulges directly through parietal peritoneum medial to the inferior epigastric vessels but lateral to the rectus abdominus

goes through extrernal superficial inguinal ring only. covered by external spermatic fascia

29
Q

Femoral hernia

A

protudes below inguinal ligament through femoral canal below and lateral to Pubic tubercle, more common in females

More likely to incarcerate

30
Q

Gastrin

A

G cells make it, (antrum of stomach, duodenum)

Increases Gastric H secretion, growth of gastric mucosa, increased gastric motility

Increased by stomach distension/ alkalinization, amino acids, peptides, vagal stimulation via gastrin-releastng peptide

Decreased by acid

increased by chronic PPI use, increased by chronic atrophic gastritis ( H pylori), increased in ZE syndrome–> gastrinoma)

31
Q

Somatostatin

A

made by D cells, pancreatic islets, GI mucosa

Inhibits the secretion of hormones
Octreotide is an analog treats agromegaly, carcinoid syndrome, variceal bleeding

32
Q

Secretin

A

S cells of duodenum

Increased HcO3- neutralizes gastric acid in duodenum, allowing pancreatic enzymes to function

33
Q

Glucose dependent insulinotropic peptide

A

K cells in duodenum and jejcunum

Increases insulin release, decreasess gastric acid

Gastric inhibitory peptide

Oral glucose load increases insulin compared to IV equivalent due to FIP secreion

34
Q

Vasoactive intestinal polypeptide

A

Parasympathetic Ganglia in sphinters, gallbadder, small intestine

Increases water and electrolyte secretion
Increases relaxation of intestinal smooth muscle and sphincters

Relaxes intestinal smooth muscles and sphincters

Vagal stimulation
decreased by adrenergic input

VIPOMA- pancreatic tumor that secretes VIP, Wattery diarrhea, hypokalemia, Achlorhydia

35
Q

Pancreatic secretions

A

Isotonic fluid, low flow–> high Cl-, high flow–> high HCO3-

Alpha amylase- for starch digestion, secreted in active form
Lipases- fat digestion
Proteases- Protein digestion (includes trypsin, chymotrypsin, elastase, carboxypeptidases). Secreted as proenzyme also called zymogens

Trypsinogen- converted to active enzyme trypsin–> activation of other proenzymes and cleaving of additional trypsinogen molecules into active trypsin (posidive feedback)- converted to trypsin by enterokinase/enteropeptidase a brush border enzyme on duodenal and jejunal mucosa

36
Q

Carb absorption

A

Only monosaccharieds (glucose, glactose, fructose) are absorbed by enterocyted

Glucose and galactose are taken up by SGLT1 (Na dependent)

Fuctose is taken up via facilitated diffusion by GLUT5, All are transported to blood by GLUT2

D-xylose absorption test: simple sugar that requires intact mucosa for absorption, but does not require digestive enzymes. So as long as your mucosa isnt damaged you should be able to take it up

37
Q

Vitamin and mineral absorption

A

Iron- absorbed as Fe++ in duodenum
Folate- absorbed in small bowel
Vitamin B12- Absorbed in terminal ileum along with bile salts, requires intrinsic factor

Iron Fist Bro- small bowel disease (vit B 12 deficienct after terminal ileum resection)

Hepcidin inhibits ferroportin1

38
Q

Peyers patches

A

unencapsulated lymphoid tissue found in lamina propria and submucosa of ileum

Contain specialized M Cells that sample and present antigens to immune cells (DCs )

B cells stimulated in germinal centers of peyer patches differentiate into IgA secreteing plasma cells, which ultimately reside in lamina propria

IgA receives protective secretory component and is then transported across the epithelium to the gut to deal with intraluminal antigen

39
Q

Bile

A

Composed of bile salts (bile acids conjugated to glycine or taurine, making them water soluble)

Phospholipids, cholesterol, bilirubin, water and ions
Cholesterol 7ahydroxylase catalyzes rate limiting step of bile acid synthesis

Functions- digestion and absorption of lipids and fat soluble vitamins
Cholesterol excretion (bodys 1' means of eliminating cholesterol) 
Antimicrobial activity (via membrane disruption)

decreased absorption of enteric bile salts at distal ileum (as in short bowel syndrome, crohn disease), prevents nnormal fat absotption

Calcium, which normally binds oxalate, binds fat instread so free oxalate is absorbed by gut –> increased frequency of calcium oxalate kidney stones

40
Q

Bilirubin

A

heme is metabolized by heme oxygenase to biliveridin (makes bruise green/yellow) which is subsequently reduced to bilirubin

Unconjugated bilirubin is removed from blood by liver, conjugated with glucuronate and excreted in bile

Some of the conjugated bilirubin that ends in the gut is converted by urobilinogen (brown color stool) stercobilin

and 20% is recycled back to kidney (excreted as urobilin)

41
Q

Sialolithiasis

A

Stones in salivary gland duct
Parotid, submandibular, sublingual

Usually submandibular gland (wharton duct)

Presents as recurrent pre/periprandial pain and swelling
Caused by dehydration or trauma

NSAIDs, gland massage, warm compresses, sour candies (to promote salivary flow)

Sialadenitis- inflamation of salivary gland due to obstruction, infection, immune mediated mechanisms

42
Q

Salivary gland tumors

A

parotid gland, usually benign

if submandibular or sublingual its malignant

Facial paralysis or pain suggests malignancy

Pleomorphic adenoma- benign mixed tumor, most common slivary gland tumor, composed of chondromyxoid stroma and epithelium and recurs if incompletely excised or ruptured intraoperatively. may undergo malignant transformation

mucoepidermoid carcinoma- malignant, mucinous and squamous components

Warthin tumor- papillary cystadenoma lympho- geminal center in smokers, typically in smokers, bilateral in 10%

43
Q

Achalasia

A

Failure of LES to relax due to degeneration of inhibitory neurons (containing NO and VIP) in the myenteric Auerbachs plexus of the esophageal Wall

Uncoordinated/absent peristalsis with high LES resting pressure-> progressive dysphagia to solids and liquids (vs obstructive)
Dilated

associated with increased risk of esophageal cancer

2’ from Chagas or extraesophageal malignancies (mass effect)

44
Q

Diffuse esophageal spasm

A

Spontaneous, nonperistaltic (uncoordinated) contractions with normal LES pressure
dysphagia, angina like chest pain
corkscrew esophagus
Nitrates and CCB

45
Q

Eosinophilic esophagitis

A

Infilitration of eosinophisl in esophagus often in atopic patients

Food allergens–> dysphagia, food impaction

esophageal rings and linear furrows often seen on endoscopy, typically unresponsive to GERD

46
Q

Esophageal perforation

A

most commonly iatrogenic following esophageal instrumentation

Non iatrogenic causes- spontaneous ruputure, foreign body ingestion, trauma, malignancy

May present with pneumediastinum subQ emphysema may be due to dissecting air (signs include crepitus in the neck region or chest wall)

Boerhaave syndrome- transmural usually distal esophageal rupture due to violent retching

47
Q

esophageal strictures

A

associated w/ caustic ingestion, acid reflux, and esophagitis

48
Q

Esophagitis

A

Candida- Pseudomembrane
HSV- punched out ulcers
CMV- linear ulcers

49
Q

Mallory weiss syndrome

A

Partial thickness longitudinal laceration
hematemisis
Alcoholics and bulimeics

50
Q

Plummer Vinson sydrome

A

Dysphagia, Iron deficiengt, Esophageal webs, Sqaumous cell carcinoma
Glottitis

Can eat steak

51
Q

Schatzki ringa

A

rings at GE junction from GERD

52
Q

Sclerodermal esophageal dysmotility

A

esophageal smooth muscle atrophy- lower LES pressure and dysmotility

ACid reflux and dysphagia-> stricture

Barret esophagus and aspiration part of CREST syndrome

53
Q

Barrett esophagus

A

intestinal metaplasia

nonkeratinized stratified squamous epithelium–> intestinal epithelium (nonciliated columnar with goble cells)

54
Q

Acute gastritis

A

Erosions can be caused by:
NSAIDs- decrease PGE2–> decrease gastric mucosa protection

Burns (Curling ulcer)- hypovolemia–> mucosal ischemia

Brain injury (cushing ulcer)-> increased Vagal stimulation–> increased Ach/GRH–> H production

Especially common in alcoholics and pts taking NSAIDs

55
Q

Chronic gastritis

A

Mucosal inflammation leading to atrophy (hypochlorhydia–> hypergastrinemia and intestinal metaplasia (increased risk of gastric cancer

H pylori- most common, increased risk of PUD, MALT lymphoma, affects the antrum first and spreads to body of stomach

Autoimmune- Ab to the HK ATPase on parietal cells and to Intrinsic factor

56
Q

Menetrier disease

A

gastric mucosa hyperplasia

hypertrophied rugai- excess mucus production with protein loss and parietal cell atrophy with decreased acid production
Precancerous
Weight loss, Anorexia, Vomiting, Epigastric pain, Edema (protein loss) cant cut up proteins

57
Q

Gastric cancer

A

gastric adenocarcinoma, lymphoma, GI stromal tumor, and rarely carcinoid

Local spread with node/liver mets

late with wt loss, abdominal pain, early satiety, acanthosis nigricans, Leser-Trelat sight

blood type A
Diffuse- E cadherin mutation signet ring cells (mucin filled cells with peripheral nuclei), stomach grossly thickened and leathery (linitis plastica)

Intestinal type- H pylori, diet, lifestyle

Virchow node- involvement of left supraclavicular node
Krukenberg tumor- bilat mets to ovaries
Sister mary joseph nodule- subQ periumbilical mets (cause nuns cross hands on belly button)
Blumer shelf- in pelvic pouch

58
Q

Gastric vs Duodenul ulcer

A

Gastric ulcer- Greater with meals,

Duodenal ulcer- better with meals cause you dilute the acid

59
Q

Ulcer complication

A

hemorrhage, lesser curvature- from left gastric artery, Posterior wall of duodenum-bleeding from gastroduodenal artery

Obstruction- pyloric channel, duodenal
Perforation- duodenal anterior> posterior. Pneumoperitoneum, free air under diaphragm

60
Q

Celiac disease

A

Gluten-sensitivity eneteropathy,

Autoimmune-mediated intolerance of gliadin (gluten protein found in wheat)–> malabsorption and steatorrhea

HLADQ2 and 8
dermatitis herpetiformis, decreased bone density

IgA antitissue transglutaminase (IgA tTG) anti endomysial, anti-deamidated gliadin peptide Ab, villous atrophy, crypt hyperplasia, intraepithelial lymphocytosis

distal duodenum and or proximal jejunum

D-xylose- decreased

61
Q

Whipple disease

A

tropheryma whipplei

PAS+ foamy macrophages in intestinal lamina propria

Mesenteric node
Cardiac symptoms, Arthralgias, Neurologic symptoms

Diarrhea/steatorrhea

First aid (12 decks)

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