Overview Flashcards
1
Q
Four muscles of the anterior abdominal wall are?
A
External oblique
Internal oblique
Transverse abdominis
Rectus abdominis - vertical
2
Q
Rectus sheath is formed by?
A
Aponeurosis of the three layers of muscle of anterior abdominal wall
3
Q
Linea alba is?
A
Where the anterior abdominal wall muscles meet
4
Q
Inguinal ligament is formed by?
A
Free border of the external oblique
5
Q
Rectus abdominis runs enclosed in what?
A
Rectus sheath
6
Q
Vessels running in the rectus sheath are?
A
Epigastric vessels - superior and inferior
7
Q
Arcuate line is?
A
Inferior epigastric artery perforates this to leave the rectus sheath superiorlyM
8
Q
Inferior epigastric artery originates from which artery?
A
External iliac
9
Q
Superior epigastric artery originates from which artery?
A
Internal thoracic
10
Q
McBurney’s point is?
A
One third from asis to the umbilicus
11
Q
McBurney’s point is landmark for?
A
Appendix
12
Q
Umbilicus is at what vertebral level?
A
T10
13
Q
Xiphoid is at what vertebral level?
A
T7
14
Q
Where do the testes develop?
A
Posterior abdominal wall next to the kidneys
15
Q
Most anterior layer of the testes is?
A
Tunica vaginalis
16
Q
Inguinal canal is?
A
Through here is descent of the testes during development from posterior to anterior
17
Q
The testes lies between which two layers?
A
Peritoneum
Transversalis fascia
18
Q
Contents of the spermatic cord are? x3
A
Testicular vessels
Ilioinguinal nerve
Genitofemoral nerve
19
Q
Conjoint tendon formed from what? x2
A
Transversalis abdominis
Internal oblique
20
Q
Spermatic cord is composed of? x4
A
Transversalis fascia
Internal oblique muscle
External oblique muscle
Superficial fascia
21
Q
Innervation of the dartos muscle is?
A
Genitofemoral nerve
22
Q
Nerve root of genitofemoral nerve is?
A
L1 and L2
23
Q
Function of dartos muscle is? x2
A
Ruggae formation
Temperature control
24
Q
Innervation of the cremaster muscle is?
A
L1 and L2
25
Function of the cremaster muscle is? x1
Cremaster reflex
26
Cremaster reflex innervation?
Genito - motor part causes movement
| Femoral - sensory to the thigh
27
Direct inguinal hernia is through?
Hassleback's triangle - orange anatomy booklet look at
28
Indirect inguinal hernia is through?
Inguinal canal into the scrotum
29
Inguinal hernias direct/indirect are either lateral or medial to which artery?
Inferior epigastric artery
30
Where is the deep inguinal ring located?
Midpoint of the inguinal ligament
31
Inguinal canal contains what in females? x2
Round ligament of the uterus
| Ilioinguinal nerve
32
Inguinal canal contains what in males? x2
Spermatic cord
| Ilioinguinal nerve
33
When does the external iliac artery become the femoral artery?
Past the inguinal ligament
34
What is the muscle seen most anterior on a CT at level L2?
Rectus abdominis
35
Caudate lobe of the liver is anterior or posterior?
Posterior
36
Quadrate lobe of the liver is anterior or posterior?
Anterior
37
Three components of the portal triad are?
Bile duct
Hepatic artery proper
Portal vein
38
What should be compressed to prevent a hepatic bleed?
Components of the portal triad
39
What is the Pringle manoeuvre?
Large clamp of the hetatoduodenal ligament to prevent bleeding from the liver
40
Hepatoduodenal ligament is in close relation to whcih three structures?
Liver
Duodenum
Gallbladder
41
Blood supply to the liver is via which artery?
Coeliac trunk
42
Hepatic portal vein is formed from?
Splenic vein
| Superior mesenteric vein
43
Hepatic portal vein forms where?
Posterior to the head of the pancreas
44
Where does the inferior mesenteric vein join?
Joins to the splenic vein
45
What is liver cirrhosis?
Fibrosis of liver tissue
46
Three causes of live cirrhosis?
Alcoholic liver disease
Metastases
Heart failure
47
Normal portal pressure is?
9mmHg
48
Pressure in the IVC?
2-6mmHg
49
Portal pressure gradient is?
Pressure difference between portal pressure and pressure in the IVC
50
Portal hypertension is?
When portal pressure gradient is >10mmHg
51
Consequence of portal hypertension is?
Splenomegaly
52
Oesopageal varices are due to anastoses between which arteries?
Oesophageal vein and left gastric vein
53
Ascites is?
Excess fluid in the peritoneal space
54
Two main causes of ascites?
Portal hypertension
| Hypoalbuminemia
55
Blood supply above and below the pectinate line is?
Superior rectal artery
Inferior rectal artery
56
Innervation above and below pectinate line is?
Inferior hypogastric plexus
Inferior rectal nerves from pudendal nerves
57
Epithelium above and below pectinate line is?
Columnar
Stratified squamous
58
Common bile duct (of biliary tree) drains into?
The major duodenal papilla
59
Bile is secreted by which organ?
The liver
60
Function of gall bladder?
Concentration of bile
61
Murphy's test tests for?
Inflamed gall bladder
62
Inflamed gall bladder is known as?
Cholecystitis
63
Blood supply to the gallbladder is?
Cystic artery
64
Cystic artery runs through which triangle?
Calot's triangle
65
Duct joining onto the pancreatic duct is?
Accessory pancreatic duct
66
Gallstones most likely to get lodged where?
(Distal end of hepatopancreatic) ampulla
67
What is the ampulla of Vater?
Where the pancreatic duct and the common bile duct meet
68
How to recognise the components of the portal triad?
Common bile duct - more brown in colour
Hepatic portal vein - very LARGE
Hepatic artery proper - smaller vessel
69
Pancreas is retro or intraperitoneal?
Retroperitoneal
70
Blood supply to the pancreas is?
Splenic artery from the coeliac trunk
71
Blood supply to the head of the pancreas is? x2
Superior and inferior pancreatoduodenal arteries
72
Superior pancreatoduodenal artery origin?
Gastroduodenal artery
73
Inferior pancreatoduodenal artery origun?
Superior mesenteric artery
74
Pancreatic duct opens into where?
Major duodenal papilla
75
Accessory pancreatic duct opens into where?
Minor duodenal papilla
76
Relation of IVC to liver?
IVC passes through the posterior region of the liver
77
Fundus of gallbladder is at which vertebral level?
L1
78
Liver metastasis is common from the GI tract why?
Due to drainage via the portal veins from the GI tract to the liver
79
Swelling of what would occur with gastric tumour?
Swelling of Virchow's node
80
Nutmeg liver is?
Congestion of the liver - accumulation of RBCs
81
Surrounding the major duodenal papilla is?
Sphincter of Oddi
82
Origin of cystic artery is?
Left hepatic artery
83
Endocrine vs. exocrine
Endocrine - secrete straight into the blood
| Exocrine - secrete into duct
84
Cushing's syndrome is?
Excess levels of cortisol - symptoms of this
85
Common symptoms of Cushing's syndrome is? x4
Fat deposits in the face - round face
Reddish/purple stretch marks on thighs, stomach, arms, legs
Weight gain
Loss of libido
86
Pituitary gland sits where and in which bone?
In sella turcica of the sphenoid bone
87
Infundibulum is?
Pituitary stalk - between posterior pituitary and the hypothalamus
88
Cells of anterior pituitary are?
Secretory
89
Cells of posterior pituitary are?
Neuronal
90
Blood supply to the anterior pituitary?
Superior hypophyseal artery
91
Origin of superior hypophyseal artery?
Internal carotid artery
92
Communication between pituitary gland adn the hypothalamus is?
What is transmitted through this system?
Hypothalamo-hypophyseal portal system
Blood - contains neurotransmitters
93
Blood supply to the posterior pituitary and the infundibulum? x3
Superior hypophyseal artery
Inferior hypophyseal artery
Infundibular artery
94
Hormones released by the anterior pituitary? x7
```
ACTH
TSH
LH
FSH
PRL
GH
MSH
```
95
Hormones secreted by the posterior pituitary x2?
ADH
| Oxytocin
96
Two components of the adrenal gland?
Adrenal cortex
| Adrenal medulla
97
Adrenal cortex secretes which hormones? x3
Aldosterone
Cortisole
Corticosterone
98
Adrenal medulla secretes which hormones? x2
Adrenaline
| Noradrenaline
99
Three zones of the adrenal cortex?
Cortex
Zona glomerulosa - mineralocorticoid aldosterone
Zona fasciculata - glucocorticoid cortisol
Zona reticularis - androgen testosterone
Medulla
100
Shape of the right adrenal gland is?
Pyramidal
101
Shape of the left adrenal gland is?
Crescent
102
Blood supply to the adrenal glands? x3
Superior suprarenal arteries
Middle suprarenal artery
Inferior suprarenal artery
103
Origin of superior suprarenal artery
Inferior phrenic artery
104
Origin of middle suprarenal artery
Abdominal aorta - by the SMA
105
Origin of inferior suprarenal artery
Renal artery
106
Venous drainage from the adrenal gland is?
Large suprarenal vein
107
Suprarenal vein drains to where on the right hand side?
IVC
108
Suprarenal vein drains to where on the left hand side?
Left renal vein
109
Four strap muscles are?
Thyrohyoid
Sternothyroid
Omohyoid
Sternohyoid
110
What is the largest strap muscle?
Sternohyoid - left side
111
What level is the thyroid gland?
C5-T1
112
Three components of the thyroid gland?
Left lobe
Right lobe
Isthmus
113
Blood supply to the thyroid is via? x2
Superior thyroid artery
| Inferior thyroid artery
114
Origin of superior thyroid artery is?
External carotid artery
115
Origin of inferior thyroid artery is?
Subclavian artery
116
Superior thyroid vein drains into?
Internal jugular vein
117
Middle thyroid vein drains into?
Internal jugular vein
118
Inferior thyroid vein drains into?
Brachiocephalic vein
119
Nerves surrounding thyroid gland which could be damaged in surgery?
Recurrent laryngeal nerves
120
How many parathyroid glands?
Four
121
Five regions of the pancreas are?
```
Tail
Body
Neck
Head
Ulcinate process
```
122
Bile is produced by which organ?
Liver
123
Bile is secreted when?
Upon consumption of food
124
How can the omohyoid muscle be recognised?
This is the one that loops and curves as it comes inferiorly down
125
What is the relation of the recurrent laryngeal nerve to the common carotid artery?
Runs medially to the common carotid
126
What is the relation of the vagus nerve to the common carotid artery?
Runs laterally to the common carotid
127
Where does the phrenic nerve run in relation to the aortic arch?
Between the aortic arch (lateral) and the lung (medial)
128
Which kidney is the most inferior?
Right (liver)
129
What vertebral level are the kidneys?
12th rib
130
What is the significance of the renal angle and where is this?
Inferior border of the 12th rib
| Examine for tenderness here - kidneys/intestines
131
What is Morrison's pouch?
Hepatorenal recess
132
What is Gerota's fascia?
Renal fascia - the kidneys have their own fascia
133
What is the significance of Gerota's fascia?
This is one of the last reserves of fat to be digested
134
Innervation to the kidneys is from which nerve roots?
Renal plexus T10-T12
135
What are the different divisions of the kidney?
Pelvis
Major calyx
Minor calyx
136
Where do the renal arteries leave the aorta?
L2
137
Where is the renal vein?
L2
138
Division of the different renal arteries?
Renal artery
Segmental arteries
Interlobar arteries
Interlobular arteries
139
How many lobar arteries are there per renal pyramid?
One lobar artery per renal pyramid
140
What is the cardiac output to the kidneys?
1/4 of the cardiac output - 1200ml/min
141
How do varicose testicular veins relate to the kidney?
A tumour in the renal vein can block the testicular vein and cause varicose veins
142
What does the ovarian artery/vein relate to in the male?
Testicular vein
143
Where does the testicular vein drain to?
Renal vein
144
Where does the ovarian vein drain to (left and right)?
Left - renal vein
| Right - IVC
145
What is the origin of the ovarian/testicular artery?
Aorta - vertebral level L2 (just inferior to renal artery)
146
What are the three layers of the ureter wall?
Transitional epithelial mucosa
Smooth muscle muscularis
Fibrous connective tissue andventitia
147
Where are the three msot likely places for a kidney stone to lodge?
Pelvo-uritary junction
Cystouretic junction
Pelvic brim
148
What are the three nerves involved in sensation of the ureters?
Ilioinguinal and iliohypogastric
Genitofemoral
149
Three layers of the bladder are?
Transitional epithelial mucosa
Thick muscular - detrousa muscle
Fibrous adventitia
150
What is the trigone?
Triangular area of the bladder outlined by the openings for the ureters and the urethra
151
Why is the trigone clinically important?
Infections tend to persist in this region
152
Where is bladder pain referred to and describe this pain?
Referred to the back - presents as back pain
Pack pain that will not go away - persistent
153
What are the sphincters of the urethras and are these present in males or females?
Internal urethral sphincter - only males
| External urethral sphincter - males and females
154
Which of the urethral sphincters are voluntary/involuntary?
Internal - involuntary
| External - voluntary
155
Which muscle assists the external urethral sphincter?
Levator ani muscle
156
How can you recognise the left renal vein on an L2 CT?
Long shape
| Crosses the aorta to join onto the IVC
157
Give the give nerves of the lumbar plexus
```
Subcostal nerve
Iliohypogastric nerve
Ilioinguinal nerve
Genitofemoral nerve
Lateral cutaneous nerve
Femoral nerve
Obturator nerve
```
158
What is the biggest nerve of the lumbar plexus?
Femoral nerve
159
Trigone is made up from?
```
Two ureters (female)/uretic orifice (male)
Urethra
```
160
Origin of uterine artery is?
Internal iliac artery
161
Normal blood glucose level is?
3.5-5mmol/L
162
Four reasons the brain is so dependent on the maintenance of blood glucose levels?
Cannot synthesise glucose
Cannot store glucose in significant amounts
Cannot metabolise substrates other than glucose (apart from ketones)
Cannot extract enough glucose from extracellular fluid at low concentrations
163
Two substrates the brain can use for metabolism are?
Glucose
| ketone bodies
164
Alpha cells of the pancreas produce?
Glucagon
165
Beta cells of the pancreas produce?
Insulin
166
Delta cells of the pancreas produce?
Somatostatin
167
PP cells of the pancreas produce?
Pancreatic polypeptide
168
Epsilon cells of the pancreas produce?
Ghrelin
169
Endocrine portion makes up what percentage of the pancreas?
2%
170
Three step process in the production of insulin?
Preproinsulin
Proinsulin
Insulin
171
Preproinsulin composed of how many amino acids?
110
172
Proinsulin composed of how many amino acids?
86
173
Insulin composed of how many amino acids?
51
174
Proinsulin cleaved to form what in the production of insulin?
Insulin - 51 amino acids
| C-peptide - 35 amino acids
175
When does insulin synthesis occur?
Only when increased levels of insulin are required
176
Glucose enters beta cells through which transporter?
GLUT1
177
What enzyme is the glucose sensor for insulin secretion in beta cells?
Glucokinase
178
When is insulin secreted?
When glucose levels exceed 5mM
179
Is insulin constantly synthesised?
No
180
Glycolysis: glucose is converted to what?
Glucose-6-phosphate
181
Glycolysis: glucose-6-phosphate is converted into what?
Pyruvate
182
Pyruvate is metabolised via which cycle?
Krebs
183
Krebs cycle results in what? x2
Raised ATP:ADP ratio in the cell
| This causes closure of the K+ channels at the membrane and hence, membrane depolarisation
184
Entry of glucose into the beta cell has what effect on the membrane?
Membrane depolarisation
185
Entry of glucose into the beta cell has what effect on K+ channels?
Closure of K+ channels
186
K+ channels at the membrane of the beta cell are normally opened or closed?
Open
187
Membrane depolarisation and closure of K+ channels in the beta cell results in what? x2
Opening of voltage gated Ca2+ channels - insulin secretion
188
Beta cells release insulin in how many phases?
Two
189
Describe the first phase of insulin release
Rapid release to rapidly increase blood glucose levels
190
Describe the second phase of insulin release
Sustained, slow release of newly formed vesicles
191
Stored insulin is released in the first or the second stage?
First
192
Newly synthesised insulin is released in the first or the second stage?
Second
193
Two amino acids that trigger insulin release?
Arginine
| Leucine
194
Hormone that triggers insulin release?
GLP-1
195
Peptide that triggers insulin release?
GIP
196
Acid that triggers insulin release?
Fatty acids
197
Neurotransmitters that trigger insulin release? x2
Acetylcholine
| CCK
198
How can arginine cause insulin release?
Directly depolarise the membrane
199
How can leucine cause insulin release?
Activation of glutamate dehydrogenase (GDH) and KIC
200
What is the receptor that GLP-1 acts on to cause insulin release?
GLP-1R
201
What is the receptor that free fatty acids act on to cause insulin release?
GPR40
202
What type of receptor is the insulin receptor?
Transmembrane tyrosine kinase receptor
203
What are the two subunits of the IR?
Intracellular beta subunit
| Extracellular alpha subunit
204
Where does insulin bind to the IR?
Extracellular alpha subunit
205
What is glucose converted to in muscles?
Glycogen
206
Location of GLUT2
Pancreas
Liver
Small intestine
Kidney
207
Location of GLUT3
Brain
| Testes
208
Location of GLUT4
Muscle
Fat
Heart
209
GLUT1 location
Ubiquitous e.g. beta cells
210
Akt is?
Protein kinase B
211
Three functions of Akt?
Translocation of GLUT4 to the plasma membrane
Phosphorylation of glycogen synthase kinase
Inactivation of glycogen synthase kinase
212
Overall function of Akt?
Increased glucose transport and glycogen synthesis
213
Effect of insulin at adipocytes? x3
Stimulates glucose uptake
Stimulates lipogenesis
Inhibits lipolysis
214
Insulin inhibits which enzyme at adipocytes?
Lipase
215
Four functions of insulin at the liver
Enhances glucose uptake - glucokinase
Increases glycogen synthesis
Increases lipogenesis
Inhibits gluconeogenesis
216
Function of glucokinase is?
Glucose to glucose-6-phosphate
217
Function of insulin on protein synthesis? x4
Stimulates transport of amino acids into cells e.g. valine, leucine, tyrosine
Increases translation of messenger mRNAs
Inhibits catabolism of proteins
Inhibits gluconeogenesis
218
Why does insulin increased amino acid uptake?
To inhibit gluconeogenesis
| Amino acids are the main substrate for glucose synthesis
219
During fasting, glucose metabolism is prioritised to which organ?
The brain
220
Two substrates for gluconeogenesis are?
Amino acids
| Glycerol
221
Acetyl-CoA is converted into what during long term fasting?
Ketone bodies
222
What can be used for gluconeogensis in anaerobic conditions adn via what pathway?
Lactate
Cori cycle
223
Where does the cori cycle occur?
Liver
224
Two enzymes that can reduce the activity of insulin are?
Serine kinase
| Threonine kinase
225
Two consequences of insulin resistance?
Hyperglycaemia
| Dyslipidaemia
226
At what blood glucose level is inuslin secreted?
Blood glucose > 5mmol/L
227
What is the hormone responsible for blood glucose level maintenance during fasting?
Glucagon
228
Alpha cells secrete?
Glucagon
229
Beta cells secrete?
Insulin
230
Delta cells secrete?
Somatostatin
231
PP cells secrete?
Pancreatic polypeptide
232
Epsilon cells secrete?
Ghrelin
233
Glucagon is how many amino acids long?
29 aa
234
Glucagon is composed of how many chains?
One
235
Insulin is composed of how many chains?
Two
236
Stages of glucagon synthesis are?
Preproglucagon
Proglucagon
Glucagon
237
Two amino acids that can result in the release of glucagon?
Alanine
| Arginine
238
Three factors that can stimulate glucagon secretion?
Reduced blood glucose concentration < 3.5mmol/L
Increased blood amino acids especially alanine and arginine
Increased exercise
239
Exercise can increased glucagon secretion to what extent?
Increases four to five fold
240
What type of receptor is the glucagon receptor?
G-protein coupled receptors
241
How many times does the glucagon receptor span the membrane?
Seven times
242
What does the glucagon receptor activate upon glucagon binding? Give the three stages
Adeno-cyclase
This activates cAMP
This activates protein kinase A
243
Increased glucagon binding to its receptor results in the overall secretion of what?
Protein kinase A
244
Three functions of glucagon at the liver
Increased amino acid uptake for gluconeogenesis
Ihibition of PFK-1
Inhibition of pyruvate kinase
245
Two enzymes involved in gluconeogenesis in the liver?
Pyruvate kinase
| Phosphate kinase
246
Enzyme that breaks down triglycerides is?
Lipase
247
Effect of insulin on lipase?
Inhibition
248
Effect of glucagon on lipase?
Activation
249
Triglycerides are broken down to?
Fatty acids and glycerol
250
Fatty acids and glycerol - how are these used for metabolism?
Fatty acids - acetyl coA for ATP synthesis
| Glycerol - glycolysis
251
What is the role of the carnitine shuttle?
Allows the beta oxidation of fatty acids
252
Carnitine shuttle requires which enzyme?
CPT-1
253
Which hormone activates CPT-1
Glucagon
254
When is acetyl-coA converted into ketone bodies?
Once oxaloacetate stores are depleted
| The acetyl-coA now undergoes a different pathway to produce ketone bodies
255
Two hormones that inhibit the release of glucagon?
Insulin
| Somatostatin
256
How long does the glycogen reserve typically last?
24 hours
257
Catecholaimes are? x2
Noradrenaline
| Adrenaline
258
Catecholamines are secreted from where?
Adrenal medulla
259
Catecholamines are released in response to? x2
Stress
| Hypoglycaemia
260
Catecholamines are synthesised from which two amino acids?
Phenylalanine
| Tyrosine
261
Function of adrenaline on blood glucose levels?
Same effect as glucagon - inhibits insulin secretion and stimulates glycogenolysis
262
Alternative name for adrenaline?
Epinephrine
263
Glucocorticoids are what type of hormone?
Steroid hormones
264
Overall effect of catechoalimes?
Increases blood glucose and fatty acid levels
265
Name a glucocorticoid
Cortisol
266
Cortisol is secreted in response to what?
ACTH
267
Four effects of cortisol on blood glucose regulation?
Enhances gluconeogenessis
Inhibits glucose uptake and utilisation
Stimulates muscle proteolysis
Stimulates adipose-tissue lipolysis
268
Overall function of cortisol
Rapid mobilisation of amino acids and fatty acids from cellular stores
269
Two other functions of cortisol are?
Maintenance of BP
| Suppression of inflammation
270
Long term elevated cortisol levels can result in? x2
Proteolysis
| Muscle wasting
271
Glucocorticoids are released by which part of the kidney?
Zona fasciculatat of the adrenal cortex
272
Growth hormone has an effect on which three tissues/organs?
Adipose tissue
Skeletal muscle
Liver
273
Name of T3 thyroid hormone?
Triiodothyronine
274
Name of T4 thyroid hormone?
Thyroxine
275
Thyroid hormones activate what type of receptors and roll of this??
Nuclear receptors - activates transcription of large number of genes
276
T3/T4 - which is more potent and by what amount?
T3 is more potent than T4 - about four times more
277
T3/T4 - which is more rapidly acting?
T3
278
T3 - action of duration is how long?
10-12 days
279
T4 - action of duration is how long?
2-3 days
280
Three specific functions of the thyroid hormone are?
Increased number adn activitiy of mitochondria
Stimulates carbohydrate metabolism
Stimulats fat metabolism
281
Overall action of thyroid hormones?
Increase the basal metabolic rate
282
Incretins are what type of hormone?
GI hormones
283
Two most common incretins are?
Glucagon like peptide-1 (GLP-1)
| Gastric inhibitory peptide (GIP)
284
Incretins effect on blood glucose control?
Increase insulin synthesis
285
Actions of GLP-1
Promotes satiety
Slows gastric emptying
Inhibits glucagon secretion
Stimulates insulin
286
Undernutrition is?
Malnutrition due to reduced supply of food or inability to digest, assimilate and utilise necessary nutrients
287
What are macronutrients?
Nutrients required in high quantities e.g. protein
288
What are micronutrients?
Nutrients required in lower quantities e.g. calcium, iron, manganese
289
Prevalence of undernutrition in the UK?
5%
| 2-3 million
290
Most vulnerable to undernutrition? x5
```
Chronic diseases
Elderly
Recently discharged from hospital
Low income
Socially isolated
```
291
Four consequences of undernutrition in the community?
Falls
Depression
Infection
Dependency
292
Five consequences of undernutrition in hospital?
```
Increased morbidity
Increased length of stay
Increased dependency
Increased mortality
Increased costs of care`
```
293
Reduced nutritional intake causes of undernutrition?
```
Anorexia
Treatment side effects
Pain
Dysphagia
Physical disability
Nil by mouth
```
294
Increased nutritional requirements causing undernutrition?
Inflammation/infection
Pyrexia
Tissue healing
Metabolic effects
295
Increased nutritional losses causing undernutrition?
Malabsorption
| Would exudate/burns
296
Consequences of undernutrition?
```
Decreased muscle mass
Organ failure
Apathy
Change in behaviour/personality
Bedridden
Depression
Fatigue
```
297
MUST stands for?
Malnutrition universal screening tool
298
Five steps to MUST?
```
BMI
Weight loss score
Acute disease effect
Overall risk of malnutrition
Management guidlines
```
299
How frequently is MUST carried out in the UK?
Upon admission to hospital and each week thereafter
300
Subjective global (SGA) assessment differs to MUST because?
Takes into account physical appearance e.g. oedema, ascites, fat stores
301
Clinical anthropometrics - two ways to assess nutrition in a patient and what are these assessing for?
Skin fold thickness (fat)
| Mid upper arm circumference (muscle)
302
Four other nutritional assessments?
Imaging - DEXA, US
Bioelectric impedance analysis
Handgrip dynamometry
303
Four laboratory investigations to assess nutrition?
Anaemia - blood
Plasma proteins
Vitamin and mineral concentrations
Immune response
304
Basal metabolic rate (BMR) is?
Obligatory energy requirements of the body in a well state when not moving
305
DIT stands for and this is?
Thermic effect of food - energy required to digest food
306
Protein requirements for adult?
52. 5g/day
| 0. 75kg/day
307
Nitrogen requirement for adult?
8.5g
308
Four indications for gastrostomy feeding?
Reduced consciousness - brain injury
Unsafe swallow - e.g. PD
Pre-head and neck cancer surgery/radiotherapy
Special e.g. CF
309
What is meant by gastrostomy?
Opening of the stomach for the provision of food
310
What is parenteral feeding?
Other than mouth and GI tract e.g. IV
311
Indications for parenteral feeding? x5
```
Intestinal obstruction
Short bowel e.g. Chron's
Small bowel fistula
Acute pancreatitis
GI motility disorders
```
312
Consequences of refeeding syndrome?
```
Hypokalaemia (drop in electrolytes)
Magnesaemjia
Phosphataemia
Thiamine deficiency
Oedema (salt retention)
```
313
Annual cost of malnutrition to NHS England?
19.6 billion
314
Can overweight patients be malnourished?
Yes
315
Underweight BMI is?
<18.5
316
Healthy BMI is?
18.5-24.5
317
Overweight BMI is?
>24.5
318
Obese BMI is?
>30
319
Three surrogate methods to measure the height of a patient?
Knee height
Demispan
Ulna length
320
Two consequences of surrogate measurements of height?
Overestimate height
| Underestimate BMI
321
Surrogate method to measure weight?
Mid upper arm circumference (MUAC)
322
MUAC for underweight individual?
<23.5
323
MUAC for overweight individual?
>32
324
Extent of mild peripheral oedema?
Ankle
325
Extent of moderate peripheral oedema?
Knee
326
Extent of severe peripheral oedema?
Sacrum
327
Three major causes of hypoalbuminemia?
Inadequate protein intake
Inflammation
Sepsis
328
Hypoalbuminemia and capillary wall relation?
Capillary walls become more porous - albumin leaks out - leads to hypoalbuminemia
329
Albumin levels of patients with anorexia nervosa?
Normal
330
Normal range of albumin?
35-50g/l
331
Who is at risk for refeeding syndrome?
Any patient with very little food intake for >5 days
332
Disadvantages of parenteral nutrition? x5
```
Risk with the placement
Risk of sepsis from catheter
Long term - disordered liver function
Risk of gut atrophy
Psychological effects
Cost
```
333
pH controls what in the body? x2
Speed of enzymatic reactions and speed of electrical reactions
334
Acid is?
H+ donor
335
Base is?
H+ acceptor
336
Acidic pH is?
<7
337
Normal blood pH?
7.35-7.45
338
Acidaemia pH?
<7.35
339
Alkalaemia pH?
>7.45
340
pH range causing death?
<6.8
| >8
341
Three methods by which H+ is continually added to the body?
Acids - breakdown of foods e.g. proteins
CO2 metabolically produced
Acids from metabolic activity e.g. lactic acid
342
Three systems to regulate pH are?
Chemical buffer
Respiratory centre in brain
Renal
343
Timescale for chemical buffer onset?
Immediate
344
Timescale for brain respiratory centre onset?
1-3 mintutes
345
Timescale for renal control of pH onset?
Hours to days
346
Three major chemical buffer systems are?
Bicarbonate
Proteins
Phosphate
347
Which system can eliminate excess acids/bases from the body?
Only the renal system
348
Anion gap is?
Difference between measured anions and cations
349
Anion is?
Negative charge
350
Cation is?
Positive charge
351
Normal anion gap range is?
8-12mEg/L (with K+)
| 12-16mEg/L (without K+)
352
What is generally excluded for the calculation of the anion gap?
Potassium
353
Causes of elevated gap acidosis?
Loss of bicarbonate
354
Causes of lack of bicarbonate x3
Severe diarrhoea
Laxative abuse
Villous adenoma
355
Causes of reduced kidney H+ excretion? x4
Ketoacidosis
Lactic acidosis
Renal failure
Toxic ingestions
356
Causes of low gap acidosis? x4
Haemorrhage
Nephrotic syndrome
Intestinal obstruction
Liver cirrhosis
357
Control of pH at the proximal convoluted tubule?
Reabsorption of all filtered bicarbonate
358
Enzyme involved in the reabsorption of bicarbonate at the proximal convoluted tubule?
Carbonic anhydrase
359
Control of pH at the distal convoluted tubule?
Active excretion of H+
360
Specialised cells at the distal convoluted tubule are?
Intercalated cells - reversed polarity
361
Two types of intercalated cells?
Alpha
| Beta
362
Alpha intercalated cells secrete and absorb?
Secrete H+
| Absorb HCO3-
363
Beta intercalated cells secrete and absorb?
Secrete HCO3-
| Absorb H+
364
Tubular cells function?
Secrete HCO3- and absorb H+ when the body is in alkalosis
365
H+ is traded for which ion?
H+
366
Unionised drug features x3
Low polarity
High lipid solubility
Can permeate the membrane
367
Ionised drug features x3
High polarity
Lower lipid solubility
Difficult to permeate the membrane
368
Cause of respiratory acidosis?
Hypoventilation
369
Cause of respiratory alkalosis?
Hyperventilation
370
Cause of metabolic acidosis? x3
Diarrhoea
Keto acidosis
Lactic acidosis
371
Cause of metabolic alkaosis x3
Vomiting
Hypokalaemia
Ingestion of HCO3-
372
One unit is how much alcohol?
10ml of pure alcohol
373
Which organ primarily metabolises alcohol?
The liver
374
Which two enzymes iare involved in the metabolism of alcohol?
Alcohol dehydrogenase
Aldehyde dehydrogenase
375
Alcohol is metabolised into what end product?
Acetate
376
Alcohol dehydrogenase enzyme results in the production of what?
Acetaldahdye
377
Four effects of alcoholic liver disease
Hepatic steatosis
Alcoholic hepatitis
Cirrhosis
Alcoholic pancreatitis
378
HCV is?
Hepatitis C
379
Two features of HCV virus?
Single stranded
| RNA
380
Presentation of acute HCV? x2
Acute
| Nonspecific e.g. lethargy, abdominal pain
381
What is cirrhosis? how is this formed?
Pathological end stage for any chronic live disease
| This is irreversible liver damage - fibrosis
382
Cells activated in cirrhosis?
Stellate cells
383
Proliferation of which cells in cirrhosis?
Fibroblasts
384
Clinical features of cirrhosis? x4
Jaundice
Melaena
Skin - spider naevi
Hands - palmar erythema
385
Three complications of cirrhosis?
Portal hypertension
Hepatorenal failure
Hepatocellular failure
386
Albumin levels in cirrhosis?
Reduced?
387
Prothrombin time in cirrhosis?
Prolonged
388
Mortality risk from liver transplant?
One year
389
Main cause of acute liver disease?
Drugs e.g. paracetamol
390
Five causes of chronic liver disease
```
Viral hep B/C
Alcoholic liver disease
Autoimmune hepatitis
Primary metabolic disorders
Hepatocellular carcinoma
```
391
Prognosis from liver transplant?
90% one year survival
| 70-85% 5 year survival
392
Definition of DM?
Chronic, non-communciable disease characterised by hyperglycaemia
393
Two causes of DM
Insulin deficiency
| Insulin resistance
394
Prevalence of diabetes in the UK?
3.5 million
395
Global prevalence of diabetes? - percentage
9%
396
Which DM is autoimmune?
DM1
397
Two causes of DM
Insulin deficiency
| Insulin resistance
398
Prevalence of diabetes in the UK?
3.5 million
399
Global prevalence of diabetes? - percentage
9%
400
Cause of DM1?
Immune T cell mediated disruption of pancreatic Beta cells in islets
Insulin deficiency
401
Treatment for DM1?
Lifelong insulin injections
402
Common age of onset of DM1?
<30 years
403
Genetics accounts for what percentage of DM1?
40-50%
404
Most common type of DM is?
DM2
405
Common characteristics of patient with DM2?
Overweight/obese
406
Two genes related to DM2 development?
GKRP
| PPARG
407
Four risk factors for DM2 development?
Obesity - BMI > 31
Family history
Increasing age
Ethnicity
408
Main cause of DM2?
Insulin resistance - insulin is being secreted but the receptors are nto responding
Lack of phosphorylation of insulin receptor
409
What type of receptor is the insulin receptor?
Tyrosine kinase
410
Why is age a risk factor for DM2?
Increased inflammation adn mitochondrial dysfunction
411
Physiological conditions causing insulin resistance x2 (non pathological)
Pregnancy
| Body weight gain
412
Cause of insulin resistance - obesity
Accumulation of lipids and free fatty acids
| Chronic inflammation
413
Causes of insulin resistance - hyperinsulinaemia
Increased lipid synthesis
414
Physiological response to non-pathological insulin resistance?
Generation of new beta cells - islet compensation
415
Two components of islet compensation? x2
Islets increase in size
| Islets increase in number
416
Five mechanisms of islet compensation?
```
Increased glucokinase activity
Increased malonyl coA
Fatty acids bind to GPR40
GLP-1 binding to receptor
Release of Ach from parasympathetic
```
417
Islet compensation in diabetics
Some people do not develop islet compensation - they then develop diabetes
418
Why do all obese people not develop diabetes?
Some will have islet compensation
419
MODY is?
Maturity onset Diabetes of the Young
| Present at birth
420
Inheritance of MODY?
Autosomal dominant
421
Prevalence of gestational diabetes in Europe?
2-6%
422
How is DM2 diagnosed? x2
One abnormal plasma glucose and presence of symptoms (>11 or >7 fasting)
OR two abnormal fasting venous plasma glucose (>7 fasting)
423
Test used to diagnose DM2?
Oral glucose tolerance test - fast and then measure blood glucose levels
424
Blood test used to diagnose DM2?
HbA1c
425
Advantages of HbA1c?
Reliable
Stable compared to glucose
Easy to sample
At patient's convenience - no need to fast
426
HbA1c level for diabetes?
48mmol/mol
427
What does HbA1c measure?
Glycation of Hb
428
Action of metformin?
Inhibition of gluconeogenesis at the liver
429
Metformin drug type?
Biguianide
430
Acetyl-coA is converted into what during long term fasting?
Ketone bodies
431
Two drugs that increase GLP-1 for DM2?
Sitagliptin - inhibits DDP-4
| Metformin - increase GLP-1
432
Hypoglycaemia defined as?
Blood glucose <3.9mmol/L
433
Five causes of hypoglycaemia
```
Alcohol excess
Insulinoma - tumour of beta cells
Excessive exercise
Reactive hypoglycaemia - high carb meal
Type 1 diabetes - injection + missed meal
```
434
Four physiological responses to hypoglycaemia?
Decreased insulin secretion
Increased glucagon secretion
Increased adrenaline secretion
Sympathetic response - behavioural - increased carbohydrate digestion
435
Two physiological responses to prolonged hypoglycaemia?
Release of growth hormone
| Release of cortisol
436
Chronic macrovascular complication of diabetes?
Atherosclerosis
437
Chronic microvascular complications of diabetes? x4
Nephropathy
Neuropathy
Retinopathy
Amputation
438
Hyperglycaemia results in the activation of what main pathway?
Protein kinase C pathawy
439
How can hyperactivation of PKCs damage blood vessels? x5
```
Increased permeability
Increased occlusion
Increased ROS
Increased inflammation
Mitochondrial dysfunction
```
440
Effect of hyperglycaemia on proteins?
Proteins can undergo post-translational modifications
441
Non-proliferative diabetic retinopathy is?
Dilatation of the retinal veins and microaneurysms cause haemorhage and oedema
442
Proliferative diabetic retinopathy is?
Growth of fragile new blood vessels from the optic disc - these then bleed and lead to detachment of the retina
443
When does retinopathy typically occur in a diabetic?
After 20 years of poorly controlled diabetes
444
Diabetic nephropathy - damage to the blood vessels are where?
Glomerulus
445
Prevalence of diabetic nephropathy amongst patients with diabetes?
One third of diabetic patients
446
Signs of diabetic nephroprathy x4
Proteinuria
Glomerular hypertrophy
Decreased glomerular filtration
Renal fibrosis
447
Four types of diabetic neuropathy?
Peripheral
Autonomic
Proximal
Focal
448
What percentage of diabetics develop some form of neuropathy?
60-70%
449
Three examples of autonomic neuropathy in a diabetic?
Changes in digestion, bowel and bladder control
Erectile dysfunction
Affect cardiac nerves
450
Proximal neuropath in a diabetic causes pain and weakness where? x3
Pain in thighs
Pain in hips
Weakness in legs
451
Peripheral diabetic neuropathy affects what?
Hands
Arms
Feet
Legs
Loss of feeling
452
Consequences of macrovascular complications in a diabetic? x3
Cerebrovascular disease - stroke
Heart disease - MI
Peripheral vascular disease - ulcers, gangrenes, amputations
453
Main centre for appetite control in the brain is the?
Arcuate nucleus
454
Arcuate nucleus is located where?
In the hypothalamus
455
Orexigenic means?
Appetite stimulating
456
Anorexigenic means?
Appetite suppressing
457
Three orexigenic neurotransmitters?
NPY
AgRP
MCH
458
Two anorexigenic neurotransmitters?
POMC - proopiomelanocortin - MAIN ONE THAT IS IMPORTANT
| CART
459
POMC binds to which receptor?
MCR4
460
Deficiency in POMC can lead to?
Obesity
461
Deletion/mutation in the MCR4 receptor in humans and mice can result in?
Obesity
462
MCR4 mutations accounts for what percentage of severe childhood obesity?
5%
463
MCR4 mutations accounts for what percentage of adult obesity?
0.5-2.5%
464
Serotonin is orexigenic or anorexigenic?
Anorexigenic
465
Two receptors that serotonin acts on?
Htr1b
| HTr2c
466
Effect of serotonin on the neurotransmitters for appetite?
Increased POMC
| Decrease NPY
467
Main anorexigenic neurotransmitter is?
POMC
468
Htr1b serotonin receptor - whcih neurotransmitter system?
AgRP
469
HTr2C serotonin receptor - which neurtrotransmitter system?
POMC
470
Effect of ghrelin on appetite?
Orexigenic
471
Ghrelin has an effect on which neurotransmitter?
NPY
472
Nerve associated with ghrelin?
Vagus nerve
473
Where is PYY 3-36 released from?
Gut
474
When is PYY 3-36 released?
When there is something in the gut
475
PYY 3-36 has an effect on?
NPY and POMC in hypothalamus
476
Effect of PYY 3-36 on appetite regulation?
Anorexigenic - suppress NPY
477
Where is GLP-1 produced and which cells?
Small intestine - L cells
478
Effect of GLP-1 on appetite regulation?
Anorexigenic
479
Where is ghrelin released from?
The stomach
480
Cholecystokinin (CCK) is released from which two organs?
Duodenum
| Small intestine
481
Cells that released CCK are?
Enterendocrine cells
482
Effect of CCK on appetite regulation?
Anorexigeni
483
Leptin is a hormone secreted from where?
Adipose tissue
484
Effect of leptin on appetite regulation?
Anorexigenic
485
Effect of leptin on teh appetite regulatory neurotransmitters?
Drops AGRP levels
486
Effect of insulin on appetite regulation?
Anorexigenic
487
Effect of leptin on the appetite regulatory neurotransmitters?
Drops AGRP levels
488
Leptin resistance is?
Ignorance of the effect of leptin - ceases to have an appetite supprsesing effect
489
Role of malonyl coA in appetite regulation?
Controller of appetite linked to fatty acid metabolism
490
The levels of Malonyl coA is controlled by what three factors?
AMPK enzyme
AMP/ATP ratio
Calcium regulated - ghrelin
491
High levels of malonyl coA have what effect on appetite?
Appetite suppressing - anorexigenic
492
Effect of cannabinoids on appetite regulation?
Increase appetite adn food consumption
493
Cannabinoid receptor expressed in the hypothalamus is?
CB1
494
Effects of SSRIs/5-HT on appetite regulation?
Appetite suppressing
495
Current most successful appetite suppressing therapeutic?
GLP-1 agonist
