Overview Flashcards
Four muscles of the anterior abdominal wall are?
External oblique
Internal oblique
Transverse abdominis
Rectus abdominis - vertical
Rectus sheath is formed by?
Aponeurosis of the three layers of muscle of anterior abdominal wall
Linea alba is?
Where the anterior abdominal wall muscles meet
Inguinal ligament is formed by?
Free border of the external oblique
Rectus abdominis runs enclosed in what?
Rectus sheath
Vessels running in the rectus sheath are?
Epigastric vessels - superior and inferior
Arcuate line is?
Inferior epigastric artery perforates this to leave the rectus sheath superiorlyM
Inferior epigastric artery originates from which artery?
External iliac
Superior epigastric artery originates from which artery?
Internal thoracic
McBurney’s point is?
One third from asis to the umbilicus
McBurney’s point is landmark for?
Appendix
Umbilicus is at what vertebral level?
T10
Xiphoid is at what vertebral level?
T7
Where do the testes develop?
Posterior abdominal wall next to the kidneys
Most anterior layer of the testes is?
Tunica vaginalis
Inguinal canal is?
Through here is descent of the testes during development from posterior to anterior
The testes lies between which two layers?
Peritoneum
Transversalis fascia
Contents of the spermatic cord are? x3
Testicular vessels
Ilioinguinal nerve
Genitofemoral nerve
Conjoint tendon formed from what? x2
Transversalis abdominis
Internal oblique
Spermatic cord is composed of? x4
Transversalis fascia
Internal oblique muscle
External oblique muscle
Superficial fascia
Innervation of the dartos muscle is?
Genitofemoral nerve
Nerve root of genitofemoral nerve is?
L1 and L2
Function of dartos muscle is? x2
Ruggae formation
Temperature control
Innervation of the cremaster muscle is?
L1 and L2
Function of the cremaster muscle is? x1
Cremaster reflex
Cremaster reflex innervation?
Genito - motor part causes movement
Femoral - sensory to the thigh
Direct inguinal hernia is through?
Hassleback’s triangle - orange anatomy booklet look at
Indirect inguinal hernia is through?
Inguinal canal into the scrotum
Inguinal hernias direct/indirect are either lateral or medial to which artery?
Inferior epigastric artery
Where is the deep inguinal ring located?
Midpoint of the inguinal ligament
Inguinal canal contains what in females? x2
Round ligament of the uterus
Ilioinguinal nerve
Inguinal canal contains what in males? x2
Spermatic cord
Ilioinguinal nerve
When does the external iliac artery become the femoral artery?
Past the inguinal ligament
What is the muscle seen most anterior on a CT at level L2?
Rectus abdominis
Caudate lobe of the liver is anterior or posterior?
Posterior
Quadrate lobe of the liver is anterior or posterior?
Anterior
Three components of the portal triad are?
Bile duct
Hepatic artery proper
Portal vein
What should be compressed to prevent a hepatic bleed?
Components of the portal triad
What is the Pringle manoeuvre?
Large clamp of the hetatoduodenal ligament to prevent bleeding from the liver
Hepatoduodenal ligament is in close relation to whcih three structures?
Liver
Duodenum
Gallbladder
Blood supply to the liver is via which artery?
Coeliac trunk
Hepatic portal vein is formed from?
Splenic vein
Superior mesenteric vein
Hepatic portal vein forms where?
Posterior to the head of the pancreas
Where does the inferior mesenteric vein join?
Joins to the splenic vein
What is liver cirrhosis?
Fibrosis of liver tissue
Three causes of live cirrhosis?
Alcoholic liver disease
Metastases
Heart failure
Normal portal pressure is?
9mmHg
Pressure in the IVC?
2-6mmHg
Portal pressure gradient is?
Pressure difference between portal pressure and pressure in the IVC
Portal hypertension is?
When portal pressure gradient is >10mmHg
Consequence of portal hypertension is?
Splenomegaly
Oesopageal varices are due to anastoses between which arteries?
Oesophageal vein and left gastric vein
Ascites is?
Excess fluid in the peritoneal space
Two main causes of ascites?
Portal hypertension
Hypoalbuminemia
Blood supply above and below the pectinate line is?
Superior rectal artery
Inferior rectal artery
Innervation above and below pectinate line is?
Inferior hypogastric plexus
Inferior rectal nerves from pudendal nerves
Epithelium above and below pectinate line is?
Columnar
Stratified squamous
Common bile duct (of biliary tree) drains into?
The major duodenal papilla
Bile is secreted by which organ?
The liver
Function of gall bladder?
Concentration of bile
Murphy’s test tests for?
Inflamed gall bladder
Inflamed gall bladder is known as?
Cholecystitis
Blood supply to the gallbladder is?
Cystic artery
Cystic artery runs through which triangle?
Calot’s triangle
Duct joining onto the pancreatic duct is?
Accessory pancreatic duct
Gallstones most likely to get lodged where?
(Distal end of hepatopancreatic) ampulla
What is the ampulla of Vater?
Where the pancreatic duct and the common bile duct meet
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
Pancreas is retro or intraperitoneal?
Retroperitoneal
Blood supply to the pancreas is?
Splenic artery from the coeliac trunk
Blood supply to the head of the pancreas is? x2
Superior and inferior pancreatoduodenal arteries
Superior pancreatoduodenal artery origin?
Gastroduodenal artery
Inferior pancreatoduodenal artery origun?
Superior mesenteric artery
Pancreatic duct opens into where?
Major duodenal papilla
Accessory pancreatic duct opens into where?
Minor duodenal papilla
Relation of IVC to liver?
IVC passes through the posterior region of the liver
Fundus of gallbladder is at which vertebral level?
L1
Liver metastasis is common from the GI tract why?
Due to drainage via the portal veins from the GI tract to the liver
Swelling of what would occur with gastric tumour?
Swelling of Virchow’s node
Nutmeg liver is?
Congestion of the liver - accumulation of RBCs
Surrounding the major duodenal papilla is?
Sphincter of Oddi
Origin of cystic artery is?
Left hepatic artery
Endocrine vs. exocrine
Endocrine - secrete straight into the blood
Exocrine - secrete into duct
Cushing’s syndrome is?
Excess levels of cortisol - symptoms of this
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
Pituitary gland sits where and in which bone?
In sella turcica of the sphenoid bone
Infundibulum is?
Pituitary stalk - between posterior pituitary and the hypothalamus
Cells of anterior pituitary are?
Secretory
Cells of posterior pituitary are?
Neuronal
Blood supply to the anterior pituitary?
Superior hypophyseal artery
Origin of superior hypophyseal artery?
Internal carotid artery
Communication between pituitary gland adn the hypothalamus is?
What is transmitted through this system?
Hypothalamo-hypophyseal portal system
Blood - contains neurotransmitters
Blood supply to the posterior pituitary and the infundibulum? x3
Superior hypophyseal artery
Inferior hypophyseal artery
Infundibular artery
Hormones released by the anterior pituitary? x7
ACTH TSH LH FSH PRL GH MSH
Hormones secreted by the posterior pituitary x2?
ADH
Oxytocin
Two components of the adrenal gland?
Adrenal cortex
Adrenal medulla
Adrenal cortex secretes which hormones? x3
Aldosterone
Cortisole
Corticosterone
Adrenal medulla secretes which hormones? x2
Adrenaline
Noradrenaline
Three zones of the adrenal cortex?
Cortex
Zona glomerulosa - mineralocorticoid aldosterone
Zona fasciculata - glucocorticoid cortisol
Zona reticularis - androgen testosterone
Medulla
Shape of the right adrenal gland is?
Pyramidal
Shape of the left adrenal gland is?
Crescent
Blood supply to the adrenal glands? x3
Superior suprarenal arteries
Middle suprarenal artery
Inferior suprarenal artery
Origin of superior suprarenal artery
Inferior phrenic artery
Origin of middle suprarenal artery
Abdominal aorta - by the SMA
Origin of inferior suprarenal artery
Renal artery
Venous drainage from the adrenal gland is?
Large suprarenal vein
Suprarenal vein drains to where on the right hand side?
IVC
Suprarenal vein drains to where on the left hand side?
Left renal vein
Four strap muscles are?
Thyrohyoid
Sternothyroid
Omohyoid
Sternohyoid
What is the largest strap muscle?
Sternohyoid - left side
What level is the thyroid gland?
C5-T1
Three components of the thyroid gland?
Left lobe
Right lobe
Isthmus
Blood supply to the thyroid is via? x2
Superior thyroid artery
Inferior thyroid artery
Origin of superior thyroid artery is?
External carotid artery
Origin of inferior thyroid artery is?
Subclavian artery
Superior thyroid vein drains into?
Internal jugular vein
Middle thyroid vein drains into?
Internal jugular vein
Inferior thyroid vein drains into?
Brachiocephalic vein
Nerves surrounding thyroid gland which could be damaged in surgery?
Recurrent laryngeal nerves
How many parathyroid glands?
Four
Five regions of the pancreas are?
Tail Body Neck Head Ulcinate process
Bile is produced by which organ?
Liver
Bile is secreted when?
Upon consumption of food
How can the omohyoid muscle be recognised?
This is the one that loops and curves as it comes inferiorly down
What is the relation of the recurrent laryngeal nerve to the common carotid artery?
Runs medially to the common carotid
What is the relation of the vagus nerve to the common carotid artery?
Runs laterally to the common carotid
Where does the phrenic nerve run in relation to the aortic arch?
Between the aortic arch (lateral) and the lung (medial)
Which kidney is the most inferior?
Right (liver)
What vertebral level are the kidneys?
12th rib
What is the significance of the renal angle and where is this?
Inferior border of the 12th rib
Examine for tenderness here - kidneys/intestines
What is Morrison’s pouch?
Hepatorenal recess
What is Gerota’s fascia?
Renal fascia - the kidneys have their own fascia
What is the significance of Gerota’s fascia?
This is one of the last reserves of fat to be digested
Innervation to the kidneys is from which nerve roots?
Renal plexus T10-T12
What are the different divisions of the kidney?
Pelvis
Major calyx
Minor calyx
Where do the renal arteries leave the aorta?
L2
Where is the renal vein?
L2
Division of the different renal arteries?
Renal artery
Segmental arteries
Interlobar arteries
Interlobular arteries
How many lobar arteries are there per renal pyramid?
One lobar artery per renal pyramid
What is the cardiac output to the kidneys?
1/4 of the cardiac output - 1200ml/min
How do varicose testicular veins relate to the kidney?
A tumour in the renal vein can block the testicular vein and cause varicose veins
What does the ovarian artery/vein relate to in the male?
Testicular vein
Where does the testicular vein drain to?
Renal vein
Where does the ovarian vein drain to (left and right)?
Left - renal vein
Right - IVC
What is the origin of the ovarian/testicular artery?
Aorta - vertebral level L2 (just inferior to renal artery)
What are the three layers of the ureter wall?
Transitional epithelial mucosa
Smooth muscle muscularis
Fibrous connective tissue andventitia
Where are the three msot likely places for a kidney stone to lodge?
Pelvo-uritary junction
Cystouretic junction
Pelvic brim
What are the three nerves involved in sensation of the ureters?
Ilioinguinal and iliohypogastric
Genitofemoral
Three layers of the bladder are?
Transitional epithelial mucosa
Thick muscular - detrousa muscle
Fibrous adventitia
What is the trigone?
Triangular area of the bladder outlined by the openings for the ureters and the urethra
Why is the trigone clinically important?
Infections tend to persist in this region
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
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
Which of the urethral sphincters are voluntary/involuntary?
Internal - involuntary
External - voluntary
Which muscle assists the external urethral sphincter?
Levator ani muscle
How can you recognise the left renal vein on an L2 CT?
Long shape
Crosses the aorta to join onto the IVC
Give the give nerves of the lumbar plexus
Subcostal nerve Iliohypogastric nerve Ilioinguinal nerve Genitofemoral nerve Lateral cutaneous nerve Femoral nerve Obturator nerve
What is the biggest nerve of the lumbar plexus?
Femoral nerve
Trigone is made up from?
Two ureters (female)/uretic orifice (male) Urethra
Origin of uterine artery is?
Internal iliac artery
Normal blood glucose level is?
3.5-5mmol/L
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
Two substrates the brain can use for metabolism are?
Glucose
ketone bodies
Alpha cells of the pancreas produce?
Glucagon
Beta cells of the pancreas produce?
Insulin
Delta cells of the pancreas produce?
Somatostatin
PP cells of the pancreas produce?
Pancreatic polypeptide
Epsilon cells of the pancreas produce?
Ghrelin
Endocrine portion makes up what percentage of the pancreas?
2%
Three step process in the production of insulin?
Preproinsulin
Proinsulin
Insulin
Preproinsulin composed of how many amino acids?
110
Proinsulin composed of how many amino acids?
86
Insulin composed of how many amino acids?
51
Proinsulin cleaved to form what in the production of insulin?
Insulin - 51 amino acids
C-peptide - 35 amino acids
When does insulin synthesis occur?
Only when increased levels of insulin are required
Glucose enters beta cells through which transporter?
GLUT1
What enzyme is the glucose sensor for insulin secretion in beta cells?
Glucokinase
When is insulin secreted?
When glucose levels exceed 5mM
Is insulin constantly synthesised?
No
Glycolysis: glucose is converted to what?
Glucose-6-phosphate
Glycolysis: glucose-6-phosphate is converted into what?
Pyruvate
Pyruvate is metabolised via which cycle?
Krebs
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
Entry of glucose into the beta cell has what effect on the membrane?
Membrane depolarisation
Entry of glucose into the beta cell has what effect on K+ channels?
Closure of K+ channels
K+ channels at the membrane of the beta cell are normally opened or closed?
Open
Membrane depolarisation and closure of K+ channels in the beta cell results in what? x2
Opening of voltage gated Ca2+ channels - insulin secretion
Beta cells release insulin in how many phases?
Two
Describe the first phase of insulin release
Rapid release to rapidly increase blood glucose levels
Describe the second phase of insulin release
Sustained, slow release of newly formed vesicles
Stored insulin is released in the first or the second stage?
First
Newly synthesised insulin is released in the first or the second stage?
Second
Two amino acids that trigger insulin release?
Arginine
Leucine
Hormone that triggers insulin release?
GLP-1
Peptide that triggers insulin release?
GIP
Acid that triggers insulin release?
Fatty acids
Neurotransmitters that trigger insulin release? x2
Acetylcholine
CCK
How can arginine cause insulin release?
Directly depolarise the membrane
How can leucine cause insulin release?
Activation of glutamate dehydrogenase (GDH) and KIC
What is the receptor that GLP-1 acts on to cause insulin release?
GLP-1R
What is the receptor that free fatty acids act on to cause insulin release?
GPR40
What type of receptor is the insulin receptor?
Transmembrane tyrosine kinase receptor
What are the two subunits of the IR?
Intracellular beta subunit
Extracellular alpha subunit
Where does insulin bind to the IR?
Extracellular alpha subunit
What is glucose converted to in muscles?
Glycogen
Location of GLUT2
Pancreas
Liver
Small intestine
Kidney
Location of GLUT3
Brain
Testes
Location of GLUT4
Muscle
Fat
Heart
GLUT1 location
Ubiquitous e.g. beta cells
Akt is?
Protein kinase B
Three functions of Akt?
Translocation of GLUT4 to the plasma membrane
Phosphorylation of glycogen synthase kinase
Inactivation of glycogen synthase kinase
Overall function of Akt?
Increased glucose transport and glycogen synthesis
Effect of insulin at adipocytes? x3
Stimulates glucose uptake
Stimulates lipogenesis
Inhibits lipolysis
Insulin inhibits which enzyme at adipocytes?
Lipase
Four functions of insulin at the liver
Enhances glucose uptake - glucokinase
Increases glycogen synthesis
Increases lipogenesis
Inhibits gluconeogenesis
Function of glucokinase is?
Glucose to glucose-6-phosphate
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
Why does insulin increased amino acid uptake?
To inhibit gluconeogenesis
Amino acids are the main substrate for glucose synthesis
During fasting, glucose metabolism is prioritised to which organ?
The brain
Two substrates for gluconeogenesis are?
Amino acids
Glycerol
Acetyl-CoA is converted into what during long term fasting?
Ketone bodies
What can be used for gluconeogensis in anaerobic conditions adn via what pathway?
Lactate
Cori cycle
Where does the cori cycle occur?
Liver
Two enzymes that can reduce the activity of insulin are?
Serine kinase
Threonine kinase
Two consequences of insulin resistance?
Hyperglycaemia
Dyslipidaemia
At what blood glucose level is inuslin secreted?
Blood glucose > 5mmol/L
What is the hormone responsible for blood glucose level maintenance during fasting?
Glucagon
Alpha cells secrete?
Glucagon
Beta cells secrete?
Insulin
Delta cells secrete?
Somatostatin
PP cells secrete?
Pancreatic polypeptide
Epsilon cells secrete?
Ghrelin
Glucagon is how many amino acids long?
29 aa
Glucagon is composed of how many chains?
One
Insulin is composed of how many chains?
Two
Stages of glucagon synthesis are?
Preproglucagon
Proglucagon
Glucagon
Two amino acids that can result in the release of glucagon?
Alanine
Arginine
Three factors that can stimulate glucagon secretion?
Reduced blood glucose concentration < 3.5mmol/L
Increased blood amino acids especially alanine and arginine
Increased exercise
Exercise can increased glucagon secretion to what extent?
Increases four to five fold
What type of receptor is the glucagon receptor?
G-protein coupled receptors
How many times does the glucagon receptor span the membrane?
Seven times
What does the glucagon receptor activate upon glucagon binding? Give the three stages
Adeno-cyclase
This activates cAMP
This activates protein kinase A
Increased glucagon binding to its receptor results in the overall secretion of what?
Protein kinase A
Three functions of glucagon at the liver
Increased amino acid uptake for gluconeogenesis
Ihibition of PFK-1
Inhibition of pyruvate kinase
Two enzymes involved in gluconeogenesis in the liver?
Pyruvate kinase
Phosphate kinase
Enzyme that breaks down triglycerides is?
Lipase
Effect of insulin on lipase?
Inhibition
Effect of glucagon on lipase?
Activation
Triglycerides are broken down to?
Fatty acids and glycerol
Fatty acids and glycerol - how are these used for metabolism?
Fatty acids - acetyl coA for ATP synthesis
Glycerol - glycolysis
What is the role of the carnitine shuttle?
Allows the beta oxidation of fatty acids
Carnitine shuttle requires which enzyme?
CPT-1
Which hormone activates CPT-1
Glucagon
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
Two hormones that inhibit the release of glucagon?
Insulin
Somatostatin
How long does the glycogen reserve typically last?
24 hours
Catecholaimes are? x2
Noradrenaline
Adrenaline
Catecholamines are secreted from where?
Adrenal medulla
Catecholamines are released in response to? x2
Stress
Hypoglycaemia
Catecholamines are synthesised from which two amino acids?
Phenylalanine
Tyrosine
Function of adrenaline on blood glucose levels?
Same effect as glucagon - inhibits insulin secretion and stimulates glycogenolysis
Alternative name for adrenaline?
Epinephrine
Glucocorticoids are what type of hormone?
Steroid hormones
Overall effect of catechoalimes?
Increases blood glucose and fatty acid levels
Name a glucocorticoid
Cortisol
Cortisol is secreted in response to what?
ACTH
Four effects of cortisol on blood glucose regulation?
Enhances gluconeogenessis
Inhibits glucose uptake and utilisation
Stimulates muscle proteolysis
Stimulates adipose-tissue lipolysis
Overall function of cortisol
Rapid mobilisation of amino acids and fatty acids from cellular stores
Two other functions of cortisol are?
Maintenance of BP
Suppression of inflammation
Long term elevated cortisol levels can result in? x2
Proteolysis
Muscle wasting
Glucocorticoids are released by which part of the kidney?
Zona fasciculatat of the adrenal cortex
Growth hormone has an effect on which three tissues/organs?
Adipose tissue
Skeletal muscle
Liver
Name of T3 thyroid hormone?
Triiodothyronine
Name of T4 thyroid hormone?
Thyroxine
Thyroid hormones activate what type of receptors and roll of this??
Nuclear receptors - activates transcription of large number of genes
T3/T4 - which is more potent and by what amount?
T3 is more potent than T4 - about four times more
T3/T4 - which is more rapidly acting?
T3
T3 - action of duration is how long?
10-12 days
T4 - action of duration is how long?
2-3 days
Three specific functions of the thyroid hormone are?
Increased number adn activitiy of mitochondria
Stimulates carbohydrate metabolism
Stimulats fat metabolism
Overall action of thyroid hormones?
Increase the basal metabolic rate
Incretins are what type of hormone?
GI hormones
Two most common incretins are?
Glucagon like peptide-1 (GLP-1)
Gastric inhibitory peptide (GIP)
Incretins effect on blood glucose control?
Increase insulin synthesis
Actions of GLP-1
Promotes satiety
Slows gastric emptying
Inhibits glucagon secretion
Stimulates insulin
Undernutrition is?
Malnutrition due to reduced supply of food or inability to digest, assimilate and utilise necessary nutrients
What are macronutrients?
Nutrients required in high quantities e.g. protein
What are micronutrients?
Nutrients required in lower quantities e.g. calcium, iron, manganese
Prevalence of undernutrition in the UK?
5%
2-3 million
Most vulnerable to undernutrition? x5
Chronic diseases Elderly Recently discharged from hospital Low income Socially isolated
Four consequences of undernutrition in the community?
Falls
Depression
Infection
Dependency
Five consequences of undernutrition in hospital?
Increased morbidity Increased length of stay Increased dependency Increased mortality Increased costs of care`
Reduced nutritional intake causes of undernutrition?
Anorexia Treatment side effects Pain Dysphagia Physical disability Nil by mouth
Increased nutritional requirements causing undernutrition?
Inflammation/infection
Pyrexia
Tissue healing
Metabolic effects
Increased nutritional losses causing undernutrition?
Malabsorption
Would exudate/burns
Consequences of undernutrition?
Decreased muscle mass Organ failure Apathy Change in behaviour/personality Bedridden Depression Fatigue
MUST stands for?
Malnutrition universal screening tool
Five steps to MUST?
BMI Weight loss score Acute disease effect Overall risk of malnutrition Management guidlines
How frequently is MUST carried out in the UK?
Upon admission to hospital and each week thereafter
Subjective global (SGA) assessment differs to MUST because?
Takes into account physical appearance e.g. oedema, ascites, fat stores
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)
Four other nutritional assessments?
Imaging - DEXA, US
Bioelectric impedance analysis
Handgrip dynamometry
Four laboratory investigations to assess nutrition?
Anaemia - blood
Plasma proteins
Vitamin and mineral concentrations
Immune response
Basal metabolic rate (BMR) is?
Obligatory energy requirements of the body in a well state when not moving
DIT stands for and this is?
Thermic effect of food - energy required to digest food
Protein requirements for adult?
- 5g/day
0. 75kg/day
Nitrogen requirement for adult?
8.5g
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
What is meant by gastrostomy?
Opening of the stomach for the provision of food
What is parenteral feeding?
Other than mouth and GI tract e.g. IV
Indications for parenteral feeding? x5
Intestinal obstruction Short bowel e.g. Chron's Small bowel fistula Acute pancreatitis GI motility disorders
Consequences of refeeding syndrome?
Hypokalaemia (drop in electrolytes) Magnesaemjia Phosphataemia Thiamine deficiency Oedema (salt retention)
Annual cost of malnutrition to NHS England?
19.6 billion
Can overweight patients be malnourished?
Yes
Underweight BMI is?
<18.5
Healthy BMI is?
18.5-24.5
Overweight BMI is?
> 24.5
Obese BMI is?
> 30
Three surrogate methods to measure the height of a patient?
Knee height
Demispan
Ulna length
Two consequences of surrogate measurements of height?
Overestimate height
Underestimate BMI
Surrogate method to measure weight?
Mid upper arm circumference (MUAC)
MUAC for underweight individual?
<23.5
MUAC for overweight individual?
> 32
Extent of mild peripheral oedema?
Ankle
Extent of moderate peripheral oedema?
Knee
Extent of severe peripheral oedema?
Sacrum
Three major causes of hypoalbuminemia?
Inadequate protein intake
Inflammation
Sepsis
Hypoalbuminemia and capillary wall relation?
Capillary walls become more porous - albumin leaks out - leads to hypoalbuminemia
Albumin levels of patients with anorexia nervosa?
Normal
Normal range of albumin?
35-50g/l
Who is at risk for refeeding syndrome?
Any patient with very little food intake for >5 days
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
pH controls what in the body? x2
Speed of enzymatic reactions and speed of electrical reactions
Acid is?
H+ donor
Base is?
H+ acceptor
Acidic pH is?
<7
Normal blood pH?
7.35-7.45
Acidaemia pH?
<7.35
Alkalaemia pH?
> 7.45
pH range causing death?
<6.8
>8
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
Three systems to regulate pH are?
Chemical buffer
Respiratory centre in brain
Renal
Timescale for chemical buffer onset?
Immediate
Timescale for brain respiratory centre onset?
1-3 mintutes
Timescale for renal control of pH onset?
Hours to days
Three major chemical buffer systems are?
Bicarbonate
Proteins
Phosphate
Which system can eliminate excess acids/bases from the body?
Only the renal system
Anion gap is?
Difference between measured anions and cations
Anion is?
Negative charge
Cation is?
Positive charge
Normal anion gap range is?
8-12mEg/L (with K+)
12-16mEg/L (without K+)
What is generally excluded for the calculation of the anion gap?
Potassium
Causes of elevated gap acidosis?
Loss of bicarbonate
Causes of lack of bicarbonate x3
Severe diarrhoea
Laxative abuse
Villous adenoma
Causes of reduced kidney H+ excretion? x4
Ketoacidosis
Lactic acidosis
Renal failure
Toxic ingestions
Causes of low gap acidosis? x4
Haemorrhage
Nephrotic syndrome
Intestinal obstruction
Liver cirrhosis
Control of pH at the proximal convoluted tubule?
Reabsorption of all filtered bicarbonate
Enzyme involved in the reabsorption of bicarbonate at the proximal convoluted tubule?
Carbonic anhydrase
Control of pH at the distal convoluted tubule?
Active excretion of H+
Specialised cells at the distal convoluted tubule are?
Intercalated cells - reversed polarity
Two types of intercalated cells?
Alpha
Beta
Alpha intercalated cells secrete and absorb?
Secrete H+
Absorb HCO3-
Beta intercalated cells secrete and absorb?
Secrete HCO3-
Absorb H+
Tubular cells function?
Secrete HCO3- and absorb H+ when the body is in alkalosis
H+ is traded for which ion?
H+
Unionised drug features x3
Low polarity
High lipid solubility
Can permeate the membrane
Ionised drug features x3
High polarity
Lower lipid solubility
Difficult to permeate the membrane
Cause of respiratory acidosis?
Hypoventilation
Cause of respiratory alkalosis?
Hyperventilation
Cause of metabolic acidosis? x3
Diarrhoea
Keto acidosis
Lactic acidosis
Cause of metabolic alkaosis x3
Vomiting
Hypokalaemia
Ingestion of HCO3-
One unit is how much alcohol?
10ml of pure alcohol
Which organ primarily metabolises alcohol?
The liver
Which two enzymes iare involved in the metabolism of alcohol?
Alcohol dehydrogenase
Aldehyde dehydrogenase
Alcohol is metabolised into what end product?
Acetate
Alcohol dehydrogenase enzyme results in the production of what?
Acetaldahdye
Four effects of alcoholic liver disease
Hepatic steatosis
Alcoholic hepatitis
Cirrhosis
Alcoholic pancreatitis
HCV is?
Hepatitis C
Two features of HCV virus?
Single stranded
RNA
Presentation of acute HCV? x2
Acute
Nonspecific e.g. lethargy, abdominal pain
What is cirrhosis? how is this formed?
Pathological end stage for any chronic live disease
This is irreversible liver damage - fibrosis
Cells activated in cirrhosis?
Stellate cells
Proliferation of which cells in cirrhosis?
Fibroblasts
Clinical features of cirrhosis? x4
Jaundice
Melaena
Skin - spider naevi
Hands - palmar erythema
Three complications of cirrhosis?
Portal hypertension
Hepatorenal failure
Hepatocellular failure
Albumin levels in cirrhosis?
Reduced?
Prothrombin time in cirrhosis?
Prolonged
Mortality risk from liver transplant?
One year
Main cause of acute liver disease?
Drugs e.g. paracetamol
Five causes of chronic liver disease
Viral hep B/C Alcoholic liver disease Autoimmune hepatitis Primary metabolic disorders Hepatocellular carcinoma
Prognosis from liver transplant?
90% one year survival
70-85% 5 year survival
Definition of DM?
Chronic, non-communciable disease characterised by hyperglycaemia
Two causes of DM
Insulin deficiency
Insulin resistance
Prevalence of diabetes in the UK?
3.5 million
Global prevalence of diabetes? - percentage
9%
Which DM is autoimmune?
DM1
Two causes of DM
Insulin deficiency
Insulin resistance
Prevalence of diabetes in the UK?
3.5 million
Global prevalence of diabetes? - percentage
9%
Cause of DM1?
Immune T cell mediated disruption of pancreatic Beta cells in islets
Insulin deficiency
Treatment for DM1?
Lifelong insulin injections
Common age of onset of DM1?
<30 years
Genetics accounts for what percentage of DM1?
40-50%
Most common type of DM is?
DM2
Common characteristics of patient with DM2?
Overweight/obese
Two genes related to DM2 development?
GKRP
PPARG
Four risk factors for DM2 development?
Obesity - BMI > 31
Family history
Increasing age
Ethnicity
Main cause of DM2?
Insulin resistance - insulin is being secreted but the receptors are nto responding
Lack of phosphorylation of insulin receptor
What type of receptor is the insulin receptor?
Tyrosine kinase
Why is age a risk factor for DM2?
Increased inflammation adn mitochondrial dysfunction
Physiological conditions causing insulin resistance x2 (non pathological)
Pregnancy
Body weight gain
Cause of insulin resistance - obesity
Accumulation of lipids and free fatty acids
Chronic inflammation
Causes of insulin resistance - hyperinsulinaemia
Increased lipid synthesis
Physiological response to non-pathological insulin resistance?
Generation of new beta cells - islet compensation
Two components of islet compensation? x2
Islets increase in size
Islets increase in number
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
Islet compensation in diabetics
Some people do not develop islet compensation - they then develop diabetes
Why do all obese people not develop diabetes?
Some will have islet compensation
MODY is?
Maturity onset Diabetes of the Young
Present at birth
Inheritance of MODY?
Autosomal dominant
Prevalence of gestational diabetes in Europe?
2-6%
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)
Test used to diagnose DM2?
Oral glucose tolerance test - fast and then measure blood glucose levels
Blood test used to diagnose DM2?
HbA1c
Advantages of HbA1c?
Reliable
Stable compared to glucose
Easy to sample
At patient’s convenience - no need to fast
HbA1c level for diabetes?
48mmol/mol
What does HbA1c measure?
Glycation of Hb
Action of metformin?
Inhibition of gluconeogenesis at the liver
Metformin drug type?
Biguianide
Acetyl-coA is converted into what during long term fasting?
Ketone bodies
Two drugs that increase GLP-1 for DM2?
Sitagliptin - inhibits DDP-4
Metformin - increase GLP-1
Hypoglycaemia defined as?
Blood glucose <3.9mmol/L
Five causes of hypoglycaemia
Alcohol excess Insulinoma - tumour of beta cells Excessive exercise Reactive hypoglycaemia - high carb meal Type 1 diabetes - injection + missed meal
Four physiological responses to hypoglycaemia?
Decreased insulin secretion
Increased glucagon secretion
Increased adrenaline secretion
Sympathetic response - behavioural - increased carbohydrate digestion
Two physiological responses to prolonged hypoglycaemia?
Release of growth hormone
Release of cortisol
Chronic macrovascular complication of diabetes?
Atherosclerosis
Chronic microvascular complications of diabetes? x4
Nephropathy
Neuropathy
Retinopathy
Amputation
Hyperglycaemia results in the activation of what main pathway?
Protein kinase C pathawy
How can hyperactivation of PKCs damage blood vessels? x5
Increased permeability Increased occlusion Increased ROS Increased inflammation Mitochondrial dysfunction
Effect of hyperglycaemia on proteins?
Proteins can undergo post-translational modifications
Non-proliferative diabetic retinopathy is?
Dilatation of the retinal veins and microaneurysms cause haemorhage and oedema
Proliferative diabetic retinopathy is?
Growth of fragile new blood vessels from the optic disc - these then bleed and lead to detachment of the retina
When does retinopathy typically occur in a diabetic?
After 20 years of poorly controlled diabetes
Diabetic nephropathy - damage to the blood vessels are where?
Glomerulus
Prevalence of diabetic nephropathy amongst patients with diabetes?
One third of diabetic patients
Signs of diabetic nephroprathy x4
Proteinuria
Glomerular hypertrophy
Decreased glomerular filtration
Renal fibrosis
Four types of diabetic neuropathy?
Peripheral
Autonomic
Proximal
Focal
What percentage of diabetics develop some form of neuropathy?
60-70%
Three examples of autonomic neuropathy in a diabetic?
Changes in digestion, bowel and bladder control
Erectile dysfunction
Affect cardiac nerves
Proximal neuropath in a diabetic causes pain and weakness where? x3
Pain in thighs
Pain in hips
Weakness in legs
Peripheral diabetic neuropathy affects what?
Hands
Arms
Feet
Legs
Loss of feeling
Consequences of macrovascular complications in a diabetic? x3
Cerebrovascular disease - stroke
Heart disease - MI
Peripheral vascular disease - ulcers, gangrenes, amputations
Main centre for appetite control in the brain is the?
Arcuate nucleus
Arcuate nucleus is located where?
In the hypothalamus
Orexigenic means?
Appetite stimulating
Anorexigenic means?
Appetite suppressing
Three orexigenic neurotransmitters?
NPY
AgRP
MCH
Two anorexigenic neurotransmitters?
POMC - proopiomelanocortin - MAIN ONE THAT IS IMPORTANT
CART
POMC binds to which receptor?
MCR4
Deficiency in POMC can lead to?
Obesity
Deletion/mutation in the MCR4 receptor in humans and mice can result in?
Obesity
MCR4 mutations accounts for what percentage of severe childhood obesity?
5%
MCR4 mutations accounts for what percentage of adult obesity?
0.5-2.5%
Serotonin is orexigenic or anorexigenic?
Anorexigenic
Two receptors that serotonin acts on?
Htr1b
HTr2c
Effect of serotonin on the neurotransmitters for appetite?
Increased POMC
Decrease NPY
Main anorexigenic neurotransmitter is?
POMC
Htr1b serotonin receptor - whcih neurotransmitter system?
AgRP
HTr2C serotonin receptor - which neurtrotransmitter system?
POMC
Effect of ghrelin on appetite?
Orexigenic
Ghrelin has an effect on which neurotransmitter?
NPY
Nerve associated with ghrelin?
Vagus nerve
Where is PYY 3-36 released from?
Gut
When is PYY 3-36 released?
When there is something in the gut
PYY 3-36 has an effect on?
NPY and POMC in hypothalamus
Effect of PYY 3-36 on appetite regulation?
Anorexigenic - suppress NPY
Where is GLP-1 produced and which cells?
Small intestine - L cells
Effect of GLP-1 on appetite regulation?
Anorexigenic
Where is ghrelin released from?
The stomach
Cholecystokinin (CCK) is released from which two organs?
Duodenum
Small intestine
Cells that released CCK are?
Enterendocrine cells
Effect of CCK on appetite regulation?
Anorexigeni
Leptin is a hormone secreted from where?
Adipose tissue
Effect of leptin on appetite regulation?
Anorexigenic
Effect of leptin on teh appetite regulatory neurotransmitters?
Drops AGRP levels
Effect of insulin on appetite regulation?
Anorexigenic
Effect of leptin on the appetite regulatory neurotransmitters?
Drops AGRP levels
Leptin resistance is?
Ignorance of the effect of leptin - ceases to have an appetite supprsesing effect
Role of malonyl coA in appetite regulation?
Controller of appetite linked to fatty acid metabolism
The levels of Malonyl coA is controlled by what three factors?
AMPK enzyme
AMP/ATP ratio
Calcium regulated - ghrelin
High levels of malonyl coA have what effect on appetite?
Appetite suppressing - anorexigenic
Effect of cannabinoids on appetite regulation?
Increase appetite adn food consumption
Cannabinoid receptor expressed in the hypothalamus is?
CB1
Effects of SSRIs/5-HT on appetite regulation?
Appetite suppressing
Current most successful appetite suppressing therapeutic?
GLP-1 agonist
