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BSCE GOER > SGU Term 5 BSCE Book 2 > Flashcards

SGU Term 5 BSCE Book 2 Flashcards

1
Q

Colestyramine

A

management of cirrhosis
help puritis
4g/8h PO, 1 hr after other drugs

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2
Q

Bacterial Endocarditis

A

Janeway lesions
Osler nodes
Roth spots
Splinter hemorrhages

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3
Q

Causes of liver cirrhosis

A 
Alcohol
Hep B,C,D
Hemochromatosis
a1 antitrypsin def.
Wilson’s disease
Autoimmune hepatitis
NAFLD
Biliary tract disease
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4
Q

Cirrhosis complications

A 
Ascites
Spontaneous bacterial peritonitis
Gastroesophageal varices
Hepatic encephalopathy
Hepatorenal syndrome
Hepatopulmonary syndrome
Hepatocellular carcinoma
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5
Q

Palmar erythema

A

Increased estrogen bc cirrhosis

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6
Q

Decreased ammonia metabolism in cirrhosis

A

Hepatic encephalopathy

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7
Q

compensated cirrhosis

A

Calculate MELD every 6 mo

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8
Q

MELD >12

A

High risk of complications of cirrhosis

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9
Q

MELD score

A

3.78 x log serum bilirubin + 11.2 x log INR + 9.57 x log serum creatinine + 6.43

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10
Q

Pt has been dialyzed twice in last week

A

Serum creatinine 4 in MELD score

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11
Q

Child Tircotte Pugh Classification of Cirrhosis

A 
A = 5 to 6
B = 7 to 9
C = 10 to 15
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12
Q

Ascites management

A

Spironactone 100 mg/day increase dose every 2 days to 400 mg/day

Should have daily weight loss of .5 kg
If not, add furosemide 120 mg/day

Do U&E, Cr often

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13
Q

Ascites fluid restriction

A

1.5 L per day

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14
Q

Ascites low salt intake recommended

A

40-100 mmol/day

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15
Q

Therapeutic paracentesis for ascites

A

Concomitant albumin transfusion 6-8g/L removed

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16
Q

Refractory ascites

A

Trans jugular intrahepatic portosystemic shunt

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17
Q

Cirrhosis + ascites of 15g/L protein or less

A

Prophylactic oral ciprofloxacin or norfloxacin, until ascites resolves

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18
Q

Spontaneous bacterial peritonitis

A

Presenting w fever usually

WCC 250mm3 in ascitic fluid or more

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19
Q

Bacterial peritonitis empiric treatment

A

Cefotaxime (claforan) and ceftriaxone (rocephin)

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20
Q

Bacterial peritonitis prophylaxis

A

Ciprofloxacin 250mg PO daily
OR
CoTrimoxazole 960 mg weekdays only

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21
Q

Cirrhosis, esophageal varices screening

A

Endoscopy every 3 years

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22
Q

Cirrhosis + medium or large esophageal varices

A

Endoscopic variceal band ligation

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23
Q

Cirrhosis + upper GI bleeding

A

Prophylactic IV Abx and vasoactive drugs

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24
Q

Cirrhosis or significant fibrosis
METAVIR stage > or equal to F2
Ishak stage > or equal to 3

A

Surveillance every 6 mo for HCC by: hepatic ultrasound, alpha fetoprotein testing

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25
Q 
no significant fibrosis or cirrhosis
METAVIR < F2
Ishak < 3
Older than 40
Family Hx of HCC
HBV DNA > or equal to 20,000
A

Surveillance every 6 mo

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26
Q 
no significant fibrosis or cirrhosis
METAVIR < F2
Ishak < 3
Younger than 40
HBV DNA < 20,000
A

No surveillance

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27
Q

Early Hep C

A 
Arthralgia
Paresthesia
Myalgia
Pruritis
Sicca
Sensory neuropathy
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28
Q

Late Hep C

A 
Hepatic encephalopathy
Ascites
Hematemesis or melena
Palmar erythema
Dupuytren contracture
Asterixis
Leukonychia
Clubbing
Icteric sclera
Temporal muscle wasting
Enlarged parotid
Cyanosis
Fetor hepaticus
Gynecomastia
Testicular atrophy
Paraumbilical hernia
Caput medusae
Hepatosplenomegaly
Abdominal bruit
Scant body hair
Spider nevi
Petechiae
Excoriations
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29
Q

Sustained eradication of HCV

A

Absence of HCV RNA in serum 12 weeks post antiviral treatment

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30
Q

Antiviral treatment for Hep C?

A 
High ALT
> 18y/o
\+ HCV antibody and serum HCV RNA
compensated
Hb at least 12 for women 13 for men, neutrophil > 1500, creatinine <1.5
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31
Q

Hep C treatment

A 
Oral PI (boceprevir BOC or telaprevir TVR)
Pegaylated IFN (PegIFN)
Ribavirin RBV
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32
Q

Alcohol cirrhosis risk

A

7-13 drinks/week women

14-27 drinks/week men

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33
Q

Alcoholic fatty liver

A

AST/ALT >2

High GGT

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34
Q

Maddrey Discriminate function

A

Bilirubin + 4.6 x prothrombin time -control

High if alcoholic hepatitis has poor prognosis

> 32: 50% mortality w/in 2 mo of onset of alcoholic hepatitis

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35
Q

DF>32

A

Corticosteroids

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36
Q

DF<32

A

Pentoxifylline

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37
Q

DF<32
MELD<21
Glasgow<9

A

Supportive care

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38
Q

DF>32
MELD>21
Glasgow>9

A

Prednisolone 40mg/day
(Or pentoxyfylline 400mg 3x per day)

Lillie score at one week

<0.45 continue prednisolone 28 days
>0.45 stop prednisolone

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39
Q

Upper GI bleed

A

Peptic ulcer
Mallory weiss tears
Esophageal varices
Esophagitis

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40
Q

Glasgow Blatchford Score

A

0: low risk

>8: ICU admission

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41
Q

Glasgow score of 0

A 
Hb>12.9 men or 11.9 women
Systolic BP >109
Pulse <100
BUN <39
No melena or syncope
No liver disease or heart failure ever
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42
Q

Upper GI bleed

A

Blood transfusion at 70-80 g/L Hb, higher threshhold of severe bleeding w hypotension

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43
Q

Upper GI bleed + glasgow <1

A

Outpatient endoscopy

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44
Q

Upper GI bleed treatment

A

Erythromycin (prokinetic agent) and PPI

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45
Q

Endoscopic therapy

A 
Injection therapy (epi, always followed by second modality)
Thermal probes (bipolar electrocoagulation, heater probe)
Clips
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46
Q

Recurrent bleeding

A

Repeat endoscopic therapy

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47
Q

Subsequent bleeding

A

Trans arterial embolization

Surgery

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48
Q

Esophageal variceal bleeding

A

Ligation

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49
Q

Gastric varices

A

Injection of tissue adhesive

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50
Q

Massive refractory esophageal variceal bleeding

A

Removable covered metal stent is preferred to balloon tamponade as temporizing measure

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51
Q

Ulcers w high risk lesions post endoscopy

A

High dose PPI for 72 h

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52
Q

Post endoscopy, pts with cirrhosis

A

Continue Abx for a week regardless of bleeding source

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53
Q

Post endoscopic Variceal bleeding

A

Vasoactive drugs for 5 days

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54
Q

Following hemostasis post endoscopy

A

Reintroduce aspirin/antithrombotics

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55
Q

External hemorrhoids

A

Minimally invasive:
Rubber band ligation
Sclerotherapy
Coagulation

Hemorrhoidectomy
Hemorrhoid stapling

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56
Q

Colon cancer clinical presentation

A

Iron deficiency anemia
Rectal bleeding
Abdominal pain
Intestinal obstruction/perforation

Early disease: nonspecific
Advanced disease: abdominal tenderness, macroscopic rectal bleeding, palpable abdominal mass, hepatomegaly, ascites

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57
Q

Colon cancer marker

A

Serum carcinoembryonic antigen

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58
Q

Colon cancer in cecum and right colon

A

Right hemicolectomy

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59
Q

Colon cancer in proximal or middle transverse colon

A

Extended right hemicolectomy

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60
Q

Colon cancer in splenic flexure and left colon

A

Left hemicolectomy

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61
Q

Colon cancer in sigmoid colon

A

Sigmoid colectomy

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62
Q

For pts with HNPCC, FAP, metachronous cancers in separate colon segments, acute malignant colon obstructions w unknown status of proximal bowel

A

Total abdominal colectomy w ileorectal anastomosis

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63
Q

Chemo for colon cancer

A

5-FU w leucovorin or capecitabine (either alone or w oxaliplatin)

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64
Q

Non surgical colon cancer options

A

Cryotherapy
Radiofrequency ablation
Hepatic arterial infusion of chemo agents

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65
Q

Diverticulitis etiology

A

Perforation of diverticula causing extracolonic inflammation

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66
Q

Clinical diverticulitis

A

Abrupt onset
LLQ pain/tenderness
Low fever
Constipation

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67
Q

Peritonitis caused by perforation

A

Rebound tenderness and abdominal rigidity

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68
Q

Diverticular abscess causing bowel obstruction

A

Diffuse abdominal pain
Abdominal distention
High fever

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69
Q

Diverticulitis I

A

Symptomatic uncomplicated
Fever, abdominal pain
Colonoscopy or enema to rule out neoplasms and colitis

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70
Q

Diverticulitis II

A

Recurrent symptomatic

CT or barium enema

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71
Q

Diverticulitis III

A

Complicated
(Abscess, hemorrhage, stricture, fistula, peritonitis, obstruction, etc)
CT

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72
Q

Uncomplicated diverticulitis

A

Abx

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73
Q

Conplicated diverticulitis

ACS hinchey Ib or II

A

Abx plus percutaneous drainage for large abscess, small one just Abx

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74
Q

Conplicated diverticulitis

ACD hinchey III or IV

A

Emergency surgery

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75
Q

Ib

A

Pericolic or mesenteric abscess

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76
Q

II

A

Large abscess extending into pelvis (walled off)

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77
Q

III

A

Gaseous release

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78
Q

IV

A

Fecal discharge

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79
Q

Drugs to avoid in diverticulitis

A

Nonsteroidal nonaspirin anti inflammatories

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80
Q

Resolution of acute diverticulitis (high quality exam not done in past 6 mo)

A

Colonoscopy

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81
Q

Colon cancer nutritional eval

A

Vit B12
Iron
RBC folate

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82
Q

Marker of intestinal inflammation

A

Fecal calprotectin

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83
Q

Enzyme check before initiation of therapy w mercaptopurine and azathioprine

A

TPMT thiopurine methyltransferase

If low, leukopenia, sepsis

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84
Q

pANCA

A

Ulcerative colitis

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85
Q

ASCA Anti saccharomyces cerevisiae antibodies

A

Crohn disease

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86
Q

Diagnose crohn’s using

A

Ultrasonography

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87
Q

Determine extent and severity of colitis

A

Colonoscopy

Flexible sigmoidoscopy

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88
Q

Crohns location

A

Entire GI tract

Mostly transition from small to large intestine

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89
Q

Ulcerative colitis location

A

Colon

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90
Q

Crohns etiology

A

Skip lesions

Increased risk of cancer

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91
Q

UC etiology

A

Uniform from rectum up to colon

Marked cancer risk

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92
Q

UC stmptoms

A

Bleeding

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93
Q

Crohns symptoms

A

Toxic megacolon

Perf of colon

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94
Q

UC extraintestinal

A

Liver disease

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95
Q

Crohns extraintestinal

A

Fistulas

Abscesses

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96
Q

Crohns histology

A

Granulomas
Lymphocytic
String sign on x ray

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97
Q

UC histology

A

Neutrophilic

Lead pipe colon on x ray

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98
Q

UC endoscopy

A

Crypts, continuous lesions, residual tissue

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99
Q

Crohns endoscopy

A

Discontinuous lesions, strictures, linear ulcerations

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100
Q

IBD diet

A

B12, D, iron

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101
Q

IBD meds

A

Aminosalicylates/metronidazole or ciprofloxacin
Steroids (oral prednisone at 10-40 mg/day tapered once symptom relief)

If steroids cant be tapered without recurrence, use immunomodulators or anti TNF therapy

TNF monoclonal antibody therapies
Immunomodulator azathioprine

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102
Q

Achalasia

A

Myenteric plexus degeneration

Nitric oxide neurons (inhibition)
VIP neurons

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103
Q

Achalasia due to malignancy secondary to

A

Pancreatic cancer
Prostatic cancer
Lymphoma

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104
Q

Achalasia due to diseases

A

Amyloidosis
MEN
glucocorticoid deficiency syndrome

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105
Q

Chagas disease may cause

A

Achalasia

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106
Q

Achalasia left untreated

A

Increased risk of squamous cell carcinoma after 50

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107
Q

Achalasia meds (not very useful)

A

Nitrates
Ca channel blocker
Viagra

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108
Q

Achalasia treatments

A

Pneumatic balloon dilation
Surgical myotomy
Endoscopic myotomy
Botox injection

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109
Q

Achalasia on x ray

A

Bird’s beak

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110
Q

Scleroderma stages

A

Neuropathy
Myopathy
Fibrosis

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111
Q

Consequence of severe GERD

A

Scleroderma

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112
Q

Scleroderma and GERD

A

Complicated by decreased saliva production

Decreased gastric emptying

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113
Q

Non cardiac chest pain

A

Nutcracker

DES

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114
Q

Diffuse esophageal spasm

A

Simultaneous prolonged contractions
Intermittent dysphagia
Atypical chest pain

(Ca channel blockers, nitrates)

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115
Q

Nutcracker esophagus

A

High amplitude peristaltic contractions

Odynophagia

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116
Q

Boerhaave syndrome

A

Transmural distal esophageal rupture due to retching

Surgical Emergency

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117
Q

Plummer vinson syndrome

A

Dysphagia (esophageal webs)
Iron deficiency
Glossitis

In ELDERLY FEMALE

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118
Q

Eosinophilic esophagitis

A

Atopy in childhood
Children>men>women
Like GERD but doesn’t respond tk gerd tx
PPI responsive EoE do not have gerd

Omeprazole blocks IL13 induced Eotaxin-3 secretion

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119
Q

EoE path

A

> 15 eos/hpf

High TGFB1
Subepithelial fibrosis/stenosis
Mucosal fragility
Rings/furrows/exudates/strictures

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120
Q

Cowdry Type A inclusion bodies

A

HSV esophagitis

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121
Q

Decreased LES

A 
Drugs
Alcohol
Chocolate
Peppermint
Fatty foods
Smoking
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122
Q

Hypersalivation

A

GERD symptom

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123
Q

Barrett’s esophagus

A

Metaplastic process
Squamous to columnar epithelium w goblet cells

Progresses to adenocarcinoma

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124
Q

Esophageal impedance

A

Measures reflux

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125
Q

GERD med adjustment

A

Discontinue aggravating meds (anticholinergics)

Therapy:
H2 antagonists
PPI

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126
Q

Fundoplication

A

Surgery for GERD

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127
Q

Adenocarcinoma

A

Most common in US

lower 1/3

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128
Q

Squamous cell carcinoma

A

Most common in world
Upper 2/3
Alcohol and smoking

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129
Q

Secondary esophageal cancer

A

Extrinsic: lung
Submucosal: breast w pseudoachalasia

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130
Q

Cases entering population

A

Incidence

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131
Q

Current cases

A

Prevalence

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132
Q

Cases leaving population

A

Recovery, death, migration

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133
Q

Type 1 and 2 error

A

1: false pos
2: false neg

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134
Q

Variance

A

(Xi - mean)^2 / n-1

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135
Q

St deviation

A

Square root of variance

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136
Q

Positively skewed

A

Peak happens earlier

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137
Q

Interval variables

A

Temp in C or F

Exam score

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138
Q

Plus or minus 1 standard deviation

A

68%

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139
Q

R^2

A

Determination

Percentage of variance of y explained by x

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140
Q

Regression

A

Units of outcome

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141
Q

Lead time bias

A

Earlier detection by screening so longer survival

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142
Q

Length time bias

A

Excess of asymptomatic cases detected, while fast progressing only detected after symptoms

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143
Q

Deceleration of gastric motility

A

Pylorostenosis
Hypokalemia
Diabetes
Peptic ulcer

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144
Q

Parietal cell

A

HCl

Intrinsic factor - B12 absorption

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145
Q

Chief cell

A

Pepsinogen - protein digestion

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146
Q

Surface mucous cells

A

Mucus, bucarbonate
Trefoil factors

For protectiob

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147
Q

ECL cells

A

Histamine - regulation

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148
Q

G cells

A

Gastrin - secretion

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149
Q

Nerves

A

Gastrin-releasing peptide - regulation

ACh - regulation

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150
Q

D cells

A

Somatostatin - regulation

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151
Q

Achylia gastrica

A

No HCl

No enzymes

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152
Q

Long term increase of stomach secretion

A 
Proteinases
Hyperacidity
Peptic ulcer
Liver disease
Hypercalcemia
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153
Q

Decreased stomach secretions

A

Achlorhydria
Achylia
Atrophic gastritis

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154
Q

Infectious gastritis

A

Decrease acid production in most people

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155
Q

Atrophic gastritis

A

Chronic

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156
Q

Type A gastritis

A

Autoimmune
Corpus affected
Pernicious anemia (B 12 def)
Megaloblastic anemia

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157
Q

Type B gastritis

A 
H pylori
Corpus affected
Gastric cancer phenotype
Or
Duodenal ulcer phenotype - Antral infection
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158
Q

Causes of gastritis

A 
Crohns
Sarcoidosis
Syphilis
Atrophic (Type A and B)
Infectious
NSAIDs
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159
Q

Curlings ulcer

A

Dec plasma volume

Burns

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160
Q

Cushings ulcer

A

Inc vagal stimulation
High ACh
High H+
Head injury

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161
Q

Gastritis vs ulcer

A

Gastritis - mucosa

Ulcer - muscularis/submucosa involvement

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162
Q

Chronic atrophic gastritis

A

Inflammatory cell infiltrate
Atrophy of mastric mucosa
Risk of adenocarcinoma

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163
Q

H pylori

A 
Gram neg
Spiral
Microaerophilic
Motile
UREASE

Associated: gastritis, ulcer, adenocarcinoma, MALToma, non-ulcer dyspepsia

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164
Q

Chronic H pylori

A

Duodenal ulcer - high gastrin and acid, protection from gastric cancer

Simple gastritis - majority, high gastrin, normal acid

Gastric cancer - very rare, corpus, multifocal atrophic gastritis, high gastrin, low chloride, low pepsinogen

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165
Q

H pylori culture

A

100% specific

Affected by PPI

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166
Q

UBT

A

Most Sensitive

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167
Q

Serology

A

Sensitive

Not useful after eradication therapy

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168
Q

COX 1

A

GI mucosal integrity

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169
Q

Peptic ulcer disease pathophys

A

Increased vagal activity
Parietal cell hyperplasia
More acid

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170
Q

Alcohol diet and caffeine cause

A

Gastritis

NOT peptic ulcer

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171
Q

Gastric ulcer causes

A

Impaired mucosal defense
Motility defects (bile backs up and messes with mucous barrier)
Delayed gastric emptying
Mucosal ischemia

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172
Q

Weight loss is seen in

A

Only in gastric ulcer

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173
Q

Gastric ulcer

Duodenal ulcer

A

Gastric - aggravated by meals

Duodenal - relieved by meals then recurs a couple hours later

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174
Q

Gastric ulcer bleeding

A

Lesser curvature bleeds from left gastric artery

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175
Q

Gastric cancer after

A

Gastric ulcer

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176
Q

Men w Blood group o inc risk of

A

Duodenal ulcer (into submucosa)

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177
Q

Rapid gastric emptying causes

A

Duodenal ulcer

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178
Q

Zollinger ellison associated w

A

Duodenal ulcers most common

tumor of G cells in langerhans islets of pancreas (can also come from duodenum)

Secretory diarrhea

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179
Q

Posterior surface bleed

A

Gastroduodenal art

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180
Q

H pylori

A

Duodenal ulcer

High gastrin

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181
Q

Duodenal perforation

A

Ant > post

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182
Q

Bleeding va perf

A

Bleeding more in post wall

Perf more in ant wall

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183
Q

Duodenal perf leads to

A 
Air under diaphragm on x ray
Peritonitis
Pancreatic pain
Hypovolemic shock
OBSTRUCTION
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184
Q

Diagnosis of duodenal ulcer

A

Stool antigen test
UBT
serology (active infx)
Antral biopsy w urease test (endoscopic)

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185
Q

Refractory ulcer

A

Zollinger ellison syndrome
Cancer
Crohn’s
Lymphoma

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186
Q

Hyperglycemia

A

Acute gastroparesis

Antral hypomotility

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187
Q

Scleroderma, vagotomy, hypothyroidism

A

Chronic gastroparesis

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188
Q

Motility disorders more in

A

Female

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189
Q

Diabetic gastroparesis

A

Autonomic neuropathy
Reduced relaxation
Inc pyloric pressure

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190
Q

Gastroparesis sympt

A 
Bloating
N/v
Anorexia
Dehydration
Not much pain
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191
Q

Dumping syndrome

A

Hyperosmolarc cholesterol rich
Early or late (hypoglycemia)
Postvagotomy diarrhea

Billroth ii surgery (stomach wall removed) - iron and calcium malabsorption

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192
Q

Infx leading to gastric cancer

A

EB virus

H pylori

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193
Q

Gastric cancer genetics

A

Germline mutation cdh1 (e-cadherin)

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194
Q

Predysposing syndrome for gastric cancer

A

Pernicious anemia (autoimmune atrophic gastritis)

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195
Q

Hypertrophic gastropathy leads to

A

Gastric cancer

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196
Q

Menetrier disease

A 
Gastric hypertrophy
Protein loss
Parietal cell atrophy
Inc mucous cells
Stomach looks like brain
Precancerous
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197
Q

Chronic gastritis leads to

A

Antral gastritis or

Multifocal atrophic gastritis -> adenocarcinoma

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198
Q

Acanthosis nigricans

A

Adenocarcinoma due to hp, early mets to liver and LN’s

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199
Q

Ulcer w raised margins

A

Intestinal type adenocarcinoma

Lesser curvature

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200
Q

Signet ring cells

A

Linitis plastica
Diffuse type adenocarcinoma
NO hp

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201
Q

Gastric lymphoma

A

Secondary to hp - MALToma

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202
Q

Symptoms of stomach cancer

A

Virchow nodes - left supraclavicular node

Krukenberg tumor - bilateral ovaries, signet ring cells, mucous

Sister mary joseph nodule - subcutaneous periumbilical mets

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203
Q

Interstitial cells of Cajal

A

GI stromal tumor

Mesenchymal tumor

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204
Q

Leiyomyoma sarcoma

A

Smooth muscle tumor

GIST

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205
Q

Acute diarrhea

A

Metabolic acidosis

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206
Q

Chronic diarrhea

A

Ca and P balance disturbance
Steatorrhea
Bleeding

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207
Q

Osmotic gap

A

<50 secretory

>125 osmotic

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208
Q

Cholera

A

Over secretion of Cl
Na and water follow
Night and day
Fasting doesnt help

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209
Q

Vibrio cholera

A 
Gram neg
Oxidase pos
Curved
Flagellated rod
Shooting star motility
Rice water stool
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210
Q

Increase cAMP in intestinal mucosa

A

Increased Cl secretion

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211
Q

Cholera risk inc w

A

PPI

grows on highly alkaline media

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212
Q

ETEC

A

Heat labile toxin LT - inc camp
Heat stable toxin ST
Pili attach intestinal epithelial cells

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213
Q

Cholera toxin

A

Activates Gs

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214
Q

Osmotic diarrhea

A 
Laxatives
Lactose intolerance
High fructose corn syrup
Sorbitol
Antibiotic related
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215
Q

Infx gastroenteritis

A

Norovirus - most common
Rotavirus - child
Usually viral, usually self limited

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216
Q

Severe diarrhea and pregnant

A

Listeria

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217
Q

Sympt w in 6 hours diarrhea

A 
Preformed toxin
Staph aureus (mayo)
Bacillus cereus (rice)
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218
Q

8-16 hours diarrhea

A

C perfringes - reheated meat, gas gangrene (lecithinase)

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219
Q

Lecithinase

A

Splits phospholipids

C perf

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220
Q

After 16 hours

A

Viral

ETEC or EHEC

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221
Q

Bloody diarrhea

A 
EHEC
Campylobacter jejuni
Yersinia enterocolitica
Shigella
Salmonella
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222
Q

EHEC

A

Shiga toxin (verotoxin)
O157:H7
Hemolytic uremic syndrome (HUS)

Undercooked ground beef

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223
Q

C jejuni

A

Children
Domestic animal exposure
Precedes guillan barre and reactive arthritis

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224
Q

Yersinia

A

Puppies

Mimics crohn disease

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225
Q

Shigella

A

Preschool outbreak

No HS on TSI agar

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226
Q

Salmonella

A

Undercooked poultry, eggs, produce
Kids playing with pet reptiles
HS on TSI agar

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227
Q

Shiga toxin vs Shiga like toxin

A

SLT does not cause host cell invasion

Shiga invades intestinal mucosa
Small inoculum 50-100 cells

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228
Q

Shiga toxin

A

Stops 60s ribosome

Blocks trna binding

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229
Q

Pediatric renal failure

A

HUS

bc cytokine release

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230
Q

HUS

A

Microangiopathic hemolytic anemia MAHA
Thrombocytopenia
Renal failure
Schistocytes

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231
Q

Salmonella typhi

A 
Gram neg rod
Facultative anaerobe
Fecal oral
Flagella
HS
ENCAPSULATED Vi antigen - asplenics!

Rose spots on chest
Sickle cell and osteomyelitis

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232
Q

Campylobacter

A 
Gram neg
Comma shaped
Corkscrew motility
42 C
Precedes guillan barre
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233
Q

Rotavirus

A

Infant

Dehydration and death

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234
Q

Cryptosporidium

A

Acid fast oocytes
In water
AIDS

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235
Q

Giardia

A

Camping/hiking
Foul smelling
Fatty diarrhea
Smiley face trophozoites

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236
Q

Entamoeba

A

Bloody diarrhea
Liver abscess
Anchovy paste exudate

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237
Q

C dif

A

Toxin A - brush border, inflamm and fluid secretion

Toxin B - cytotoxic, pseudomembrane

PPI inc risk
Gram pos
Spore forming
Toxic megacolon
Fecal transplant
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238
Q

Inflamm diarrhea can lead to

A

Obstruction

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239
Q

Pancreatic cholera

A

Non beta islet cell tumor
VIP
multiple endocrine tumors
Chronic diarrhea - secretory

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240
Q

Carcinoid syndrome

A 
5-hydroxytryptophan
Histamine
Paroxysmal flushing, explosive diarrhea, tachycardia, low BP
ELEVATED URINE 5-HIAA
Chronic diarrhea - secretory
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241
Q

Limited ileal resection

A

<100 cm
malabsorbed bile in colon causes secretion

Rx - cholestyramine

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242
Q

Extensive ileal resection

A 
>100 cm
Impaired enterohepatic circulation
Impaired micelles
Fat malabsorption and secretion
Rx - low fat diet, medium chain triglycerides
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243
Q

Uncontrolled diabetes

A

Constipation

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244
Q

Osmotic gap

A

290 - 2(Na + K) stool

50-125 mixed diarrhea

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245
Q

Stool fat > 14g/100g stool

A

Malabsorption
Pancreatic insufficiency
Bacterial overgrowth

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246
Q

Stool fat <14

A

Lactose intolerance (genetic or old)
Laxatives
Sugars

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247
Q

Normal stool weight

A

<300g/day

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248
Q

Normal osmotic gap or <50
Normal stool fat
Increased wt >300

A

> 1000 secretory diarrhea

Laxative abuse

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249
Q

Hematochezia

A

Bleeding from rectum, red

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250
Q

Stable

A

<500 cc

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251
Q

Orthostatic inc HR

A

500-700 cc

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252
Q

Orthostatic dec BP

A

700-1000 cc

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253
Q

Resting inc HR

A

20% or >1L

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254
Q

Resting dec BP

A

30-40%

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255
Q

Death

A

> 50%

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256
Q

When to transfuse

A

High risk: HCT <27% Hb <9

Variceal bleeding: <21% Hb <7

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257
Q

Melenic stool

A

200 cc blood

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258
Q

BUN/Cr >35

A

UGIB

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259
Q

Clean based ulcers

A

Almost no serious recurrent bleeding

Can go home

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260
Q

Vasoactive meds for esophageal varices

A

Octreotide
Somatostatin
Vapreotide
Terlipressin

For 2-5 days

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261
Q

Long term meds for esophageal varices

A

Nonselective Beta blockers + endoscopic ligation

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262
Q

Dont use barium x rays for

A

GI bleeding

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263
Q

Acute acid suppression in UGIB bc

A

Platelets aggregate poorly at pH < 6

Inhibit pepsinogen

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264
Q

Small intestine bleeding in kids

A

Meckel’s diverticulum

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265
Q

Eval small intestine bleeding

A

Angio
Second look procedure
Capsule endoscopy to look at whole small intestine

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266
Q

Pts with small bowel narrowing

A

Use CT enterography instead of capsule endoscopy

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267
Q

Small intestine bleed meds

A

Hormonal tx: orthonovum 1/50 BID

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268
Q

LGIB in kids

A

IBD or juvenile polyps

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269
Q

Positive fecal occult blood

A

Colonoscopy
Upper endoscopy if upper symptoms
If iron deficiency do both

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270
Q

D-xylose

A

Differentiate btw malabsorption from small intestine vs pancreatic insufficiency

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271
Q

Celiac diseased

A 
Diarrhea chylosa
Consumption of bowels
Small bowel disorder
Mucosal inflammation
Villous atrophy
Crypt hyperplasia
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272
Q

Chances of getting celiac

A

1 first degree = 10%
2 first degree = 25%
1 second degree = 8%
Identical twins = 70%

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273
Q

Celiac disease genetics

A

Genetic predisposition

HLA-DQ2 and/or DQ8 + other

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274
Q

Celiac trigger

A

Virus or bacteria allow gliadin to pass to lamina propria

Adenovirus type 12 sensitizes T cells to gliadin

TTG deaminates glutamine at 4,6,7 on gliadin

Inc T cell response

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275
Q

Celiac serology

A

Anti-deamidated gliadin peptide (DGP) IgA, IgG

DO NOT USE antigliadin IgA, IgG
Antiendomysial IgA (EMA)
ANTI-tissue transglutaminase IgA (TTG IgA)

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276
Q

Celiac symptoms

A 
Diarrhea
Overweight/obese - 32%
Bruising, skin rash
Dermatitis herpetiformis
Iron deficiency anemia
Bone pain
Ascites
Epilepsy
Infertility
Short stature
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277
Q

Extraintestinal celiac

A

Liver disease - elevated transaminases, autoimmune hepatitis, primary biliary corrhosis

Ascites
Weight loss
Anemia (iron/folate def)
Bruising - vit k def, elevated prothrombin time

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278
Q

Celiac path

A 
Small intestine
Villi blunted
Crypts elongated
Inflammatory infiltrate
Mucosal cracks
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279
Q

Celiac treatment

A

Gluten free diet plus

Take glutenases
Tight junction modulator: larazotide .5 mg TID
Antiinflammatory

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280
Q

Non-celiac gluten sensitivity

A

IBS-like symptoms
More common than celiac
No evidence of celiac or wheat allergy
More symptoms than celiac

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281
Q

Wheat allergy

A

IgE mediated
Itching
Swelling of lips, tongue

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282
Q

Tropical sprue

A

Persistent Contamination of mucosa by: klebsiella, enterobacter cloacae, e coli)

Toxins make structurally abnormal mucosa

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283
Q

Tropical sprue symptoms

A

Megaloblastic anemia (folate def)
Watery diarrhea
Abdominal cramps
Flatulence

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284
Q

Tropical sprue treatment

A

Tetracycline and folate for 6 mo

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285
Q

Bacterial overgrowth dx

A

Small bowel barium x ray
13c-xylose breath test
Lactulose hydrogen breath test

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286
Q

Whipple’s disease

A

Tropheryma whipplei - gram pos bacilli

Small bowel, CNS, heart, kidneys, joints
Edema

PAS pos granules in macrophages on biopsy

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287
Q

Whipple’s disease tx

A

Ceftriaxone then bactrium

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288
Q

IBD smoking

A

Causes crohn’s

Prevents UC

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289
Q

Appendectomy IBD

A

Protective in UC

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290
Q

Abx use in first year of life: risk factor for

A

IBD

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291
Q

IBD breastfeeding

A

Protective

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292
Q

Omegas in IBD

A

High omega 6, low omega 3: inc risk

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293
Q

Vit D IBD

A

Protective

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294
Q

IBD: regulation of secretory activity

A

XBP1
ORMDL3
OCTN

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295
Q

IBD: innate immunity and autophagy

A

NOD2
ATG16L1

IRGM
JAK2
STAT3
C13orf31

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296
Q

IBD: regulation of adaptive immunity

A

IL23R
IL12B
IL10

PTPN2

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297
Q

IBD: development and resolution of inflammation

A

MST1
CCR6
TNAAIP3
PTGER4

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298
Q

Fibrostenosing CD

A

NOD polymorphisms

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299
Q

Fistulizing CD

A

ATG16L1

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300
Q

Loss of haustrations
No granuloma
Limited to mucosa and submucosa

A

UC

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301
Q

Granuloma formation
Transmural
Rectum spaired

A

Crohns

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302
Q

Ilieocolitis mimics appendicitis

A

Crohns

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303
Q

Crohn’s

A

Oxalate kidney stones bc Ca bound by fat, so Na binds oxalate and is absorbed

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304
Q

Primary sclerosing cholangitis

A

UC

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305
Q

Gallstones

A

CD

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306
Q

Pyoderma gangrenosum

A

UC

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307
Q

Sweet’s syndrome

A

Map like red lesion
High neutrophils
Extraintestinal for IBD

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308
Q

Episcleritis

A

CD

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309
Q

Aphthous ulcers

A

CD

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310
Q

AA, hispanic, asian

A

Ileocolonic CD

pancolonic UC

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311
Q

East asians

A

Perianal disease

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312
Q

African American

A

Joint and ocular involvement

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313
Q

Hispanic

A

Dermatologic manifestations

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314
Q

Endoscopy in crohns

A

Cobblestoning
Serpiginous ulcers
Aphthous ulcers

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315
Q

IBD treatment

A

5-ASA (mesalamine) - remission
Anti inflammatory
Azathioprine, 6-mercaptopurine, methotrexate, tacrolimus
anti TNF (infliximab, adalimumab)
anti integrins (natalizumab, vedolizumab)

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316
Q

Rome IV diagnostic criteria

A

For IBS

Symptom onset 6 mo ago
Criteria fulfilled for last 3 mo
Abdominal pain 1 day/week in 3 mo + 2:

Defacation
Frequency of stool
Appearance of stool

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317
Q

Prolonged fasting

A

Improves diarrhea in IBS

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318
Q

IBS pathophys

A

Mid cingulate cortex - more pain
More motility

Inc IL-6,IL1ß, TNF and TRPV1 -> visceral hypersensitivity, permeability

Inc EC cells, TPH1 polymorphism -> inc serotonin -> inc motility

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319
Q

Visceral hypersensitivity in IBS

A

Afferent disfunction

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320
Q

Hydrophilic colloid, psyllium

A

Stool bulling agents for IBS

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321
Q

Anti depressants for IBS

A

TCA’s - delay gut transit time, visceral afferent neural function changed

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322
Q

Post infectious IBS

A

Campylobacter
Shigella
Salmonella

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323
Q

Good bacteria in low levels in IBS

A

Bifidobacterium

Lactobacillus

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324
Q

True diverticulum

A

Ex. Meckel’s

Herniation of entire bowel wall

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325
Q

False diverticulum

A

Mucosa and submucosa thru muscularis propria

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326
Q

Diverticula more common in

A

Left colon
Sigmoid
(Rectum spared)

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327
Q

Diverticula in Asians

A

70% in right colon and cecum

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328
Q

Diverticula pathophys

A

Nutrient artery (vasa recti) penetrates muscularis propria

Vasa recti compressed or eroded -> bleeding or perf

High press in sigmoid colon -> high amp contractions -> chronic inflamm -> neuron degeneration -> dysmotility and high intraluminal pressures

High fat stool

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329
Q

Diverticulosis

A

Hematochezia
Or
Asymptomatic

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330
Q

Diverticulitis

A

Symptomatic uncomplicated diverticular disease (SUDD)

fever
Anorexia
LLQ pain
Obstipation

Complicated: perf, abscess, stricture

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331
Q

Abdominal distension + localized peritonitis

A

Pericolonic abscess

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332
Q

Diverticulitis Tx

A

Bowel rest
3rd gen cephalosporin
Cipro + metro
Amp added for non responders

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333
Q

Most colorectal cancers arise from

A

Adenomatous polyps

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334
Q

Sessile, serrated polyps

A

Invasive cancer

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335
Q

Villous adenoma

A

Mostly sessile

Malignant 3x more than tubular

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336
Q

Colorectal cancer pathophys

A

Microsatellite/chromosomal instability

APC inactivation or b catenin activation
KRAS or BRAF activation
SMAD4 or TGFbII inactivation
TP53 inactivation

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337
Q

Polyposis coli

A

5q deletion
Absence of tumor suppressors
1000s of adenomatous polyps, cancer by 40

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338
Q

MYH associated polyposis

A

MUT4H mutation

Polyposis coli or colorectal CA w/out polyposis

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339
Q

Hereditary nonpolyposis colon CA

A

Lynch’s syndrome
hMSH2 or hMLH1 mutations
Errors in DNA replication

Proximal/ascending colon by 50

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340
Q

IBD and colorectal CA?

A

UC>CD

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341
Q

Endocarditis from Strep Bovis

A

Higher risk of colorectal CA

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342
Q

Tobacco use >35y

A

Higher risk of colorectal CA

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343
Q

Colorectal cancer - cecum

A

Tumor may be large w/out obstructive sympt bc stool is liquid here

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344
Q

Colorectal CA - right colon

A

Ulcerate
Hypochromic microcytic anemia
Fatigue
Palpitations

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345
Q

Colorectal CA - transverse and descending colon

A

Obstruction
Abd cramping
“Apple core” lesion

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346
Q

Colorectal CA - rectosigmoid

A

Hematochezia
Tenesmus
Narrowed stool

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347
Q

Colorectal CA screening

A

Flexible sigmoidoscopy every 5 y after 50

Colonoscopy every 10 y after 50

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348
Q

Descending colon colorectal CA

A

Apple core

Napkin ring

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349
Q

Sigmoid colon CA

A

U shape

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350
Q

Lab tests for colorectal CA

A 
Liver function (most common for mets)
Plasma CEA
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351
Q

Post op colon CA

A

CEA every 3 mo
PE every 6 mo for 5 yr
Endoscopy every 3 yr

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352
Q

Rectal cancer

A

Recurrence of 25% so give post op radiation therapy

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353
Q

Primary prevention of colorectal CA

A

Aspirin and NSAIDs

Suppress proliferation by inhibiting prostaglandin synthesis

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354
Q

Acute liver failure

A

In a previously healthy person

Coagulopathy (PT>20 or 4-6 sec longer, INR>1.5)

Encephalopathy

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355
Q

Fulminant liver failure

A

Encephalopathy w/in 2 weeks

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356
Q

Subfulminant liver failure

A

W/in 3 mo

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357
Q

Hyperacute LF

A 
Acetaminophen toxicity
Acute Hep A or E
Jaundice -> encephalopathy <1 week
Severe coagulopathy
Moderate intracranial HTN
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358
Q

Acute LF

A

Hep B
Jaundice -> encephalopathy 1-4 weeks
Moderately severe coagulopathy
Mild to moderate intracranial HTN

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359
Q

Subacute LF

A 
Nonacetaminophen drug toxicity
SEVERE JAUNDICE
Jaundice -> encephalopathy 4-12 weeks
Mild coagulopathy
Absent or mild intracranial HTN
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360
Q

Viral Hepatitis

A

PAMPs

Innate immune mediated response leading to ALF

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361
Q

Toxin mediated liver injury

A

DAMPs
Innate immune mediated response
Leading to ALF

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362
Q

Acetaminophen liver damage

A

Causes necrosis of hepatocytes

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363
Q

Metabolism of acetaminophen

A

Some acetaminophen -> NAPQI (cyp450 2E1)

NAPQI needs glutathione to flush it out as cysteine and mercapturic acid

Not enough glutathione? Liver cell damage (covalently binds proteins, oxidative damage and mitochondrial dysfunction)

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364
Q

Acetaminophen toxicity antidote

A

N acetylcysteine

Precursor of glutathione

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365
Q

NAPQI excretion?

A

Renally excreted

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366
Q

NAPQI hepatocellular damage

A

Necrosis in centrilobular (zone III) region bc greater production of NAPQI here

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367
Q

Liver biopsy indicated

A

Lymphoma

Wilson’s

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368
Q

Lab findings in ALF

A

Decreased platelets

Hypoglycemia

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369
Q

AST of 3500 units/L

A

Acetaminophen hepatotoxicity

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370
Q

Alcoholic liver injury fibrosis

A

Stellate cells

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371
Q

Wilson’s

A 
Hepatolenticular degeneration
Autosomal recessive
Copper
Mutation in ATP7B (chr 13q)
Late childhood onset
Acute hepatitis -> cirrhosis
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372
Q

Wilson disease pathophys

A

Defective copper transporting P-type ATPase bc of ATP7B mutation

Most common: histidine to glutamine H1069Q

Copper doesnt get into bile for excretion
Copper not incorporated into apo-ceruloplasmin to form ceruloplasmin (binds Cu in blood)

Free radicals, oxidation of lipids and proteins

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373
Q

Non toxic Cu storage

A

Metallothionein

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374
Q

Kayser fleischer

A

Cu in descemet membrane in limbus of cornea

Electron dense granules rich in copper and sulfur

Also seen in chronic cholestatic disorders - primary biliary cirrhosis

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375
Q

Wilson’s kidneys

A

Renal disease bc proximal tubule damage leading to Fanconi syndrome

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376
Q

Hemolytic anemia in wilsons

A

Oxidative injury by Cu

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377
Q

Lab findings in wilsons

A

Decreased total serum copper

Decreased serum ceruloplasmin (early stage)

Increased cerum and urine free copper (late stage)

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378
Q

Diagnosing wilsons

A

Low ceruloplasmin <50

Urinary Cu >100/day

In hepatic tissue >250

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379
Q

Wilsons Tx

A

D-penicillamine or Trientine - Cu chelator

Zinc therapy - inhibits Cu reabsorption in gut

Ammonium tetrathiomolybdate - competes for Cu reabsorption in bowel, inc Cu excretion in urine

380
Q

Alpha 1-Antitrypsin Def

A 
Autosomal co-dominant
Defects in SERPINA1 (chr 14q)
North european
Liver, lung, skin
Most common cause of cirrhosis in kids
Early onset panacinar emphysema
381
Q

M/c cause of cirrhosis in children

A

Alpha-1 antitrypsin def

382
Q

Alpha-1 antitrypsin

A

Inhibit neutrophil derived proteases - elastase

MM - normal, 150-350

Def variants - Z, S

Severe def - ZZ (PiZZ)

383
Q

PiZZ

A

Misfolding and aggregation in liver bc glutamine to lysine

Accumulate in endoplasmic reticulum

Unfolded protein response -> apoptosis

384
Q

Panniculitis

A

Painful cutaneous nodules at sites of trauma in alpha-1 antitrypsin def

385
Q

Lab findings in alpha-1 antitrypsin def

A

Decreased a1-AT <80 or dec activity

PAS-pos, diastase-resistant globules in periphery of hepatic lobule

386
Q

a1-AT def Tx

387
Q

Hereditary hemochromatosis

A

Iron in parenchymal organs

Autosomal recessive

HFE mutation - chr 6p

Reduced Hepcidin secretion so overload of Fe released from macrophages and enterocytes, uncontrolled absorption

Northern european

388
Q

Hepcidin

A

Low in low Fe or anemia or hypoxia

Elevated in inflammation, High Fe

Binds ferroportin and internalizes it

Loss of Fe absorption

389
Q

HHC iron deposition

A

Liver then endocrine organs, heart etc

390
Q

HHC asymptomatic until

A

20g of stored Fe accumulated

391
Q

Liver damage in HHC

A

Lipid peroxidation
Stimulation of collagen formation
DNA damage by ROS

392
Q

Nonreversible effects of HHC

A 
Hypothyroidism
DM
Arthropathy (mp joints) - hemosiderin and Ca pyrophosphate in joints, pseudogout
Chondrocalcinosis
Pituitary gonadotropins MSH - Fe in pituitary, amenorrhea, dec libido
Cirrhosis
Hepatocellular carcinoma
Testicular atrophy
Impotence
393
Q

Reversible HHC symptoms

A

Skin pigmentation
Cardiomyopathy - a fib
Liver biochemistries

394
Q

Pigmentation in HHC

A

Inc melanin production

Hemosideron deposition in macrophage and fibroblast

395
Q

DM in HHC

A

Bronze diabetes
Destruction of ß islet cells -fibrosis, atrophy
Inc insulin resistance

396
Q

Malabsorption in HHC

A

Destruction of exocrine pancreas

397
Q

HHC lab findings

A

Inc Fe, %transferrin sat, ferritin (ferritin used to follow therapy)
Dec TIBC, LH, FSH

398
Q

HHC best screening test

A

Inc % transferrin saturation, cutoff at 45%

HFE gene testing for C282Y mutation

399
Q

AIH pathophys

A

1) cytotoxic T cell, diverse autoantibodies - cell mediated cytotoxicity
2) plasma cell - antibody mediated cytotoxicity

400
Q

Type 1 AIH

A

Middle age and older
ANA, ASMA, anti-SLA/LP
HLA DR3 and DR4

401
Q

Type 2 AIH

A

Children and teens
ALKM-1 antibody
HLA DR7

402
Q

Clinical AIH

A

Acute - inc transaminase
Fulminant
Cirrhosis

Fatigue
Dark urine light stool
RUQ pain
Anorexia

Fever, hepatomegaly
Scleral icterus
Encephalopathy

403
Q

AIH may be associated w

A

Autoimmune diseases

UC

404
Q

AIH histo

A

Interface hepatitis
Bridging necrosis
Lymphocytes invading limiting plate

Lymphoplasmocytic infiltrate in portal triad

405
Q

AIH lab findings

A

Elevated ALT, AST (10x)

Serum gamma globulin (3x)

406
Q

Bile components

A

Bile acids 80%
Lecithin and PL 16%
Cholesterol 4%

407
Q

Pancreas secrets

A

3L alkaline fluid daily

408
Q

Acinar cells secrete

A 
Enzymes
Amylase
Lipase
Phospholipase A2
Colesterol esterase
Endopeptidases trypsin and chymotrypsin
Exopeptidases carboxypeptidase and aminopeptidase
Elastase
409
Q

Ductal cells secrete

A

Fluid and bicarb

410
Q

Enterokinase

A

In duodenum

Trypsinogen -> Trypsin

411
Q

Pancreas intracellular Ca

A

Low in acinar cell to promote destruction of spontaneously activated trypsin

412
Q

Pancreatic secretory trypsin inhibitor

A

PSTI

SPINK1

413
Q

Bind and inactivate intracellular trypsin

A

Chymotrypsin C

414
Q

Common Acute pancreatitis

A 
Idiopathic
Gallstones - microlithiasis
Ethanol
Trauma
Steroids - estrogens
Mumps
Autoimmune
Scorpion sting
Hypercalcemia/hypertriglyceridemia
ERCP
Drugs - azathioprine, 6-MP, sulfonamides, tetracycline, valproic acid, antiretrovirals, 5-ASA

Postop

415
Q

Uncommon acute pancreatitis

A 
Vascular
Connective tissue disorder, TTP
Cancer
Periampullary diverticulum
Pancreas divisum
Hereditary pancreatitis
CF
RF
Infx - mumps, coxsackie, CMV, echo, parasite
416
Q

Acute pancreatitis pathophys

A

1) digestive enzyme activation, acinar cell injury
2) leukocytes, macrophages, inflammation
3) effects on distant organs

417
Q

Causes of acute pancreatitis

A

Duct obstruction
Acinar cell injury
Defective intracellular transport

418
Q

Acute pancreatitis clinical features

A 
And pain - steady and boring, radiate to back
Abd distention - GI hypomotility
PE: distressed
Low fever
Tachycardia
Hypotension
Rare Jaundice - edema of pancreatic head 
Abd rigidity
Dec bowel sounds
Basilar rales
419
Q

Acute pancreatitis signs

A

Cullen sign - periumbilical

Grey turner sign - flank

420
Q

Acute pancreatitis diagnosis

A

Atlanta classification (2/3)

Abd pain acute persistent severe, radiates to back

High serum lipase or amylase (3x upper limit)

Imaging

Also:
Leukocytosis (15-20k)
Hemoconcentration (Hct >44%: necrotizing)
Metabolic panel:
Azotemia (BUN >22) hypoxemia (PaO2 <60)
Hyperglycemia
Hypocalcemia
Hyperbilirubinemia
Hypertroglyceridemia
High LDH and persistent hypocalcemia: bad prognosis
421
Q

Normal pancreatic secretion

A 
Isoosmotic
Higher bicarb
Lower chloride
Secretin triggers fluid and bicarb release
Cck triggers enzyme release
Somatostatin inhibits any release
422
Q

Early acute pancreatitis complications

<2 weeks

A

Shock, SIRS
DIC
ARDS
organ failure

423
Q

Late acute pancreatitis complications

>2 weeks

A 
Persistent organ failure (>2 days)
Pancreatic paeudocysts
Necrosis
Pancreatic ascites
Pancreatic fistulas
424
Q

Modified Marshall scoring

Organ failure

A

Assesses CPR
2 or higher in any category - organ failure
If 2 or more systems involved - multiorgan failure

425
Q

Chronic pancreatitis

A

Toxic-metabolic - alcohol, tobacco, phenacetin abuse, DBTC
Idiopathic
Genetic - PRSS1, CFTR, CAASR, CTRC, SPINK1
Autoimmune - type 1,2, IgG4 systemic
Recurrent
Obstructive

426
Q

Pancreatic stellate cells

A

Maintain architecture of pancreas
Normally quiescent
When activated -> fibrogenesis
Periacinar myofibroblasts (other name)

427
Q

Chronic pancreatitis clinical

A

Abd pain, diabetes, steatorrhea

Eating makes pain worse
N/V
Maldigestion
Weight loss

428
Q

Chronic pancreatitis labs

A 
Gold standard: secretin test (abnormal when 60% function lost) + MRCP
Hyperglycemia
Inc ALP
X ray: calcifications
FPE-1 <100
429
Q

Fecal pancreatic elastase-1

A

Marker of exocrine pancreatic function

<100 - severe insufficiency

430
Q

Chronic pancreatitis on MRCP

A

Dilated pancreatic duct w side branches

431
Q

Pancreatic cancer

A 
Worst survival rate of any cancer
African american males
Cadmium
Cigarette
Meat, fat, fizzy sugary drinks
BRCA2, PRSS1/SPIN11
DM
432
Q

Pancreatic infiltrating ductal adenocarcinoma

A

Infiltrating desmoplastic stromal rxns
Late dx bc posterior location

KRAS
p16/CDKn2A
TP53
DPC4/MADH4

433
Q

Elevated bilirubin in Pancreatic Cancer

A

Jaundice at 3

Pruritis at 6

434
Q

Pancreatic cancer clinical

A 
Abd pain like CP
worse when lying flat 
Weight loss
Jaundice, pruritis
Light stool
Steatorrhea
Diabetes onset in last year
435
Q

PE for pancreatic cancer

A 
Palpable gallbladder - courvoisier sign
Hepatosplenomegaly
Migratory superficial thrombophlebitis - Trousseau Syndrome
Virchow node
Sister mary joseph node
436
Q

Pancreatic cancer diagnosis

A

Surrounds sma so contrast enhanced CT
PET for mets
Markers: CA19-9, CEA, CA125 (if others are neg)

Whipple procedure - surgical resection

437
Q

NPO

A

management of acute pancreatitis

Dont eat until pain and nausea resolve

438
Q

Gallstones

A

Cholesterol stones - cholesterol monohydrate

Pigment stones - calcium bilirubinate

Mexican female >50

439
Q

Cholesterol stones

A

Clofibrate
Inc HMG-CoA Reductase activity
Gain of function ABCG5/G8 (hepatic cholestorl transporter)

CYP7A1 mut -> low cholesterol 7-hydroxylase -> cholesterol not turned into bile

MDR3 (ABCB4) mut - phospholipid/lecithin export pump to hepatic canaliculi (dec Lecithin)

Inc pro nucleating - mucin, igg, pigment (gilbert syndrome)

Dec anti nucleating - apo A-1, A-2

Pregnancy - 3rd trimester

440
Q

Pigment stones

A

Black/dark green

Ca w unconjugated bilirubin - ß glucuronidase (unconjugates)

Chronic hemolytic state - sickle cell, spherocytosis, thalassemia, liver cirrhosis, gilbert, CF, ileal disease

Infx - bacteria produce ß glucuronidase

Asia

441
Q

Cholelithiasis clinical

A 
Biliary colic
Sudden onset severe
After fatty meal
N/V
Radiate to interscapular area or right shoulder
442
Q

Cholelithiasis US

A

Acoustic shadowing

443
Q

Gallbladder x ray

A

Porcelain GB
emphysematous cholexystitis
Limey bile - high Ca
Gallstone ileus

444
Q

Cholecystitis

A

After stone
Mechanical - ischemia
Chemical - phospholipase converts lecithin to lysolecithin (irritant)
Bacterial - e coli, klebsiella, strep, clostridium

445
Q

Acute cholecystitis

A 
Progressively worse
RUQ tenderness, fever, leukocytosis
Murphy sign
Abd distention
Hypoactive bowel
Pain w jarring movement
446
Q

Bile duct obstruction dx

A

Bilirubin and aminotransferases mildly elevated

447
Q

Mirizzi syndrome

A

Comp of cholecystitis

Gallstone in GB neck or cystic duct compresses common bile duct -> obstruction, jaundice

448
Q

Choledocholithiasis

A

Cholesterol stones move into cbd

De novo - pigment stones - MDR3 mut

449
Q

Choledocholithiasis labs

A

Elevated liver enzymes acutely

Alk phos elevated, bilirubin elevated

Jaundice

450
Q

Primary sclerosing cholangitis

A

IBD - UC

Riedel struma, pseudotumor of orbit

451
Q

PSC histo

A

Fibrous obliteration of small bile ducts replaced by connective tissue in ONION SKIN pattern

Ludwig staging:

1) portal inflammed
2) periportal
3) septal fibrosis/necrosis
4) biliary cirrhosis

452
Q

PSC Dx

A

Beaded appearance on cholangiography bc strictures

453
Q

PSC Tx

A

Cholestyramine, Abx
Vit D, Ca
Balloon stenting

454
Q

PBC vs PSC

A

PBC - female, older, intrahepatic, granulomatous, sjogren, RA, thyroid, AMA and ANCA, loss of small ducts

PSC - male, younger, intra and extrahepatic, fibrosis, IBD-UC, pancreatitis, only ANCA, onion skin

455
Q

Bilirubin

A

Normal <1

Jaundice >2

456
Q

First place to see jaundice

A

Conjunctiva

Under tongue

457
Q

Hep B

A 
Double stranded DNA
hepadnavirus
Reverse transcription like HIV (DNA to RNA)
Sexual, blood, vertical
Hepatocellular CA
Acute phase - sicker patient more likely to clear it
Mostly asymptomatic
Vaccine - anti HBs pos only
458
Q

Hep B associated conditions

A

Polyarteritis nodosa
MPGN
Cryoglobulinemia

459
Q

Hep B phases

A

Proliferative - CD8 destroy hepatocytes

Integrative

460
Q

Hep B only hepatitis virus to have

A

DNA dependent DNA pol

461
Q

HBsAg

A

First to appear in serum
Screening
Acute and chronic

462
Q

Bilirubin

A

Normal <1

Jaundice >2

462
Q

First place to see jaundice

A

Conjunctiva

Under tongue

462
Q

Hep B

A 
Double stranded DNA
Enveloped
hepadnavirus
Reverse transcription like HIV (DNA to RNA)
Sexual, blood, vertical
Hepatocellular CA
Acute phase - sicker patient more likely to clear it
Mostly asymptomatic
Vaccine - anti HBs pos only
462
Q

Hep B associated conditions

A

Polyarteritis nodosa
MPGN
Cryoglobulinemia

463
Q

Hep B phases

A

Proliferative - CD8 destroy hepatocytes

Integrative

464
Q

Hep B only hepatitis virus to have

A

DNA dependent DNA policy

465
Q

HBsAg

A

First to appear in serum
Screening
Acute and chronic

466
Q

Anti-HBs

A

Previously vaccinated or

Recovered from acute hep b

467
Q

HBcAg

A

Core antigen
Not circulated in blood
Cant be checked

468
Q

Anti-HBc

A

IgM - acute hep b and window phase

IgG - chronic hep b and recovery

469
Q

HBeAg

A

High rates of viral replication

Acute and chronic hep B with high infectivity

470
Q

Anti-HBe

A

Dec viral rep
Pos for several years after acute infx
Window phase, chronic hep with low infectivity, recovery

471
Q

Immune due to natural infx Hep B

A

anti-HBc

anti-HBs

472
Q

Immune due to hep B vacc

473
Q

Acutely infected

A

HBsAg
anti-HBc
IgM anti-HBc

474
Q

Chronically infected hep B

A

HBsAg

anti-HBc

475
Q

Only pos for anti-HBc

A

Resolved infx
False pos
Low level chronic
Resolving acute

476
Q

Hep C

A 
RNA pos flavivirus enveloped
Cirrhosis
HCC
No proofreading (no 3 - 5 exonuclease)
Blood
Chronic
Acute - asymptomatic
477
Q

Hep B transmission

478
Q

Hep C screening

A

Anti-HCV Ab

479
Q

Hep C Dx

A

HCV viral load

480
Q

Hep C Tx

A

RNA dep pol inhibitors
Inhibit enzymes needed for Hep C RNA synth

Sofosbuvir
Ledispasvir

481
Q

Hep A

A

RNA pos naked
picornavirus
Raw or steamed SHELLFISH
Fecal oral

NO HCC RISK

482
Q

Active Hep A

A

IgM antibody to HAV

Acute only, resolves in 3-6 weeks
Vaccinate international travelers

483
Q

Hep D

A

Enveloped circular RNA
Dane particle
Requires Hep B surface antigen to coat hep d and allow hepatocyte entry

Maternal fetal transmission

HCC

superinfection - hep d and chronic hep B

Most fatal

484
Q

Hep E

A 
Naked
ssRNA
fecal oral
Waterborne
Clinically like hep A
485
Q

Hep E Dx

A

Check HEV Ag or RNA in stool

486
Q

Susceptible to Hep E

A

Expectant mothers

Immunosupression after organ transplant

487
Q

Waterborne epidemics

488
Q

Alcoholic liver disease

A

> 35 drinks per week (each one 10g ethanol)

Female - bc less alcohol dehydrogenase and lower body fluid

489
Q

At risk of developing ALD

A

Chronic hep C
Acetaminophen overdose
Hereditary hemochromatosis

490
Q

Metabolism of alcohol

A

NAD used by cytosolic ADH

NADPH and O2 used by MEOS (microsomal ethanol oxidizing system - cyp 450 2E1)

Hydrogen peroxide used by peroxismal catalase

Makes acetaldehyde

491
Q

Consequences of too much NADH produced by alcohol metabolism

A

Fasting hypoglycemia
Lactic acidosis
Triglycerides
ßOHB

492
Q

Earliest response of liver to alcohol abuse

A

Hepatocellular steatosis

493
Q

Alcohol increases fatty acid synth

494
Q

Alcohol decreases mitochondrial ß oxidation of fatty acids bc

A

Less NAD+/NADH

495
Q

Alcohol inhibits FA oxidation in liver by

A

Inactivation of PPAR-alpha

496
Q

Long term alcohol consumption inhibits

497
Q

Alcoholic hepatitis

A

Inflammation
Bc acetaldehyde at toxic level
Free radicals - produced by neutrophils

498
Q

Final stage of ALD

A

Alcoholic cirrhosis

Gut bacteria and bacterial LPS go to portal system

Gut derived endotoxin activate kupffer cells

TNF-alpha and TNF-ß

Stellate cell activation

499
Q

ALD labs

A

Hugh AST ALT, <500
High GGT (SER enzyme)
Low folate - macrocytosis, MCV >100
Hypertriglyceridemia, neutrophilic leukocytosis, hypoglycemia

500
Q

Hepatic steatosis

A

Macrovesicular fat
Centrilobular
Perivenular

501
Q

Alcoholic hepatitis

A

Perivenular fibrosis -> pericellular fibrosis

Ballooned hepatocytes w Mallory’s hyaline

Fatty change

Necrosis and neutrophil rxn

502
Q

Mallory Bodies

A

Alcoholic hepatitis

503
Q

NAFLD

A

Accumulation of triglycerides

Either simple steatosis (no inflamm) or steatohepatitis (NASH - inflamm and fibrosis)

504
Q

NAFLD associated w

A

Metabolic syndrome
Obesity
Diabetes
Hyperlipidemia

505
Q

NAFLD path

A

First hit - insulin resistance

Second hit - inflammatory cytokines, lipopolysaccharides, oxidative stress, TNF-alpha and interleukins

506
Q

Absence of insulin in NAFLD

A

Failure of suppression of hormone sensitive lipase

FFA come to liver

507
Q

Elevated insulin in NAFLD

A

Synth of triglycerides

508
Q

NAFLD lipid peroxidation and release of OH radicals caused by

A

FFA

hyperinsulinemia

509
Q

NAFLD labs

A

AST/ALT < 1

510
Q

NASH vs uncomplicated NAFLD

A

Liver biopsy

511
Q

NASH Dx

A

Steatosis
Lobular inflamm
Ballooned hepatocytes

512
Q

PBC path

A

Susceptible
Exposure
Molecular mimicry
Anti mitochondrial antibodies to pyruvate dehydrogenase E2 complex (PDC-E2)

CD8T cell infiltrate portal triad and ensue destruction of biliary epithelial cells of intrahepatic bile ducts

BEC loss inflammation - mixed cells respond B T macro eos NK

regeneration of bile ducts not possible

513
Q

AMA+ against PDC-E2

514
Q

PBC clinical

A

Early - skin hyperpigmentation, excoriation from itching, steatorrhea

Late - jaundice, xanthomas, kayser fleischer, stigma of cirrhosis

Sicca, systemic sclerosis
Fatigue
Pruritis - inc opioidergic tone, worse at night and exacerbated by heat

RUQ discomfort

515
Q

PBC labs

A

High ALP, GGT, cholesterol, IgM

AMA+ not correlates w activity of disease

516
Q

Addison’s

A

Def cortisol

Hyperpigmentation

517
Q

Cushings

A 
Cortisol excess
Striae
Telangiectasias
Buffalo hump
Hypertrichosis
518
Q

Diabetes

A 
Acanthosis nigricans
Diabetic dermopathy
Necrobiosis lipoidoica
Eruptive xanthomas
Foot ulcers
519
Q

Hypothryroidism

A 
Alopecia - lateral third of eyebrow
Dry rough pale skin
Myxedema
Cool skin
Brittle nails
520
Q

Hyperthyroidism

A 
Warm skin
Thine fine hair
Alopecia
Vitiligo
Pretibial myxedema - Graves
Hyperpigmentation
521
Q

Low thyroglobulin

Low thyroid uptake

A

Exogenous hormone for weight loss

522
Q

Increased thyroglobulin

(Low thyroid uptake

A

Iodide exposure
Thyroiditis
Extraglandular production

523
Q

High TSH

High T4

A

Secondary hyperthyroidism

In hypothalamus or pituitary

524
Q

Suppressed TSH

Normal T3 and T4

A

Subclinical hyperthyroidism

525
Q

Hyperthyroidism management

A 
Beta blockers
Antithyroid drugs (thionamides) - inhibit thyroid hormone synthesis

Methimazole
Propylthiouracil

SE: agranulocytosis

526
Q

Propylthiouracil

A

For hyperthyroidism
Inhibits T4 to T3
1at trimester pregnancy
Less teratogenic than methimazole

527
Q

Rapid decrease in thyroid hormone level

A

Iodides
Sodium ipodate
Iopanoic acid
Block T4 to T3 and inhibit hormone release

528
Q

Amiodarone induced hyperthyroidism

A

Iodides + antithyroid drugs

529
Q

Graves disease tx

A

Radioiodine 131 - nonpregnant

CONTRAINDICATED if moderate or severe ORBITOPATHY

Destroys follicular cells
Can cause hypothyroidism

530
Q

Hashimoto’s thyroiditis labs

A

Increased antimicrosomal antibodies

Anemia - normocytic
High LDL, low HDL

531
Q

Subclinical hypothyroidism Tx

A 
Levothyroxine if:
TSH>10
Inc thyroid peroxidase antibody titer
Desires pregnancy
Symptomatic
532
Q

Cushings syndrome from ectopic ACTH

A

lung, small cell carcinoma

533
Q

Cushings clinical

A 
Weakness
Weight gain
HTN
Amenorrhea
Back pain
Moon face
Acne
Purple striae
534
Q

Cushings test

A

Late night salivatory cortisol
24 hr urine free cortisol
1mg overnight DST
48hr 2gm DST

535
Q

1 mg DST

A

Given at night, cortisol should be suppressed in morning, if not, pos test

536
Q

ACTH < 5

A

ACTH independent

Tumor in adrenals

537
Q

ACTH > 15

A

ACTH dependent

Cushings disease (pituitary)
Ectopic ACTH (malignancy, eg lung)
538
Q

Pituitary source excreting excess ACTH

A

Cushings disease

539
Q

Addison’s

A 
Primary adrenal insufficiency
Destruction of adrenals
Cortisol and aldosterone def
Inc ACTH
Inc pro-opiomelanocortin synth
Inc in melanocyte stimulating hormone
540
Q

Addisons labs

A 
Hypotension
N/V
Abd pain
Low Na
High K
Metabolic acidosis
541
Q

Standard ACTH test

A

Give IV ACTH, in primary adrenal insufficiency cortisol does not increase sufficiently

542
Q

Primary adrenal insufficiency

A

Low cortisol

High ACTH

543
Q

Secindary adrenal insufficiency

A

Low cortisol

Low ACTH

544
Q

Adrenal insufficinecy Tx

A

Daily oral glucocorticoid (hydrocortisone or prednisone) and daily fludrocortisone (mineralocorticoid, only if primary)

545
Q

PTH in kidney

A

25-hydroxyvitamin D to 1,25-dihgdroxyvitamin D

546
Q

Hypocalcemia w hypoparathyroidism

A

Surgery (thyroidectomy, parathyroidectomy)
Autoimmune polyglandular syndrome
Radiation
HIV

547
Q

Hypocalcemia w secondary hyperparathyroidism in response

A 
Vit D def
PTH resistance
Renal disease
Pancreatitis
Osteoblastic metastasis
Phenytoin
Disorders of Mg metabolism
548
Q

Hypocalcemia

A 
Paresthesias
Muscle twitching
Spasms
Prolonged QT
Papilledema

Chronic: parkinsonism, extopic calcification, extrapyramidal

549
Q

Hypocalcemia signs

A

Chvostek’s sign - tap facial nerve, get contraction of facial muscles

Trousseau’s sign - BP cuff higher than systolic for 3 min, elicits carpal spasms

550
Q

Low Ca
High P
PTH way too low
Low urine cAMP

A

Hypoparathyroid

551
Q

Hypoparathyroid Tx

A

IV calcium gluconate if severe

Oral calcium if mild or moderate

Vit D supplement (calcitriol)

Goal is Serum Ca 8-8.5

552
Q

Autoimmune polyendocrine syndrome Type 1

A

Addison
Hypoparathyroidism
Chronic mucocutaneous candidiasis

Onset in childhood, adolescents

553
Q

Autoimmune polyendocrine Syndrome type II

A

Autoimmune adrenal insufficiency
Autoimmune Thyroid disease
Type I DM

Onset adolescent to adulthood

554
Q

Prolactin releasing hormone secreted by hypothalamus

A

thyrotropin releasing hormone (TRH)

555
Q

Artery that supplies anterior pituitary

A

Superior hypophyseal artery

556
Q

Artery supplying posterior pituitary

A

Inferior hypophyseal artery

557
Q

Postpartum pituitary necrosis

A

Sheehan’s syndrome

558
Q

Hypopituitarism in children

A

Growth retardation

Delayed puberty

559
Q

Hypopituitary test for female (FSH LH)

A

17 ß-estradiol

560
Q

Hypopituitary test GH

A

Arginine stimulation test

561
Q

Pituitary adenoma

A

Benign, epithelial cell
Micro - <10 , secretory, hormone overproduction
Macro - >10 , non secretory, mass lesions

562
Q

Incidence of pituitary adenoma

A

Prolactin - m/c
Nonsecretory/null
GH,ACTH,LH/FSH
TSH - rare

563
Q

Pit adenoma path

A

Single clone
MEN-1, CNC, GNAS1 mut
Chromosomal instability
Aneuploidy

564
Q

MEN-1

A

Pituitary
Parathyroid
Pancreas

565
Q

Bitemporal hemianopsia

A

Nasal fibers pushed by pit tumor

566
Q

Mild hyperprolactinemia

A

Maybe pit macroadenoma bc loss of dopamine inhibition bc infundibular stalk disrupted by tumor

567
Q

Acromegaly labs

A

High GH in blood from inferior petrosal sinuses

568
Q

Acromegaly associated w

A

Colonic polyps

Preneoplastic adenomatous polyps

569
Q

GH direct action

A

Insulin resistance - causes HTN and hyperglycemia, DM

Lipolysis

570
Q

GH indirect

A

IGF1 secretion

Growth
Protein synth
Cell proliferation

571
Q

Headache in Acromegaly

A

Stretching of dura matter

572
Q

Acromegaly Dx

A

Elevated serum IGF-1, GH 2 hours after 75 g oral glucose

573
Q

Prolactinoma Dx

A

Serum PRL >200

Mild elevation could be infundibular stalk compression

Hypogonadism: low GnRH, LH, FSH, Sex steroids

574
Q

Primary polydipsia

A

Psychiatric pt
like diabetes insipidus
Overdrinking in absence of genuine thirst

575
Q

Central diabetes insipidus

A

Craniopharyngioma
Pit macroadenoma
Meningioma

Vascular
Sheehans
Aneurysm

Sarcoidosis
Histiocytosis

576
Q

Nephrogenic DI - congenital

A

Defect in V2 receptor in principal cell of distal nephron, x linked recessive (most)

Aquaporin 2 channel defect, autosomal dom or rec

577
Q

Acquired nephrogenic DI

A

Hypokalemia
Hypercalcemia

Lithium
Demeclocycline

All reversible!

578
Q

Urine in DI

A

Always hypotonic

Unlike osmotic diuresis or medullary washout by diuretics

579
Q

Plasma ADH in DI

A

Central - low

Nephro - high

580
Q

Water deprivation then vasopressin inj

A

Central - urine osmolarity inc

Nephro - no

581
Q

SIADH

A

opposite of central DI

Primary polydypsia - like central DI, but low plasma osmolarity

582
Q

Graves Dx

A

Detection of TSH receptor stimulating antibodies

583
Q

Congenital hypothyroidism

A

Thyroid peroxidase def

584
Q

Hashimoto’s antibodies

A

Thyroid peroxidase antibody - TPO Ab

Thyroglobulin antibody - Tg Ab

585
Q

Grave’s antibodies

A

TSH stimulating (TSH-R stim Ab)

586
Q

Maternal serum of newborn w congenital hypothyroidism

A

TSH blocking (TSH-R block Ab)

587
Q

Polyglandular failure syndrome

A

More than one endocrine gland being destroyed by autoimmunity

588
Q

Myxedema

A

Hypothyroidism

589
Q

Goiter vs thyroid nodule

A

Goiter - high TSH and diffuse

Nodule - benign or malignant neoplasm, focal

590
Q

Toxic multinodular goiter

In hyperthyroidism

A

Autonomous hyperfunction

591
Q

Follicular adenoma

In hyperthyroidism

A

Autonomous hyperfunction

592
Q

Pituitary adenoma

In hyperthyroidism

A

TSH hyper secretions

593
Q

Hypothalamic disease

In hyperthyroidism

A

Excess TRH production

594
Q

Hashimoto’s thyroiditis

In hyperthyroidism

A

Transient release of stored hormone

595
Q

Ingestion of excess exogenous thyroid hormone

A

Thyrotoxicosis medicamentosa

Thyrotoxicosis factitia

596
Q

Cardio in hyperthyroidism

A 
High CO
Inc pulse pressure
Tachycardia
A fib
High output heart failure
597
Q

thyroid hormone and growth hormone

A

TH allows GH to exert its action

TH important in growing kids

598
Q

Graves path

A 
defect in suppressor T cells
helper T's stimulate B's
antibodies against TSH in follicular cells
thyroid stimulated by LATS
familial
599
Q

Symptoms of hyperthyroidism ONLY IN GRAVES

A

eye complaints - proptosis

Swelling of legs - pretibial myxedema

600
Q

Graves hypersensitivity

A

Type II hypersensitivity

601
Q

orbital soft tissue in graves

A

inc sympathetic tone

infiltration of lymphocytes, mucopolysaccharides, edema

602
Q

diplopia in graves

A

fibrosis of extraocular muscles

603
Q

circulating autoantibodies in graves attack

A

thyroid and orbital fibroblasts

604
Q

dermopathy in graves

A

late manifestation

605
Q

pretibial myxedema

A

hyperthyroidism
graves
antibodies to fibroblasts in skin

606
Q

Graves Dx

A

low TSH
high fT4
TSH - R (stim) antibodies pos

ophthalmopathy and/or dermopathy

607
Q

Subacute granulomatous thyroiditis

A

de Quervain thyroiditis
viral etiology
self limited
young girl

608
Q

de Quervain thyroiditis path

A

triphasic

1) acute - tender enlarged gland 3-6 wk
2) hypothyroid phase - 2-4 mo
3) recovery 4-6 mo

609
Q

follicular adenoma of thyroid

A

benign

fibrous capsule

610
Q

radionuclide scanning of thyroid

A

cancer is a cold nodule

611
Q

most aggresive thyroid neoplasm

A

anaplastic carcinoma

612
Q

mets to lymph nodes of neck

A

thyroid papillary carcinoma

psammoma bodies

613
Q

bloodstream to bone or lung

A

thyroid follicular carcinoma

614
Q

medullary carcinoma of thyroid

A

C cells (parafollicular)
calcitonin
MEN2

615
Q

hypophyseal arteries are branches of

A

internal carotid

616
Q

cells of anterior pituitary

A

acidophil: somatotropes, lactotropes
basophil: corticotropes, thyrotropes, gonadotropes
chromophobes - nonsecretory, undifferentiated

617
Q

GH increases bone mass by

A

endochondral formation

618
Q

linear bone growth by GH

A

IGF-1
differentiating prechondrocytes
inc epiphyseal plate growth

619
Q

GH effects on adipose tissue

A

stimulates HSL

inhibits LPL

620
Q

GH direct

A

lipolysis
IGF-1
insulin resistance

621
Q

endogenous GH in obese person

A

cleared rapidly

622
Q

obesity causes

A

suppresses IGF-1 binding protein from liver
high free plasma IGF-1
inhibition of pit GH release
promotes more fat

623
Q

V2 receptor mechanism for ADH

624
Q

V1 receptor mechanism for ADH

625
Q

SIADH

A

small cell carcinoma of lung, ectopic ADH

626
Q

pulmonary cause of SIADH

A

TB
COPD
(impaired baroreceptor input from thorax)

627
Q

Drug induced SIADH

A

carbamazepine
chlorpropamide
narcotics
phenothiazine

628
Q

SIADH CNS effects

A

central pontine myelinolysis

629
Q

SIADH clinical

A

euvolemia (bc ANP)

hyponatremia (<136)

630
Q

cerebral salt washing (CSW) vs SIADH

A

extracellular volume inc in SIADH

dec in CSW

631
Q

active thyroid histo

A

scanty colloid

reabsorption lacunae

632
Q

graves histo

A

packed follicles

scalloping

633
Q

hashimotos histo

A

scattered follicles
eosinophilic hurthle cells
lymphocytes and germinal centers
fibrosis

634
Q

T3 and T4 in serum

A

bound to thyroxine binding globulin (TBG)

Albumin and Transthyretin (30%)

635
Q

interacts w intranuclear receptors more

636
Q

5′-deiodinase

A

converts T4 to T3 in target cells

637
Q

5-deiodinase

A

converts T4 to rT3

638
Q

congenital hypothyroidism

A

sporadic - PAX-8, TTF-2 (transcription factors) mut
hereditary - inborn
transient - transplacental TSH-R block Ab from mom

639
Q

Thyroid hormones CNS effects

A

mental retardation in kids - irreversible

decreased hearing, “hung up” relaxation phase of reflexes in adults, slow thinking etc - reversible

640
Q

hypothyroidism cardiac

A

mucopolysaccharide deposition

pericardial effusion w HIGH PROTEIN

641
Q

hypothyroid skin

A

carotene makes u yellow, mistake for jaundice

642
Q

hyperprolactinemia

A

hypothyroidism (thyroid hormone normally inhibits prolactin secretion)
high TRH stimulates prolactin release

643
Q

thyroid has permissive action on

644
Q

low T3 reduces

A

GH secretion

645
Q

ECG in hypothyroidism

A

low voltage

inc circulation time

646
Q

TRH administration in secondary hypothyroidism

A

corrected - hypothalamic

not corrected - pituitary

647
Q

antithyroid meds

A

propylthiouracil
methimazole

both inhibit thyroid peroxidase

648
Q

elevated CK in

A

hypothyroidism

649
Q

Wolff-Chaikoff block

A

large amount of iodide -> blocks iodide organification in graves -> hypothyroidism

650
Q

lithium

A

concentrated in thyroid, inhibits hormone secretion -> hypothyroidism

651
Q

hashimoto’s goiter

652
Q

hashimoto’s hypersensitivity

653
Q

hashimoto’s genetics

654
Q

hashimoto’s labs

A

Antithyroglobulin antibody Tg Ab - early stage

Antithyroid peroxidase Antibody TPO Ab - many years

655
Q

parathyroid glands

A

superior: 4th pharyngeal pouches
inferior: 3rd pharyngeal pouches (also gives rise to thymus)
blood supply to all: inferior thyroid arteries

656
Q

parathyroid histo

A

chief cells/clear cells

657
Q

Type 1 PTH receptors

A

bone and kidney (PTH and PTHrP)
cAMP
Type 2: only PTH, no Ca homeostasis

658
Q

PTH effect on bone

A

receptor on osteoblast, which then activates osteoclast

bone resorption

659
Q

PTH on kidney

A

Ca resorption in DCT
phosphate uric effect - PCT (Na,P cotransporter, Na in, P out)
1 alpha hydroxylase to get activated vit D

660
Q

Ca sensing receptors (CaSR)

A

in parathyroid and kidney (thick ascending loop of henle)

661
Q

Factitious Hypercalcemia

A

Hypergammaglobulinemia
inc Ca binding proteins
total Ca high, Ca2+ normal

662
Q

drugs that cause hypercalcemia

A

lithium

thiazides

663
Q

Squamous cell carcinoma secretes

A

PTHrP -> hypercalcemia

664
Q

clinical hypercalcemia

A 
short QT
impaired concentration
peptic ulcer
pancreatitis
muscle weakness
665
Q

brown tumors

A

hyperparathyroidism, bone resorption, puched out lesions

666
Q

familial benign hypocalciuric hypercalcemia

A

autosomal dominant

faulty CaSR

667
Q

archibald sign

A

fist, if you can see dimples, shortened metacarpals

668
Q

Pseudohypoparathyroidism

A

Albright’s hereditary osteodystrophy - AD, cafe au lait spots, short stature, obese, mental retardation, short 4 and 5 joints
defective PTH receptors of target organs
hypocalcemia

669
Q

hypocalcemia in Renal Failure

A

low GFR -> hyperphosphatemia -> Ca efflux from bone inhibited
low 1 alpha -> low vit D3 -> low Ca absorption

stimulates PTH -> secondary hyperparathyroidism

670
Q

basal ganglia calcifications

A

HYPOcalcemia

671
Q

PTH and phosphate both high

A

renal failure

pseudohypoparathyroidism

672
Q

always low in vit D def

A

25-hydroxy vitamin D

673
Q

hypomagnesemia can cause

A

hypocalcemia

674
Q

confirm pseudohypoparathyroidism

A

inject PTH, measure urinary cAMP and Phosphate

normal: both inc
positive: no rise in either one

675
Q

C-peptide catabolized only by

676
Q

insulin catabolized in

A

liver and kidney

677
Q

GLP and GIP

A

gut hormones/incretins

stimulate insulin release

678
Q

glucose sensor in beta cells

A

GLUT2 - beta cells, hepatocytes

679
Q

insulin responsive glucose transporter

A

GLUT4 - skeletal, cardiac, adipocyte

680
Q

insulin enzyme effects

A 
inc phosphofructokinase
dec fructose 1,6-bisphosphatase
dec hormone sensitive lipase
inc acetyl co A carboxylase
dec glycogen phosphorylase
dec glucose-6-phosphatase
681
Q

DM criteria

A

RBS 200 + classic symptoms
fasting venous 126
HbA1c 6.5%
OGTT 200 in 2 hr

same test 2 diff times or 2 diff tests at one time

682
Q

Type 1 DM antibodies

A 
anti-GAD65
IAA
ICA
antityrosine phosphatase IA2 (ICA-512)
anti-ZnT8
683
Q

signaling activated by insulin

A

tyrosine kinase phosphorylates IRS 1,2 -> P13k -> insulin actions

684
Q

obesity and insulin

A

TNF-alpha, resistin, fatty acids
activate serine/threonine kinase
blocks IRS tyrosine phosphorylation

685
Q

acanthosis nigricans in insulin resistance

A

bc epidermal karatinocyte proliferation

NOT MELANOCYTES

686
Q

diabetic ketoacidosis

A

more common in type 1, in type 2 if stress
kussmaul breathing
hyperkalemia - bc k comes out of cells, but total k is low in body
inc HSL activity

687
Q

coma in DKA

A

hyperosmolarity and acidosis

688
Q

hyperosmolar coma

A

type 2 DM
dec fluid intake
worse hyperglycemia and dehydration than DKA
k loss less than DKA

689
Q

somogyi effect

A

hyperglycemia after overcorrection of hypoglycemia in DM due to insulin Tx

690
Q

B cells secrete

A

insulin, c-peptide, amylin

691
Q

F cells secrete

A

pancreatic polypeptide

692
Q

liver effects

A

both insulin and glucagon

glycogenesis and lipid synth inc insulin

693
Q

muscle protein catabolism

A

dec insulin

694
Q

adipose fatty acid esterification

A

inc insulin

695
Q

type 1 DM genetics

A

HLA-DR, HLA-DQ

696
Q

HTN in DM

A

type 1 - nephropathy

type 2 - metabolic syndrome (syndrome x)

697
Q

polyol pathway

A

inc aldose reductase

698
Q

advanced glycated end products (AGE)

A

angiopathy

699
Q

earliest clinical sign of diabetic retinopathy

A

microaneurysms

700
Q

proliferative retinopathy

A

initiated by ischemia
cotton wool spots/soft exudates
vitreous hemorrhage/retinal damage

701
Q

nonproliferative retinopathy

A

initiated by microaneurysms

hard exudates

702
Q

prevent progression of diabetic nephropathy

A

control HTN

703
Q

autonomic neuropathy

A

sexual dysfunction
neurogenic bladder
anhidrosis

704
Q

hypoglycemia Dx

A

whipple’s triad: symptoms, low gluc, better w food

705
Q

sulfonylurea

A

hypoglycemia

706
Q

zellballen

A

nests of cells in pheochromocytoma

707
Q

sipple syndrome

A

MEN type 2a

708
Q

pheochromocytoma screening

A

1) urine vanillylmandelic acid, metanephrine, normetanephrine
2) plasma metanephrine and normetanephrine (more sens and spec)

709
Q

locating extraadrenal pheochromocytoma

A

radionuclide test - uptake of radioactive amine by chromaffin cells

710
Q

MEN 1

A

Wermer’s
parathyroid
pituitary
pancreatic

711
Q

MEN 2a

A

medullary carcinoma of thyroid
parathyroid
pheochromocytoma

712
Q

MEN 2b/3

A

medullary carcinoma of thyroid
neuromas of oral/intestinal mucosa
pheochromocytoma

713
Q

osteomalacia and rickets labs

A

low Ca and P

high ALP and PTH

714
Q

phases of paget

A

lytic, mixed lytic and blastic, sclerotic

715
Q

paget histo

A

mosaic pattern

716
Q

paget clinical

A

inc hat size
hearing loss
high CO failure

717
Q

paget labs

A 
high BSAP (bone specific alkaline phosphatase)
high urine hydroxyproline
718
Q

congenital adrenal hyperplasia

A

autosomal recessive

719
Q

21 hydroxylase def

A 
elevated 17-OH progesterone
virilization/ambiguous genitals in girls
hypotension
salt washing
hyponatremia
hyperkalemia
720
Q

11 hydroxylase def

A

elevated 11-deoxycortisol
virilization/ambiguous genitals in girls
HTN
hypokalemic alkalosis

721
Q

ACTH affects which zones of adrenal gland

A

inner 2 (fasciculata and reticularis)

722
Q

primary adrenal insufficiency

A

hyperkalemia and metabolic acidosis

hyperpigmentation

723
Q

cushings disease

A

pituitary tumor that secretes high ACTH

724
Q

high dose dexamethasone suppression test

A

to identify where ACTH secretion is coming from? pituitary or ectopic?

725
Q

primary hyperaldosteronism

A

HTN
hypokalemia
high renin
low aldosterone

726
Q

Conn syndrome

A

hyperaldosteronism
metabolic alkalosis
solitary, unilateral

727
Q

idiopathic hyperaldosteronism

728
Q

hyperaldosteronism Dx

A

PAC/PRA >20 gold standard - primary, if less, secondary
low plasma renin
high plasma aldosterone

729
Q

bilateral adrenal vein catheterization

A

to determine if conn’s or bilateral

730
Q

SCID genetics

A

cytokine - IL2RG, JAK3, IL7Ra
migration - ADA
antigen receptor: RAG1, RAG2, ARTEMIS

731
Q

x linked SCID

A 
IL2RG mut
gamma subunit problem
IL 2,4,7,9,15,21 dont work
T-NK-B+ (no antibodies produced tho)
only boys
732
Q

SCID bc JAK3

A

AR
T-NK-B+ like x linked but more rare
boys and girls

733
Q

ADA def SCID

A

adenosine deaminase def (involved in purine metabolism)
toxic levels of nucleotide metabolites - high in thymus and bone marrow
T-NK-B-
Tx - PEG-ADA, stem cell, gene therapy

734
Q

ADA def SCID path

A

high d-adenosine activatese caspase 9
low ribonucleotide reductase activity
block DNA synth

735
Q

IL7RA def SCID

A

T-NK+B+

IL7 alpha chain defect

736
Q

di george

A 
22q11 deletion (TBX1 gene)
10p13 less common
3, 4 pharyngeal pouches not formed
hypocalcemic seizures bc no parathyroid
CHD7 mut -> charge association
infant of diabetic mother
737
Q

complete di george

A

low excision circles (TREC - marker of maturation/thymic development)

738
Q

bruton’s x linked agammaglobulinemia

A

BTK Xq21.22
drives maturation signals - stops after heavy chain rearrangement
symptomatic at 6 mo when don’t have moms ig

739
Q

common variable immunodeficiency

A

heterogenous for ppl w symptoms
autoimmunity - develop RA!!!
lymphoproliferation, immunodef
inc risk of lymphoma and gastric cancer

740
Q

LRBA def - CVID

A

dec CTLA4 in T cell endocytic vesicles
competes w CD28 for CD80/86 to downregulate costimulation
Tx - abatacept - a CTLA4 Ig-fusion protein, chloroquine - prevents degradation of CTLA4 by inhibiting lysosomes

741
Q

IgA def

A

usually asymptomatic
<5, normal is 130-250
can get autoimmune
naïve B cells don’t become IgA plasma cells

fatal anaphylaxis to transfused blood bc IgA in blood looks foreign to body

742
Q

Chediak Higashi

A 
AR
CHS1/LYST mut
microtubule dysfunction
defective formation of melanin granules
albinism, visual defects
bone marrow transplant corrects immunologic but not neurologic probs
743
Q

chronic granulomatous

A 
phagocytes cant make H202 to counter microbial catalase
 recurrent catalase pos infx
acne
gingivitis
granulomas
nasal inflammation
massive lymphadenopathy
744
Q

cat pos infx in chronic granulomatous disease

A 
staph aureus
burkholderia cepacia
serratia marcescens
aspergillus
nocardia
745
Q

chronic granulomatous path

A

defect in NADPH oxidase complex

746
Q

respiratory burst

A

identify chronic granulomatous
no change - pos
green - normal, neg

747
Q

CGD Tx

A 
trimethoprim sulfa
itraconazole
IFN-gamma
3 yrs old - x linked
8 yrs old - AR
more ability to produse ROS, live longer
748
Q

leukocyte adhesion def

A

leukocytes and monocytes
Type 1 - ß-2 integrin CD18 mut
delayed separation of umbilical cord, peridontal disease,

749
Q

hypersensitivities

A

1) anaphylactic, allergy, asthma
2) Ab (killer cell w Fc, complement)
3) immune complex (serum sickness, SLE)
4) delayed or cell mediated - TB, contact dermatitis, cellular transplant rejection, also know it peaks 48-96 hr

750
Q

idiopathic membranous glomerulopathy

A

autoantibodies to phospholipase A2 receptor (PLA2R1)

some have THSD7A - only 5% have autoantibodies to this

751
Q

Th1 and Th17

A

Th1 - macrophages

Th17 - neutrophils, monocytes

752
Q

nitroblue tetrazolium assay

A

insoluble blue formazan crystals in phagocytes that can oxidize

753
Q

hyper IgM

A 
defect in Ig class switching
only have IgM

x linked - CD40L (CD154), NEMO
AR - CD40, activation induced cytidine deaminase (AID), uracyl DNA glycosylase (UNG)

754
Q

to opsonize bacteria you need

755
Q

stem cell transplant for HIGM

A

busulfan, cyclophosphamide, ATG

756
Q

hyper IgE (Job syndrome)

A

chronic skin infx - “cold”

bone defects, late shedding of baby teeth

757
Q

HIES path

A

defect in Th17
dont respond to IFN-gamma, IL 6, 10,12,23
AD: STAT3
AR: Tyk2, DOCK8

758
Q

LAD Type 1 Tx

A

neutrophil infusions
IL 12/23 therapy
GVHD chemo for stem cell transplants
ustekinumab

759
Q

LAD Type 2

A

rare
mental retardation, short
absence of E-selectin ligands (sialyl Lewis X, or CD15s)
Tx fucose if defective fucose synth

760
Q

Wiskott Aldrich

A 
x linked recessive
WAS gene mut
T cell depletion in periphery
low igM, high igA and igE
no response to sugar or protein Ag
thrombocytopenia
eczma
vasculitis
761
Q

Ataxia Telangiectasia

A

AR
ATM mut (imp for fixing ds DNA breaks, make cell cycle go)
purkinje in cerebellum degenerate
low Ig, low T cell function

762
Q

C3 def

A

Fc receptor dependent leukocyte activation is impaired

763
Q

C5-9 def

764
Q

C1 inhibitor def

A

hereditary angioedema
AD
high bradykinin
C1R,C1S,XII,kallikrein targeted by C1 inh

765
Q

defect in C’ reg

A

glycophosphatidyl inositol linkages needed for CD55 and 59

766
Q

paroxysmal nocturnal hemoglobinuria

A 
PIGA mut (needed for GPI linkages)
excessive C' activation -> hemolysis
767
Q

HIV infx of non-T cells

A

lungs and brain
dendritic - carry to LN
polyclonal B cell activation

768
Q

vpr gene

A

allow HIV replication in non-dividing cells

769
Q

malignancy immunosuppresion

A

TGF-ß, T regs, myeloid derived suppressor cells
indoleamine 2,3-dioxygenase (IDO)

toxic products of Trp breakdown inactivate effector T cells and make DC immunosuppressive

770
Q

sarcoidosis

A

non caseating granulomas

anergy due to expansion of Tregs

771
Q

TB

A

lower lobes
ghon foci - walled off calcified caseated granuloma
ghon complex - LN involvement
treat for 6 mo

772
Q

PPD

A

Type IV hypersensitivity

if pos - 9 mo INH

773
Q

interferon gamma release assay

A

Quantiferon-TB Gold
BCG doesnt affect it
measure IFN-gamma released by T lymphocytes

774
Q

reactivation TB

A

upper lobes

775
Q

scrofula

A

TB affecting LN of neck

776
Q

TB meningitis

A

looks like bacterial meningitis EXCEPT:

LYMPHOCYTES instead of pmn

777
Q

Thrush/candida

A

oral - red bleeding base, <400 CD4
esophageal - <100 , HIV
KOH - pseudohyphae, budding yeast
germ tube - true hyphae at 37

778
Q

oral hairy leukoplakia

A

EBV
cant scrape off
tobacco
lateral tongue

779
Q

kaposi sarcoma

A

HHV 8

purple nodules

780
Q

pneumocystic jirovecci

A 
CD4 100-200
fungal/yeast
ground glass
hypoxia more than CXray shows
silver stain of lung - cysts/sporozoites
TMP-SMX in <200 CD4 prophylaxis
781
Q

histoplasmosis

A 
soil fungus
CD4 100-200
inhale spores, bird bat droppings
tongue ulcer, hepatosplenomegaly
ohio river valley
lung granulomas
Dx from lungs - OVAL yeast in macrophages at 37, 
branching hyphae at 25 - sabouraud agar
782
Q

coccidiomycosis

A 
valley fever
CD4 100-200
soil fungus, larger than RBC
earthquake
erythema nodosum
deser rheumatism
thick walled spherules containing endospores
hyphae at 25
southwest - AZ,NM,CA
783
Q

cryptococcus neoformans

A 
encapsulated fungus
meningitis in AIDS, but signs may be absent
soap bubble lesions in brain
fatal
pigeon droppings
CD4 50-100
mucicarmine stain
narrow based budding and large capsule
culture on sabouraud agar
784
Q

cryptosporidiosis

A 
CD4 50-100
protozoan parasite
severe diarrhea in AIDS
mucous stools
acid fast oocytes in stool
contaminated water
785
Q

CMV

A 
HHV5
CD4 50-100
mono - like for immunocompetent
for compromised - chorioretinitis - cotton wool, esophagitis, colitis, hepatitis
transplant pts
owl eyes inclusion bodies
786
Q

MAC

A 
CD4 <50
azithro prophylaxis
intracellular
acid fast, non branching bacilli
fatal
787
Q

Hegar’s sign

A

pregnancy

softening of isthmus

788
Q

chadwick’s sign

A

pregnancy

blue cervix

789
Q

naegle’s rule

A

estimate due date

LMP - 3 mo + 7 days

790
Q

normal fetal heart rate

A

120-160 BPM

791
Q

pregnant mom weight gain, food

A

normal is about 25 lb

300 kcal more food for baby

792
Q

leopold’s maneuver

A

head or is the baby breach

793
Q

urine tests during pregnancy

A

ketones - dehydration
proteins - pre eclampsia
leukocyte esterase - UTI

794
Q

20 weeks pregnant

A

uterus palpable at umbilicus

btw umbilicus and symphysis at 16 weeks

795
Q

drugs to terminate pregnancy

A

mifepristone/RU486 - antiprogestin

misoprostol - prostaglandin E analog

796
Q

small stable ectopic pregnancy

A

methotrexate

797
Q

placentia previa

A

placenta overlies cervix
painless bleeding
needs a c section

798
Q

hypoglycemic drugs for pregnant diabetics

A

metformin
glyburide
insulin

799
Q

pre eclampsia

A

HTN 140/90
edema
proteinuria 300g/day

too much thromboxane, too little prostacyclin

800
Q

HELLP

A

hemolysis
elevated liver enzymes
low platelets

liver can rupture
symptom of preeclampsia

801
Q

abruptio placenta

A

placenta prematurely separates
risks - HTN, cocaine
medullary vessels of desidua basalis rupture

802
Q

pre eclampsia Tx

A

hydralazine, labetalol, nifedipine for BP
MgSO4 for seizures
deliver baby immediately

baby aspirin for prevention

803
Q

eclampsia

A

new onset tonic clonic seizure
headache
hyperreflexia
photophobia, blurry vision

give valium, give MgSO4 for seizure, lower BP, deliver baby

804
Q

HLA gene location

805
Q

acute humoral rejection

A

type 2/3 hypersensitivity

deposition of inactive C4d

806
Q

acute cellular rejection

A

liver - venous endothelium
lung - arterioles
heart - myocytes

therapy: pulse steroids, anti T cell Ab (OKT-3)

807
Q

post transplant therapy

A

cyclosporine
prednisone
azathioprine

808
Q

chronic allograft rejection

A

linked to all hypersensitivities

kidney vasculature
liver - vanishing bile ducts
lung - bronchioles
heart - vasculature

thickening intimal vasculature

809
Q

obliterative bronchiolitis

A

chronic rejection

810
Q

chronic GVHD Tx after HSCT

A

ibrutinib - anti BTK mAb

811
Q

acute GVHD

812
Q

alpha subunit of which hormones is the same

A

TSH
LH
FSH
HCG

813
Q

when does implantation happen

A

6th day post fertilization

814
Q

ectopic pregnancy rupture

A

6-8 wk: isthmus

8-12 wk: ampulla

815
Q

hCG discriminatory zone

A

above this level u should see gestational sack

816
Q

progesterone

A

<5 - abnormal pregnancy

>20 - normal pregnancy

817
Q

complete mole

A

empty ovum + haploid sperm that duplicates or 2 sperm
46XX (or 46XY - less common)
46YY - LETHAL, not seen
high risk or choriocarcinoma

818
Q

partial mole

A

normal ovum + 2 haploid sperm
69XXY
69XXX
69XYY

819
Q

P57, PHLDA2 immunostaining

A

partial mole - pos

complete mole - neg

820
Q

c-erbB-2, c-myc, c-fms, mdm-2 oncogenes

A

more aggressive mole

821
Q

EGFR

A

highly expressed in complete mole and choriocarcinoma

822
Q

choriocarcinoma

A

high EGFR
downreg of p53, p21, Rb tumor suppressor genes

malignant trophoblastic cells from normal or abnormal pregnancy or mole, anaplasmic tissue made of cyto and syncitiotrophoblast

no villi! vs molar pregnancy which has villi

823
Q

paternal vs maternal genes

A

paternal - placental

maternal - fetus

824
Q

preeclamspsia before 20 weeks

825
Q

H mole complications

A

pulmonary embolism

high output congestive heart failure

826
Q

blood in myometrium from abruptio placenta

A

uterine tetany

fibrinogen correlates w severity of bleeding

827
Q

placentia previa

A

placenta covering inner cervical os, bc placenta grows toward areas that are well vascularized

828
Q

bleeding pain or no pain

A

pain - abruptio

no pain - previa

829
Q

abortion timeline

A

occurs before 20 weeks

830
Q

prostatic carcinoma mets

A

check iliac LN

831
Q

testicular tumor or ovarian

A

check para-aortic nodes

832
Q

leydig cells

A

synth testosterone
last step: androstenedione to testosterone via
17 beta-hydroxysteroid dehydrogenase

833
Q

cholesterol desmolase in leydig cells

A

stimulated by LH

cholesterol to pregnenolone

834
Q

17 beta-hydroxysteroid dehydrogenase

A

only present in leydig cells

835
Q

testosterone to dihydrotestosterone in target cells

A

5alpha reductase

836
Q

testosterone to estrogen

A

in bone and brain

by aromatase

837
Q

sertoli cells

A

spermatogenesis and inhibin

838
Q

inhibin feedback

A

only on FSH

839
Q

testosterone feedback

A

only on LH

840
Q

seminiferous tube failure

A

high FSH, low sperm count

841
Q

absent seminal fructose

A

vas deferens or seminal vesicle problem

842
Q

secondary hypogonadism

A

low testosterone, LH, FSH

hypothalamic or pituitary failure

843
Q

primary ciliary diskynesia

A

abnormal sperm motility

844
Q

everything normal but no conception

A

acrosomal enzyme defect

845
Q

meds that inhibit testosterone synth

A

ketoconazole
spironolactone
alcohol

846
Q

autoimmune male infertility

A

disruption of blood testes barrier
anti-sperm antibodies
trauma, torsion, mumps/orchitis etc

847
Q

chlamydia

A

decreases sperm motility and viability

848
Q

bladder cancer

A

painless hematuria

849
Q

prostatitis

A

mostly gram neg aerobes - usually e coli

in young: gonorrhea or chlamydia

850
Q

kallman’s syndrome

A

GnRH def
anosmia
eunuchoid appearance
KAL1,2 mut - migration of GnRH neurons during embryogenesis - don’t migrate to ventral hypothalamus from olfactory placode

851
Q

Turner syndrome

A

elevation of Gonadotropins (FSH and LH) by 12 yr bc low estrogen
if y chr present, high risk for germ cell cancer

852
Q

mayer rokitansky kuster hauser

A

mullerian dysgenesis
no uterus or upper 1/3 vagina
type 1: no uterus or vagina
type 2: other defects - renal, cardiac etc

853
Q

androgen insensitivity syndrome

A 
AR gene mut
x linked recessive
anti mullerian hormone
no internal genitalia at all
risk of gonadoblastoma bc temp
paramesonephric part of vagina is absent
854
Q

DHT vs Testeosterone

A

DHT - external male genitalia

Testosterone - internal male genitalia

855
Q

5 alpha reductase deficiency

A

AR in genetic males, voice deepens etc bc surge in testosterone in puberty
SRD5A1 - chr 5 - male pattern hair
SRD5A2 - chr 2p23 - no external genitalia

856
Q

CAH

A

17a - hydroxyprogesterone accumulation -> androstenedione and testosterone

zona reticularis hyperplasia

hyponatremia
hypoglycemia
hyperkalemia

advanced skeletal maturation

857
Q

urinary dehydroepiandrosterone

A

DHEA
<2x -> CAH
>2x -> adrenal tumor

858
Q

GnRH pulses

A

impaired in anorexia

originate in mediobasal hypothalamus, arcuate nucleus

859
Q

PCOS path

A

SHBG dec steroid hormone binding globulin
IGFBP-1 dec insulin growth factor binding protein 1

free testosterone and estradiol inc -> follicular atresia, hirsutism

high insulin and IGAF -> theca cells -> more androgens

LH inc
FSH dec

endometrial carcinoma

860
Q

AMH in women tells you

A

ovarian follicle reserve

861
Q

DUB

A

prolonged anovulation

anovulatory DUB - too much estrogen
ovulatory DUB - too much progesterone

862
Q

amenorrhea alternating w prolonged bleeding

A

obese women, high estrogen, ovulatory DUB

863
Q

ovary chocolate cyst

A

endometriosis

864
Q

young syndrome

A

sinusitis
bronchiectasis
obstructive azoospermia

865
Q

toxic to sperm

A

cyclophosphamide
chlorambucil
nitrogen mustard

alkylating agents

866
Q

genetic male infertility

A

deletion of Yq - long arm

AZFa,b,c - c most common (azoospermia factor regions) del

867
Q

xx males

A

SRY translocation to x

sertoli cell only syndrome (SCOS)

868
Q

klinefelter

869
Q

kallman

A

Kal1 - x linked

kal 2 - autosomal

870
Q

kartagener

A

autosomal recessive
defective dynein arms

situs inversus
chronic sinusitis
primary ciliary dyskinesia

871
Q

turner

A

low testosterone and inhibin
high LH FSH and estradiol
degenerated leydig cells

tall stature

872
Q

cryptorchidism

A

intratubular germ cell neoplasia - early, immunostain for placental alkaline phosphatase to detect
seminoma

873
Q

varicocele

A

pampiniform plexus - venous drainage of testes

874
Q

alcohol and erectile dysfunction

A

low LH, leydig cell damage

cirrhosis - estrogen

875
Q

innervation of penis

A

parasymp: cavernous S2-4 - autonomic -> helicine arteries dilate
dorsal nerve: pudendal S2-4 - somatic -> contraction of ischiocavernosus muscles

876
Q

erection chemicals

A

NO -> sequesters Ca in cytoplasm -> muscles relax

Ach

877
Q

PDE5

A

removes cGMP during erection to stop erection

sildenafil/viagra -> inhibit PDE5 -> dec Ca

878
Q

cavernous never

A

branch of pelvic splanchnic (which innervates bladder etc)

879
Q

pretesticular, testicular, post

A

pre: kallman, steroids
test: klinefelter, kartagener
post: androgen receptor insensitivity, CF, erectile dysfunction

880
Q

nonseminoma

A

grow and spread fast

881
Q

seminoma

A

sensitive to radiation
distinct cell borders
clear
glycogen rich cytoplasm

882
Q

Yolk sack tumor

A

AFP

schiller duval body - central vessel surrounded by tumor

883
Q

hCG

A

choriocarcinoma, embryonal carcinoma

leads to hyperthyroidism bc cross reactivity of hCG w TSH

884
Q

choriocarcinoma of testis

A 
extensive mets
trophoblastic
sheets of small cuboidal cells
large eosinophilic syncitial cells
pleomorphic nuclei
blood tinged sputum, cough
unilateral gynecomastia
hepatomegaly
supraclavicular lymph nodes palpable
ß-hCG elevated
CANNON BALL masses in lung
885
Q

Teratoma

A

benign - prepuberty
mature - fully differentiated tissues
immature - small hyperchromatic, undifferentiated mesenchymal, little cytoplasm (blastema)

886
Q

embryonal carcinoma

A

hemorrhage and necrosis
primitive cells
indistinct cell borders

887
Q

leydig cell tumor

A 
precocious puberty
adults - asymptomatic
high testosterone and estradiol
golden brown tumor
Reinke crytals on histo
888
Q

Sertoli cell tumor

A

calcifications in lumen, next to normal tubules w advanced spermatogenesis

889
Q

BPH

A

transition zone and central zone
tall columnar cells and flattened basal cells
corpora amylacea

890
Q

BPH path

A

bc of DHT and androstanolone

age related inc estrogen -> inc DHT receptors

891
Q

prostate cancer

A

african american
peripheral
single cell layer glands - basal layer absent
osteoblastic mets - radiodense

892
Q

why prostate cancer doesnt infiltrate rectum?

A

denonvillier’s fascia / rectoprostatic fascia

893
Q

PSA levels

A

normal - less than 4
above 20 - highly elevated: adenocarcinoma of prostate
PSA density more than 0.15 - cancer
PSA velocity of 0.75 per year - cancer

894
Q

prostatic acid phosphatase - PAP

A

prognostic, not diagnostic

895
Q

gleason score

A

cells got by needly biopsy
1- well diff, 5- poor diff

add 2 most common patterns
6 or more = adenocarcinoma

896
Q

prostate cancer and bone

A

cancer cells secrete bone paracrines -> inc osteoblastic activity

osteoblasts -> growth factors -> more cancer

897
Q

trichomoniasis

A

yellow-green frothy, mucopurulent
WBC>10
whiff test pos
strawberry cervix - colpitis macularis

898
Q

chancre

A

primary syph

painless

899
Q

chancroid

A 
haemophilus ducreyi
painful
multiple lesions
ragged edges, purulent base, bleeds
"school of fish"
900
Q

condyloma acuminata

901
Q

condyloma lata

A

secondary syph

large raised grey lesion on warm mucous

902
Q

chronic granulomas

A

tertiary syph

903
Q

jarisch herxheimer rxn

A

Abx given for primary syph -> endotoxins released by dead syph -> resembles sepsis

904
Q

lues maligna

A

ulcertations
secondary syph
HIV, immunocompromised

905
Q

secondary syph

A

systemic
alopecia - moth eaten - reversible
uveitis
hepatitis

906
Q

tertiary syph

A

cardio - dilated aorta, regurg

gummatous - HIV pt

907
Q

argyll robertson pupil

908
Q

non treponemal tests NTT

A

reactivity of serum w cardiolipin-cholesterol-lecithin Ag
VDRL - pos weeks after infx, rapid plasma regain (RPR), Toluidine Red Unheated Serum Test (TRUST)

screening
monitor response to therapy

909
Q

NTT false pos

A

collagen vascular disorders
yaws
malaria
leprosy

910
Q

treponemal antibody tests TAT

A 
fluorescent treponemal antibody absorption FTA-ABS
micro hemagglutination assay MHA-TP
t pallidum particle agglutination TP-PA
enzyme immunoassays TP-EIA
chemiluminescence immunoassays CIA
911
Q

chlamydia tropism

A

columnar and transitional epithelium
A-C - trachoma
D-K urethritis, PID, conjunctivitis, reactive arthritis
L1-3 lymphogranuloma venereum

912
Q

fitz hugh curtis syndrome

A

perihepatitis - chlamydia and gonnhorea

913
Q

gonorrhea evading immune system

A

IgA 1 protease
blocking antibodies to reduction modifiable protein Rmp
antigenic/phase variation of Opa, Pil, and LOS
sialylation of LOS masks gonococcal antigen, prevents phagocytosis

914
Q

giant cells on Tzanck smear w eosinophilic inclusions (Cowdry A)

915
Q

HPV path

A

microscopic breaks in skin
integrates genes into nuc of replicating basal epithelial cells
6 E - gene regulation, cell transformation
2 L - virus shell
long control region/ upstream regulatory region

malignant - E6 and E7
E7 binds Rb (E2F/pRb)
E6 binds p53

G1 to S dysregulation (Rb issues)

916
Q

pain from testes

A

sympathetic afferents T10 - L2

917
Q

non infx epididymitis

A

amiodarone

cordarone

918
Q

acute epididymitis

A

pos phren sign

919
Q

scrotal lymphatics

A

inguinal nodes

920
Q

nerves of scrotum

A

genital branch of genitofemoral nerve

ilioinguinal nerve

921
Q

blue domed cysts of breast

A

fibrocystic - not malignant

922
Q

intraductal papilloma

A

blood from nipple

lactiferous ducts

923
Q

paget’s

A

DCIS into lactiferous ducts
eczematous rash
intraepithelial adenocarcinoma
noninvasive

924
Q

invasive lobular carcinoma

A

bilateral
multiple lesions
dec E cadherin
linear fashion-bulls eye, indian file

925
Q

medullary carcinoma of breast

A

bulky soft tumor, large cells
lymphoid infiltrate
BRCA
ER PR neg, poor prognosis

926
Q

menopause

A

E1 predominant, E2 goes down

FSH drastically increase 20x, LH 3x

927
Q

hot flashes

A

IL1,7
obese protected
less estrogen induced opioid activity on hypothalamus

928
Q

estrogen def

A 
osteoclasts -> IL1,6, TNF-a, PGE2
inc IL7 -> T cell activation
T cells -> IFN-gamma, TNFa
IFN-gamma -> MHC II
MHC II -> T cells secrete RANKL
929
Q

RANK

A

receptor on osteoclasts

930
Q

osteoprotegerin OPG

A

inhibitor of RANKL

suppresses bone resorption

931
Q

bone density T , Z

A

T - same sex and age

Z - sex age race height weight

932
Q

osteopenia, porosis, severe porosis

A

penia - 1-2.5
porosis - 2.5
severe - 2.5 and fractures

933
Q

leiyomyomam

A

MED12 gene mut

934
Q

tamoxifen in post menopausal

A

type 1 endometrial CA (too much estrogen)

935
Q

nulliparity and breast CA risk for

A

type 2 endometrial CA (endometrial atrophy)

936
Q

overexpression of p53
ki-67
EGFR
HER2/neu

A

type 2 endometrial CA

937
Q

PTEN

KRAS

A

type 1 endometrial carcinoma

938
Q

area of squamous metaplasia

A

transformation zone of cervix

939
Q

Dysgerminoma

940
Q

non gestational choriocarcinoma

A

resistant to treatment

941
Q

Meig’s syndrome

A

fibroma/thecoma +ascites, pleural effusion

942
Q

granulosa theca cell tumor

A

inhibin marker
produce estrogen
endometrial cancer association
call-exner bodies, nests of cancer cells

BSCE GOER (3 decks)

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