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780 Cards in this Set

  • Front
  • Back
What two blood vessels and one nerve run anterior to the spine at the level of the umbilicus?
The aorta, inferior vena cava, and sympathetic trunk run together along the spine.

2010-302
What is the deepest muscle group making up the lateral abdominal wall?
Transversus abdominis

2010-302
What is the name of the connective tissue that lies between the rectus muscles at the midline?
Linea alba

2010-302
What individual layers of fascia join to make the rectus sheath?
Fascia of the external oblique, internal oblique, and transversus abdominus

2010-302
What is the most superficial muscle group making up the lateral abdominal wall?
External oblique

2010-302
Which portion of the colon is not retroperitoneal?
Transverse colon

2010-302
Which parts of the duodenum are retroperitoneal?
The second, third, and fourth parts of the duodenum

2010-302
Name two major organs that lie completely in the retroperitoneal space.
The kidneys and adrenal glands

2010-302
What part of the pancreas is not found in the retroperitoneal space?
The tail of the pancreas

2010-302
Which two parts of the urinary system are retroperitoneal?
The kidney and ureters

2010-302
In the gastrointestinal tract, the gastrocolic ligament connects which two structures?
The transverse colon and the greater curvature of the stomach

2010-303
The hepatoduodenal ligament contains what structures?
The portal triad (the portal vein, the portal artery, and the common bile duct)

2010-303
The splenorenal ligament contains what structures?
The splenic artery and the splenic vein

2010-303
In the gastrointestinal tract, the falciform ligament connects which two structures?
The liver and the abdominal wall

2010-303
The _____ ligament connects the liver and the duodenum.
Hepatoduodenal

2010-303
What ligament separates the greater and lesser sacs?
Gastrosplenic ligament

2010-303
The gastrohepatic ligament contains what structures?
The gastric arteries

2010-303
The portal triad can be compressed through what opening to control bleeding?
The omental foramen (also known as the epiploic foramen of Winslow)

2010-303
In the gastrointestinal tract, the gastrosplenic ligament connects which two structures?
The spleen and the greater curvature of the stomach

2010-303
In the gastrointestinal tract, the splenorenal ligament connects which two structures?
The spleen and the posterior abdominal wall

2010-303
The falciform ligament contains what structure?
The ligamentum teres

2010-303
From what fetal structure is the falciform ligament derived?
Fetal umbilical vein

2010-303
What ligament is part of the greater omentum?
Gastrocolic ligament

2010-303
What gastrointestinal ligament can be cut to access the lesser sac during surgery?
The gastrohepatic ligament

2010-303
In the gastrointestinal tract, the gastrohepatic ligament connects which two structures?
The liver and the lesser curvature of the stomach

2010-303
The gastrocolic ligament contains what structures?
The gastroepiploic arteries

2010-303
What is the rate of basal electrical rhythm in the ileum?
8-9 waves/min

2010-304
Meissner's plexus controls what three functions of the submucosal gut wall?
Secretions, blood flow, and absorption

2010-304
List three components of the gut wall mucosa.
Epithelium, lamina propria, and muscularis mucosa

2010-304
What is the primary function of the muscularis mucosa of the gut wall mucosa?
Mucosal motility

2010-304
What is the rate of basal electrical rhythm in the stomach?
3 waves/min

2010-304
List the four main layers of the gut wall, starting from the inside and going out.
Mucosa, submucosa, muscularis externa, and serosa

2010-304
What structure is found within the submucosa of the gut wall?
The submucosal nerve plexus (Meissner's plexus)

2010-304
Which layer of the muscularis externa is closer to the lumen: the circular layer or the longitudinal layer?
The circular layer

2010-304
Villi are found in which section of the digestive tract?
Small intestine

2010-304
What lies between the inner circular and outer longitudinal layers of the muscularis externa?
The myenteric nerve plexus (Auerbach's plexus)

2010-304
What is the rate of basal electrical rhythm in the duodenum?
12 waves/min

2010-304
What is the primary function of the epithelium of the gut wall mucosa?
Absorption

2010-304
What is the primary function of the lamina propria of the gut wall mucosa?
Support

2010-304
A patient presents with intractable diarrhea and is found to have celiac disease. What microstructure is damaged and where is it located?
The villi and the microvilli of the small intestine are likely damaged resulting in decreased absorptive capacity and diarrhea

2010-304
These epithelial glands are found throughout the small intestine.
Crypts of Lieberkühn

2010-304
Name a submucosal structure that is unique to the duodenum.
Brunner's glands

2010-304
Goblet cells are highly concentrated in this area of the small intestine.
Jejunum

2010-304
Name a major histological difference between the duodenum and the colon.
The duodenum has villi whereas the colon only has crypts

2010-304
What part of the small intestine has the highest concentration of villi and microvilli?
Duodenum; villi increase the surface area of the epithelium to maximize absorption

2010-304
Describe the epithelium of the esophagus in histological terms.
Nonkeratinized stratified squamous cell epithelium

2010-304
Which immunologic structures are unique to the Ileum?
Peyer's patches

2010-304
The submucosal plexus is located between what two layers?
The mucosa and the inner layer of smooth muscle

2010-304
The primary function of the myenteric plexus is to coordinate what function?
Motility along the entire gut wall

2010-304
The myenteric plexus is located between what two smooth muscle layers?
The inner circular layer and the outer longitudinal layer (remember: AUerbach's is on the Autside)

2010-304
What are the functions of the submucosal nerve plexus?
Regulation of secretions, blood flow, and absorption

2010-304
The upper one-third of the esophagus is composed of _____ muscle.
Striated

2010-304
What type of muscle fibers make up the middle one third of the esophagus?
Both striated and smooth muscle

2010-304
The lower one-third of the esophagus is composed of ______ muscle.
Smooth

2010-304
At what level does the abdominal aorta bifurcate?
L4

2010-305
Which paired arteries come off the aorta at the level of L1?
The renal arteries

2010-305
Which branch of the aorta comes off at the level of L1?
The superior mesenteric artery

2010-305
This branch of the aorta supplies the foregut.
Celiac trunk

2010-305
Which paired arteries come off the aorta at the level of L2?
The ovarian or testicular arteries

2010-305
Which two arteries does the aorta become after the bifurcation?
Left and right common iliac arteries

2010-305
What are the three embryologic divisions of the gastrointestinal tract?
The foregut, midgut, and hindgut

2010-305
Which artery supplies the foregut?
Celiac artery

2010-305
Which segments of the gastrointestinal tract receive parasympathetic innervation from the vagus?
Foregut (stomach to proximal duodenum, liver, gallbladder, pancreas, spleen) and midgut (distal duodenum to proximal 2/3 of transverse colon)

2010-305
An elderly patient presents with bright red bleeding per rectum and is found to be hypotensive. On colonoscopy, she is found to have necrotic mucosa at the splenic flexure. What is the blood supply to this region?
Inferior and superior mesenteric arteries

2010-305
What are the main gastrointestinal structures derived from the embryonic foregut?
The stomach, proximal duodenum, liver, gallbladder, and pancreas

2010-305
Which artery supplies the midgut?
The superior mesenteric artery

2010-305
What organ supplied by the celiac trunk is not an embryonic gut derivative?
Spleen

2010-305
What portion of the gastrointestinal tract is derived from the embryonic midgut?
From the distal duodenum to the proximal two-thirds of the transverse colon

2010-305
Which artery supplies the hindgut?
Inferior mesenteric artery

2010-305
What portion of the gastrointestinal tract is derived from the embryonic hindgut?
From the distal one-third of the transverse colon to the upper rectum

2010-305
What are the branches of the splenic artery?
The short gastrics and left gastroepiploic artery

2010-306
The short gastric arteries have poor anastomoses if the _____ artery is blocked.
Splenic

2010-306
What are the main branches of the common hepatic artery?
The right gastric artery, gastroduodenal artery, and hepatic artery proper

2010-306
Name the three main branches of the celiac trunk.
Common hepatic artery, splenic artery, and left gastric artery

2010-306
Strong anastomoses exist between what two sets of arteries of the celiac trunk?
Left and right gastroepiploics and left and right gastrics

2010-306
What arteries feed the greater curvature of the stomach?
The right and left gastroepiploic arteries

2010-306
What are the two branches of the gastroduodenal artery?
Superior pancreaticoduodenal and right gastroepiploic arteries

2010-306
From what artery does the cystic artery arise?
The right hepatic artery, a branch of the common hepatic artery; the cystic artery supplies the gallbladder

2010-306
What arteries feed the lesser curvature of the stomach?
The right and left gastric arteries

2010-306
The stomach receives its main blood supply from branches of what structure?
The celiac trunk

2010-306
If the abdominal aorta is blocked, there are several anastomoses that will provide collateral flow. Complete this one: _____ _____ (from the inferior mesenteric artery) to the middle rectal (normally fed by the internal iliac).
Superior rectal

2010-306
If the abdominal aorta is blocked, there are several anastomoses that will provide collateral flow. Complete this one: middle colic (from the superior mesenteric artery) to the _____ _____ (normally fed by the inferior mesenteric artery).
Left colic

2010-306
If the abdominal aorta is blocked, there are several anastomoses that will provide collateral flow. Complete this one: internal mammary (from the subclavian) to the superior epigastric (internal thoracic) to the _____ _____ (normally fed by the external iliac).
Inferior epigastric

2010-306
If the abdominal aorta is blocked, there are several anastomoses that will provide collateral flow. Complete this one: superior pancreaticoduodenal (from the celiac trunk) to the _____ _____ (normally fed by the superior mesenteric artery).
Inferior pancreaticoduodenal

2010-306
If the abdominal aorta is blocked, which artery can anastamose with the left colic artery (of the inferior mesenteric artery)?
Middle colic artery (of the superior mesenteric artery)

2010-306
If the abdominal aorta is blocked, there are several anastomoses that will provide collateral flow. Complete this one: _____ _____ (from the superior mesenteric artery) to the left colic (normally fed by the inferior mesenteric artery).
Middle colic

2010-306
If the abdominal aorta is blocked, there are several anastomoses that will provide collateral flow. Complete this one: _____ _____ (from the subclavian) to the superior epigastric (internal thoracic) to the inferior epigastric (normally fed by the external iliac).
Internal mammary

2010-306
If the abdominal aorta is blocked, the superior pancreaticoduodenal artery of the celiac trunk can anastamose with what vessel?
Inferior pancreaticoduodenal artery (of the superior mesenteric artery)

2010-306
If the abdominal aorta is blocked, there are several anastomoses that will provide collateral flow. Complete this one: superior rectal (from the inferior mesenteric artery) to the _____ _____ (normally fed by the internal iliac).
Middle rectal

2010-306
If the abdominal aorta is blocked, there are several anastomoses that will provide collateral flow. Complete this one: _____ _____ (from the celiac trunk) to the inferior pancreaticoduodenal (normally fed by the superior mesenteric artery).
Superior pancreaticoduodenal

2010-306
If the abdominal aorta is blocked, there are several anastomoses that will provide collateral flow. Complete this one: internal mammary (from the subclavian) to the _____ _____ (internal thoracic) to the inferior epigastric (normally fed by the external iliac).
Superior epigastric

2010-306
The superior rectal artery (of the inferior mesenteric artery) can anastamose with what artery?
Middle rectal artery (of the internal iliac)

2010-306
If the abdominal aorta is blocked, blood can travel through the subclavian artery into the internal thoracic artery and then through an anastomosis to which artery?
Superior epigastric (internal thoracic)

2010-306
Portal-systemic anastomoses from the paraumbilical vein to the inferior epigastric and superior epigastric veins can manifest as what?
Caput medusae at the navel

2010-307
A patient with portal hypertension presents with discomfort on defecation and bright red blood per rectum. Physical examination shows prolapsed dilated veins around the anus that are not tender. What is the explanation of these findings?
A portosystemic anastomoses between the superior and middle rectal arteries created internal hemorrhoids, which are painless

2010-307
Name two potential shunts that can be created surgically to relieve portal hypertension.
Splenic vein to left renal vein; portal vein to inferior vena cava

2010-307
Give three examples of clinical manifestations of portosystemic anastomoses seen in patients with portal hypertension.
Esophageal varices, internal hemorrhoids, and caput medusae (remember: gut, butt, and caput

2010-307
A chronic alcoholic patient presents with mental status change, tense ascites, and hematemesis. What is a likely cause of his hematemesis?
Portal hypertension from his cirrhosis (as evidenced by his ascites) created esophageal varices that ruptured, causing hematemesis

2010-307
What condition causes portal-systemic anastomoses?
Portal hypertension

2010-307
What is the underlying principle in surgical treatment of portal hypertension?
Creation of anastomoses to shunt blood from portal circulation into systemic circulation, thereby bypassing the liver

2010-307
What type of hemorrhoids occur above the pectinate line? Below the pectinate line?
Internal; external

2010-307
The superior rectal artery is a branch of what artery?
The inferior mesenteric artery

2010-307
Below the pectinate line, there is what type of innervation, somatic or visceral?
Somatic innervation

2010-307
The inferior rectal artery is a branch of what artery?
The internal pudendal artery

2010-307
True or False? Internal hemorrhoids are painful.
False; internal hemorrhoids are not painful whereas external hemorrhoids are painful

2010-307
_____ hemorrhoids receive somatic innervation and are therefore _____.
External; painful

2010-307
What type of cancer occurs above the pectinate line in the rectum? Below the pectinate line?
Adenocarcinoma; squamous cell carcinoma

2010-307
Above the pectinate line, there is what type of innervation: visceral or somatic?
Visceral innervation

2010-307
Above the pectinate line, the arterial supply comes from what artery?
The superior rectal artery

2010-307
The pectinate line is formed where the embryonic _____ derivatives meet the _____ derivatives.
Hindgut; ectodermal

2010-307
Below the pectinate line, the arterial supply is from what artery?
The inferior rectal artery

2010-307
A patient with hepatocellular carcinoma and tense ascites presents with mental status change and bright red blood per rectum. On physical exam, you see dilated veins but cannot deduce if they are painful given the patient's mental status. What is the likely diagnosis of the rectal exam findings?
Internal hemorrhoids, which can result from portal hypertension

2010-307
The basolateral surface of hepatocytes face what space?
The sinusoids

2010-308
Describe bile flow through the liver.
Hepatocytes secrete bile via their apical surfaces into the bile canaliculi, which then drain into the bile ductule

2010-308
Whereas portal veins drain from ____, the central vein drains to ____.
Splanchnic (gut) circulation; hepatic vein and systemic circulation

2010-308
A patient presents with jaundice, encephalopathy, and oliguria. He has elevated liver enzymes. What zone of his liver is likely affected?
Zone III

2010-308
A patient presents with elevated alanine aminotransferase and aspartate aminotransferase levels with an alanine aminotransferase to aspartate aminotransferase ratio > 2.0. What zone of his liver is likely affected?
Zone III; alcoholic hepatitis usually affects Zone III

2010-308
Zone III of the liver is also known as what?
Pericentral vein zone (centrilobular zone)

2010-308
Why is Zone II of the liver most affected by ischemia?
It is furthest away from the hepatic artery

2010-308
Which zone is affected most by viral hepatitis?
Zone I

2010-308
What major structure is found in Zone III of the liver?
Branches of the central vein

2010-308
The apical surface of hepatocytes face which space?
The bile canaliculi

2010-308
Which zone of the liver contains the P450 enzyme system?
Zone III (pericentral vein/centrilobular zone)

2010-308
What fluid drains through the space of Disse in the liver?
Lymph (in the liver)

2010-308
Zone I of the liver is also known as the _______ zone.
Periportal

2010-308
Describe the venous blood flow of the liver in order.
Portal circulation, portal vein, liver sinusoids, central vein, inferior vena cava

2010-308
What structures are found in Zone I of the liver?
The portal triad (the portal vein, the portal artery, and the common bile duct)

2010-308
Notably, the sinusoids of the liver are lacking what structure that most capillaries have?
Basement membrane

2010-308
En route from the liver sinusoids to the hepatocytes, plasma macromolecules must pass through what space?
The perisinusoidal space (the space of Disse)

2010-308
Why is it advantageous to have fenestrated capillaries in the liver sinusoids?
They allow macromolecules to have access to the hepatocytes, thereby facilitating appropriate metabolism of these macromolecules

2010-308
Liver sinusoids are lined with what kind of endothelium?
Fenestrated

2010-308
A gallstone in what location would lead to elevated amylase and lipase as well as serum bilirubin and alkaline phosphatase?
Ampulla of Vater

2010-308
Blockage of which biliary structure would cause a dilated gallbladder but no other blockage?
The cystic duct

2010-308
A patient presents with right upper quadrant abdominal pain. Further work-up reveals a gallstone obstructing the common bile duct. Which two biliary ducts drain directly into the common bile duct?
The cystic duct and common hepatic duct

2010-308
What is the name of the structure formed by the common bile duct and the pancreatic duct as they empty into the duodenum?
The ampulla of Vater

2010-308
What is the name of the sphincter through which bile passes to enter the duodenum?
The sphincter of Oddi

2010-308
A patient presents with right upper quadrant pain, fever, and jaundice. She has elevated liver enzymes but normal pancreatic enzymes. If a gallstone is the cause of these findings, where is it likely to be located?
In the common bile duct

2010-308
What structure forms the medial border of the femoral triangle?
The adductor longus muscle

2010-309
What structure forms the superior border of the femoral triangle?
The inguinal ligament

2010-309
Going from lateral to medial, list the components that are found within the femoral triangle.
Nerve, artery, vein, empty space, lymphatics (remember: the contents lateral to medial are NAVEL as well as venous near the penis)

2010-309
What femoral triangle structure lies outside of the femoral sheath?
The femoral nerve

2010-309
What structure forms the lateral border of the femoral triangle?
The sartorius muscle

2010-309
What three main structures are contained within the femoral sheath?
Femoral artery, femoral vein, and femoral canal

2010-309
Between which two structures would you find a direct inguinal hernia?
The inferior epigastric vessels and the rectus abdominus

2010-309
From the most superficial layer to deep, what are the three muscles that cover the internal (deep) inguinal ring?
External oblique, internal oblique, and transversus abdominis

2010-309
Name the layers that compose the spermatic cord, from the most superficial to the deepest layer.
External spermatic fascia, cremasteric muscle and fascia, and internal spermatic fascia

2010-309
What is the site of protrusion of an indirect hernia into the inguinal canal?
The internal inguinal ring

2010-309
Which type of hernia usually occurs among older men?
The direct inguinal hernia

2010-310
Trace the path of an indirect inguinal hernia.
Internal (deep) inguinal ring, through external (superficial) ring, into scrotum

2010-310
What structure do both direct and indirect inguinal hernias pass through?
The external (superficial) inguinal ring

2010-310
Which type of hernia is much more common among males?
The indirect inguinal hernia

2010-310
What structures are displaced in a paraesophageal hernia?
The cardia of the stomach is displaced into the thorax whereas the gastroesophageal junction is unaffected

2010-310
What structure is useful for spatially differentiating direct inguinal hernias from indirect inguinal hernias?
The inferior epigastric artery (remember: MDs don't LIe: Medial to inferior epigastric artery = Direct hernia and Lateral to inferior epigastric artery = Indirect hernia to recall locations

2010-310
A direct inguinal hernia bulges directly through the abdominal wall _____ to the inferior epigastric artery.
Medial

2010-310
What type of hernia is most likely to become incarcerated?
Femoral

2010-310
What is the difference between sliding and paraesophageal hernias?
Sliding hernias result in a displaced gastroesophageal junction, resulting in increased risk for gastroesophageal reflux disease, whereas paraesophageal hernias lead to displacement of the gastric cardia increasing risk of gastric incarceration

2010-310
Which type of hiatal hernia is associated with gastroesophageal reflux disease refractory to medical treatment?
Sliding hernias result in a displaced gastroesophageal junction, resulting in increased risk for gastroesophageal reflux disease

2010-310
What type of inguinal hernia is seen in infants?
Indirect, especially in males

2010-310
Are femoral hernias more common in men or women?
Women

2010-310
Indirect hernias occur in infants as a result of the failure of the _____ _____ to close.
Processus vaginalis

2010-310
Hesselbach's triangle is defined by what structures?
The inguinal ligament, rectus abdominus muscle, inferior epigastric artery

2010-310
An indirect inguinal hernia enters the internal inguinal ring _____ to the inferior epigastric artery.
Lateral

2010-310
How many layers of the spermatic cord cover the sac of an indirect hernia? A direct hernia?
Only the superficial layer; all layers

2010-310
Diaphragmatic hernias in infants are often a result of the defective development of what membrane?
The pleuroperitoneal membrane

2010-310
Relative to the pubic tubercle, where is a femoral hernia typically located?
Below and lateral to the pubic tubercle (through the femoral canal)

2010-310
Secretin is produced by which cells?
S cells of the duodenum

2010-311
What are the functions of gastrin?
Gastrin increases acid secretion, promotes growth of the gastric mucosa, and increases gastric motility

2010-311
What serves as negative feedback for gastrin release?
Acid secretion; a pH < 1.5 will inhibit gastrin secretion

2010-311
Why is it important that secretin-stimulated bicarbonate neutralize gastric acid within the duodenum?
Pancreatic enzymes would otherwise be denatured and nonfunctional in the acidic environment created by unopposed gastric acid

2010-311
What are the actions of secretin?
Increases bicarbonate secretion, increases bile acid secretion, decreases gastric acid secretion

2010-311
What stimulates cholecystokinin release?
The presence of fatty acids and amino acids in the duodenum

2010-311
What is the major symptom of a vasoactive intestinal peptide-secreting tumor?
Profuse, watery diarrhea

2010-311
What stimuli increase secretion of vasoactive intestinal peptide?
Distention, vagal stimulation

2010-311
What are two tumors that can be treated with somatostatin?
Vasoactive intestinal peptide tumors and carcinoid tumors; somatostatin reduces symptoms by inhibiting secretions from the tumors

2010-311
What are the actions of cholecystokinin?
Stimulation of gallbladder contraction and pancreatic enzyme secretion; slowing of gastric emptying

2010-311
What increases glucose-dependent insulinotropic peptide secretion?
Fatty acids, amino acids, and oral glucose load

2010-311
Glucose-dependent insulinotropic peptide is made by which cells?
K cells of the duodenum and jejunum

2010-311
Somatostatin is made by which cells?
D cells of pancreatic islets and gastrointestinal mucosa

2010-311
Secretin-stimulated pancreatic bicarbonate functions to neutralize _____ _____ within the _____.
Gastric acid; duodenum

2010-311
What effect does vasoactive intestinal peptide have on intestinal smooth muscle and sphincters?
Relaxation of these structures

2010-311
Where is vasoactive intestinal polypeptide secreted within the gastrointestinal tract?
Parasympathetic ganglia in sphincters, gallbladder, small intestine

2010-311
Does somatostatin lead to increased or decreased pepsinogen secretion? Increased or decreased gastric acid secretion?
Decreased; decreased

2010-311
Vasoactive intestinal polypeptide _____ (increases/decreases) intestinal water and electrolyte secretion.
Increases

2010-311
What is the function of motilin?
Production of migrating motor complexes in the small intestine, thereby promoting peristalsis

2010-311
What is the exocrine regulatory effect of glucose-dependent insulinotropic peptide?
Decreased secretion of gastric acid

2010-311
What are stimuli for the release of gastrin?
Distension, amino acids, vagal stimulation

2010-311
Motilin secretion is _____ (increased/decreased) while in a fasting state.
Increased

2010-311
Which cells in the gastrointestinal tract make cholecystokinin?
I cells of the duodenum and jejunum

2010-311
What is the pathophysiology of achalasia?
Increase in lower esophageal tone secondary to loss of nitric oxide secretion

2010-311
The presence of what substance in the gut lumen causes increased somatostatin release?
Acid

2010-311
A young, obese male presents to the office with increased aggression and hyperphagia. He has an IQ of 60 and small testicles. What is his diagnosis and what hormone is implicated in his hyperphagia?
Prader-Willi; ghrelin

2010-311
What is a negative regulator of vasoactive intestinal peptide release?
Adrenergic input

2010-311
What functions to inhibit somatostatin release?
Vagal stimulation

2010-311
What are the functions of ghrelin?
Regulation of hunger and meal initiation

2010-311
Secretion of which hormones is stimulated by ghrelin?
Growth hormone, adrenocorticotropic hormone, cortisol, and prolactin

2010-311
Does somatostatin increase or decrease pancreatic secretions?
Decrease

2010-311
A patient presents with peptic ulcer disease refractory to medical treatment. On endoscopy, he is found to have multiple ulcers in the stomach and a few in the jejunum. Fasting gastrin levels are markedly elevated. What is the likely diagnosis?
Zollinger-Ellison syndrome due to ectopic production of gastrin

2010-311
Given the functions of somatostatin, why is it classified as an antigrowth hormone?
Somatostatin inhibits digestion and absorption of nutrient, thereby preventing the body from receiving nutrient needed for growth

2010-311
What two amino acids are especially potent stimulators of gastrin release?
Tryptophan and phenylalanine

2010-311
Which two substances stimulate secretin release within the duodenum?
Acid and fatty acids

2010-311
Why is an oral glucose load used more rapidly by the body than an equivalent load that is given intravenously?
Because oral (but not intravenous) glucose stimulates glucose-dependent insulinotropic peptide, which stimulates insulin release

2010-311
Which small messenger molecule causes an increase in smooth muscle relaxation in the gut?
Nitric oxide

2010-311
Does somatostatin increase or decrease fluid secretions in the small intestine?
Decrease

2010-311
A patient undergoes gastric bypass surgery for weight loss. He reports feeling less hungry. What is a possible explanation for this finding?
Decreased ghrelin secretion by the stomach after bypass surgery

2010-311
What is the endocrine regulatory effect of glucose-dependent insulinotropic peptide?
Increased release of insulin

2010-311
In cholelithiasis, pain worsens after the ingestion of what type of foods?
Fatty foods; due to stimulation of cholecystokinin release, which causes gallbladder contraction

2010-311
The G cells of the antrum produce which hormone?
Gastrin

2010-311
What effect does somatostatin have on the gallbladder?
Somatostatin decreases gallbladder contraction

2010-311
Inactive pepsinogen is converted to pepsin by _____ _____.
Low pH

2010-312
What stimulates pepsin release?
Acid in the stomach and vagal stimulation

2010-312
What is the main action of gastric acid?
To decrease stomach pH

2010-312
By secreting bicarbonate within the stomach and the duodenum, mucosal cells prevent what harmful process from occurring?
Autodigestion

2010-312
Intrinsic factor is a product of what cells?
Parietal cells of the stomach

2010-312
The destruction of parietal cells is seen in which two conditions?
Chronic gastritis and pernicious anemia

2010-312
Which substances decrease gastric acid secretion?
Somatostatin, glucose-dependent insulinotropic peptide, prostaglandin, and secretin

2010-312
Which cells secrete bicarbonate?
Mucosal cells throughout the gastrointestinal tract and Brunner's glands in the duodenum

2010-312
What is the function of intrinsic factor?
Vitamin B12 binding and B12 absorption in the ileum

2010-312
What cells make gastric acid?
Parietal cells

2010-312
Which substances increase gastric acid secretion?
Acetylcholine (from the vagus nerve), histamine, and gastrin

2010-312
Bicarbonate secretion within the gastrointestinal tract is increased by what substance?
Secretin

2010-312
A patient presents with chronic abdominal pain and nonhealing gastric ulcers despite treatment. What is a likely cause?
Gastrinoma

2010-312
What is the action of pepsin?
Protein digestion

2010-312
Which cells make pepsin?
Chief cells

2010-312
What substances are secreted directly into the lumen of the stomach?
Mucus, pepsinogen, intrinsic factor, and HCl

2010-312
Does atropine affect vagal stimulation of the G cells?
No, the G cells are stimulated by gastrin-releasing peptide

2010-312
Does gastrin stimulate the basal or apical surface of the parietal cells?
Basal surface; gastrin is secreted into circulation to stimulate enterochromaffin-like cells and parietal cells

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What are two stimuli that cause increased acid secretion by parietal cells?
Histamine and acetylcholine secretion by the vagus nerve

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Somatostatin is made by _____ cells in what organ?
D; pancreas

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HCl and intrinsic factor are released by _____ cells in the _____ of the stomach.
Parietal; body

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What substances are secreted into the lumen of the duodenum?
Cholecystokinin, secretin, glucose-dependent insulinotropic peptide, and somatostatin

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Name three different types of secretory cells found in the duodenum.
I cells (cholecystokinin), K cells (glucose-dependent insulinotropic peptide), S cells (secretin)

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Gastrin stimulates the production of which two substances?
Histamine (causes acid secretion) and intrinsic factor

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_____ is produced by chief cells in the _____ of the stomach.
Pepsinogen; body

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What influence does atropine have on the gastrointestinal secretory cells?
Blocks vagal stimulation of parietal cells only

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Which of the sympathetic nerves stimulate salivary secretion?
The T1-T3 superior cervical ganglion

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Why does a low flow rate result in hypotonic salivary secretion?
There is more time to reabsorb electrolytes from the saliva

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Which constituent of salivary secretions is important for maintaining dental health?
Bicarbonate

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Which salivary gland produces the most mucinous saliva? The most serous?
Sublingual; parotid

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What is the role of growth factors in salivary products?
Epithelial renewal of the oral mucosae

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The mucins found in salivary secretions are composed of what category of biochemical compounds?
Glycoproteins

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What are the sources of salivary secretions?
Parotid, submandibular, submaxillary, and sublingual glands

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α-Amylase, which is found in salivary secretions, is inactivated by what?
A low pH, as is found in the stomach

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Which branch of the autonomic system regulates salivary secretion?
Both sympathetic and parasympathetic

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The main function of α-amylase, which is found in salivary secretions, is to begin what process?
Starch digestion

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Which two nerves carry the parasympathetic control of salivary secretions?
The facial and the glossopharyngeal nerves

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A patient comes to the clinic complaining of unilateral facial weakness after a parotidectomy. Which nerve was most likely damaged during surgery?
CN VII (facial nerve)

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If salivary secretions flow at a high flow rate, do they then tend to be isotonic or hypotonic to the blood?
Isotonic

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In what two ways does gastrin stimulate acid production by parietal cells?
Gastrin directly binds cholecystokinin receptors on parietal cells and stimulates a G protein cascade; gastrin also stimulates histamine production by enterochromaffin-like cells

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Which common class of drugs inhibit the parietal cell's proton pump? Give an example of one
Proton pump inhibitors such as omeprazole

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The proton pump of the parietal cells pumps _____ into the cell and sends _____ out of the cell and into the lumen.
Potassium; hydrogen

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How does acetylcholine stimulate acid production by parietal cells?
It activates an M3 receptor on the cells that directly stimulates acid secretion via a G protein cascade

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Which cells make gastric acid?
Parietal cells

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The proton pump of parietal cells can be found on which side of the cell?
The luminal side

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What substances inhibit acid secretion by the parietal cells?
Prostaglandins, somatostatin

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What is the second messenger that is used in histamine-induced acid secretion?
cAMP, stimulated by the H2 receptor

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Brunner's glands are located in what layer of the gastrointestinal tract?
The submucosa

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Which disease results in hypertrophy of Brunner's glands?
Peptic ulcer disease

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Is the mucus secreted by Brunner's glands acidic, alkaline, or neutral?
Alkaline

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Brunner's glands are located in what portion of the gastrointestinal tract?
The duodenum

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What is the function of Brunner's gland secretions?
To neutralize acid contents entering the duodenum from the stomach

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In addition to enterokinase, what other enzyme can convert trypsinogen to the active form of trypsin?
Trypsin itself

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Which pancreatic enzyme is also present in saliva?
Amylase

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Which pancreatic enzymes are involved in protein digestion?
Trypsin, chymotrypsin, elastase, and carboxypeptidase

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After being converted to its active form in the intestinal lumen, trypsin then does what?
It activates the other proenzymes as well as more trypsin molecules

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Are proteases secreted in active or inactive forms?
Inactive forms called proenzymes or zymogens

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What enzyme converts trypsinogen to trypsin?
Enterokinase/enteropeptidase

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Where is enterokinase (a protein that activates trypsin) located?
In the duodenal brush border

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Lipase, phospholipase A, and colipase function primarily in what process?
Fat digestion

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What is the function of α-amylase?
To digest starch

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What are the functions of salivary amylase?
Starts digestion by hydrolyzing α-1,4 linkages in starches

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Pancreatic amylase hydrolyzes starch to what two types of substances?
Oligosaccharides and disaccharides

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Where are oligosaccharide hydrolases found?
At the brush border of the intestine

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What are the three basic enzyme groups that digest carbohydrates?
Salivary amylase, pancreatic amylase, and oligosaccharide hydrolases

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What are the products of carbohydrate digestion by salivary amylase?
Disaccharides such as α-limit dextrin, maltose, and maltotriose

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Pancreatic amylase is at its highest concentration in what area of the gastrointestinal tract?
The duodenal lumen

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What are the products of the reactions catalyzed by oligosaccharide hydrolases?
Monosaccharides

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Name the 3 monosaccharides that can be absorbed by enterocytes.
Glucose, galactose, fructose

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Fructose is taken up by what transporter in the gastrointestinal tract?
Glucose transporter 5, which works by facilitated diffusion

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True or False? Only monosaccharides are absorbed by enterocytes.
True; this includes glucose, galactose, and fructose

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All monosaccharides are transported from the enterocytes to the blood by what transporter?
Glucose transporter 2

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Can sucrose be directly absorbed by enterocytes?
No, sucrose is a disaccharide; only monosaccharides (glucose, galactose, fructose) are absorbed directly by enterocytes

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Glucose and galactose are taken up by what transporter in the gastrointestinal tract?
Sodium-glucose linked transporter 1, which is sodium dependent

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Where is iron absorbed in the gastrointestinal tract?
Duodenum; iron must be absorbed as a divalent cation, which is the reduced form of the ion and favored in an acidic environment

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Where is vitamin B12 absorbed in the gastrointestinal tract?
Ileum; B12 must be bound by intrinsic factor to be effectively absorbed

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Where is folate absorbed in the gastrointestinal tract?
Jejunum

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After stimulated B cells from Peyer's patches have differentiated into plasma cells, what do they then secrete?
Immunoglobulin A; (remember: Intra-gut Antibody)

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After being secreted, immunoglobulin A functions to bind what?
Intraluminal antigens

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In what two layers of the gastrointestinal tract are Peyer's patches found?
The lamina propria and the submucosa

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What is the main action of M cells?
M cells take up antigens from the gut lumen for presentation to B cells and eventual creation of immunoglobulin A antibodies

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Peyer's patches are what kind of tissue?
Unencapsulated lymphoid tissue

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Are bile salts water soluble?
Yes, they are conjugated to glycine and taurine (bile acids are not water soluble)

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What is the function of bile?
Bile salts aid in triglyceride absorption and micelle formation

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What is the only means of cholesterol excretion from the body?
Via bile

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What are the six components of bile?
Bile salts, phospholipids, cholesterol, bilirubin, water, and ions

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Bile acids are composed of bile acids conjugated to which two organic acids?
Glycine or taurine

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What type of bilirubin is water insoluble, direct or indirect?
Indirect

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Can unconjugated bilirubin be excreted by the kidneys?
No, it is bound to albumin and therefore cannot pass through the glomerular basement membrane

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Unconjugated bilirubin travels through the circulation bound to _____. This complex can be measured as _____ _____.
Albumin; indirect bilirubin

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What is the essential structural difference between direct and indirect bilirubin?
Direct bilirubin is conjugated; indirect bilirubin is not

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From the gut, urobilinogen that does not get excreted fecally enters the _____ _____, which takes it back to the _____.
Enterohepatic circulation; liver

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The form of bilirubin that gets excreted in the feces is called _____.
Stercobilin

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The form of bilirubin that gets excreted renally is called _____.
Urobilin

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Stercobilin gives feces what characteristic?
Its dark color

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The conjugated bilirubin that gets excreted into the bile by the liver can be measured as _____ _____.
Direct bilirubin

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Direct bilirubin is conjugated with what?
Glucuronic acid

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Within the colon, conjugated bilirubin gets converted to _____ by _____.
Urobilinogen; bacteria

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The liver excretes what form of bilirubin into the bile?
Conjugated (direct) bilirubin

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Bilirubin is a breakdown product made during _____ metabolism.
Heme

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What is jaundice?
Yellow skin and sclerae due to elevated levels of bilirubin

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Which enzyme catalyzes bilirubin conjugation?
Glucuronyl transferase

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What type of bilirubin is water soluble, direct or indirect?
Direct

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Salivary gland tumors are generally _____ (benign/malignant).
Benign

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A patient presents with a painless, movable mass in a salivary gland. The mass is removed and found to be benign. It later recurs. What type of tumor is it?
Pleomorphic adenoma

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What is the most common malignant salivary gland tumor?
Mucoepidermoid carcinoma

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Name the benign tumor composed of heterotopic salivary gland tissue trapped in a lymph node, surrounded by lymphatic tissue.
Warthin's tumor

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Where is the most common location for a salivary gland tumor?
Parotid gland

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What is the most common presenting symptom of achalasia?
Dysphagia

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In patients with achalasia, the lower esophageal sphincter cannot relax as a result of the loss of what source of innervation?
The myenteric (Auerbach's) plexus

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What is the underlying pathophysiology of dysphagia associated with CREST?
There is esophageal dysmotility (poor peristalsis) and low esophageal pressure proximal to the lower esophageal sphincter

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Secondary achalasia can result from what parasitic disease endemic to South America?
Chagas' disease

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Achalasia is associated with an increased risk of what malignancy?
Esophageal carcinoma

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Achalasia results from the failure of what process to occur?
Relaxation of the lower esophageal sphincter

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In patients with achalasia, what test yields a classic diagnostic image?
Barium swallow

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Describe the findings of achalasia on barium swallow.
Bird's beak appearance: dilated proximal esophagus with tapering at the lower esophageal sphincter

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Ingestion of what compound classically causes esophageal strictures?
Lye; strictures are also seen with gastroesophageal reflux disease

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A 45-year-old woman presents to the emergency department with a five-hour history of vomiting and retching. In the last hour, her vomitus was bloody and painful. What is the likely cause of her hematemesis?
Mallory-Weiss tears

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A patient with a history of asthma presents with a nonproductive cough and chest pain that is not associated with activity. It is worse with recumbency and is not relieved by inhalers or nitroglycerin. What is the likely diagnosis?
Gastroesophageal reflux disease

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An alcoholic is brought into the emergency department vomiting copious amounts of blood. The condition this patient likely has causes painless bleeding from which vessels?
Submucosal veins in the lower one third of the esophagus, forming varices

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Esophagitis is commonly associated with what three etiologies?
Reflux, infection, or chemical ingestion

2010-316
Which three infectious agents can cause esophagitis?
Herpes simplex virus type 1, cytomegalovirus, and Candida

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A patient is having difficulty swallowing. He has a swollen, tender tongue that appears smooth. Laboratory tests reveal iron deficiency anemia. What is the most likely diagnosis?
Plummer-Vinson syndrome

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Plummer-Vinson syndrome has a triad of what symptoms?
Dysphagia due to esophageal webs, glossitis, and iron deficiency anemia

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A patient presents with chest pain after severe vomiting and is found to have substernal crepitus. What is the diagnosis?
Boerhaave syndrome (remember: "been-heaving syndrome")

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What causes Barrett's esophagus?
Chronic acid reflux resulting in epithelial metaplasia

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What specific malignancy is associated with Barrett's esophagus?
Adenocarcinoma (remember: BARRett's = Becomes Adenocarcinoma, Results from Reflux)

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In patients with Barrett's esophagus, there is a replacement of _____ _____ epithelium with _____ epithelium.
Nonkeratinized squamous; intestinal (columnar)

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Is Barrett's esophagus an example of glandular dysplasia, hyperplasia, neoplasia, or metaplasia?
Metaplasia

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Squamous cell carcinoma is most common in which section(s) of the esophagus?
Upper and middle one third

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Adenocarcinoma is most common in which section(s) of the esophagus?
Lower one third

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In the United States, which type of esophageal cancer is most common?
Squamous cell carcinoma and adenocarcinoma of the esophagus have a roughly equal incidence

2010-317
List four pathologic states of the esophagus that are risk factors for esophageal cancer.
Barrett's esophagus, diverticuli, esophagitis, achalasia, and esophageal webs

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What are two behavioral risk factors for esophageal cancer?
Alcohol use and cigarette use

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Worldwide, which type of esophageal cancer is most common?
Squamous cell carcinoma is most common

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What is a common history associated with esophageal cancer?
Progressive dysphagia that starts with dysphagia for solids and eventually includes liquids; also associated with weight loss, as is usually the case with malignancies

2010-317
Tropical sprue can be treated with which class of drugs?
Antibiotics

2010-317
Pancreatic insufficiency causes the malabsorption of which vitamins?
Vitamins A, D, E, and K

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Are the villi in lactase deficiency normal or abnormal in appearance?
Normal; as opposed to celiac disease in which villi are blunted

2010-317
What symptoms are often associated with malabsorption syndromes?
Diarrhea, steatorrhea, weight loss, weakness

2010-317
What is the most common presentation for abetalipoproteinemia?
It usually presents in childhood with failure to thrive (malabsorption) and neurologic manifestations

2010-317
Pancreatic insufficiency causes the malabsorption of which macronutrient(s)?
Fat

2010-317
What are three common causes of pancreatic insufficiency?
Cystic fibrosis, chronic pancreatitis, obstructing cancer

2010-317
True or False? Self-limited lactase deficiency can occur following bowel damage from viral diarrhea.
True; lactase is located at the tips of intestinal villi, making it vulnerable to damage

2010-317
What is the pathophysiology of abetalipoproteinemia?
Decreased apolipoprotein B leads to decreased level of chylomicrons, which leads to decreased cholesterol and very-low-density lipoprotein in blood stream and accumulations of fat in enterocytes

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The classic macrophages seen in Whipple's disease stain positive with what stain? Where are they located?
Periodic acid-Schiff stain; the intestinal lamina propria and the mesenteric nodes

2010-317
What nongastrointestinal symptoms are associated with Whipple's disease?
Arthralgias as well as cardiac and neurological symptoms

2010-317
Patients with celiac sprue develop autoantibodies to what substance?
Gluten (gliadin)

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Which section(s) of the gastrointestinal tract can be affected by tropical sprue?
The entire small bowel

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The most common disaccharidase deficiency involves what disaccharidase?
Lactase

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List six examples of underlying etiologies for malabsorption syndromes.
Celiac sprue, tropical sprue, Whipple's disease, disaccharidase deficiency, pancreatic insufficiency, and abetalipoproteinemia

2010-317
Celiac sprue primarily affects what part of the bowel?
Proximal small bowel

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What type of diarrhea is associated with disaccharidase deficiency?
Osmotic diarrhea

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What organism causes Whipple's disease?
Tropheryma whippelii

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Celiac sprue is associated with what type of malignancy?
T-lymphocyte lymphomas

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What region of the gastrointestinal tract is most affected by celiac sprue?
The jejunum

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Why does celiac disease result in a malabsorption syndrome?
Antibodies destroy jejunal villi, decreasing absorption and causing diarrhea

2010-318
Define celiac sprue.
Autoimmune damage to the small intestine caused by sensitivity to gluten, which damages the villi resulting in a decreased absorption surface; patient can present with vitamin deficiencies and steatorrhea due to decreased fat absorption

2010-318
What serum test is used to screen for celiac sprue?
Serum levels of antitissue transglutaminase antibodies; antigliadin antibodies are also seen in celiac disease

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A patient presents with voluminous diarrhea and a diffuse rash on his extensor surfaces; restriction of wheat resolves his diarrhea and rash. What is the diagnosis of his rash?
Dermatitis herpetiformis resulting from celiac disease

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What are two histological findings for celiac sprue?
Blunting of villi and the presence of lymphocytes in the lamina propria

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A patient with rheumatoid arthritis, controlled by nonsteroidal antiinflammatory drugs, complains of dull stomach pain and is found to be anemic. What is the likely diagnosis and pathophysiology?
Nonsteroidal antiinflammatory drugs decrease prostaglandin E2 production, which, in turn, decreases gastric mucosa production. The resulting erosive gastritis can cause mild anemia through occult blood loss

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Cushing's ulcer refers to the situation in which _____ _____ leads to acute gastritis.
Brain injury (remember: Always Cushion the brain)

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Etiologically, type A (fundal) gastritis is best grouped in what category of diseases?
Autoimmune diseases

2010-318
How can brain injury lead to increased risk of gastric cancer?
Cushing's ulcers cause an increase in vagal stimulation, causing increased acetylcholine, in turn increasing acid production by parietal cells

2010-318
What is the name for the acute gastritis that occurs in patients with severe burns?
Curling's ulcer (remember: Burned by the Curling iron)

2010-318
What are the two types of chronic gastritis?
Type A (in the fundus or body of the stomach) and type B (in the antrum)

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Etiologically, type B (antral) gastritis is best grouped within what category of diseases?
Infectious diseases

2010-318
True or False? Acute gastritis carries an increased risk of gastric carcinoma.
False; chronic gastritis increases the risk of mucosa-associated lymphoid tissue lymphoma

2010-318
Where does type A chronic gastritis occur?
Fundus/body

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Where does type B chronic gastritis occur?
Antrum

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In type A (fundal) gastritis, there are autoantibodies to what?
Parietal cells

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A 45-year-old patient with a history of Graves's disease is found to be anemic and has an elevated mean red blood cell volume. She takes iron supplements daily and is no longer menstruating. What is the likely diagnosis?
Pernicious anemia caused by autoantibodies against parietal cells

2010-318
Type B (antral) gastritis is caused by infection with what organism?
Helicobacter pylori

2010-318
List six causes of acute gastritis.
Nonsteroidal antiinflammatory drugs, alcohol, stress, uricemia, burns, and brain injury

2010-318
Type A (fundal) gastritis is characterized by what two pathologic states?
Pernicious anemia and achlorhydria (remember: AB pairing—pernicious Anemia affects gastric body)

2010-318
_____ (Acute/chronic) gastritis is erosive, whereas _____ (acute/chronic) gastritis is nonerosive.
Acute; chronic

2010-318
By what mechanism do severe burns cause acute gastritis?
Curling's ulcers cause a decrease in plasma volume, leading to a sloughing of gastric mucosa

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What are the endoscopic findings associated with Ménétrier's disease?
Massively enlarged gastric rugae

2010-318
A patient undergoes endoscopy, which reveals a thickened gastric lining. Gastric biopsy reveals increased mucous cells and parietal cell atrophy. What condition does this patient likely have?
Ménétrier's disease

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True or False? Ménétrier's disease is a precancerous condition.
True

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What is Krukenberg's tumor?
Bilateral metastasis of gastric cancer to the ovaries.

2010-318
What is the histologic appearance of Krukenberg's tumor?
Metastatic gastric adenocarcinoma often has mucus filled cells termed "signet ring cells"

2010-318
What blood type is associated with increased incidence of stomach cancer?
Type A

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A patient presents with dark leathery patches in the nape of his neck and in the axillae. What two things should you suspect?
Insulin resistance and stomach cancer

2010-318
What is the Saint Mary Joseph node and where is it located?
It is a palpable periumbilical metastasis

2010-318
What is the most common histological subtype of stomach cancer?
Adenocarcinoma

2010-318
What are risk factors for stomach cancer?
Nitrosamines (from smoked foods), achlorhydria, chronic gastritis, type A blood

2010-318
What organ is often the first to be affected by the metastases of stomach cancer?
The liver

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A patient presents with two months of fatigue and weight loss and mentions that he has notices a new bump above his collarbone. What diagnosis do you suspect?
The supraclavicular node suggests a metastasis from a stomach cancer

2010-318
What is meant when stomach cancer is termed "linitus plastica"?
Diffuse infiltrative cancer makes the stomach rigid

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A 69-year-old male with chronic back pain presents with stomach pain associated with meals. He is on metoprolol and naprosyn, smokes 2 packs/day, drinks 3 beers every other day, and has a negative urease breath test. What is the likely cause of his presenting symptom?
Chronic use of nonsteroidal antiinflammatory drugs leading to gastric ulcers

2010-319
Peptic ulcer disease affects what two regions of the gastrointestinal tract?
The stomach (gastric ulcers) and the duodenum (duodenal ulcers)

2010-319
A patient presents with stomach pain associated with meals. He is found to have ulcers in his gastrointestinal tract. Where are these ulcers likely located?
Stomach (remember: Gastric ulcer pain is Greater with meals)

2010-319
Recurrent duodenal ulcers due to increased gastric acid secretions and increased gastrin levels described which syndrome?
Zollinger-Ellison syndrome

2010-319
Is Helicobacter pylori implicated in duodenal ulcers?
Yes, almost 100% of duodenal ulcers are associated with Helicobacter pylori infection

2010-319
What etiologic factor is associated with 70% of gastric ulcers?
Helicobacter pylori infection

2010-319
What is the pathophysiology of gastric ulcers?
Decreased mucosal production leading to destruction of tissue by gastric acid

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Does the pain associated with duodenal ulcers increase, decrease, or remain the same with food?
Decrease (remember: Duodenal ulcer pain is Decreased with food)

2010-319
Duodenal ulcers may lead to what constitutional symptom?
Weight gain; due to symptom relief with consumption of food

2010-319
Patients with duodenal ulcers tend to have hypertrophy of _____ _____.
Brunner's glands

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A patient complaining of stomach pain is found on endoscopy to have a lesion with irregular, raised margins. Does this finding indicate an ulcer or a malignancy?
This is likely a carcinoma; peptic ulcers have clean margins and have a "punched-out" appearance

2010-319
List four common complications of peptic ulcers.
Bleeding, penetration into the pancreas, perforation, and obstruction

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A patient is newly diagnosed with irritible bowel syndrome. He is instructed to have screening colonoscopies starting 8 years from now. What is his likely diagnosis?
Ulcerative colitis; patients with ulcerative colitis must receive colonoscopies starting 8 years after initial diagnosis because of the increased risk of colon cancer

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What general category of disease includes ulcerative colitis?
Autoimmune diseases

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What are the extraintestinal manifestations of Crohn's disease?
Migratory polyarthritis, erythema nodosum, ankylosing spondylitis, uveitis, and immunologic disorders

2010-320
Name the two treatments most commonly used for Crohn's disease?
Corticosteroids and infliximab

2010-320
A 20-year-old patient presents with recurrent bloody diarrhea, weight loss, mouth ulcers, a painful rash on the extensor surfaces of her legs, and a perianal fistula. What is her likely diagnosis?
Crohn's disease

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Is toxic megacolon a complication of Crohn's disease, ulcerative colitis, or both?
Ulcerative colitis

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Name the three current treatments most commonly used for ulcerative colitis.
Sulfasalazine, infliximab, colectomy

2010-320
What type of inflammatory bowel disease tends to show skip lesions (noncontiguous areas of mucosal involvement)?
Crohn's disease

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On colonoscopy, a patient with inflammatory bowel disease is found to have friable intestinal mucosa that abruptly stops in the midtransverse colon. There is no break in the involved portion. What is the likely diagnosis?
Ulcerative colitis

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Are strictures a complication of Crohn's disease, ulcerative colitis, or both?
Crohn's disease; the strictures can lead to obstruction and require multiple resections of small bowel

2010-320
Is perianal disease a complication of Crohn's disease, ulcerative colitis, or both?
Crohn's disease

2010-320
What is the finding seen in this image and what is the associated disease?
String sign; Crohn's disease

2010-320
Involvement of what part of the gastrointestinal tract favors a diagnosis of ulcerative colitis over Crohn's disease?
Rectum

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What is the histologic appearance of ulcerative colitis?
Microscopy shows crypt abscesses and ulcers, but no granulomas

2010-320
Compare and contrast the layers of tissue involved in Crohn's disease and ulcerative colitis.
Crohn's disease exhibits transmural inflammation whereas ulcerative colitis demonstrates mucosal or submucosal inflammation only

2010-320
What are the extraintestinal manifestations of ulcerative colitis?
Pyoderma gangrenosum, primary sclerosing cholangitis

2010-320
What gastrointestinal disease can cause linear ulcers, fissures, and fistulas?
Crohn's disease

2010-320
Is malabsorption a complication of Crohn's disease, ulcerative colitis, or both?
Crohn's disease; ulcerative colitis affects only the colon and thus does not cause malabsorption

2010-320
What is hypothesized to be the etiology of Crohn's disease?
Overactive response to normal intestinal flora leading to tissue damage

2010-320
The mucosal and submucosal inflammation with friable mucosal pseudopolyps and freely hanging mesentery of ulcerative colitis can cause what appearance on imaging?
The loss of haustra leads to lead pipe appearance

2010-320
What gastrointestinal disease shows noncaseating granulomas and lymphoid aggregates on microscopy?
Crohn's disease (remember: for Crohn's, a fat granny and an old crone skipping down a cobblestone road away from the wreck (rectal sparing)

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What is the treatment for irritable bowel syndrome?
Since the symptoms fluctuate, it is important to reassess the patient's chief complaint and treat the current symptoms (eg, diarrhea, constipation, both)

2010-320
Name three findings of irritable bowel syndrome.
Abdominal pain relieved with defecation, change in stool frequency, change in appearance of stool

2010-320
On colonoscopy, what is the most common finding of a patient with irritable bowel syndrome?
Normal mucosa; irritable bowel syndrome is not associated with structural abnormalities and is therefore a diagnosis of exclusion

2010-320
In elderly patients, what important condition must be included in the differential diagnosis of acute abdominal pain in addition to appendicitis?
Diverticulitis

2010-321
Describe the pattern of pain commonly associated with appendicitis.
It starts as diffuse pain around the umbilicus then migrates to McBurney's point

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An 8-year-old child presents with 2 days of fever, vomiting, and severe abdominal pain. On examination, the right lower quadrant is very tender. She has a white blood cell count of 21,000. What is the treatment for her condition?
Surgery (appendectomy)

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A 21-year-old woman presents to the emergency room with diffuse periumbilical pain and nausea. Other than appendicitis, what condition should be ruled out?
Ectopic pregnancy with β-human chorionic gonadotropin test

2010-321
Diverticula are often due to weakness in the muscular wall caused by what?
Muscularis externa

2010-321
Diverticula are most often found in what segment of the gastrointestinal tract?
The sigmoid colon

2010-321
Diverticulitis classically causes pain in what region of the abdomen?
The left lower quadrant

2010-321
True or False? Patients with diverticulosis usually have symptoms.
False; these patients are most often asymptomatic

2010-321
A patient presents with fever, severe left lower quadrant pain, and a high white blood cell count. She is given antibiotics and defervesces. On hospital day 4, she notices that she is passing gas per her urethra. What complication likely occurred?
A fistula created by the infection between her colon and bladder leading to pneumaturia

2010-321
What is the difference between a true diverticulum and a false diverticulum?
A true diverticulum contains three layers (mucosa, submucosa, and serosa) whereas a false diverticulum contains only two layers (mucosa and submucosa)

2010-321
What is the etiology of diverticulosis?
Increased intraluminal pressure combined with focal weakness of the colonic wall

2010-321
Diverticulosis is associated with what types of diets?
Low-fiber diets

2010-321
List the four most common complications that may be caused by diverticulitis.
Perforation, peritonitis, abscess formation, and bowel stenosis

2010-321
What is the mainstay of treatment for diverticulitis?
Antibiotics although surgery may be required

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A _____ is a blind pouch that leads off of the alimentary tract.
Diverticulum

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List two symptoms that can be associated with diverticulosis.
Vague abdominal discomfort and painless rectal bleeding

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What are symptoms of Zenker's diverticulum?
Halitosis and dysphagia

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Is Zenker's diverticulum a true or a false diverticulum?
False diverticulum; it contains only the mucosa and submucosa

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Define Zenker's diverticulum.
A herniation of mucosal tissue at the junction of the pharynx and the esophagus

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Approximately what size is a typical Meckel's diverticulum?
Two inches long

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Meckel's diverticulum represents what embryonic structure?
Vitelline duct or yolk stalk

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What type of ectopic tissue is sometimes found in a Meckel's diverticulum?
Gastric and pancreatic tissue

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In approximately what percentage of the population can Meckel's diverticula be found?
2%

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List four pathologic conditions that can be caused by a Meckel's diverticulum.
Bleeding, intussusception, volvulus, and obstruction

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Where are Meckel's diverticula typically located?
Within two feet of the ileocecal valve

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What is the most common congenital anomaly of the gastrointestinal tract?
Meckel's diverticulum

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When in life do Meckel's diverticula typically present?
During the first two years of life

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Is intussusception found more commonly in adults or infants?
Infants

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What is intussusception?
The sliding of one segment of bowel into the bowel proximal to it, thereby shortening the bowel in a "telescope" fashion

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An 82-year-old woman presents with acute onset abdominal pain, obstipation, and a large segment of air-filled bowel in the right upper quadrant on plain film. Stool is occult blood negative. What is the likely diagnosis?
Cecal volvulus

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What is a serious complication of intussusception?
Compromised blood supply leading to infarction and necrotic bowel

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Why does volvulus have a predilection for specific parts of the bowel?
Volvulus tends to occur in locations with redundant mesentery

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What is volvulus?
The twisting of a portion of bowel around its mesentery

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What are the etiologies of intussusception in adults and children?
A "lead point" or an intraluminal mass that, with peristalsis, can cause a part of the bowel to slide into the lumen of the adjacent bowel

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What are two common locations of volvulus?
Sigmoid colon and cecum

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In patients with Hirschsprung's disease, which segment of the colon is constricted?
The aganglionic segment

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In patients with Hirschsprung's disease, what is noted on intestinal biopsy?
Lack of ganglionic cells that allow relaxation of the affected bowel

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How does Hirschsprung's disease typically present?
Inability to pass meconium after birth or chronic constipation in a child

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In patients with Hirschsprung's disease, where is the dilated segment of the colon relative to the aganglionic segment?
Proximal

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Hirschsprung's disease results from the failure of what process?
Neural crest cell migration

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A two-week-old boy does not pass meconium at birth. He is referred to a gastroenterologist who finds increased resting pressures on anal manometry. The mother remarks that she had abnormal prenatal genetic testing. What is the karyotype of this patient?
Trisomy 21

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A newborn boy has been vomiting bilious stomach contents since birth and his abdomen has become progressively distended. What condition is likely in this newborn?
Duodenal atresia

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What is a common complaint of patients with ischemic colitis?
Pain after eating; increased metabolic demand in intestine and inability to appropriately increase blood flow leads to an ischemic state

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Where is angiodysplasia typically found in the gastrointestinal tract?
Cecum, terminal ileum, ascending colon

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True or False? Necrotizing enterocolitis affects only the colon.
False; the colon is usually involved, but this condition can involve the entire gastrointestinal tract

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Angiodysplasia causes what symptom?
Bleeding from tortuous and dilated vessels

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Is angiodysplasia more common in a younger population or in the elderly?
Elderly

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What test can confirm a diagnosis of angiodysplasia?
Angiography

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An 80-year-old man with coronary artery disease presents with 6 months of weight loss due to pain after eating. What do you suspect?
Ischemic colitis associated with low blood flow to intestine; the splenic flexure is a watershed site and thus is most affected by low blood flow states

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Which patients are most at risk for necrotizing enterocolitis?
Premature neonates because of their decreased immunity

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Duodenal atresia is associated with what chromosomal abnormality?
Down syndrome

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Duodenal atresia is associated with what sign on imaging?
Double bubble sign

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A newborn boy fails to pass meconium at birth. Rectal exam and anal manometry is normal. His older brother died from severe pneumonia. What is this patient's underlying genetic disorder and diagnosis for his chief complaint?
Cystic fibrosis; meconium ileus

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Duodenal atresia is due to the failure of _____ of small bowel during development.
Recanalization

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What is the most common cause of adhesions?
Abdominal surgery

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An infant born at 25 Weeks develops feeding intolerance and a distended abdomen and grows gram-negative rods from blood culture. What is the underlying disease?
Necrotizing enterocolitis followed by perforation and sepsis

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Where does ischemic colitis commonly occur?
The splenic flexure; it is a watershed area between the superior mesenteric artery and inferior mesenteric artery circulation and has poor blood flow

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Ischemic colitis typically affects _____ (neonates/children/adults/the elderly).
The elderly

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Adhesions cause _____ (acute/chronic) bowel obstruction.
Acute

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A patient being treated for colon cancer is found to have multiple hamartomas throughout the gastrointestinal tract and hyperpigmentation of the mouth and genitals. What is the diagnosis?
Peutz-Jeghers syndrome

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A mother brings in her son for bleeding per rectum. Exam shows a single rectal polyp and barium enema shows no other pathology. What is the most likely natural history of this lesion?
A single juvenile polyp; it has no malignant potential if it is truly the only one

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What is the most common nonneoplastic polyp and where are they most commonly found?
hyperplastic; rectosigmoid colon

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A patient has a number of hamartomas through his gastrointestinal tract and dark patches around his mouth and palms. What is the likelihood that his daughter will have his disease?
50%. This patient has Peutz-Jeghers syndrome, an autosomal dominant disorder

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Is a child at increased risk for cancer if he/she has multiple polyps?
Yes, the child is at increased risk of adenocarcinoma

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Where in the colon are polyps most commonly found?
Rectum and sigmoid colon

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The more villous the colonic polyp, the _____ (more/less) likely it is to be malignant.
More (remember VILLOUS = VILLainOUS)

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What appearance does colorectal cancer classically present with on barium enema x-ray?
An "apple-core" lesion

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Iron-deficiency anemia is particularly concerning for colon cancer in which patient population?
Men and postmenopausal women

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A patient is found to have thousands of polyps on colonoscopy; he has a history of bone and soft-tissue tumors. What syndrome do you suspect?
Gardner's syndrome

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Hereditary nonpolyposis colon cancer, or Lynch syndrome, involves mutations of DNA ____ ____ genes.
Mismatch repair

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What is the most common presentation of a distal colonic tumor?
Obstruction, colicky pain, hematochezia

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What is the prognosis for a patient found to have familial adenomatous polyposis?
100% of patients will develop colon cancer if the colon is not removed

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What is a nonspecific serum tumor marker for colorectal cancer?
Carcinoembryonic antigen

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True or False? Hereditary nonpolyposis colon cancer rarely involves the proximal colon.
False; the proximal colon is always involved

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You are going to perform a colonoscopy on a patient with familial adenomatous polyposis. What do you expect to find?
Pancolonic involvement, including the rectum

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At what age is screening for colorectal cancer typically initiated?
50 years

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A patient presents with fever, low blood pressure, and new murmur. Blood cultures grow Streptococcus bovis and he is started on appropriate antibiotics. After he is stabilized, what is the most appropriate next step in management?
Streptococcus bovis bacteremia is associated with colorectal cancer; this patient needs a colonoscopy when he is stable

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What is a common presentation of right-sided colon cancer?
Dull pain, iron-deficiency anemia, fatigue

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What is the inheritance pattern for familial adenomatous polyposis ?
It is inherited in an autosomal dominant fashion. Afflicted individuals inherit one faulty copy of the gene and lose the other through an acquired mutation; this is two-hit hypothesis

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Familial adenomatous polyposis involves mutation of the ____ gene on chromosome ____.
APC; 5q

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Which autoimmune disease is a risk factor for colorectal carcinoma?
Ulcerative colitis

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What are risk factors for colorectal cancer?
Age, genetic syndromes, family history, irritable bowel disease, tobacco use, villous adenomas

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What is the ranking of colorectal cancer among the most common cancers?
Colorectal cancer is the third most common cancer

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Turcot syndrome describes the combination of FAP and what other finding?
Glioma and medulloblastoma (remember: TURcot = TURban)

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What two tests play the most important role in colorectal cancer screening?
Stool occult blood testing and colonoscopy

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What are the two major molecular pathways that lead to colorectal cancer?
The microsatellite instability and chromosomal instability pathways

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Sporadic mutation leading to loss of function of which tumor suppressor gene is often the last step in malignant transformation of colonic epithelial cells?
p53

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Loss of function of which gene leads to decreased intracellular adhesion in the colonic epithelium?
APC

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True or False? Loss of the APC gene will lead to adenoma formation.
False. Both APC and KRAS gene mutation must be present for adenoma formation

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KRAS gene mutation leads to dysregulation of what cellular function?
Signal transduction; the cell will respond abnormally to growth factors, contributing to tumorigenesis

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In the microsatellite instability pathway, what type of mutation is responsible for carcinogenesis in colonic epithelium?
DNA mismatch repair mutation

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Explain why a patient does not present with carcinoid syndrome when a carcinoid tumor is confined to the gastrointestinal tract.
The patient would not present with carcinoid syndrome because the liver metabolizes serotonin on the first pass and it does not reach systemic circulation

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What finding is seen on electron microscopy in carcinoid tumors?
Dense core bodies; these are secretory vesicles containing serotonin

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What are the presenting symptoms of carcinoid tumor confined to the small intestine?
None; carcinoid syndrome only occurs once the tumor metastasizes to the liver

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What is the most common site of a carcinoid tumor?
The small intestine

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What are the classic presenting symptoms of carcinoid syndrome?
Flushing, wheezing, diarrhea, right-sided heart murmurs

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What percentage of small bowel tumors are carcinoid tumors?
50%

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Carcinoid tumors are malignancies of which type of cell?
Carcinoid tumors are derived from endocrine cells

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Is the bleeding tendency of cirrhosis considered to be an effect of portal hypertension or an effect of liver cell failure?
An effect of liver cell failure; it is due to the inability to synthesize clotting factors

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The foul-smelling breath of patients with cirrhosis is referred to as what?
Fetor hepaticus

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Why do patients with cirrhosis have an increased tendency to bleed?
Liver cell failure leads to the decreased production of prothrombin and clotting factors

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Visible dilated capillary proliferation within the skin secondary to the effects of liver failure and cirrhosis is called what?
Spider nevi

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Name six direct effects of portal hypertension.
Splenomegaly, caput medusae, ascites, hemorrhoids, esophageal varices, peptic ulcers

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What is the name for the coarse ‘flapping’ tremor of the hands that may occur in patients with cirrhosis?
Asterixis

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Is the ankle edema of cirrhosis considered to be an effect of portal hypertension or an effect of liver cell failure?
An effect of liver cell failure; it is due to the inability to synthesize albumin resulting in lack of oncotic pressure

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Which form of cirrhosis is most associated with an increased risk of hepatocellular carcinoma: micronodular or macronodular?
Macronodular

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Describe the pathogenesis of cirrhosis.
Destruction of hepatocytes results in diffuse fibrosis; cells regenerate in nodular pattern, destroying normal architecture

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What physical findings in liver failure patients are seen as a result of the inability of the liver to make adequate albumin?
Edema, ascites

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List two hematologic abnormalities that may result from liver cell failure in patients with cirrhosis?
Bleeding tendency and anemia

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In patients with cirrhosis and portal hypertension, melena may be the result of bleeding from either _____ _____ or _____ _____.
Esophageal varices; peptic ulcers

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What condition may be noted on the eye examination of patients with cirrhosis as a result of the effects of liver cell failure?
Scleral icterus; caused by increased serum bilirubin

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Cirrhosis can be further characterized as being either _____ or _____, depending on the etiology of the liver injury.
Micronodular; macronodular

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Micronodular cirrhosis is often the result of what category of liver damage?
Metabolic insult such as from alcohol, hemochromatosis, or Wilson#039;s disease

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Give two examples of disease processes that typically lead to macronodular cirrhosis.
Postinfectious hepatitis and drug-induced hepatitis

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What physical signs are seen in patients with liver failure as a result of the buildup of bilirubin in the body?
Jaundice, icterus

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Macronodular cirrhosis is usually the result of significant liver injury leading to _____ _____.
Hepatic necrosis

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What physical signs are seen in male patients as a result of the hyperestrogenic state seen in liver failure?
Gynecomastia, testicular atrophy

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A surgical portacaval shunt allows blood to flow between the _____ _____ and the _____ _____ _____.
Splenic vein; left renal vein

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Which serum protein is decreased in Wilson's disease?
Ceruloplasmin

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Which aminotransferase is the strongest marker of viral hepatitis?
Alanine transaminase

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Elevated serum γ-glutamyl transpeptidase may indicate which diagnoses?
Chronic alcoholism or biliary tree disease

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Alkaline phosphatase is a marker of _____ _____ as well as of obstructive liver disease.
Bone disease

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What two gastrointestinal enzymes are markers of injury to hepatocytes?
Alanine aminotransferase and aspartate aminotransferase

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Which enzyme marker is elevated in bile duct disease?
Alkaline phosphatase

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Which two gastrointestinal enzymes are used as markers for acute pancreatitis?
Amylase and lipase

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What enzyme is a marker of obstructive liver disease?
Alkaline phosphatase, γ-glutamyl transferase

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Which serum marker of hepatocyte necrosis can also be elevated after myocardial infarction?
Aspartate transaminase

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Which aminotransferase is the strongest marker of alcoholic hepatitis?
Aspartate transaminase

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What metabolic disturbance is often found in children with Reye's syndrome?
Hypoglycemia

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List two specific viral infections that are especially associated with Reye's syndrome.
Varicella-zoster virus and influenza B

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Because aspirin is associated with Reye's syndrome in children, what drug is instead recommended for this age group for treatment of fever?
Acetaminophen

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A mother brings in her son for lethargy. A week ago he broke out in a vesicular rash and had a slight fever. After giving him some medicine, his mental status deteriorates. What medication did she likely give him?
Salicylates

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How does aspirin cause Reye's syndrome?
Aspirin metabolites decrease β-oxidation by inhibiting mitochondrial enzymes

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A child with seasonal influenza is given aspirin to treat his fever and subsequently develops a deterioration in mental status and elevated hepatic enzymes. What is your diagnosis?
Reye's syndrome

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What liver pathology is associated with Reye's syndrome?
Microvesicular fatty changes

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In alcoholic hepatitis, which is typically elevated more: aspartate aminotransferase or alanine aminotransferase levels?
Aspartate aminotransferase levels

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What microscopic changes are seen on liver biopsy of a patient with alcoholic hepatitis?
Hepatocytes become swollen and necrotic; Mallory bodies (intracytoplasmic inclusions) and neutrophilic infiltration are often present

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In viral hepatitis, which is typically elevated more: aspartate aminotransferase levels or alanine aminotransferase levels?
Alanine aminotransferase levels

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What potentially reversible liver pathology can be seen with moderate alcohol intake?
Macrovesicular fatty changes of the liver (hepatic steatosis)

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______ _____ are intracytoplasmic eosinophilic inclusions that are often seen in alcoholic hepatitis.
Mallory bodies

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In alcoholic hepatitis, what is the pattern of transaminase elevation?
Aspartate aminotransferase > alanine aminotransferase (ratio usually > 1.5) (remember: You're toASTed with alcoholic hepatitis)

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In alcoholic cirrhosis, sclerosis may be noted around the central vein in zone _____ on liver histology.
Zone III

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What is the appearance of a liver with alcoholic cirrhosis on gross pathology?
Micronodular, irregularly shrunken liver (also called "hobnail" appearance)

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What are typical signs and symptoms of hepatocellular carcinoma?
Tender hepatomegaly, hypoglycemia, ascites, and/or polycythemia

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A patient with hemochromatosis presents with jaundice, tender hepatomegaly, ascites and is found to have elevated serum AFP. What diagnosis do you suspect?
Hepatocellular carcinoma

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What two infectious diseases are associated with an increased incidence of hepatocellular carcinoma?
Hepatitis B and C

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Name seven risk factors for hepatocellular carcinoma.
Infectious diseases and exposures, Wilson's disease, hemochromatosis, and a1-antitrypsin deficiency

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Excessive exposure to what two substances is associated with an increased incidence of hepatocellular carcinoma?
Alcohol (alcoholic cirrhosis) and carcinogens such as aflatoxin B1

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What is the mode of metastasis of hepatocellular carcinoma?
Hematogenous spread

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What symptom of hepatocellular carcinoma predisposes a patient to Budd-Chiari syndrome?
Hepatocellular carcinoma can cause polycythemia, which, in turn, results in a hypercoagulable state leading to Budd-Chiari syndrome

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What laboratory finding is sometimes used as a marker for hepatocellular carcinoma?
Elevated α-fetoprotein level

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What are the two common causes of nutmeg liver?
Right-sided heart failure and Budd-Chiari syndrome (backup of blood into the liver)

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What type of damage occurs in nutmeg liver?
Centrilobular congestion and necrosis, possibly leading to cirrhosis

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In Budd-Chiari syndrome, there is occlusion of the _____ _____ _____ or of the _____ veins.
Inferior vena cava; hepatic

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How can you differentiate Budd-Chiari syndrome from cardiac cirrhosis?
There is absence of jugular venous distention (JVD) in Budd Chiari syndrome

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What medical conditions can predispose a patient to Budd-Chiari syndrome?
Budd-Chiari syndrome is associated with polycythemia vera, pregnancy, and hepatocellular carcinoma

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A patient with polycythemia vera develops new-onset ascites, abdominal pain, and elevation of liver enzymes. What do you suspect?
Congestive liver failure secondary to Budd-Chiari syndrome

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What liver region becomes congested and necrotic in Budd-Chiari syndrome?
The centrilobular region

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What effect does α1-antitrypsin deficiency have on the lungs?
Leads to increased breakdown of elastic fibers of the lungs, causing panacinar emphysema

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α1-Antitrypsin deficiency leads to the accumulation of misfolded proteins in which cells?
In the endoplasmic reticulum of hepatocytes

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α1-Antitrypsin deficiency can be diagnosed histologically by seeing what in liver biopsy samples?
Periodic acid-Schiff-positive globules

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A newborn baby is found to have a yellowish hue 12 hours after birth. What is the molecular basis of this condition?
Immature UDP-glucuronyl transferase, which leads to increased unconjugated bilirubin and jaundice

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What is the treatment for physiologic neonatal jaundice?
Phototherapy, which converts the unconjugated bilirubin into a water-soluble form that can be excreted in the urine

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Describe the level of urine bilirubin in the case of hepatocellular jaundice, obstructive jaundice, and hemolytic jaundice.
Elevated; elevated; absent

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Is the hyperbilirubinemia of hepatocellular jaundice conjugated, unconjugated, or both?
Both

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What organ performs the function of converting unconjugated bilirubin into conjugated bilirubin?
The liver

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In addition to the bacterial conversion of bilirubin, how else is urobilinogen formed?
Directly from heme metabolism

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Describe the level of urine urobilinogen in the case of hepatocellular jaundice, obstructive jaundice, and hemolytic jaundice.
Normal or low; depressed; elevated

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Is the hyperbilirubinemia of obstructive jaundice conjugated, unconjugated, or both?
Conjugated

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How can direct bilirubin be excreted from the body?
Urine, bile, feces

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What organ excretes bilirubin as bile?
The liver

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Is the hyperbilirubinemia of hemolytic jaundice conjugated, unconjugated, or both?
Unconjugated

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After being excreted into bile by the liver, direct bilirubin is then converted by _____ _____ into _____.
Gut bacteria; urobilinogen

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What form of bilirubin is water soluble?
Direct bilirubin

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List three findings that are associated with Crigler-Najjar syndrome type I.
Jaundice, kernicterus, and high unconjugated bilirubin

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Which levels are elevated in patients with Dubin-Johnson syndrome: conjugated bilirubin, unconjugated bilirubin, or both?
Conjugated bilirubin

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What is kernicterus?
Bilirubin deposition in the brain that can cause cerebral palsy

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True or False: Gilbert's syndrome is associated with hemolysis.
False; however, it causes an unconjugated hyperbilirubinemia

2010-327
True or False? The bilirubin that enters hepatocytes is water soluble.
False; the bilirubin that enters hepatocytes is water insoluble and must be bound to albumin to be transported in blood

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Which is more severe: Crigler-Najjar syndrome type I or type II?
Type I

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Unconjugated bilirubin is formed from _____ by Kupffer cells and other parts of the mononuclear phagocyte system.
Heme

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In what condition is the activity of UDP-glucuronyl transferase absent?
Crigler-Najjar syndrome type I

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A college student comes to health services during finals for yellowing of the skin. He is found to have an elevated indirect bilirubin but is otherwise asymptomatic. What is the likely diagnosis?
Gilbert's syndrome

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True or False: The bilirubin that exits hepatocytes is water-soluble.
True

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Which levels are elevated in patients with Crigler-Najjar syndrome type I: conjugated bilirubin, unconjugated bilirubin, or both?
Unconjugated bilirubin

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What disease is similar to Dubin-Johnson syndrome but does not involve the finding of a grossly black liver?
Rotor's syndrome

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Crigler-Najjar syndrome type II responds to what treatment?
Phenobarbital, which increases liver enzyme synthesis

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What enzyme within the hepatocyte converts bilirubin to its water-soluble form?
Glucuronyl transferase (specifically UDP-glucuronyl transferase)

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What is the cause of Gilbert's syndrome?
It is either due to decreased UDP glucuronyl transferase activity or decreased bilirubin uptake by hepatocytes

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When in life does Crigler-Najjar syndrome type I typically present?
Early; death occurs in childhood

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Which levels are elevated in Gilbert's syndrome: conjugated bilirubin, unconjugated bilirubin, or both?
Unconjugated bilirubin

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What process is defective in patients with Dubin-Johnson syndrome?
The hepatocyte's excretion of bilirubin from the cell

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What finding is characteristic of Dubin-Johnson syndrome on gross pathology?
The liver is black

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What treatments are used for Crigler-Najjar syndrome type I?
Plasmapheresis and phototherapy

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What cells found within the liver are part of the mononuclear phagocyte system and therefore aid in the conversion of heme to unconjugated bilirubin?
Kupffer cells

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What are the clinical consequences of Dubin-Johnson syndrome?
There are no clinical consequences, this condition is benign

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What are the potential complications of Gilbert's syndrome?
Gilbert's syndrome has no clinical consequences other than jaundice

2010-327
Copper enters blood circulation in what form?
Ceruloplasmin

2010-327
What process is defective in patients with Wilson's disease?
Hepatic copper excretion

2010-327
What is the classic ocular finding in Wilson's disease?
The cornea; these are called Kayser-Fleisher rings

2010-327
What cancer is associated with Wilson's disease?
Hepatocellular carcinoma

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What five organs accumulate copper in patients with Wilson's disease?
Liver, brain, cornea, kidneys, and joints

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What specific type of anemia is associated with Wilson's disease?
Hemolytic anemia (remember ABCD to recall the other common findings: Asterixis, Basal ganglia degeneration, Ceruloplasmin [decreased], Cirrhosis, Corneal deposits, Copper accumulation, Carcinoma (hepatocellular), Choreiform movements, and Dementia)

2010-327
What is the classic laboratory finding in patients with Wilson's disease?
Low serum ceruloplasmin level

2010-327
With what medication are patients with Wilson's disease treated?
Penicillamine

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Which region of the brain is particularly vulnerable to degeneration in patients with Wilson's disease?
The basal ganglia

2010-327
With what pattern of inheritance is Wilson's disease passed?
Autosomal recessive

2010-327
What movement disorder is associated with Wilson's disease?
Choreiform movements due to preferential copper deposition in the basal ganglia

2010-327
Wilson's disease is characterized by what tremor?
Asterixis, due to liver failure

2010-327
What processes occur in the liver of patients with Wilson's disease?
Cirrhosis, hepatocellular carcinoma

2010-327
A 30-year-old patient presents with new-onset dementia, choreiform movements, and flapping hand tremor; he also has severely elevated liver enzymes and discolored rings around his irises on ocular exam. What lab results will confirm the diagnosis? How will you treat the patient?
This patient has Wilson's disease. Decreased ceruloplasmin; chelation with penicillamine

2010-327
In Wilson's disease, basal ganglia degeneration results in what neurological symptoms?
Parkinsonian symptoms

2010-327
What is the most common cause of secondary hemochromatosis?
Chronic transfusion therapy

2010-328
True or False: It is possible to develop hemochromatosis without being genetically predisposed to the disease.
True (secondary hemochromatosis); due to recurrent blood transfusions

2010-328
Hemochromatosis classically affects what three organs?
Liver, skin, and pancreas

2010-328
Iron deposition in the heart due to hemochromatosis can lead to what condition?
Congestive heart failure secondary to restrictive cardiomyopathy

2010-328
What two treatments are often used for hemochromatosis?
Repeated phlebotomy and deferoxamine chelation

2010-328
Hemochromatosis is associated with an increased risk of what cancer?
Hepatocellular carcinoma

2010-328
Hemochromatosis classically causes what liver finding?
Micronodular cirrhosis

2010-328
A man presents to the office with new-onset insulin-dependent diabetes. His skin is darkly pigmented and he is found to have elevated liver enzymes. What is his likely diagnosis?
Hemochromatosis

2010-328
Describe ferritin capacity, iron capacity, and total iron-binding capacity and transferrin saturation in patients with hemochromatosis.
High; high; low; high

2010-328
Hemochromatosis is associated with what genetic marker?
Human leukocyte antigen A3

2010-328
With what pattern of inheritance is primary hemochromatosis passed?
Autosomal recessive

2010-328
What is the appearance of primary sclerosing cholangitis on endoscopic retrograde cholangiopancreatography?
Alternating strictures and dilation of the bile ducts, which is also called " beading"

2010-328
What class of immunoglobulin is elevated in primary sclerosing cholangitis?
Immunoglobulin M

2010-328
What disease is associated with primary sclerosing cholangitis?
Ulcerative colitis

2010-328
Which autoantibodies are seen in the serum of patients with primary biliary cirrhosis?
Antimitochondrial antibodies

2010-328
What is the underlying change in primary sclerosing cholangitis?
Fibrosis of the bile ducts

2010-328
The biliary stasis caused by PSC can be so severe as to cause liver failure, a process known as what?
Secondary biliary cirrhosis

2010-328
Which symptoms are common in the presentation of biliary tract disease?
Jaundice, light stool, pruritus, dark urine

2010-328
Secondary biliary cirrhosis is often complicated by what infectious process?
Ascending cholangitis, a bacterial infection facilitated by biliary stasis

2010-328
Primary biliary cirrhosis is commonly associated with what autoimmune disorders?
Rheumatoid arthritis, CREST syndrome, celiac disease

2010-328
What abnormal lab results are common to most forms of biliary tract disease?
Increased conjugated bilirubin, cholesterol, and alkaline phosphatase

2010-328
Is primary sclerosing cholangitis intrahepatic, extrahepatic, or both?
Both; the entire biliary tree is affected

2010-328
In secondary biliary cirrhosis, increased pressure in the intrahepatic ducts leads to what?
Hepatic injury and fibrosis

2010-328
What is likely to be found on biopsy of a patient with primary biliary cirrhosis?
Lymphocytic infiltrate and granulomas

2010-328
What causes secondary biliary cirrhosis?
Extrahepatic biliary obstruction

2010-328
Name the components of Charcot"s triad of symptoms of cholangitis.
Jaundice, fever, and right upper quadrant pain

2010-329
In addition to biliary infections, what two other medical conditions are associated with pigment stone formation?
Chronic RBC hemolysis and alcoholic cirrhosis

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Which substances in bile increase the solubility of bilirubin and cholesterol to prevent formation of gallstones?
Bile acid and lecithin

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Symptomatic gallstones are treated with _____.
Cholecystectomy

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List the two types of gallstones.
Cholesterol stones and pigment stones

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Gallstones are best diagnosed by what radiologic modality?
Ultrasound

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About what percent of cholesterol stones are radiopaque?
10% to 20%

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Are most cholesterol stones radiolucent or radiopaque?
Radiolucent; as a result, ultrasound is the preferred method of imaging

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What percentage of gallstones are cholesterol stones?
80%

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In what population of patients is biliary colic uncommon?
Diabetic patients; neuropathy can reduce the sensation of pain from gallstones

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Are pigment stones radiolucent or radiopaque?
Radiopaque

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Why are some cholesterol stones radiopaque?
Calcified stones are radiopaque

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Define biliary colic.
Pain caused by gallstones interfering with bile flow, causing bile duct contraction

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Disproportionately high amounts of _____ and/or _____ in bile tend to favor the formation of gallstones.
Cholesterol; bilirubin

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Gallstones can cause what four major complications?
Ascending cholangitis, acute pancreatitis, bile stasis, and cholecystitis

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List the risk factors associated with formation of cholesterol stones.
Obesity, Crohn's disease, cystic fibrosis, advanced age, clofibrate, estrogens, multiparity, rapid weight loss, and Native American origin

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What radiographic finding is associated with obstruction of the ileocecal valve by a gallstone?
Air in the biliary tract (also known as pneumobilia)

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Why does Crohn#039;s disease predispose patients to gallstones?
Because of the inability of the diseased terminal ileum to absorb bile salts

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Name the "four F's" associated with increased risk of developing gallstones.
Female, fat, fertile, and forty

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A patient presents with right upper quadrant pain, jaundice, and fever. He is found to have gallstones on ultrasound and a high white blood cell count. What is the likely diagnosis?
Acute cholangitis

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A patient presents complaining of abdominal pain. On deep palpation of the right upper quadrant, she appears to hold her breath. Name this finding.
The patient has a positive Murphy's sign, which is inspiratory arrest on deep palpation

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Name three possible causes of cholecystitis.
Gallstones (most common), infection (cytomegalovirus), ischemia

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What pattern of pain is characteristic of acute pancreatitis?
Epigastric pain that radiates to the back

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Which has higher specificity for acute pancreatitis: amylase or lipase?
Lipase

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Is acute or chronic pancreatitis associated with an increased risk of pancreatic cancer?
Chronic

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What two laboratory findings are classically diagnostic of acute pancreatitis?
Elevated amylase and lipase

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What are complications of acute pancreatitis?
Disseminated intravascular coagulation, acute respiratory distress syndrome, hypocalcemia, diffuse fat necrosis, pseudocyst formation, hemorrhage, infection, multisystem organ failure

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Chronic pancreatitis leading to pancreatic insufficiency results in what constellation of symptoms?
Steatorrhea, fat-soluble vitamin deficiency, and diabetes mellitus

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Chronic calcifying pancreatitis is strongly associated with what condition?
Alcoholism

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List the causes of acute pancreatitis.
Gallstones, ethanol, trauma, steroids, mumps, autoimmune disease, scorpion sting, hypercalcemia/hyperlipidemia, drugs (sulfa drugs) (remember: GET SMASHeD)

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What is the mechanism causing hypocalcemia in acute pancreatitis?
Ca2+ collects in pancreatic calcium soap deposits, causing hypocalcemia

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Define the pathophysiology of acute pancreatitis.
Pancreatic enzymes become activated leading to the autodigestion of the pancreas

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A patient presents with weight loss, night sweats, and painless jaundice. He is found to have a mass on his pancreas suspicious for malignancy. What is the most likely location of the mass?
The head of the pancreas

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A mass is found on the head of the pancreas of a patient. What abnormal lab findings would be found in this patient?
Increased alkaline phosphatase and bilirubin levels indicating obstructive jaundice

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Name two tumor markers associated with pancreatic cancer.
Carcioembryonic antigen and carbohydrate antigen 19-9

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What is an abdominal exam finding in a patient with pancreatic adenocarcinoma?
Courvoisier's sign (palpable gallbladder)

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What two ethnic groups have an increased risk of pancreatic cancer? Male or female?
Jewish and African-American males

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True or False? Pancreatic cancer has a strong association with alcohol abuse.
False; pancreatic cancer has been linked to cigarette smoking

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True or False? Pancreatic adenocarcinoma often presents with inguinal lymphadenopathy.
False; presentation typically includes abdominal pain that radiates to the back, weight loss, migratory thrombophlebitis, and obstructive jaundice

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When migratory thrombophlebitis is noted in patients with pancreatic adenocarcinoma, it is called what?
Trousseau's syndrome

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What is the average survival of a person newly diagnosed with pancreatic adenocarcinoma?
Six months or less

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Why are misoprostol, sucralfate, and bismuth beneficial in treatment of gastric ulcers?
These drugs have a protective effect on the mucosa underlying ulcers

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H2-blockers work on which stomach cell type?
Parietal cells

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Muscarinic antagonists work on which two cell types in the stomach?
Enterochromaffin-like cells (with M1 receptors) and parietal cells (with M3 receptors)

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Proton pump inhibitors work on pumps that exchange which two ions?
Hydrogen and potassium

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What substance is the endogenous agonist of the H2-receptor?
Histamine

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What is the effect of H2-blockers on parietal cells?
Reversible decrease of hydrogen ion secretion

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Which H2-blocker has important toxicities that are not seen with other H2-blockers?
Cimetidine

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Which adverse effects of cimetidine are seen specifically in males?
Prolactin release, gynecomastia, impotence, decreased libido

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By what mechanism does cimetidine cause confusion, dizziness and headaches?
It is able to cross the blood-brain barrier

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List three clinical uses of H2-blockers.
Peptic ulcer, gastritis, mild esophageal reflux

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Give four examples of H2-blockers.
Cimetidine, ranitidine, famotidine, and nizatidine (remember: Take H2-blockers before you DINE)

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What effect does cimetidine have on the kidneys?
Decreased creatinine excretion

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Cimetidine is a potent _____ of P450.
Inhibitor

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True or False? Cimetidine is safe during pregnancy.
False; cimetidine crosses the placenta

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Which two H2 blockers can decrease the renal excretion of creatinine?
Ranitidine and cimetidine

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Give at least two examples of proton pump inhibitors.
Omeprazole and lansoprazole

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Proton pump inhibitors work by inhibiting _____ _____ _____ in stomach parietal cells.
Hydrogen potassium adenosine triphosphatase

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What are the clinical indications for use of proton pump inhibitors?
Peptic ulcers, gastritis, esophageal reflux, and Zollinger-Ellison syndrome

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What are two of the infectious indications for bismuth or sucralfate?
Traveler's diarrhea, Helicobacter pylori infection (as part of triple therapy)

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What is the mechanism of action of bismuth and sucralfate?
They provide a physical barrier in ulcers to protect from stomach acid

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What are the three components of triple therapy?
Metronidazole, bismuth, and amoxicillin or tetracycline

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True or False? A proton pump inhibitor can also be used when treating an ulcer caused by Helicobacter pylori infection.
True (remember: Please MAke Tummy Better for drugs used to treat Helicobacter pylori infection: proton pump inhibitor, metronidazole, amoxicillin, tetracycline, bismuth)

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Misoprostol functions by increasing the production and secretion of the _____ _____ _____ and decreasing the production of _____.
Gastric mucous barrier; acid

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A neonate becomes cyanotic on the third day of life despite 100% supplemental oxygen administration. The attending orders infusion of a medication and the neonate's oxygen saturation slowly returns to normal. What medication did the attending order an
Misoprostol; it maintains the patent ductus arteriosus thereby allowing mixing of pulmonary and systemic circulation in the case of congenital heart disease

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A woman with rheumatoid arthritis was recently started on misoprostol because of adverse effects of her arthritis medicine. What is the adverse effect and the medication that caused it?
Peptic ulcers induced by nonsteroidal antiinflammatory drugs

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Misoprostol is a _____ ____ analogue.
Prostaglandin E1

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Within what population is misoprostol contraindicated?
Women of childbearing potential; it is an abortifacient

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In addition to being an abortifacient, what other toxicity does misoprostol have?
Diarrhea

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A woman presents to her OB/GYN at 42 weeks' gestation and is admitted to the hospital. You look at the orders and see that misoprostol is administered. What is the role of misoprostol in this patient?
To induce labor

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Name three major adverse effects caused by muscarinic antagonists.
Tachycardia, dry mouth, and difficulty focusing eyes (anticholinergic adverse effects)

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What are the muscarinic antagonists pirenzepine and propantheline used for clinically?
Peptic ulcers (rarely used)

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List two muscarinic antagonists that are used to treat peptic ulcers.
Pirenzepine and propantheline

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By blocking the M3 receptors on parietal cells, muscarinic antagonists achieve what effect?
Decreased hydrogen secretion

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Muscarinic antagonists block what receptors on enterochromaffin-like cells?
M1 receptors

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By blocking the M1 receptors on enterochromaffin-like cells, muscarinic antagonists achieve what effect?
Decreased histamine secretion

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Muscarinic antagonists block what receptors on parietal cells?
M3 receptors

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What are the two target cells of muscarinic antagonists when used to decrease acid secretion?
Enterochromaffin-like cells and parietal cells

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What effects can antacids have on the efficacy of other drugs?
Interference with absorption, bioavailability, and urinary excretion by altering gastric and urinary pH and delaying gastric emptying

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List three compounds that are commonly used as antacids.
Aluminum hydroxide, magnesium hydroxide, and calcium carbonate

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The overuse of the antacid aluminum hydroxide can cause what toxicities?
Constipation, hypophosphatemia, hypokalemia, proximal muscle weakness, osteodystrophy, seizures

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A patient is found to have hypophosphatemia and osetodystrophy. What medication is he most likely chronically overusing to treat his gastroesophageal reflux disease?
Aluminum hydroxide

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Diarrhea, hyporeflexia, hypotension, cardiac arrest and hypokalemia are side effects of which antacid?
Magnesium hydroxide; remember Mg = Must go to the bathroom

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A patient becomes hypotensive and hyporeflexive. She mentions that she has gastroesophageal reflux disease and takes large amounts of antacids. Which antacid is she most likely overusing?
Magnesium hydroxide

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A patient has a witnessed first seizure. Afterward he complains of recent constipation and proximal muscle weakness. What medication is he most likely overusing to treat his gastroesophageal reflux disease?
Aluminum hydroxide; remember Aluminimum amount of feces

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A patient who heavily self-medicates her gastroesophageal reflux disease complains of dizziness and diarrhea. Which antacid is she most likely overusing?
Magnesium hydroxide

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Overuse of the antacid calcium carbonate can cause what three toxicities?
Hypercalcemia, rebound acid increase, and hypokalemia

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All antacids cause what electrolyte abnormality if overused?
Hypokalemia

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What test should be conducted before starting a patient on infliximab?
Purified protein derivative test; this medication can cause reactivation tuberculosis

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What is the mechanism of action of infliximab?
It is a monoclonal antibody to tumor necrosis factor-a remember INFLIXimab INFLIX pain on TNF

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What are the adverse effects of infliximab?
Reactivation of latent tuberculosis, hypotension, fever

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List two diseases that are treated with infliximab.
Crohn's disease and rheumatoid arthritis

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Sulfasalazine is a combination of what two drugs?
Sulfapyridine and mesalamine

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What unique mechanism of delivery of mesalamine is created when it is combined with sulfapyridine?
It is activated by colonic bacteria

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What is the function of sulfapyridine?
It is an antibiotic

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Sulfasalazine is used to treat what two diseases?
Crohn's disease and ulcerative colitis

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A patient is found to have Crohn's ileitis. He asks if he can be started on sulfasalazine. What is the appropriate response?
Sulfasalazine would be ineffective because it is activated by colonic bacteria and thus has no effect proximal to the colon

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What are the adverse effects of sulfasalazine?
Oligospermia, malaise, nausea, and sulfonamide toxicity

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Ondansetron is used to control vomiting in which two situations?
After an operation and for patients getting cancer chemotherapy (remember: you will not vomit with ONDANSetron, so you can go ON DANCing)

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Ondansetron is an antagonist of what receptor type?
5-hydroxytryptamine3

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What are two toxicities of ondansetron?
Headache and constipation

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What are the clinical uses of metoclopramide?
Diabetic gastroparesis and postsurgical gastroparesis

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What are side effects of metoclopramide?
restlessness, drowsiness, fatigue, depression, nausea, diarrhea

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What is the mechanism of metoclopramide?
It is a dopamine receptor antagonist

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Metoclopramide is contraindicated in patients with what serious gastrointestinal disorder?
Small bowel obstruction, because it is prokinetic and thus will worsen the discomfort of these patients

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With what drugs does metoclopramide interact?
Digoxin and diabetic agents

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On what parts of the gastrointestinal tract does metoclopramide act?
The lower esophageal sphincter (it increases tone and contractility), the stomach, and the small bowel (increases motility); it has no effect on the colon

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What specific dopamine receptor is blocked by metoclopramide?
D2 receptor

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