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170 Cards in this Set
- Front
- Back
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Baby vomits milk when fed/air bubble
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Blind esophagus with lower segment of esphagus attached to trachea
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30 y/o M transmural inflamm, bloody poo
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Crohns dz
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Brown pigment in ring around cornea
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Wilson's dz (treat with penicillamine)
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20 y/o idiopathic hyperbilirubinemia
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Gilber's syndrome
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chronic GERD and esoph CA, type?
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Adenocarcinoma
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Abdominal layers
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Skin, superficial fascia, External and Internal Obliques, Transfversus abdominis, Transversalis fascia, peritoneum
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Retroperitoneal structures
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Kidneys, adrenals, ureters, Pancreas (not tail), Duodenum (2,3,4), Ascend colon, Descend colon, Rectum, Esophagus
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Name the pancreatic enzyme that works on starch digestion.
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alpha-amylase
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Name the 3 pancreatic enzymes that works on fat digestion.
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lipase, phospholipase A, colipase
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Name the 4 pancreatic enzymes that work on protein digestion.
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trypsin, chymotrypsin, elastase, carboxypeptidases
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How are glucose, galactose, and fructose are absorbed?
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Glucose and galactose are absorbed by the sodium-glucose transport protein 1. Fructose is absorbed through facilitated diffusion by GLUT-5.
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A man with Chaga's disease presents with complaints of dysphagia. A barium swallow shows a dilated esophagus that looks like a birds beak. What is his diagnosis?
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achalasia (secondary)
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What is achalasia?
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Failure of relaxation of lower esophageal sphincter due to loss of myenteric (Auerbach's) plexus
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What is the difference between esophageal varices and Mallory-Weiss syndrome?
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Esophageal varies: PAINLESS bleeding in lower 1/3 of esophagus; Mallory-Weiss: PAINFUL lacerations at the gastroesophageal junction
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Name the triad of Plummer-Vinson syndrome.
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Dysphagia, glossitis, iron deficiency anemia
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Define Barrett's esophagus.
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Replacement of nonkeratinized squamous(stratified) epithelium with intestinal (columnar)epithelium, due to GERD
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Describe the most common tracheoesophageal fistula.
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Blind upper esophagus with lower esophagus connected to the trachea
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A mother brings in her two-week old baby after seeing NONBILIOUS projectile vomiting. The doctor diagnoses pyloric stenosis. If correct, what physical exam finding would be seen and how would you treat?
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Physical exam: palpable olive mass in epigastric region, treatment: surgical incision
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What is the difference between celiac sprue and tropical sprue?
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Celiac: autoantibodies to gluten, affects proximal small bowel; Tropical: infectious, similar to celiac but affects entire small bowel
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What is Wipple's Disease?
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Infection with Tropheryma whippelii, PAS POSITIVE MACROPHAGES, malabsorption syndrome; arthralgias, cardiac, and neurologic symptoms are common
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A 20 y.o.with Celiac disease presents with pruritic papulovesicles over his extensor surfaces. Examination of his skin showed deposits of Ig A at the tips of the dermal papillae. What is the skin disorder?
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Dermatitis Herpetiformis
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What is the difference between Type A and B Chronic gastritis?
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Type A: Autoimmune disease characterized by autoantibodies to pernicious anemia, affects the fundus/body; Type B: Caused by H. pylori infection, affects the antrum
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What are some common findings with stomach cancer?
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Thickened, rigid appearance (leather bottle) of stomach, signet ring cells, and acanthosis nigricans
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Where are the two common metastases from stomach cancer?
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Virchow's node-involvement of left supraclavicular node by mets from stomach, Krukenberg's tumor-bilateral mets to ovaries
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What is the difference between gastric ulcer and duodenal ulcer?
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Gastric Ulcer: Pain greater with meals, weight loss, 70% infection with H.pylori, due to decrease mucosal protection; Duodenal ulcer: pain decreases with meals, weight gain, 100% infection with H. pylori, due to increase gastric acid secretion or decrease mucosal protection
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What is the difference between direct and indirect bilrubin?
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Direct: conjugated with glucuronic acid, found in the liver, water soluable; Indirect: unconjugated, water insoluable, found in the blood
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What converts the conjugated bilirubin into urobilinogen?
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Gut bacteria in the colon
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List out the steps of Heme metabolism.
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Senescent RBC----->Unconjugated bilirubin-----Liver---->Conjugated bilirubin----->Urobilinogen
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What is the enzyme that conjugates bilirubin in the liver?
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UDP glucuronyltransferase (UGT1A1)
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Hepatocellular carcinoma is associated with elevated levels of what compound?
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alpha-fetoprotein
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What are the clinical findings in Reye's syndrome?
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fatty liver, hypoglycemia, coma
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What are the four major risk factors for developing gallstones?
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The 4 F's: female, fat, fertile, forty
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What are the abnormal lab results in acute pancreatitis?
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elevated amylase, lipase (higher specificity)
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What are the classic symptons of Carcinoid syndrome?
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wheezing, right-sided heart lesions, diarrhea, flushing
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What are some side effects of the H2 blocker Cimetidine?
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Inhibits P-450, antiandrogenic effects (gynecomastia, impotence), can cross the BBB and cause confusion, dizziness, headaches
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What is the mechanism of misoprostol?
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PGE1 analog. Increased mucous, decreased acid production
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What is a toxicity associated with misoprostol?
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Diarrhea, c/I in women of childbearing potential (abortifacient)
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What is the mechanism of pirenzepine and propantheline?
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Muscarinic antagonists, block M1 receptors on ECL cells (decrease histamine secretion) and M3 receptors on parietal cells (decrease H+ secretion)
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What is the clinical use of sulfasalazine?
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Ulcerative colitis, Crohn's disease
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What is the mechanism of ondansetron?
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5-HT3 antagonist, central-acting antiemetic
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What is the mechanism of metoclopramide?
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D2 receptor antagonist, increases resting tone, contractility, motility
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What is a toxicity associated with metoclopramide?
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Increased parkinsonian effects; restlessness, drowsiness, fatigue, depression, nausea, constipation
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Etiology of Crohn's Disease vs. Ulcerative Colitis
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Crohn's: Post-infectious; UC:autoimmune
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Location of Crohn's in GI tract
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Any part, usually in terminal ileum and colon. Skip lesions, rectal sparing
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Location of Ulcerative Colitis
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Continuous colonic lesions, always with rectal involvement
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Gross morphology of Crohn's Disease
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Transmural inflammation, cobblestone mucosa, creeping fat, bowel wall thickening (string sign on barium swallow x-ray), linear ulcers, fissures, fistulas)
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Gross morphology of ulcerative colitis
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mucosal and submucosal inflammation only; friable mucosal pseudopolyps with freely hanging mesentery. lead pipe appearance on imagin
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Microscopic morphology of Crohn's Disease
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noncaseating granulomas and lymphoid aggregates
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Microscopic morphology of UC
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crypt abcesses and ulcers, bleeding, no granulomas
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complications of crohn's disease
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strictures, fistulas, perianal disease, malabsorption, nutritional depletion
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complications of UC
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severe stenosis, toxic megacolon, colorectal carcinoma
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intestinal manifestations of Crohn's (what is your poo like?)
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diarrhea that may or may not be bloody
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intestinal manifestations of UC (what is your poo like?)
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bloody diarrhea
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extraintestinal manifestations of Crohn's disease
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migratory polyarthritis, erythema nodosum, anklylosing spondylitis, uveitis, immunologic disorders
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extraintestinal manifestations of UC
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pyoderma gangrenosum, primary sclerosing cholangitis
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treatment of chron's disease
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corticosteroids
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treatment of ulcerative colitis
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sulfasalazine
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Fat granny and an old crone skipping down a cobblestone road away from the wreck (rectal sparing)
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Crohn's disease (see Images 118, 119)
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appendicitis- who gets it
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all age groups; m/c indication for emergent abdominal surgery in kids
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appendicitis- symptoms
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initial diffuse periumbilical pain--> localized pain at McBurney's point; nausea, fever, may perforate--> peritonitis
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what is diverticulum?
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blind pouch leading off the alimentary tract that communicates with the lumen of the gut. Most diverticula (esophagus, stomach, duodenum, colon) are acquired and termed false in that they lack or have an attenuated muscularis externa. Most often in sigmoid colon
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true diverticulum
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all 3 gut wall layers outpouch
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false diverticulum or psuedodiverticulum
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only mucosa and submucosa outpouch. Occur especially where vasa recta perforate muscularis externa
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what is diverticulosis?
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many diverticula; common (in 50% of people >60
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what causes diverticulosis?
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increased intraluminal pressure and focal weakness in colonic wall
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what is diverticulosis associated with?
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low-fiber diets
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most common location of diverticulosis
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sigmoid colon; often asymptomatic or associated with vague discomfort and/or rectal bleeding
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what is diverticulitis?
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inflammation of diverticula classically caussing LLQ pain, fever, leukocytosis; may perforate-->perotinitis, abscess formation, or bowel stenosis. ( See color image 31). May cause bright red rectal bleeding
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how to treat diverticulitis
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antibiotics
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what is Zenker's diverticulum
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false diverticulum; herniation of mucosal tissue at junction of pharynx and esophagus
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presenting sx of Zenker's diverticulum
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halitosis, dysphagia, obstruction
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what is Meckel's diverticulum
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persistence of vitelline duct or yolk stalk. May contain ectopic acid-secreting gastric mucosa and/or pancreatic tissue
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most common congenital anomaly of the GI tract
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meckel's diverticulum
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what can Meckel's diverticulum cause?
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bledding, intussusception, volvulus, or obstruction near the terminal ileum
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what is omphalomesenteric cyst
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cystic dilation of vitelline duct
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Meckel's diverticulum- description
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the five 2's: 2 inches long, 2 feet from the ileocecal valve, 2% of population, commonly presents in first 2 years of life, may have 2 types of epithelia (gastric/pancreatic)
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what is intussusception?
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telescoping of 1 bowel segment into distal segment; can compromise blood supply (see color image 34). Often d/t intraluminal mass; usually in infants
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what is volvulus? Where does it occur? In which pts?
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twisting of portion of bowel around its mesentery; can lead to obstruction and infarction.
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where does volvulus occur? In which pts?
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may occur at sigmoid colon, where there is redundant mesentary; usually in elderly
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what is Hirschprung's disease?
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congenital megacolon characterized by lack of ganglion cells/enteric nervous plexuses (auerbach's and meissner's plexuses) in segment on intestinal biopsy; think of a giant spring that has sprung in the colon
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what is cause of Hirschprung's disease?
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d/t failure of neural crest cell migration
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what has increased risk of Hirschprung's disease?
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Down syndrome
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what is duodenal atresia?
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causes early bilious vomiting with proximal stomach distention (double bubble) d/t failure of recanalization of small bowel.
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what is duodenal atresia associated with?
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Down syndrome
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meconium ileus
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in cystic fibrosis, meconium plug obstructs intestine, preventing stool passage
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necrotizing enterocolitis
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necrosis of intestinal mucosa and possible perforation. Colon is usually involved, but can involve entire GI tract. In neonates, more common in preemies (decrease immunity)
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ischemic colitis
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reducitng in intestinal blood cuases ischemia. Typically affects elderly.
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consquences of ischemic colitis
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sepsis, bowel infarction, death
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intestinal adhesion
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acute bowel obstruction, commonly from a recent surgery. Can have well-demarcated necrotic zones
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angiodysplasia (GI)
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tortuous dilation of vessels--> bleeding. Most often found in cecum and ascending colon. More common in older patients. Confirmed by angiography
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colonic polyps- what are they? Where are they?
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90% are benign hyperplastic hamartomas, not neoplasms. Often rectosigmoid. Sawtooth appearance. The more villous the polyp, the more likely it is to be malignant. (see color image 30)
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colorectal cancer- causes? Incidence?
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3rd m/c cancer. Most are sporadic, d/t chromosomal instability (85%) or microsatellite instability (15%). See color image 107
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colorectal cancer- risk factors
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colorectal villous adenomas, chronic IBD (esp. d/t UC, increased age), FAP, HNPCC, PMH, FHx
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colorectal cancer- who do you screen? How?
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pts>50 with stool occult blood test and colonoscopy
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colorectal cancer- what does it look like on imaging?
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apple core lesion seen on barium enema x-ray
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colorectal cancer- tumor marker
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CEA tumor marker
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Familial adenomatous polyposis (FAP)-inheritance
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AD mutation of APC gene on chromosome 5q; 2 hit hypothesis
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Familial adenomatous polyposis (FAP)-features
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thousands of polyps, always involving rectum
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Gardner's syndrome
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FAP with osseous and soft tissue tumors, retinal hyperplasia
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Turcot's syndrome
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FAP with possible brain involvement (glioblastoma)
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HNPCC or Lynch syndrome
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Mutations of DNA mismatch repair genes; ~80% progress to CRC; proximal colon always involved
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Peutz-Jeghers syndrome- what is it? What is it associated with?
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benign polyposis syndrome; associated with increased risk of CRC and other visceral malignancies (pancreas, breast, stomach, ovary)
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Peutz-Jeghers syndrome- findings
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hamartomatous polyps of colon and small intestine; hyperpigmented mouth, lips, hands, and genitalia
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Carcinoid tumor- what is it? Most common site? Histology? What does it cause?
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tumor of endocrine cells; comprise 50% of small bowel tumors. M/c site is SI. dense core bodies seen on EM. Often produce 5HT (depending on location--> carcinoid syndrome)
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Carcinoid tumor- symptoms?
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wheezing, right-sided heart murmurs, diarrhea, flushing (need to have Mets to liver in order to have heart murmur)
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Effects of portal hypertension
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esphageal varices that cause hematemesis and melena; peptic ulcer, that also can cause melana; splenomegaly, caput medusa, ascites, hemorrhoids
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effects of liver cell failure
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coma, scleral icterus, fetor hepaticus (breah smells like a freshly opened corpse), spider nevi, gynecomastia, jaundice, testicular atrophy, liver flap (asterixis; coarse hand tremor), bleeding tendency (decreased prothrombin and clotting factors), anemia, ankle edema
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asterixis
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coarse hand tremor, aka liver flap
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cirrhosis- what is it
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diffuse fibrosis of liver, destroys normal architecture; nodular regeneration
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micronodular liver nodules
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nodules <3mm, uniform size. D/t metabolic insult (ex. Alcohol, hemochromatosis, Wilson's disease)
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macronodular liver nodules
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nodules >3mm, varied size. Usually d/t significant liver injury leading to hepatic necrosis (ex. Postinfectious or drug-induced hepatitis); increased risk of hepatocellular carcinoma
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what may relieve portal hypertension?
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portacaval shunt between splenic vein and left renal vein (see color image 29)
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aminotransferases (AST and ALT)- major dx use in GI path?
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viral hepatitis, alcoholic hepatitis, myocardial infarction (AST)
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GGT (gamma-glutamyl transpeptidase)- major dx use in GI path?
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various liver diseases
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Alkaline phosphatase- major dx use in GI path?
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obstructive liver disease (hepatocellular carcinoma), bone disease, bile duct disease
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amylase-major dx use in GI path?
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acute pancreatitis, mumps
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Lipase-major dx use in GI path?
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actute pancreatitis
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ceruloplasmin-major dx use in GI path?
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wilson's disease; will be decreased in serum
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Reye's syndrome- what is it?
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rare, often fatal childhood hepatoencephalopathy
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Reye's syndrome- findings
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fatty liver (microvesicular fatty change), hypoglycemia, coma.
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Reye's syndrome- what is it associated with?
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associated with viral infection (especially VZV and influenza B) that has been treated with salicylates
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What pain med is not recommended for use in kids? Why? What do you use instead?
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aspirin is not recommended in kids; can cause Reye's syndrome; use acetaminophen, with caution
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alcoholic liver disease: hepatic steatosis
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short-term change with moderate alcohol intake. Reversible macrovesicular fatty change upon alcohol cessation (see color image 28)
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alcoholic liver disease- chemical markers
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AST>ALT (ratio usually >1.5; you'r toASTed with alcoholic hepatitis
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viral hepatitis- chemical markers
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ALT>AST
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Alcoholic hepatitis
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requires sustained, long-term consumption. Swollen and necrotic hepatocytes with neutrophilic infiltration. Mallory bodies(intracytoplasmic eosinophilic inclusions) are present
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Mallory bodies
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intracytoplasmic eosinophilic inclusions; associated with alcoholic hepatitis
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alcoholic cirrhosis
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final and irreversible form of alcoholic liver disease; micronodular irregularly shrunken liver with hobnail appearance (see color image 29). Sclerosis around central vein (zone III). Has manigestations of chronic liver disease (ex. Jaundice, hypoalbulinemia)
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What are the (8) layers of the abdominal wall?
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(external - internal) Skin, Superficial fascia, External oblique, Internal oblique, Transversus abdominis, Transversalis fascia, Extraperitoneal tissue, Peritoneum
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What parts of the intestine are retroperitoneal?
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duodenum (2nd, 3rd, 4th parts); desc. colon; asc. colon; rectum
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What abdominal structures are retroperitoneal?
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duodenum (2nd, 3rd, 4th parts); desc. colon; asc. colon; kidney & ureters; pancreas (except tail); aorta; IVC; adrenal glands; rectum
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Which arteries supplied the different embryonic gut regions?
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celiac a. - foregut; SMA - midgut; IMA - hindgut
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What adult structures are supplied by the celiac a.?
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stomach through prox. duodenum; liver; gallbladder; pancreas
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What adult structures are supplied by the SMA?
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distal duodenum through prox. 2/3 of transverse colon
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What adult structures are supplied by the IMA?
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distal 1/3 transverse colon through upper part of rectum
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Where is the watershed region of the intestine?
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splenic flexure (SMA - IMA)
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What are the (3) branches of the celiac trunk?
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common hepatic a., splenic a., left gastric a.
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What is the innervation for the GI structures supplied by the celiac a.?
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parasympathetic: vagus; vertebral level: T12/L1
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What is the innervation for the GI structures supplied by the SMA?
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parasympathetic: vagus; vertebral level: L1
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What is the innervation for the GI structures supplied by the IMA?
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parasympathetic: pelvic; verterbral level: L3
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Which arterial anastamoses compensate if the abdominal aorta is blocked?
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1) internal thoracic/mammary a. (subclavian) ↔ superior epigastric a. (internal thoracic) ↔ inferior epigastric a. (external iliac); 2) superior pancreaticoduodenal a. (celiac trunk) ↔ inferior pancreaticoduodenal a. (SMA); 3) middle colic a. (SMA) ↔ left colic a. (IMA); 4) superior rectal a. (IMA) ↔ middle recltal a. (internal iliac)
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What are the 3 major anastomoses commonly seen in portal HTN?
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1) Esophagus: L gastric v. ↔ esophageal v. (=esophageal varices); 2) Umbilicus: paraumbilical v. ↔ superficial & inferior epigastric vv. (=caput medusae); 3) Rectum: superior rectal v. ↔ middle & inferior rectal vv. (=caput medusae); think: gut, butt, caput
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Describe the architecture of hepatic lobules.
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Hexagonal loblules centered around central v. draining radial sinusoids from the peripheral portal triads. Bile drains in bile canaliculi flowing parallel to the sinusoids but in opposite direction (bile flows into the portal bile ductules). Also organized into zones I, II, and III, which are concentric around the portal triads.
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Which are the apical and basal surfaces of hepatocytes?
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Apical surface = faces bile cAnAliculi; baSolateral surface = faces Sinusoids
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What is zone I (of liver anatomy)?
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Zone I = the periportal zone, is the 1st part affected by viral hepatitis
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What is zone II (of liver anatomy)?
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Zone II = intermediate zone (ie. middle ground between portal triads and central vv.)
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What is zone III (of liver anatomy)?
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Zone III = pericentral vein zone aka centrilobular zone; contains P-450 system; is the 1st part affected by ischemia; is most sensitive to toxic injury, eg. alcoholic hepatitis
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What are the sinusoids of the liver?
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sinusoids = irregular capillaries with fenestrated epithelium (pores 100-200nm); NO basement membrane. This allows macromolecules in plasma full access to the basolateral surface of hepatocyes through the perisinusoidal space (of Disse)
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Where is the cystic duct?
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cystic duct drains bile from the gallbladder and joins the common hepatic duct to form the common bile duct
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Where is the common hepatic duct?
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common hepatic duct is formed by the union of the R and L hepatic ducts; common hepatic duct joins the cystic duct to form the common bile duct
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Where is the sphincter of Oddi?
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sphincter of Oddi = at the ampulla of Vader (duodenum) and the common bile duct/pancreatic duct
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What is the falciform ligament and what does it contain?
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connects liver to anterior abdominal wall; contains ligamentum teres; =derivative of umbilical v.
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What is the hepatoduodenal ligament and what does it contain?
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connects liver to duodenum; contains the portal triad: hepatic a., portal v., common bile duct; also connects greater and lesser sacs
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Where should you compress the hepatoduodenal ligament to control bleeding?
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compress between thumb and index finger placed in the epiploic foramen (of Winslow)
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What is the gastrohepatic ligament and what does it contain?
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connects liver to lesser curvature of stomach, separates R greater and lesser sacs; contains gastric aa.; may be cut in surgery to access lesser sac
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What is the gastrocolic ligament and what does it contain?
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connects greater curvature of stomach to transverse colon, is part of greater omentum; contains gastroepiploic aa.
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What is the gastosplenic a. and what does it contain?
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connects greater curvature of stomach to spleen, separates L greater and lesser sacs; contains short gastrics
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What is the splenorenal ligament and what does it contain?
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connects spleen to posterior abdominal wall; contains splenic a. and v.
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What kind of muscle is in the upper 1/3 esophagus?
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striated muscle
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What kind of muscle is in the middle 1/3 esophagus?
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striated and smooth muscle
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What kind of muscle is in the lower 1/3 esophagus?
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smooth muscle
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What are the 4 layers of the gut wall (inside to out)?
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1. Mucosa (epithelium, lamina propria, muscularis mucosa); 2. Submucosa (Submucosal nerve plexus = MeiSSner's); 3. Muscularis externa (Myenteric nerve plexus = Auerbach's); 4. Serosa/adventitia
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What is the frequency of the slow waves (basal electric rhythm) in the stomach?
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3 waves/min
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What is the frequency of the slow waves (basal electric rhythm) in the duodenum?
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12 waves/min
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What is the frequency of the slow waves (basal electric rhythm) in the ileum?
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8-9 waves/min
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Where is the myenteric plexus and what does it do?
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Myenteric (Auerbach's) plexus coordinates Motility along entire gut wall; contains cell bodies of some parasympa. terminal effector neurons; located between inner (circular) and outer (longitudinal) layers of smooth muscle
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Where is the submucosal plexus and what does it do?
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Submucosal (MeiSSner's) plexus regulates local Secretions, blood flow, and absorption; contains cell bodies of some parasympa. terminal effector neurons; located between mucosa and inner layer of smooth muscle
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What is the pectinate line?
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where hindgut meets rectum
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What is the blood supply and innervation for areas above the pectinate line?
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arterial supply: superior rectal a. (a branch of IMA); venous drainage: superior rectal v. → inferior mesenteric v. → portal system; visceral innervation (thus internal hemorrhoids are NOT painful)
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What is the blood supply and innervation for areas below the pectinate line?
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arterial supply: inferior rectal a. (branch of internal pudendal a.); venous drainage: inferior rectal v. → internal pudendal v. → internal iliac v. → IVC; somatic innervation: inferior rectal n., a branch of pudendal n. (thus external hemorrhoids are PAINFUL); note: below pectinate line = site for squamous cell carcinoma
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