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174 Cards in this Set
- Front
- Back
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What structures are retroperitoneal?
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SAD PUCKER
Suprarenal glands Aorta/IVC Duodenum (2nd to 4th) Pancreas (no tail) Ureters Colon (only ascending and descending) Kidneys Esophagus Rectum |
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what is the derivative of the fetal umbilical vein
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ligamentum teres
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what is the portal triad
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hepatic artery
portal vein common bile duct |
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What ligament contains the portal triad
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hepatoduodenal ligament
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What ligament contains the short gastrics
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gastrosplenic ligament (connects greater curvature and spleen)
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what are the layers of gut wall (from inside to outside)
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mucosa
submucosa muscularis externa serosa/adventitia |
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what is Auerbach's plexus
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Myenteric nerve plexus
in Muscularis externa |
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what is Meissner's plexus
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Submucosa nerve plexus
in Submucosa |
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What is the order of frequency of basal electric waves in the gut (from fastest to slowest)
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duodenum (12 waves/min) > ileum (8-9) > stomach (3)
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what part of the small intestine has the largest number of goblet cells
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jejunum
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Where are Brunner's glands located?
What are they? |
in the submucosa of the duodenum
Mucous-rich alkaline secretion producing glands |
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Where are Peyer's patches located?
what are they? |
ileum
aggregated lymmphatic nodules |
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what is the function of the myenteric nerve plexus
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coordinates Motility along the entire gut wall
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What is the function of the submucosal nerve plexus
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regulates local Secretions, blood flow, and absorption
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What is superior mesenteric artery syndrome?
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caused by decreased aorto-mesenteric angle either from decresaed mesenteric fat or pronounced lordosis
traps transverse duodenum b/t superior mesenteric artery and aorta causing sxs of partial intestinal obstuction |
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at what vertebrae level are each of these located?
Celiac trunk SMA IMA Bifurcation of the abdominal aorta Left renal artery |
T12: Celiac trunk
L1: SMA, left renal artery L3: IMA L4: Bifurcation of abdominal aorta |
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what varices are seen in portal HTN
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Esophageal varices
Caput medusae (umbilicus) Internal hemorrhoids |
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what is the portal-systemic anastomoses in esophageal varices? Internal hemorrhoids?
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left gastric (portal) -> esophageal (systemic)
superior rectal (portal) -> middle and inferior rectal (systemic) |
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what is the portal-systemic anastomoses in caput medusae?
2 sites for portocaval shunts? why use them? |
paraumbilical (portal) -> superficial and inferior epigastric (systemic)
portocaval shunts are used in portal HTN site 1: b/t splenic and left renal vein site 2: portain vein to the IVC |
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what does the pectinate line signify?
what type of hemorrhoids are painful? why? |
where the hindgut (columnar cells) meets the ectoderm (squamous cells)
external hemorrhoids are painful b/c they are innervated by the inferior rectal nerve (branch of pudendal nerve), which is somatic. occurs due to portal HTN b/t superior rectal vein (portal) and inferior rectal vein (systemic) |
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What are the 3 zones of the liver
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Zone 1: periportal zone
Zone 2: intermediate zone Zone 3: pericentral vein (centrilobular) zone |
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What zone is affected by 1st by viral hepatitis
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Zone 1
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What zone is affected 1st by ischemia
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Zone 3
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What zone contains the P-450 system
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Zone 3
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What zone is most sensitive to toxic injury and alcoholic hepatitis
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Zone 3
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What is in the femoral triangle
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femoral vein, artery, nerve
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what is the femoral sheath
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femoral vein, artery and canal (deep inguinal lymph nodes)
NOT femoral nerve |
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What are the borders of the femoral triangle
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superior: inguinal ligament
lateral: sartorius muscle medial: adductor longus muscle |
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What is the organization of the femoral region (from lateral to medial)
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NAVEL
Nerve, Artery, Vein, (Empty), Lymphatics |
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How does a diaphragmatic hernia most commonly present
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as a hiatal hernia
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what is the most common hiatal hernia
what are it's characteristics |
sliding hiatal hernia is most common
GE junction is displaced ("hourglass stomach) |
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What is a paraesophageal hernia
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GE junction is NL
Cardia moves into the thorax |
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What is the path of an indirect inguinal hernia
Where does it protrude from What causes it |
Goes through the INternal (deep) inguinal ring -> external (superficial) inguinal ring -> INto scrotum
(follows the path of the testes) Protrudes lateral to the inferior epigastric artery Caused by failure of processus vaginalis to close (in INfants, more common in males) |
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Where does a direct inguinal hernia protrude from?
Describe its path of descent/protrusion |
through the inguinal (Hesselbach's) triangle; medial to inferior epigastric a.
protrudes through the external (superficial) inguinal ring ONLY usually in older men |
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What is the leading cause of bowel incarceration
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femoral hernia
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What layers cover an indirect inguinal hernia?
a direct inguinal hernia? |
indirect: covered by all 3 layers of spermatic fascia
direct: external spermatic fascia ONLY |
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Where does a femoral hernia protrude from
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below the inguinal ligament through the femoral canal and lateral to pubic tubercle
more common in women |
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what are the borders of Hesselbach's triangle
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inferior epigastric artery
lateral border of rectus abdominus inguinal ligament |
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if the abdominal aorta is blocked, what are the 4 anastomoses (and their origin) that compensate?
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1. Internal thoracic/mammary (subclavian) <-> superior epigastric (internal thoracic) <-> inferior epigastric (internal iliac)
2. superior pancreaticoduodenal (celiac trunk) <-> inferior pancreaticoduodenal (SMA) 3. Middle colic (SMA) <-> left colic (IMA) 4. Superior rectal (IMA) <-> middle rectal (internal iliac) |
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what is the most serous salivary gland
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parotid
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what is the most mucinous salivary gland
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sublinguinal
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What nerves are innervating salivary glands?
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symphathetic: T1-T3 superior cervical ganglion
parasympathetic: facial (sublingual and submandibular), glossopharyngeal (parotid) |
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What is Gastrin's mechanism of action
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major: acts on ECL cells (which lead to histamine release), rather than direct effect on parietal cells
Minor: direct effect on parietal cells through Gq protein receptor |
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when do you see hypertrophy of brunner's glands
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in peptic ulcer disease
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What do Brunner's glands do
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secrete alkaline mucus to neutralize acid contents entering duodenum from stomach
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what are the only GI submucosal glands
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Brunner's glands
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what enzyme converts trypsinogen to trypsin
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enterokinase/enterpeptidase
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what transporter transports all monosaccharides to the blood from the intestinal lumen
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GLUT-2
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Where is the highest concentration of pancreatic amylase
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in the duodenal lumen
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what is the rate-limiting step in carbohydrate digestion
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oligosaccharide hydrolases at the brush border of the intestine
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what does salivary amylase do
what does pancreatic amylase do |
salivary: starts digestion, hydrolyzed alpha-1,4 linkages -> disaccharides (maltose, maltotriose, alpha-limit dextrans)
pancreatic: hydrolyzes starch to oligosaccharides and disaccharides |
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where are these absorbed?
Iron Folate B12 |
Iron: in the duodenum as Fe+2
Folate: jejunum B12: terminal ileum w/bile acids |
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why is bile acid needed in the small intestine
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to digest triglycerides and to form micelles
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how do bile acids become water-soluble
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conjugate to glycine or taurine
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What is direct bilirubin
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conjugated w/glucoronic acid
water soluble |
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what is indirect bilirubin
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unconjugated (forms a complex w/albumin)
water INsoluble |
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what is warthin's tumor
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benign, heterotopic salivary gland tissue trapped in a lymph node, surrounded by lymphatic tissue
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what disease can lead to secondary esophageal achalasia
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Chagas' disease
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what is lost in esophageal achalasia
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myenteric (Auerbach's) plexus
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Boerhaave syndrome
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transmural esophageal rupture due to violent retching
"Been-Heaving syndrome" |
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what can lye ingestion and acid reflux cause
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esophageal strictures
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plummer-vinson syndrome
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triad:
dysphagia (due to esophageal webs) glossitis Fe deficiency anemia |
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what are risk factors for esophageal cancer
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ABCDEEF
Alcohol/Achalasia Barrett's esophagus Cigarettes Diverticuli (e.g., Zenker's) Esophageal webs (Plummer-Vinson)/Esophagitis Familial |
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what's the difference b/w celiac and tropical sprue
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celiac has autoantibodies to gliadin and effects proximal small bowel mainly
tropical is infectious (responds to Atbx), and can effect entire small bowel |
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how can you have a self-limited lactase deficiency
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lactase is at the tips of intestinal villi
can get deficiency after an injury, like viral diarrhea |
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what is Abeta-lipoproteinemia
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malabsorption syndrome
decreased synthesis of apo B -> inability to make chylomicrons -> decreased secretion of cholesterol and VLDL into bloodstream -> fat accumulation in enterocytes presents in early childhood w/malabsorption and neurologic manifestations |
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what are the Sx of Whipple's dz
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a malabsorption syndrome
athralgias, cardiac and neurologic Sx are common; most often occur in older men |
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where are the PAS-positive macrophages in Whipple's dz
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intestinal lamina propria, mesenteric nodes
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what antibodies are found in celiac sprue?
what is used for screening? what is there an increased risk of? |
antibodies to gliadin and tissue transglutaminase
serum levels of tissue transglutaminase antibodies used for screening moderately increased risk of malignancy (e.g., T-cell lymphoma) |
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Curling's ulcer
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in acute gastritis
decreased plasma volume -> sloughing of gastric mucosa assoc w/burns |
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Cushing's ulcer
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in acute gastritis
increased vagal stimulation -> increased ACh -> increased H+ production assoc w/brain injury |
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in what type of patients is acute gastritis common
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Alcoholics and pts taking daily NSAIDS (like RA pts)
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What are the 2 types of chronic gastritis
which most common |
Type A (fundus/body) and Type B (antrum)
both nonerosive Type B is most common |
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What is Type A chronic gastritis
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Autoimmune disorder
Autoantibodies to parietal cells pernicious Anemia Achlorhydria assoc w/ other autoimmune disorders |
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What is Type B chronic gastritis
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most common
caused by H. pylori infection increased risk of MALT lymphoma |
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Menetrier's dz
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gastric hypertrophy w/protein loss, parietal cell atrophy and increased mucous cells
precancerous to adenocarcinoma rugae of stomach so hypertrophies that look like brain gyri causes hypoproteinemia |
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What are common features of stomach cancer
What type of cancer is stomach cancer |
Signet rings cells and acanthosis nigricans common features
almost always adenocarcinoma |
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What is Virchow's node?
Sister Mary Joseph's nodule? |
Virchow's: left supraclavicular node by mets from stomach
Sister MJ: subcutaenous periumbilical metassis from stomach |
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Peptic ulcers:
Gastric ulcer vs duodenal ulcer |
Gastric ulcer: greater pain with food, in older pts, due to decreased mucosal protection against gastric acid; 70% has H. pylori infection and chronic NSAID use also implicated
Duodenal ulcer: pain decreaes with meals; almost 100% has H pylori infection. due to high gastric acid or mucosal protection. Hypertrophy of Brunner's glands |
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linitis plastica
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term used for stomach cancer when diffusely infiltrative
thickened, rigid appearance not associated with H. pylori |
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What is stomach cancer associated with
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dietary nitrosamines (smoked foods), achlorhydria, chronic gastritis, Type A blood
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what are extraintestinal manifestations of Crohn's disease
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migratory polyarthritis, erthyema nodosum, ankylosing spondylitis (HLA B27 association), uveitis, immunologic disorders
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What are extraintestinal manifestations of Ulcerative colitis
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pyoderma gangrenosum, PSC (bile duct fibrosis)
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Which of the IBD has a "string sign" on barium swallow x-ray
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Crohn's
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Which of the IBD has loss of haustra -> "lead pipe" appearance on imaging
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UC
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what is McBurney's point
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location of appendix
1/3 the distance from the iliac crest to the umbilicus |
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what is a false diverticulum
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only mucosa and submucosa outpouch
lacks/attenuated muscularis externa (occur esp where vasa recta perforate muscularix externa) |
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how does diverticulitis present
what can it lead to |
LLQ pain, fever, leukocytosis
bright red rectal bleeding can lead to colovesical fistula -> pneumaturia (fistula w/bladder) |
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what can cause diverticulosis
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low fiber diets
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what is the most common congenital anomaly of the GI tract
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Meckel's diverticulum
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what is a meckel's diverticulum
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persistence of the vitelline duct or yolk stalk
can contain ectopic acid-secreting gastric mucosa +/or pancreatic tissue |
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how is a meckel's diverticulum different from an omphalomesenteric cyst
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Meckel's diverticulum is caused by persistence of vitelline duct or yolk stalk
omphalomesenteric cyst is a cystic dilatation of vitelline duct |
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what is lost in Hirschsprung's dz
what causes this dz |
Auerbach's and Meissner's plexuses are gone
caused by failure of neural crest cell migration |
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the risk for Hirschsprung's increases in what genetic condition?
presentation? |
Down syndrome
chronic constipation in early in life. dilated portion of the colon PROXIMAL to the aganglionic segment. involves rectum |
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what is angiodysplasia
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tortuous dilation of vessels -> bleeding
most often in cecum, terminal ileum, and ascending colon more common in older patients; confirmed by angiography |
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what is juvenile polyposis syndrome
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multiple juvenile polyps in GI tract
increased risk of adenocarcinoma |
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what is peutz-jeghers syndrome
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autosomal dominant
multiple non-malignant hamartomas throughout GI tract hyperpigmented mouth, lips, hands, genitalia assoc w/increased risk of CRC and other visceral malignancies |
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"apple core" lesion on barium enema x-ray
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CRC
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If CRC in the distal colon, what is the presentation
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obstruction, colicky pain, hematochezia (passage of fresh blood through the anus, usually in or with stools (contrast with melena))
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if CRC in proximal colon, what is the presentation
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dull pain, Fe deficiency anemia, fatigue
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Gardner's syndrome
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FAP, osseus and soft tissue tumors, retinal hyperplasia
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what causes micronodular cirrhosis
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metabolic insult (EtOH, hemochromatosis, Wilson's dz)
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What causes macronodular cirrhosis
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due to significant liver injury -> hepatic necrosis
(e.g., post-infectious, or drug-induced hepatitis) |
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what serum enzyme markers used for acute pancreatitis
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amylase and lipase
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What is amylase used for as diagnostic
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acute pancreatitis and mumps
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what is reye's syndrome
what is the mechanism of action |
rare, often fatal childhood hepatoencephalopathy;
mitochondrial abnormalities, fatty liver, hypoglycemia, coma MOA: aspirin metabolites decrease B-oxidation by reversible inhibition of mitochondrial enzymes |
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Mallory bodies
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intracytoplasmic eosinophilic inclusions
found in Alcoholic Hepatitis |
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what is the final and irreversible form of alcoholic liver disease
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alcoholic cirrhosis
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alcoholic cirrhosis
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sclerosis around central vein (zone 3)
micronodular, irregularly shrunken liver w/"hobnail" appearance manifestations of chronic liver dz (jaundice, hypoalbuminemia) |
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List risk factors for hepatocellular carcinoma.
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hepatitis B and C
Wilson's disease hemochromatosis alpha-1 trypsin deficiency alcoholic cirrhosis carcinogen (e.g. aflatoxin in peanuts) |
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what are the clinical findings in HCC
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jaundice, tender hepatomegaly, ascites, polycythemia, hypoglycemia
elevated alpha-FP |
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what causes a "nutmeg" liver
what conditions can it lead to |
from backup of blood into liver. caused by right-sided heart failure and Budd-Chiari syndrome
if persists, centrilobular congestion and necrosis can lead to cardiac cirrhosis |
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what can lead to cardiac cirrhosis
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persistent nutmeg liver, caused by right-sided heart failure and Budd-Chiari syndrome
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what is Budd-Chiari syndrome
What can it lead to |
occlusion of IVC or hepatic veins w/centrilobular congestion and necrosis
can lead to congestive liver dz |
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findings of congestive liver disease?
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hepatomegaly, ascites, ab pain, eventual liver failure
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What are the clinical manifestations of Budd-Chiari syndrome
What conditions is it assoc w/ |
occlusion of IVC or hepatic veins
may develop varices and have visible ab and back veins, absent JVD assoc w/polycythemia vera, pregnancy, HCC |
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what is alpha1-antitrypsin deficiency
what is the major histological finding |
misfolded gene product protein accumulated in hepatocellular ER
a codominant trait causes decreased elastic tissue in lungs -> panacinar emphysema histo: PAS-positive globules in Liver |
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what is physiologic neonatal jaundice
How do you treat it |
at birth, immature UDP-glucuronyl transferase -> unconjugated hyperbilirubinemia -> jaundice/kernicterus
trx: phototherapy (converts UCB to water-soluble form) |
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Gilbert's syndrome
describe its pathogenesis what is it associated with? |
elevated unconjugated bilirubin w/o overt hemolysis; asymptomatic
mildly decreased UDP-glucuronyl transferase or decreased bilirubin uptake -problem w/bilirubin uptake assoc w/stress |
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what is Crigler-Najjar syndrome, Type 1
how do you treat it |
absent UDP-glucuronyl transferase
presents early in life; pts die in a few yrs -problem w/bilirubin conjugation -jaundice, kernicterus (bilirubin induced brain dysfunction) increased unconjugated bilirubin trx: plasmapheresis and phototherapy |
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Crigler-Najjar Type 2
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less severe than type 1
responds to phenobarbital, which increase liver enzyme synthesis |
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what is Dubin-Johnson syndrome
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conjugated hyperbilirubinemia
due to defective liver excretion -problem w/excretion of conjugated bilirubin grossly black liver; benign |
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what is rotor's syndrome
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similar to Dubin-Johnson
even milder and doesn't cause black liver |
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what is Wilson's dz
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hepatolenticular degeneration (auto-recessive)
inadequate hepatic copper excretion and failure of copper to enter circulation as ceruloplasmin -> Cu accumulation, esp in liver, brain, cornea, kidneys, and joints |
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What are the main characteristics of Wilson's dz
How do you treat it |
ABCD
Asterixis Basal ganglia degeneration (parkinsonian Sx) Ceruloplasmin decreased, Cirrhosis, Corneal deposits, Cu accumulation, HCC, Choreiform movements Dementia Hemolytic anemia Trx: penicillamine |
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What is hemosiderosis
What is hemochromatosis |
Hemosiderosis is the deposition of hemosiderin (iron)
Hemochromatosis is the dz caused by this Fe deposition (assoc w/HLA-A3) |
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What is the classic triad of hemochromatosis
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micronodular Cirrhosis, DM, skin pigmentation -> "Bronze diabetes"
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What causes "bronze diabetes"
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hemochromatosis
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What causes hemochromatosis
How you treat hereditary hemochromatosis |
Can be primary (auto recessive) or secondary to chronic transfusion therapy (e.g., B-thalassemia major)
trx: repeated phlebotomy, deferoxamine |
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What can hemochromatosis lead to
What are the lab findings |
can result in CHF and increased risk of HCC
Labs: increased ferritin, increased iron, decreased TIBC -> increased transferrin saturation |
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in pancreatic adenocarcinoma, where are tumors more common, and what does it lead to
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in the pancreatic head -> obstructive jaundice
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what are tumor markers for pancreatic adenocarcinoma
what is it associated w/ |
CEA and CA-19-9
assoc w/smoking, not EtOH |
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How does pancreatic cancer present
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1. ab pain radiating to back
2. wt loss (from malabsorption and anorexia) 3. Migratory thrombophlebitis (redness and tenderness on palpation of extremities--Trousseau's syndrome) 4. Obstructive jaundice w/palpable gallbladder (Courvoisier's sign) |
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what is Trousseau's syndrome
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migratory thrombophlebitis--redness and tenderness on palpation of extremities
in pancreatic cancer |
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What is Courvoisier's sign
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obstructive jaundice w/palpable gallbladder
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when is there an increase in alk phos in cholecystitis
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if bile duct becomes involved (e.g., ascending cholangitis)
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how do gallstones form
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when solubilizing bile acids and lecithin are overwhelmed by increased cholesterol +/or bilirubin or gallbladder stasis
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What are the 2 types of gallstones
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Cholesterol and pigment stones
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What are the risk factors for gallstones
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4 F's: female, fat, forty, fertile
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What is Charcot's triad
|
of cholangitis (inflammation of common bile duct)
jaundice, fever, RUQ pain |
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What is cholangitis
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inflammation of the bile duct
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How do you diagnose gallstones
How do you treat it |
dx w/ ultrasound
trx w/ cholecystectomy |
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what is a Positive Murphy's sign
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inspiratory arrest on deep palpation
commonly positive in cholecystitis and choledocholithiasis (gallstone in common bile duct) |
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What happens if a gallstone blocks the ileocecal valve
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gallstone ileus
air can be seen in the biliary tree on imagine |
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gallstones can lead to biliary colic. What is biliary colic
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gallstones interfere w/bile flow, causing bile duct contraction
can present w/o pain, like in diabetics |
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what conditions can gallstones cause
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ascending cholangitis, acute pancreatitis, bile stasis, cholecystitis
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Which of the 2 types of gallstones are more common
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cholesterol stones
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What gallstones are assoc w/obesity, Crohn's dz, CF, advanced age, clofibrate, estrogens, multiparity, rapid wt loss, Native American origin
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Cholesterol stones
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What gallstones are assoc w/chronic hemolysis, alcoholic cirrhosis, advanved age, biliary infection
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pigment stones
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what is the clinical presentation of acute pancreatitis
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epigastric ab pain radiating to back, anorexia, nausea
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what can chronic pancreatitis lead to
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pancreatic insufficiency -> steatorrhea, fat-soluble vitamin deficiency, DM
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What is chronic calcifying pancreatitis assoc w/
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alcoholism and increased risk of pancreatic cancer
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What are the causes of acute pancreatitis
|
GET SMASHED
Gallstones, EtOH Trauma, Steroids, Mumps, Autoimmune dz, Scorpion sting, Hypercalcemia/Hyperlipidemia, ERCP, Drugs (e.g., sulfa drugs) |
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What serum enzymes are elevated in acute pancreatitis
Which one has higher specificity |
amylase and lipase
lipase has more specificity |
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What biliary tract dz has increased serum mitochondrial antibodies
|
Primary Biliary Cirrhosis
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What biliary tract dz has hypergammaglobulinemia
what Ig? |
Primary Sclerosing Cholangitis
IgM |
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What causes secondary biliary cirrhosis
|
extrahepatic biliary obstruction -> increased pressure in intrahepatic ducts -> injury/fibrosis and bile stasis
obstruction: gallstone, biliary stricture, chronic pancreatitis, carcinoma of pancreatic head |
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what causes PBC
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autoimmune rxn -> lymphocytic infiltrate and granulomas
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what causes PSC; what is the histopath? complication?
|
unknown causes
"onion skin" bile duct fibrosis -> alternating strictures and dilation w/ "beading" of intra- and extrahepatic bile ducts on ERCP Can lead to biliary cholagiocarcinoma |
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what conditions have an increased conjugated bilirubin, increased cholesterol, increased alk phos
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secondary biliary cirrhosis, PBC, PSC
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What are the labs in secondary biliary cirrhosis, PBC, PSC
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increased conjugated bilirubin, increased cholesterol, increased alk phos
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what conditions present w/pruritus, jaundice, dark urine, light stools, hepatosplenomegaly
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secondary biliary cirrhosis, PBC, PSC
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How do secondary biliary cirrhosis, PBC, and PSC present
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pruritus, light stools, dark urine, hepatosplenomegaly, jaundice
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List 4 H2 blockers.
MOA |
take H2 blockers before you DINE.
Cimetidine, ranitidine, famotidine, nizatidine reversible block of histamine H2 blcokers -> decreased H+ secretion by parietal cells |
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toxicities of cimetidine
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inhibitor of P450
antiandrogenic effects (prolactin release, gynecomastia, impotence, decreased libido in males) can cross BBB (confusion, dizziness, headaches) cross placenta |
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what class of drug is indicated for zolliger-Ellison syndrome?
MOA? |
Omeprazole, lansoprazol
irreversibly inhibit H/K ATPase in stomach parietal cells |
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Triple therapy for H. pylori? (2 ways)
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1. Metronidazole, bismuth (pepto), tetracycline (or amoxicillin)
2. Metronidazole, omeprazole, and clarithromycin |
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Misoprostol
MOA? |
A PGE1 analog
increase production and secretion of gastric mucous barrier, decrease acid production |
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Pirenzepine, propantheline
MOA? clinical use? |
Block M1 on ECL cells (less histamine)
block M3 on parietal cells (less H+) peptic ulcer (rarely used) |
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Aluminum hydroxide
toxicities? use? |
constipation, hypophosphatemia; proximla muscle weakness, osteodystrophy, seizures, HYPOKALEMIA
antacid |
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Mg hydroxide
toxicties? use? |
HYPOKALEMIA, diarrhea, hyporeflexia, hypotension, cardiac arrest
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Sulfasalazine
MOA? use? |
a combo of sulfapyridine (antibacterial) and 5-aminosalicylic acid (anti-inflammatory). Activated by colonic bacteria
used in ulcerative colitis and Crohn's |
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Ondansetron
MOA? clinical use? |
5HT3 antagonist. Powerful central acting anti-emetic.
control vomiting postoperatively and in pts undergoing cancer chemotherapy |
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Metoclopramide
MOA? Clinical use? Major toxicity? |
D2 receptor antagonist. Increase resting tone, contractility, LES tone, motility
Used in diabetic and post-surgery gastroparesis can have parkinsonian effects. |
