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202 Cards in this Set
- Front
- Back
What is the source of gastrin? |
G cells (antrum of the stomach)
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What is the action of gastrin?
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Inc gastric H+ secretion, inc growth of gastric mucosa, inc gastric motility
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How is gastrin regulated?
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Inc by stomach distention/alkalinization, amino acids, peptides, vagal stimulation. Dec by stomach pH <1.5
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What disease has increased gastrin?
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Zollinger-Ellison syndrome
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What medication can cause increased gastrin?
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Chronic PPI use (proton pump inhibitors).
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What amino acids are potent stimulators of gastrin production?
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Phenylalanine and tryptophan
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What is the source of Cholecystokinin?
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I cells (duodenum, jejunum)
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What is the action of Cholecystokinin?
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Increases pancreatic secretion, galbladder contraction, and spincter of Oddi relaxation. Decreases gastric emptying
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How is Cholecystokinin regulated?
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Increased by fatty acids and amino acids
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How does Cholecystokinin cause pancreatic secretions to increase?
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Acts on neural muscarinic pathways
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What is the source of secretin?
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S cells (duodenum)
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What is the action of secretin?
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Increases pancreatic bicarbonate (HCO3-) and bile secretion.
Decreases gastric acid secretion. |
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What regulates secretin levels?
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Increased by acid and fatty acids in the lumen of duodenum
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How does secretin help to allow pancreatic enzymes to function?
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It increase bicarb, which neutrolizes gastric acid in the duodenum, allowing pancreatic enzymes to function
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What is the source of somatostatin in the GI tract?
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D cells (pancreatic islets, GI mucosa)
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What is the action of somatostatin in the GI tract?
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Decreases gastric acid and pepsinogen secretion, decreases pancreatic and small intestine fluid secretion, decreases gallbladder contraction, and decreases insulin and glucagon release
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How is somatostatin regulated in the GI tract?
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Increased by acid and decreased by vagal stimulation
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What type of hormone is somatostatin (stimulatory or inhibitory?)
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Inhibitory
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What is the effect of somatostatin on growth hormone?
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Inhibits growth hormone (inhibits digestion and absorption of substances needed for growth)
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What is the source of glucose-dependent insulinotropic peptide?
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K cells (duodenum, jejunum)
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What are the actions of glucose-dependent insulinotropic peptide?
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Exocrine: decreases gastric H+ secretion.
Endocrine: increases insulin release |
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How is glucose-dependent insulinotropic peptide regulated?
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Increased by fatty acids, aminoacids, and oral glucose
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Why is an oral glucose load used more rapidly than the equivalent by IV?
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GIP (Glucose-dependent insulinotropic peptide) secretion
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What is the source of VIP (vasoactive intestinal polypeptide)?
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Parasympathetic ganglia in sphincters, gallbladder, and small intestine
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What is the action of VIP?
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increase intestinal water and electrolyte secretion, increases relaxation of intestinal smooth muscle and sphincters.
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What regulates VIP levels?
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Increased by distention and vagal stimulation.
Decreased by adrenergenic input |
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What is a VIPoma and what are the symptoms?
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VIPoma = non-alpha, non-beta islet cell pancreatic tumor that secretes VIP.
Symptoms: copious watery diarrhea, hypokalemia, achlorhydria |
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What is the action of nitric oxide in the GI tract?
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Inc smooth muscle relaxation, including lower esophageal sphincter
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What is a potential cause of achalasia wrt GI tract hormones?
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Loss of Nitric Oxide secretion is implicated in inc lower esophageal tone of achalasia
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What is the source of motilin in the GI tract?
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Small intestine
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What is the action of motilin in GI tract?
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Produces migrating motor complexes (MMCs)
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What regulates motilin levels in GI tract?
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Increased in fasting state
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What drug is used to stimulate intestinal peristalsis in GI tract?
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Motilin receptor agonists (ex: erythromycin)
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What is the source of intrinsic factor?
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Parietal cells (stomach)
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What is the action of intrinsic factor?
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Vitamin B12-binding protein (required for B12 uptake in terminal ileum)
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What happens when autoimmune disease destroys parietal cells?
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Chronic gastritis and pernicious anemia
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What is the source of gastric acid in GI tract?
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Parietal cells (stomach)
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What is the action of gastric acid?
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Decreases stomach pH
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What regulates gastric acid levels?
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Increased by histamine, ACh, gastrin.
Decreased by somatostatin, GIP, prostaglandin, secretin |
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What is a gastrinoma?
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Gastrin-secreting tumor that causes continuous high levels of acid secretion and ulcers
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What is the source of pepsin?
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Chief cells (stomach)
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What is the action of pepsin in GI tract?
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Protein digestin
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What regulates pepsin levels?
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Increased by vagal stimulation, local acid
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What converts inactive pepsinogen to pepsin?
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H+
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What is the source of bicarbonate (HCO3-) in GI tract?
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Mucosal cells (stomach, duodenum, salivary glands, pancreas) and Brunner's glands (duodenum)
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What is the action of bicarb in GI tract?
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Neutralizes acid
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What regulates bicarb levels in GI tract?
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Increased by pancreatic and biliary secretion with secretin
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Where is bicarb found on cells in GI tract?
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It is trapped in the mucosa that covers the gastric epithelium
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What glands secrete saliva?
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Parotid, submandibular, and sublingual galnds via sympathetic and parasympathetic activity
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What are the components of saliva and what are their actions?
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Amylase digests starch, bicarb neutralizes bacterial acids, mucins lubricate food.
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Is saliva normally hypo, iso, or hypertonic?
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Hypotonic because of absorption but more isotonic with higher flow rates (less time for absorption)
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How does atropine affect vagal stimulation of parietal cells and G cells?
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Atropine blocks vagal stimulation of parietal cells.
Vagal stimulation of G cells is unaffected, as a different transmitter (GRP) is used, not ACh |
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How does gastrin increase acid secretion?
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Primarily through its effects on ECL cells (leading to histamine release) rather than directly through its affects on parietal cells
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Where are Brunner's glands located?
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Duodenal submucosa
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What is the action of Brunners glands?
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Secrete alkaline mucus
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When do you see Brunner's gland hyperplasia?
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Peptic ulcer disease
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Are pancreatic secretions hypo, iso, or hypertonic?
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Isotonic
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How do low flow and high flow affected pancreatic secretions?
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Low flow -> high Cl-
High flow -> high HCO3- |
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What is the role of alpha-amylase?
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Starch digestion
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Is alpha-amylase secreted in the active or passive form?
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Active form
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What are the roles of lipase, phospholipase A, and colipase?
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Fat digestion
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What is the role of proteases?
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Protein digestion
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What are the proteases?
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Trypsin, chymotrypsin, elastase, carboxypeptidases.
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How are proteases secreted?
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Proenzymes also known as zymogens
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What is the role of trypsinogen?
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Converted to active enzyme trypsin which activates other proenzymes and creates more trypsinogen (positive feedback loop)
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What converts trypsinogen to trypsin?
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Enterokinase/enteropeptidase (an enzyme secreted from duodenal mucosa)
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What is the action of salivary amylase and how does it do it?
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Starch digestion. Hydrolyzes alpha-1,3 linkages to yield disaccharides (maltose and alpha-limit dextrins)
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Where is the concentration of pancreatic amylase the highest?
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Duodenal lumen
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What does pancreatic amylase do?
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Hydrolyzes starch to oligosaccharides and disaccharides
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Where are oligosaccharide hyrolases located?
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A brunch border of intestine
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What is the rale limiting step in carbohydrate digestion?
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Oligosaccharide hydrolases
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What do oligosaccharide hydrolases produce?
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Monosaccharides from oligo- and disaccharides
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Which type of sugars can be absorbed by enterocytes?
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Only monosaccharides (glucose, galactose, and fructose)
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How are sugars taken up by enterocytes?
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Glucose and galactose are taken up by the SGLT1 (Na+ dependent).
Fructose is taken up by facilitated diffusion by GLUT-5. All are transported by GLUT-2. |
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What is the D-xylose absorption test?
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Distinguishes GI mucosal damage from other cauess of malabsorption
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How/where is Iron absorbed?
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As Fe2+ in duodenum
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Where is folate absorbed?
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Jejunum
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Where/how is B12 absorbed?
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In terminal ileum alone with bile acids; requires intrinsic factor
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What are Peyer's patches? Where are they found? What type of cells do they contain?
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Unencapsulated lymphoid tissue found in the lamina propria and submucosa of ileum.
Contain specialized M cells that take up antigen |
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What happens to B cells in Peyer's patches?
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B cells stimulated in germinal centers of Peyer's patches differentiate into IgA-secreting plasma cells, which ultimately reside in lamina propria.
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What is the path of IgA in the GI mucosa and what is its role in GI mucosa?
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Made form B cells in Peyer's patches.
IgA receives a protective secretory component and is then transported across the epithelium to the gut to deal with intraluminal antigen |
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What makes up bile?
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Composed of bile salts (Bile acids conjugated to glycine or taurine, making them water soluble), phospholipids, cholesterol, bilirubin, water, and ions.
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What is the rate limiting step of bile formation?
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Cholesterol 7alpha-hydroxylase catalyzes the rate limiting step.
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What are the 3 main functions of bile?
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1. Digestion and absorption of lipids and fat-soluble vitamins
2. Cholesterol excretion (body's only means of eliminating cholesterol) 3. Antimicrobial activity (via membrane disruption) |
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What is the body's only means of eliminating cholesterol?
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Bile
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What metabolic pathway makes bilirubin?
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Heme metabolism
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How is bilirubin removed from the body?
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1. From blood by the liver
2. Conjugated with glucuronate 3. Excreted in bile |
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What is Direct Bilirubin?
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Conjugated with glucuronic acid. Water soluble
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What is Indirect bilirubin?
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Unconjugated. Water insoluble
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What constitutes the foregut?
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Pharynx to duodenum
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What constitutes the midgut?
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Duodenum to transverse colon
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What constitues the hindgut?
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Distal transverse colon to rectum
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What disorder results form failure of rostal fold closure of anterior abdominal wall?
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Sternal defects
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What 2 disorders result from failure of lateral fold closure of anterior abdominal wall?
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Omphalocele, gastroschisis
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What disorder results form failure of caudal fold closure of anterior abdominal wall?
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Bladder extrophy
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What is duodenal atresia and what patients is it most common in?
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Failure to recanalize.
Seen commonly in trisomy 21 |
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What causes jejunal, ileal, and colonic atresia?
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Due to vascular accident (apple peel atresia)
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What are the 2 main steps in midgut development and when do they happen?
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1. 6th week: midgut herniates through umbilical ring.
2. 10th week: return to abdominal cavity + rotates around SMA |
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What are the types of pathology that can be seen with failure of GI tract development?
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Malrotation of midgut, omphalocele, intestinal atresia or stenosis, volvulus
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Compare gastroschiss and omphalocele
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Gastroschisis:
-extrusion of abdominal contents through abdominal folds. -NOT covered by peritoneum. Omphalocele: -Persistence of herniation of abdominal contents into umbilical cord -COVERED by peritoneum |
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What is the most common trachoesophageal anomaly?
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Esophgeal atresia with distal tracheoesophagel fistula (85%)
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What are the signs of tracheoesphageal fistula?
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-Drooling, choking, vomiting with first feed.
-TEF allows air to enter stomach, which is visible on CXR. -Cyanosis is secondary to laryngospasm (to avoid reflux-related aspiration). |
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What clinical test can be used to diagnose TEF?
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Failure to pass NG tube into stomach
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What is an H-type TEF?
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Fistula alone (no atresia).
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What will CXR show in pure esophageal atresia?
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CXR will show gasless abdomen
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What is congenital pyloric stenosis? What will see on PE? What are symptoms?
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Hypertrophy of pylorus causes obstruction.
PE: palpable "olive" mass in epigastric region and nonbilious projectile vomiting at ~2 weeks of age. |
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What is the treatment for pyloric stenosis?
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Surgery
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How common is pyloric stenosis and who is it more common in?
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1/600 live births.
More common in first born males |
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What is the pancreas derived from and how does it happen?
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Foregut.
-Ventral pancreatic buds contribute to the pancreatic head and main pancreatic duct. -The uncinate process is formed by the ventral bud alone. -The dorsal pancreatic bud becomes everything else (body, tail, isthmus, and accessory pancreatic duct) |
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What is an annular pancreas?
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Ventral pancreatic bud abnormally encircles 2nd part of duodenum; forms a ring of pancreatic tissue that may cause duodenal narrowing
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What is pancreas divisum?
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Ventral and dorsal parts fail to fuse at 8 weeks
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What is the spleen derived from?
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Arises in mesentery of stomach (therefore is mesodermal) but is supplied by foregut (celiac artery)
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What does the term retroperitoneal mean? Why are they important?
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GI strcutres that lack mesentery (as well as non-GI structures).
Injury to retroperitoneal structures can cause blood or gas accumulation in retroperitoneal space. |
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What are the retroperitoneal structures?
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SAD PUCKER:
Suprarenal (adrenal) glands Aorta and IVC Duodenum (2nd and 3rd parts) Pancreas (except tail) Ureters Colon (descending and ascending) Kidneys Esophagus (lower 2/3) Rectum (lower 2/3) |
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What does the falciform ligament connect?
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Liver to anterior abdominal wall
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What structures are contained in the falciform ligament?
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Ligamentum teres hepatis
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What is the ligamentum teres hepatis a derivative of?
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Fetal umbilical vein
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What is the falciform ligament a derivative of?
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Ventral mesentery
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What does the hepatoduodenal ligament connect?
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Liver to duodenum. Also connects the greater and lesser sacs
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What structures are contained in the hepatoduodenal ligament?
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The portal triad: hepatic artery, portal vein, common bile duct
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What structures make up the portal triad?
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Hepatic artery, portal vein, common bile duct
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What is the Pringle maneuver?
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The hepatoduodenal ligament may be compressed between the thumb and index finger placed in omental foramen to control bleeding
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What does the gastrohepatic ligament connect?
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Liver to lesser curvature of the stomach
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What structures are contained in the gastrohepatic ligament?
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Gastric arteries
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What does the gastrohepatic ligament separate?
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The greater and lesser sacs on the right (may be cut during surgery to access the lesser sac)
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What does the gastrocolic ligament connect?
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Greater curvature and transverse colon.
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What structures are contained in the gastrocolic ligament?
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Short gastrics, L gastroepiploic vessels
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What does the gastrosplenic ligament separate?
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Greater and lesser sacs on the left
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What does the splenorenal ligament connect?
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Spleen to posterior abdominal wall
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What does the splenorenal ligament contain?
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Splenic artery and vein, as well as the tail of the pancreas
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What are the 4 layers of the gut wall from inside to outside?
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MSMS: mucosa, submucosa, muscularis externa, serosa/adventitia
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What are the layers of the mucosa and what are their functions?
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Epithelium (absorption), lamina propria (support), muscularis mucosa (motility)
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What nerve plexus is in the submucosa?
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Submucosal nerve plexus (Meissner's)
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What nerve plexus is in the muscularis externa?
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Myenteric nerve plexus (Auerbach's)
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When do you call the outermost layer of the gut wall serosa vs adventitia?
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Serosa when intraperitoneal, adventitia when retroperitoneal
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Where can ulcers extend to in the gut wall? What about erosions?
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Ulcers can extend into the submucosa, inner, or outer muscular layer whereas erosions are in the mucosa only
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What are the frequencies of basal electrical rhythm (slow waves) in the sotmach, duodenum, and ileum?
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Stomach: 3 waves/min.
Duodenum: 12 waves/min. Ileum: 8-9 waves/min |
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What is the histology of the esophagus?
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Nonkeratinized stratified squamous epithelium
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What is the histology of the stomach?
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Gastric glands
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What is the histology of the duodenum?
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Villi and microvilli increase absorptive surface. Brunner's glands (submucosa) and crypts of Lieberkuhn
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What is the histology of the jejunum?
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Plicae circulares and crypts of Lieberkuhn
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What is the histology of the Ileum?
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Peyer's patches (lamina propria, submucosa), plicae circulares (proximal ileum), and crypts of Lieberkuhn.
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Where is the largest number of goblet cells in the GI tract?
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Small intestine
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What is the histology of the colon?
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Crypts but no villi. Numerous goblet cells
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What direction do aortic arteries supplying the GI structures branch?
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Anteriorly
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What direction do aortic arteries supplying the non-GI structures branch?
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Laterally
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Whas is SMA (superior mesenteric artery) syndrome?
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Transverse portion (3rd segment) of the duodenum is entrapped between the SMA and aorta, causing intestinal obstruction
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At what level do the celiac trunk, SMA, L renal artery, inferior mesenteric artery, and bifurcation of the abdominal aorta branch off?
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Celiac trunk T12
SMA L1 L renal artery L1 Inferior mesenteric L3 Bifurcation L4 |
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What artery supplies the foregut? What is its parasympathetic innervation and at what vertebral level does it sit?
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Celiac artery
vagus nerve T12/L1 |
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What artery supplies the midgut? What is its parasympathetic innervation and at what vertebral level does it sit?
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SMA
vagus nerve L1 |
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What artery supplies the hindgut? What is its parasympathetic innervation and at what vertebral level does it sit?
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IMA
pelvic nerve L3 |
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What structures are contained in the foregut?
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Stomach to proximal duodenum, liver, GB, pancreas, spleen (mesoderm)
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What structures are contained in the midgut?
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Distal duodenum to proximal 2/3 of transverse colon
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What structures are contained in the hindgut?
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Distal 1/3 of transverse colon to upper portion of rectum
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What is the watershed area of the hindgut?
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Splenic flexure
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What are the branches of the celiac trunk?
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common hepatic
splenic L gastric (these are the main blood supply of the stomach) |
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Do the short gastrics have good anastomoses if the spleic artery is blocked?
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Nonkeratinized stratified squamous epithelium
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Where are there strong anastamoses in the stomach blood supply?
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L and R gastroepiploics, L and R gastrics
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What are the 4 collateral circulations in the GI blood supply if the the branches off the abdominal aorta are blocked?
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1. Superior epigastric (internal thoracic/mammary) <-> inferior epigastric (external iliac)
2. Superior pancreaticoduodenal (celiac trunk) <-> inferior pancreaticoduodenal (SMA) 3. Middle colic (SMA) <-> L colic (IMA) 4. Superior rectal (IMA) <-> middle and inferior rectal (internal iliac) |
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What is the clinical sign of portosystemic anastamosis at the esophagus and what is the portal <-> systemic anastamosis?
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Esophageal varices. Left gastric <-> esophageal
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What is the clinical sign of portosystemic anastamosis at the umbilicus and what is the portal <-> systemic anastamosis?
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Caput medusae. Paraumbilical <-> superficial and inferior epigastric below the umbilicus, adn superior epigastric and lateral thoracic above the umbilicus.
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What is the clinical sign of portosystemic anastamosis at the rectum and what is the portal <-> systemic anastamosis?
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Internal hemorrhoids. Superior rectal <-> middle and inferior rectal
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What varices are often seen in pts with portal hypertension?
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gut (esophageal), butt (hemorrhoids), caput (medusae)
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How can you treat portal-systemic antastamoses in patients with portal hypertension?
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TIPS (transjugular intrahepatic portosystemic shunt) between the portal vein and hepatic vein percutaneously relieves portal hypertension by shunting blood to the systemic circulation
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What is the pectinate (dentate) line?
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Formed where the endoderm (hindgut) meets the ectoderm
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What is the pathology above the pectinate line?
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Internal hemorrhoids, adenocarcinoma
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What is the arterial blood supply to above the pectinate line?
|
Superior rectal artery (branch of IMA)
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What is the venous drainage for above the pectinate line?
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To the superior rectal vein -> inferior mesenteric vein -> portal system
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Compare internal and external hemorrhoids
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Internal are above the pectinate line; external are below. Internal receives visceral innervation and are NOT painful. External receives somatic innervation (inferior branch of pudendal nerve) and ARE painful
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Where does lymph drain to from above and below the pectinate line?
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Above: deep nodes. Below: superficial inguinal nodes
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What is the pathology below the pectinate line?
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External hemorrhoids, squamous cell carcinoma
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What is the arterial blood supply to below the pectinate line?
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Inferior rectal artery (branch of internal pudendal artery)
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What is the venous drainage from below the pectinate line?
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Inferior rectal vein -> internal pudendal vein -> internal iliac vein -> IVC
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What does the apical surface of hepatocytes face?
|
Bile canaliculi
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What does the basolateral surface of hepatocytes face?
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Sinusoids
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What are the 3 zones of the liver?
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Zone I: periportal zone. Zone II: intermediate zone. Zone III: Pericentral vein (centrilobular) zone
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Which zone of the liver is first affected by viral hepatitis?
|
Zone I
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Which zone of the liver is first affected by ischemia?
|
Zone III
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Which zone of the liver contains the P-450 system?
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Zone III
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Which zone of the liver is most sensitive to toxic injury?
|
Zone III
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Which zone is the site of alcoholic hepatitis?
|
Zone III
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What can happen when gallstones reach the common channel at the ampulla of Vater?
|
They can block both the bile and pancreatic ducts
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What can happen when tumors arise at the head of the pancreas (near the duodenum)?
|
They can cause obstruction of the common bile duct
|
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What is the organization of the vessel/structures in the femoral region?
|
Lateral to medial: Nerve-Artery-Vein-Empty space-Lymphatics (you go from lateral to medial to find your NAVEL)
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What is contained in the femoral triangle?
|
Femoral vein, artery, and nerve
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What is the femoral sheath and what does it contain?
|
Fascial tube 3-4cm below the inguinal ligament. Contains the femoral vein, artery, and canal (deep inguinal LN) but NOT the femoral nerve
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What is a hernia?
|
Protrusion of peritoneum through an opening, usually at a site of weakness
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What is a diaphragmatic hernia?
|
Abdominal structures enter the thorax
|
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How can diaphragmatic hernias happen in infants?
|
As a result of defective development of pleuroperitoneal membrane
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What type of diaphragmatic hernia is most common?
|
Hiatal hernia (stomach herniates upward through the esophageal hiatus of the diaphragm. Of these, sliding hiatal hernia is more common than paraesophagel hernias.
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What is the difference between sliding and paraesophageal hiatal hernias?
|
Sliding: GE junction is displaced upwards, leading to "hourglass stomach".
Paraesophageal: GE junction is normal and the fundus protrudes into the thorax |
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What is an indirect inguinal hernia?
|
Goes through the INternal (deep) inguinal ring, external (superficial) inguinal ring, and INto the scrotum. It follows the path of the descent of the testes and is covered by all 3 layeres of spermatic fascia
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Where does an indirect hernia enter the internal inguinal ring?
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Lateral to the inferior epigastric artery
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How does an indirect hernia occur in infants?
|
Failure of processus vaginalis to close (can form hydrocele)
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What sex is indirect inguinal hernias more common?
|
Males
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What is a direct inguinal hernia?
|
Protrudes through the inguinal (Hesselbach's) triangle. Goes through the external (superficial) inguinal ring only. It is covered by external spermatic fascia
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Where do direct hernias bulge through the abdominal wall?
|
Medial to the inferior epigastric artery.
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Who do direct hernais most commonly occur in?
|
Older men
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What is a femoral hernia?
|
Protrudes below inguinal ligament through femoral canal below and lateral to pubic tubercle.
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What is the leading cause of bowel incarceration?
|
Femoral hernia
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Who are femoral hernias more common in?
|
Females
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What are the borders that make up Hesselbach's triangle?
|
Inferior epigastric vessels, lateral border of rectus abdominis, and inguinal ligament
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