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290 Cards in this Set

  • Front
  • Back
Stomach contents are emptied in a ________ fashion for optimum digestion and absorption
Pulsatile
(Stomach emptying)
Which macronutrient slows digestion/emptying?
Fat (digestion speed)
The four components of bile are:
Bilirubin, Bile salts, Water, Lipid
(Alternatively: Electrolytes, bilirubin, cholesterol, bile salts)
Contraction of gallbladder is controlled by which hormone?
Cholecystokinin (Physiological action)
Pancreatic enzyme efficacy is increased in the small intestine via which mechanism?
Bicarbonate is released from the pancreas, raising intestinal pH and neutralizing chyme
Explain the first step in protein digestion once in the stomach.
Chief cells secrete pepsinogen, which is converted into pepsin by hydrogen ions. Pepsin digests about 20% of peptide bonds.
The effects of pepsin can be eliminated in vomiting patients by which class of drugs? Why is this clinically important?
Proton Pump Inhibitors. Insufficient hydrogen ions prevents the conversion of pepsinogen to pepsin. Pepsin digests blood clots, preventing proper coagulation.
What is the "orchestra leader" of pancreatic enzymes for protein digestion?
Trypsinogen. It is activated to Trypsin by enzymes found in the small intestine (enteropeptidase)
The final step of protein digestion is carried out by which class of enzyme?
Aminopeptidase
Absorption of amino acids is linked to which electrolyte?
Sodium
What are the three main biological functions of fats? (as mentioned in the digestion and absorption lecture)
Energy storage, Cell walls, Signalling molecules (hormones)
Low amounts of bile salts can cause jaundice via which mechanism?
Buildup of cholesterol can cause gallstones, which can get lodged in the common bile duct, preventing bilirubin drainage.
Bile salts are notable for which chemical property?
Amphoteric; Both polar and non-polar ends.
What is the first step of lipid digestion?
Emulsification by bile salts, allowing for fat droplets to become soluble
What is the second step in fat digestion? Which enzyme is crucial to this step?
Micelle formation: Lipase from the pancreas chews up the triglyceride, converts it to monoglycerides and fatty acids. Bile salts then form an "oreo" structure, with lipids in the middle. Fats stay in this state until they can diffuse across the mucosa
Once across the intestinal wall, fats are packaged into chylomicrons by which class of proteins?
Apolipoproteins
Once through the intestinal wall, chylomicrons are transported by which type of vessel?
Lacteals, which travel to a local lymph node to be distributed into the bloodstream
Salivary amylase converts starch into which type of sugar?
Maltose, and short chains of glucose
Lactose is broken down into which two monosaccharides?
Glucose + Galactose
Sucrose is broken down into which two monosaccharides?
Glucose + Fructose
Maltose is broken down into which two monosaccharides?
Glucose + Glucose
Approximately how much water passes through the ilium in a day? Through the ligament of treitz?
Ilium: 1L; Ligament of treitz: 9L
Water absorption is associated with movement of which electrolyte? What pump is responsible for the gradient?
Sodium. Sodium(2)/Potassium(1) ATPase pump
Dysfunctional chloride channels are present in which disease?
Cystic fibrosis
Name 6 common pathologies of the small intestine.
Inflammation, Ulceration, Fibrosis/stricture, Masses, Vascular lesion (angiodysplasia), Reduced surface area
Name three symptoms related to small intestine malabsorption
Weight loss, Muscle loss, Vitamin/Mineral deficiency
Inflammation and Ulceration of the intestines can lead to which four symptoms?
Mid-abdominal visceral pain, Overt or occult bleeding, Diarrhea, Malabsorption
What is the difference between Colitis diarrhea and small intestine diarrhea?
Small intestine: Non-bloody, not as frequent, gassy, bloated;
Colitis: Bloody, small volume, frequent, urgency
Three symptoms associated with small intestine fibrosis/stricture
Mid-abdominal visceral pain; Diarrhea (from bile salt malabsorption); Malabsorptive symptoms
Two symptoms associated with small intestine masses are:
Mid-abdominal visceral pain; Overt or occult bleeding (Also, nausea/vomiting & weight loss - from GI malignancies lecture)
Vascular lesions of the small intestine are associated with which symptom?
Overt or occult bleeding
Reduced small intestine surface area is associated with which two symptoms?
Diarrhea, Malabsorption
During WWII, Dr. Dicke noticed that dietary restriction was beneficial in some children with which condition?
Celiac disease
The prevalence of celiac disease is approximately what in the Western world?
1% (approximately)
Dermatitis herpetiformis is associated with which GI condition?
Celiac disease
HLA DQ2 & DQ8 are 100% sensitive for which condition?
Celiac disease
The most common antibody test used to diagnose celiac disease is:
Tissue trans-glutaminase Ab (IgA)
The gold standard for diagnosis of celiac disease is what test?
Duodenal biopsy
What is the most common cause of gluten-free diet failure? What are some symptoms which can be alleviated by a gluten-free diet?
Noncompliance. GI symptoms, Iron deficiency anemia, Increased BMI, nonspecific symptoms (eg: fatigue), reduced non-hodgkins lymphoma rate
The three classic presentations of diarrhea are Acute, Persistant, and Chronic. What is the timeframe for each type?
Acute: <14 days
Persistant: 14-42 days
Chronic: >42 days
What is the third most common cause of death in low-income countries?
Acute diarrhea
What are the four broad mechanisms of bacterial-caused acute diarrhea?
Enterotoxin (fluid/electrolyte imbalance & secretion), Neurotoxin (ANS motility), Cytotoxin, Direct invasion
Obstruction, Stricture, Ulcers and GI bleeding are all associated with what class of drugs?
NSAIDs
Decreased prostagland synthesis (by NSAIDs) alters which two mucosal properties?
Permeability & Reduced blood flow
What cell types are associated with the following 4 types of small intestinal tumours, respectively: Adenocarcinoma, Lymphoma, Stromal tumour, Carcinoid
Epithelial, Lymphoma, Mesenchymal, Neuroendocrine
Occlusion of which artery will cause acute intestinal failure?
Superior mesenteric artery
What are four anatomical factors influencing the clinical extent of intestinal failure?
Length of small intestine, jejunum/ileal loss, intact colon, ileocecal valve loss
Which artery off the abdominal aorta gets occluded most frequently, and why?
The SMA comes off the abdominal aorta at a more gradual angle than the IMA or celiac artery, and is thus more likely to be embolized.
How has the prevalence of Crohn's in Canada as compared to Ulcerative Colitis changed in the past few decades?
Crohn's is now much more common than UC, it was reversed 30 years ago.
What two requirements exist for development of IBD? What are three examples of the second requirement? (Theoretically)
Genetic susceptibility & Environmental trigger (Toxic response to luminal contents, enhanced immune response to normal luminal contents, autoimmune response)
Which proinflammatory cytokine is targeted by biologics in IBD?
TNF-alpha
What are five key history factors in diagnosis of IBD?
Abdominal pain, Diarrhea, Weight loss (failure to grow in children), Fever, Family history of IBD
What are four lab test results used in the diagnosis of IBD?
Anemia, Elevated ESR/CRP, Decreased albumin, Fecal leukocytes
Inflammation is limited to which layer in ulcerative colitis? Which structure is always involved in UC?
Mucosa; Rectum
Inflammation in UC extends in a ________ manner.
Continuous
Apple core lesions in suspected ulcerative colitis could be indicative of what?
Cancer
Name four complications of ulcerative colitis.
Bleeding, Toxic dilatation (Megacolon), Perforation, Strictures
What are the three basic patterns of clinical and pathological behaviour of Crohn's disease? (i.e. how do they present?)
Inflammatory (leading to bleeding, malabsorption, anemia), Stenosis (obstructive symptoms), Fistulizing (eg: ilium-sigmoid colon; bowel-cutaneous)
True or false: A stricture in the context of UC is much more worrying than one in the context of Crohn's.
True. Cancer is much more likely if a stricture appears in UC.
What two substances get absorbed in the terminal ilium?
B12, Bile salts (Ilium = "Bottom" of small bowel; "B" for B12 & Bile salts)
Why is bile salt malabsorption clinically important?
Bile salts in the colon act as laxatives. Malabsorption of bile salts may also result in gallstones.
What are five extra-intestinal manifestations of IBD? (Think: Opthalmologist, Dermatologist, Rheumatologist)
Peripheral arthritis; Central (axial) arthritis; Erythema nodosum, Pyoderma gangrenosum, Uveitis
What are two liver problems associated with IBD?
Sclerosing cholangitis (cholistatic liver diesease), Cholangiocarcinoma
What are 6 ways which you can differentiate Crohn's disease from Ulcerative Colitis?
Crohn's: Small bowel involvment, Rectal sparing, Perianal disease, Skip lesions, Fistulas (UC is only mucosal inflammation), Granulomas (diagnostic for Crohn's disease)
What are three disease factors influencing the risk of colon cancer in IBD?
Duration of disease, Extent of disease, Disease severity (not as important)
Colonic dysplasia in the context of IBD: what is the recommended treatment?
Colectomy
When should screening for colorectal cancer in IBD patients begin if they have left-sided colitis? If they have pancolitis?
Left-sided: 15 years after initial symptoms
Pancolitis: 8-10 years
What are the three main goals of treatment of IBD? What are four classes of drugs used in the treatment of IBD?
-Two goals: Induction and maintenance of remission, prevention of complications -5-ASA agents, Steroids, Immunosuppressives, Biologics
Which drug class is helpful in UC, but rarely in Crohn's?
5-Aminosalicylates
Describe the usefulness of steroids in IBD.
Useful for induction of remission, not for maintenance. Many IBD-patient deaths in the past have been associated with chronic steroid use.
True or false: Ulcerative colitis is curable with surgery? When is surgery most likely to be indicated?
- True. However, complications of bowel resection can be significant depending on the extent of removal. Crohn's is not curable by surgery.
- Surgery is most likely indicated in the presence of complications of IBD.
What are three mechanisms of pain in functional bowel diseases?
Gut hypersensitivity, Central sensitization, abnormal neural processing
What are three ways in which stress can affect an irritable bowel?
An irritable gut is hypersensitive; Stress may exacerbate an irritable bowel; Stress upsets the normal bowel rhythm
True or false: Symptomatic IBS patients tend to have increased intestinal gas?
False. Pain and bloating symptoms in IBS tend to occur from a visceral hypersensitivity to distention and gas, rather than an absolute increase in amount of gas.
Does the prevalence of IBS increase or decrease with age?
Decrease - Possibly due to better manangement and coping strategies
Investigation of dyspepsia in someone under 55, what is the first thing to test for? What are some alarm features warranting further investigation?
- H. pylori infection
- Alarm features: bleeding/anemia, weight loss, dysphagia, protracted vomiting
What do we check for in patients over 55 years of age who complain of dyspepsia? How do we check for it?
Stomach cancer via gastroscopy
What is the first goal of treatment of dyspepsia/functional upper GI disorders?
Eliminate acid (via high dose PPI)
How does a motility agent help in dyspepsia?
Increased stomach emptyting prevents acid irritation by stomach contents.
What are the 6 Manning Criteria (1978) for diagnosis of IBS?
Abdominal pain relieved with defecation; Increased stool frequency (w/pain); Increased stool looseness (w/pain); Mucous in stool (not blood); Abdominal bloating; Sensation of incomplete rectal emptying
The Rome III diagnostic criteria for IBS is recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with two or more of what characteristics? (Sorry for the poor wording...)
Improvement with defecation; Onset associated with change in frequency of stool, Onset associated with a change in form (appearance) of stool
What are some red flags/alarm symptoms associated with an alternative diagnosis of IBS? (There are a bunch)
Weight loss; Rectal bleeding; Arthritis or Skin rash (EIM of IBD); Nighttime symptoms; FHx of CRC/IBD/Celiac; Age of onset >50; Abnormal lab or physical exam findings (mass, hepatomegaly)
To avoid false negatives in TTG results in suspect Celiac disease, what other marker should be checked?
IgA. If a patient is IgA deficient and has celiac disease, their TTG levels may appear normal
PEG 3350 powder is effective in treating what GI symptom?
Constipation. PEG 3350 is an effective osmotic laxative.
What should be avoided in IBS patients presenting with constipation and pain, but may be indicated in diarrhea and pain?
Trycyclic antidepressants. TCAs are potent constipators, as well as being useful for pain.
Occult bleeding in the lower GI tract presents most commonly with:
Iron deficiency anemia
If the origin of GI bleeding is unknown, which test do you use to rule out upper GI bleeding?
Gastroscopy to rule out an upper lesion. Alternatively, nasogastric tube for bile aspiration
What are four possible aetiologies of lower GI bleeding?
Anatomic (diverticulosis); Vascular (angiodysplasia); Inflammatory (infectious); Neoplastic (Cancer)
Dilated, tortuous submucosal vessels in the GI tract are a description of what aetiology of bleeding?
Angiodysplasia
The pain associated with hemorrhoid bleeding is due to what?
Thrombosis of the hemorrhoid, not the bleeding itself
Chornic lower GI bleeding will be indicated by _______ (Macro/Normo/Microcytic) anemia, while acute GI bleeding will have a ________ MCV.
Microcytic; Normal
What are four procedures used in the diagnosis of aetiology of lower GI bleeding (Whether having therapeutic potential or not)?
Colonoscopy, Radionucleotide imaging, Angiography; Surgery (rare, used if active exsanguination is occurring)
Colonoscopy can perform therapeutics on which three sources of bleeding?
Diverticular bleeds, Angiodysplasia, Polyps
Neoplastic colon polyps are known as:
Adenomas
Four types of non-neoplastic colon polyps include:
Mucosal polyps, submucosal polyps, inflammatory pseudopolyps, hyperplastic polyps
Presentation of right side colon cancer differs from that of left side in which ways?
Right sided: Often asymptomatic, IDA, Melena
Left sided: Bright red blood per rectum, change in bowel habits
The prevalence of diverticulosis in developed countries is much ________ than that in developing countries.
Higher. 30-40% @ age 65; 65% @ age 85
What is the most common location of diverticulosis in the colon?
Near the Vasa Recta (blood vessels). The mucosal wall is much thinner in these areas.
What is the most common cause of lower GI bleeding?
Diverticulosis
What four mechanisms are involved in the processing of micro and macronutrients in the body?
Which two are regulated by either neural or chemical mechanisms?
Motility, Secretion, Digestion, Excretion. Only motility and secretion are under regulatory control.
What are the three phases of regulation of GI processes? (Named for their sites)
Cephalic, Gastric, Intestinal
The vagus nerve is primarily a _______ nerve of the autonomic nervous system.
Parasympathetic
Digestion is ________ by activation of the sympathetic nervous system.
Inhibited
What are the two sections (plexi) of the enteric nervous system? What are their regulatory functions?
Myenteric plexus: Motility; Submucosal plexus: Secretion (and blood flow)
The two long reflexes related to the GI tract are what?
Swallowing & Vomiting
What is the function of the gastroileal short reflex?
Contractile activity in ilium increases due to food in the stomach
What is the function of the enterogastic short reflex?
Food entering the duodenum sends signals to the stomach to slow the rate of emptying
What is the function of the gastrocolic short reflex?
Food in the stomach signals the colon to empty/contract
Intestinal smooth muscle cells are connected how?
Gap junctions
3 basic contractile patterns in the GI tract are:
Peristalsis (coordinated wave of contractions and relaxations - involves both circular and longitudinal muscles);
Rhythmic segmentation (maximizes exposure to digestive enzymes and absorptive surfaces - involves circular smooth muscle);
Tonic contraction (Region of sustained contraction/pressure - sphincters)
Secondary peristalsis performs which function?
Peristaltic activity after swallowing, helpful in clearing excess or refluxed material from the esophagus ("Housekeeping")
Diffuse esophageal spasm is also know as what?
Tertiary peristalsis
Receptive relaxation (in the stomach) is regulated by which nerve?
Vagus nerve
Retropulsion is triggered by the combination of which two GI events?
Peristalsis & Pyloric closure (resulting in a mechanical wave of gastric peristalsis important for mixing and grinding of stomach contents)
Segmentation contractions in the large intestine are called what?
Haustrations
What is the source, the stimuli for release (3) and the major actions (3) of Gastrin?
Source: Antral 'G' cells
Stimulus: Vagal stimulation (ACh); Gastric distention; Digested protein
Major actions: Increased gastric acid secretion; Increased gastric motility; Increased mucosal growth
What is the source, the stimuli for release (2) and the major actions (4) of Cholecystokinin?
Source: 'I' cells in duodenum and ilium
Stimulus: Digested fat & protein
Major actions: Increased pancreatic enzyme secretion; increased gallbladder contraction; decreased tone at the sphincter of Oddi; Decreased gastric emptying
What is the source, the stimulus for release (1) and the major actions (2) of Secretin?
Source: Duodenal 'S' cells
Stimulus: Acid (pH < 4.5)
Major actions: Increased pancreatic and biliary bicarbonate secretion; decreased gastric acid secretion
What is the source, the stimulus for release (1) and the major action (1) of Motilin?
Source: Endocrine cells in duodenum & jejunum
Stimulus: Neural stimulation
Major actions: Increased smooth muscle contraction
What is the source, the stimulus for release (2) and the major actions (~1) of Histamine?
Source: Gastric mast cells
Stimulus: Vagal stimulation; Gastrin
Major actions: Stimulates and potentiates release of gastric acid
What is the source, the stimuli for release (2) and the major actions (2) of Somatostatin?
Source: 'D' cells from the stomach to the ilium
Stimulus: Acid (pH < 3); Digested fat
Major actions: Decreased gastrin release; Decreased gastric acid release
Parietal cell H+ production is potentiated when which three receptors are occupied? Which paracrine hormone has an inhibitory effect on acid production?
- Gastrin, Histamine (H2), Acetylcholine
- Inhibited by somatostatin
Is the majority of the pancreas intra- or retroperitoneal?
Retroperitoneal. The pancreas lies behind the stomach. However, the tip of the tail lies in the peritoneal cavity.
What are the five anatomical divisions of the pancreas?
Tail, Body, Neck, Head, Uncinate
Through where does the main pancreatic duct (Wirsung) drain?
Major duodenal papilla
What is the functional unit of the exocrine pancreas?
Acinus
What are zymogens?
Prepackaged, inactive precursors to (pancreatic) enzymes
Where is colipase located?
On the brush border of the duodenum. It prevents the inhibitory effects of bile salts on lipase.
Which of the three main active pancreatic enzymes is NOT typically measured in a lab to determine pancreatic insufficiency?
Protease. Lipase and amylase are both readily measurable.
A defect in the fusing of the dorsal and ventral anlages is termed what?
Pancreas divisum. Pancreatic secretions are forced to drain through the smaller, minor papilla.
What is the most common method of diagnosis of ectopic pancreatic tissue?
Autopsy [Trick question ;)]
Explain the pathophysiology of acute pancreatitis.
Acinar cells burst due to injury, releasing zymogens, which activate due to trypsin, and the active enzymes begin to digest the pancreas (lipase: digest pancreas fat; proteases: inflammation around the vessels)
In patients with acute pancreatitis, which position is typically more comfortable, supine or fetal?
Fetal position/sitting forward.
True or false: patients with acute pancreatitis typically present with high-grade fever?
False. Fever arises from the inflammation itself, and if present is only low-grade (< 38 C)
What is Grey-Turner's sign? What is Cullen's sign?
- Grey-Turner's: Flank bruising (due to retroperitoneal hemorrhage)
- Cullen's: Peri-umbilical bruising (due to peritoneal hemorrhage, inflamed tip of pancreatic tail)
What are the two most common causes of acute pancreatitis, making up about 75% of cases?
Alcohol (toxic) & Common bile duct stones (obstructive)
What are the differentiators for mild and severe acute pancreatitis?
- Mild: No complications of pancreatitis; short hospital stay (<7 days)
- Severe: Pancreatic necrosis & associated complications; prolonged hospital stay
Aside from removing the offending agent and managing pain symptoms in acute pancreatitis, what is the first therapeutic intervention to be done?
Volume resuscitation with iv fluid
What are five complications of acute pancreatitis?
Pseudocyst formation; Pancreatic ascites; GI bleeding; Pancreatic insufficiency & diabetes; multi-organ failure
What is a pseudocyst lacking?
Pseudocysts do not have epithelial walls
Why is endocrine insufficiency more problematic in chronic pancreatitis than in regular diabetes?
Endocrine insufficiency related to chronic pancreatitis occurs when less than 10% of the pancreas is viable. Not only is insulin affected, as in diabetes, but glucagon is also affected, causing dramatic highs and lows. This is also known as "brittle diabetes".
Why does steatorrhea occur with chronic pancreatitis?
Exocrine pancreatic insufficiency causes a decrease in available lipase, which is required for digestion (and thus absorption) of fat. The excess fat is therefore excreted in the stool.
What is the most common cause of chronic pancreatitis?
Chronic alcohol consumption. Alcohol can cause chronic toxicity to pancreatic tissue.
True or false: Amylase and lipase are useful in diagnosis of chronic pancreatitis.
False. These are not reliable measures in CP.
What is the "best test" for diagnosis of chronic pancreatitis (which is rarely performed in the Maritimes)?
Secretin direct test. Secretin stimulates the pancreas to release bicarbonate and enzymes into the duodenum.
What is the usefulness of plain X-ray in imaging the pancreas? What is the gold standard for imaging of structural changes of the pancreatic duct?
- X-ray can show pancreatic calcifications
- Gold standard for imaging: ERCP
What is the most common type of pancreatic cancer?
Adenocarcinoma (85% of all pancreatic cancers)
What is the eponymous title for the left supraclavicular lymph node, occasionally enlarged in pancreatic cancer?
Virchow's node
CA 19-9 is a useful marker for which type of GI cancer?
Pancreatic cancer
Which of the following is NOT a risk factor for pancreatic cancer?
Hypertension, Smoking, Alcohol consumption, Chronic pancreatitis, Family history
Hypertension is not a named risk factor for pancreatic cancer.
Zollinger-Ellison syndrome is a tumour which secretes which hormone?
Gastrin
What is the name of a tumour which is secreting insulin? What is a typical patient presentation?
Insulinoma. Typical presentation is hypoglycemic symptoms.
What are the chances of malignancy for the following tumours? (>90%, <10%, 50%, one each) Zollinger-Ellison Syndrome; Insulinoma; Glucagonoma.
Z-E: 50%
Insulinoma: <10%
Glucagonoma: >90%
What three large blood vessels drain into the portal vein?
Superior mesenteric vein, Inferior mesenteric vein, Splenic vein
Is the portal vein or hepatic artery more important in supplying blood to the liver?
The portal vein supplies 80% of the blood supply to the liver
Hepatic lobules drain into what type of blood vessel?
Central vein
What property of the liver endothelium allows plasma to go between the space between the endothelial cell and the liver?
Fenestration (holes)
Kupffer cells act as what type of cell?
Macrophage (in liver)
What are four common causes of liver injury?
Ischemic, Toxic, Inflammatory, Infectious (or a combination thereof)
Hepatocytes in which zone are most protected from ischemia?
Zone 1 (most 'distal', as oxygen concentrations are typically higher in this zone). Zone 3 (centro-lobular) hepatocytes are most affected by hypoxia.
Which hepatocyte zone is most likely to be susceptible to active toxic injury? What toxin characteristics define where the injury occurs?
- Zone 1, as toxins tend to be concentrated closest to the portal circulation.
- If a metabolite is toxic, then Zone 2 and 3 are more at risk for toxic injury.
Cholestasis is a form of what type of injury to hepatocytes?
Toxic injury (backflow of bile can lead to hepatocyte necrosis)
Diffuse autoimmune inflammation of the liver tends to affect which hepatocyte zone first? How does this change in focal inflammation?
- Diffuse: Zone 1
- In focal inflammation, the inflammation can be anywhere
Hepatitis C is considered a _______ virus, due to its direct infectious effects on the hepatocytes, while inflammation associated with Hepatitis B is due to the body's _______________.
C: Cytotoxic
B: Immune response
What are the two main categories of testing the liver clinically?
Liver function & Liver injury
What are the three most common liver function tests?
INR (clotting factors synthesized in the liver), Albumin, Bilirubin, (Glucose)
Why is past history of jaundice or hepatitis important in asking about liver disease?
It may be indicative of chronic liver disease
On a liver biopsy, what is the hallmark of chronic liver disease?
Fibrosis
Stellate cells in the liver recognize what property of inflamed cells?
Shaved off villi from hepatocytes. Stellate cells are responsible for closing the fenestrated gap.
Approximately how much of your liver is for reserve purposes? (10%; 25%; 50%; 75%)
75% of your liver is reserve, only 25% of the liver needs to be present for normal functioning.
Normal liver function in the presence of cirrhosis is called what?
Compensated cirrhosis
Liver function abnormalities and hepatic encephalopathy is indicative of what?
Fulminant Hepatic Failure
Fulminant Hepatic Failure is defined as encephalopathy within __ weeks of the onset of symptoms, and within 2 weeks of the onset of _________.
8 weeks of the onset of symptoms; 2 weeks of the onset of jaundice
Why does hepatic encephalopathy occur?
Accumulation in the bloodstream of toxic substances that are normally removed by the liver.
Portal hypertension, Ascites and Renal failure can be a sign of what? (Besides cirrhosis)
Subacute fulminant hepatic failure
What is the first step in decompensation of cirrhosis?
Architectural distortion of the liver (fewer hepatocytes in contact with portal blood; smaller hepatocellular mass due to fibrosis)
How does portal hypertension occur in cirrhosis?
Higher resistance to portal blood flow due to fibrosis, etc.
(According to the liver disease lecture), How many people in 1000 have a BMI > 25? (200, 400, 600, 750).
How about a BMI > 30? (160, 230, 330, 400)
> 25: 600/1000 people are classified as being at least overweight
> 30: 230/1000 people are classified as being obese
In Canada, which strain of hepatitis virus is most prevalent?
Hepatitis C Virus is the most prevalent in Canada (at about 50/100,000)
What type of Vaccine is the Hepatitis B Vaccine?
Hepatitis B surface antigen (protein coat)
Wilson's disease has a classic presentation of Kayser-Fleischer rings. Where are these located?
In the eye. (edge of the iris)
Hemochromatosis occurs from an accumulation of what in the liver?
Iron
What two immune conditions cause cholistatic liver disease?
Primary biliary cirrhosis; Primary sclerosing cholangitis
What are the two main types of esophageal cancer?
Squamous cell cancer & Adenocarcinoma
Are overall rates of esophageal Squamous Cell Cancer increasing, staying the same, or declining in the Western world?
Declining. The highest rates of SCC are found in Asia, Africa & Iran
Betel nut chewing is associated with higher rates of which malignancy?
Squamous Cell Cancer (Esophageal)
Where is the most common location of esophageal SCC?
It is usually located in the midportion, and sometimes the proximal esophagus. Distal esophageal tumours tend to be adenocarcinomas.
Esophageal Squamous Cell Carcinoma invades what structures earlier than most other tumours?
Local lymph nodes (due to proximity)
Does esophageal adenocarcinoma occur at higher or lower rates (in the Western world) than squamous cell cancer?
Adenocardinomas are more prevalent now. In the 1960's, SCC made up 90% of esophageal tumours.
What is the largest risk factor for esophageal adenocarcinoma?
GERD
Is gastric cancer more common in men or women?
Men
What are the differences between intestinal gastric cancer and diffuse/infiltrative type?
- Intestinal: More common in men; older age groups; more prevalent in high risk areas, linked to environmental factors
- Diffuse/infiltrative: No sex differences, more common in younger age groups, worse prognosis
What is the sequence of events leading to intestinal-type gastric cancer? (Starting from Chronic Gastritis)
Chronic gastritis => Chronic atrophic gastritis => Intestinal metaplasia => Dysplasia => Adenocarcinoma
E-cadherin genetic abnormalities are associated with what type of GI cancer?
Diffuse-type gastric cancer
What are two possible symptoms of a malignancy in the proximal stomach? Distal stomach?
Proximal: Dysphagia, GERD
Distal: Gastric outlet obstruction symptoms (nausea, vomiting, decreased appetite, weight loss)
What are four malignant small intestine tumours? What are three benign SI tumours?
- Malignant: Adenocarcinoma, Carcinoid, Lymphoma, Sarcoma
- Benign: Adenoma, Leiomyoma, Lipoma
What is the most common malignancy affecting the duodenum? What about the ileum?
Duodenum: Adenocarcinoma
Ileum: Carcinoid
Which of the following locations is not one of the three most common places where a small bowel carcinoid tumour will metastasize to? (Liver, Lung, Breast, Bone)
Breast. (Liver, Lung & Bone are the most common locations of SB mets)
What is the condition called which is characterized by a tumour's ability to secrete serotonin and other bioactive products?
Carcinoid syndrome (occurs in ~10% of intestinal tumours, and typically only with hepatic mets)
What are four criteria for diagnosis of Primary GI tract lymphoma? (Mainly to differentiate it from a hematologic lymphoma)
No peripheral or mediastinal lymphadenopathy; Normal WBC; Tumour must be in GI tract; No evidence of liver/spleen involvement
What is the most likely diagnosis for a patient presenting with Heartburn, Dysphagia and Regurgitation?
GERD
What are three extraesophageal manifestations of GERD?
Bronchospasm, Laryngitis, Chronic cough
Barrett's esophagus is characterized by a change in cell type from ___________ epithelium to ___________ epithelium.
Squamous to Columnar
tLESRs are a risk factor for what condition? What does that acronym stand for?
- GERD
- tLESR: Transient lower esophageal sphincter relaxations
What are five lifestyle modifications for treatment of GERD?
- Elevate the head of the bed; Smoking cessation; Avoid eating late at night; Weight loss if overweight; Minimizing foods that lower LES pressure (chocolate, caffeine, mint)
Why is there a high concentration of mitochondria in gastric parietal cells?
The energy requirements for proton pumping is significant, as it has to pump protons from a pH of 7.4 to less than 1.
Parietal cells express receptors for which positive stimulators?
Histamine, Acetylcholine, Gastrin
Carbonic anhydrase stimulates the conversion of which two molecules to form Carbonic acid? What is the carbonic acid broken down into?
- Carbon dioxide & Water
- Carbonic acid is broken down into a hydrogen ion and bicarbonate.
(CO2 + H2O =CA=> H2CO3 => H+ + HCO3-)
Which ion is exchanged for hydrogen in the proton pump?
K+.
A protonized PPI (PPI+) will form a covalent bond with which amino acid to block the proton pump?
Cysteine
Why do PPIs not completely block acid secretion?
PPIs neutralize active proton pumps. However, these pumps are continuously being synthesized, and thus will regenerate in number over time.
What are four complications of GERD?
Peptic stricture; Esophageal ulceration; GI bleeding; Barrett's Esophagus/Adenocarcinoma
A 48 year old female with a 10-year history of burning in the back of her throat, acid regurgitation, which is worse when she bends over or lies down. She has no weight loss, fever, sense of food sticking or signs of GI bleeding.

-What is the most likely diagnosis? (Cancer, reflux, ulcer disease, heart attack)
-What is she at risk for given the longevity of her symptoms? How would you check?
-How would you treat her?
- Reflux
- Barrett's esophagus, check with endoscopy
- Lifestyle modifications => H2 blocker or PPI
95% of peptic ulcers are caused by which two aetiologies? Bonus: What are two other less common causes?
- Medications (NSAIDs) or Infections (H. Pylori)
- Less common: Smoking & Hypersecretory states (Zollinger-Ellison)
Which of the following is not a characteristic of NSAID-induced alterations in the gastric mucosal barrier? (Decreased mucus production; Decreased submucosal blood flow; Decreased cell turnover; Increased prostaglandin production)
NSAIDs decrease prostaglandin production, causing increased gastric acid secretion and decreased bicarbonate secretion.
H. Pylori grows best in the presence of which gas?
Carbon dioxide. (Considered "microaerophilic" - will grow in O2, but only in reduced amounts as compared to the natural environment)
Urease production is characteristic of which common GI bug?
H. Pylori (Urease catalyses the hydrolysis of urea to ammonia and carbon dioxide)
Why can increased heartburn occur after eradication of an H. Pylori infection in the body of the stomach?
H. Pylori suppresses HCl production, which stimulates production of gastrin to compensate. Elimination of H. Pylori normalizes HCl production, but gastrin is still being produced in high amounts, leading to a surge of acidity.
90% of duodenal ulcers occur as a result of which condition?
H. Pylori infection
Treatment of bleeding ulcers may involve injection of what compound (aside from saline)?
Epinephrine (constricts peripheral blood vessels and fluid volume has a tamponade stabilizing effect)
During development, a shortened esophagus can lead to what condition? (i.e. pulling up on the stomach)
Hiatal hernia
What is the proper developmental sequence of the following events: (Gastric motility, Mature migrating motor complex, Mouthing, Non-nutritive sucking, Nutritive sucking, Swallowing observed)
Swallowing observed; Mouthing; Gastric motility; Non-nutritive sucking; Mature MMC; Nutritive sucking
Is swallowing in a newborn a voluntary or involuntary behaviour?
Involuntary.
What are three pre-ejection phase symptoms of vomiting with retching?
Pallor, nausea, tachycardia
Pyloric stenosis can cause which type of vomiting in babies?
Projectile vomiting
Intestinal obstruction (past the ligament of treitz) can cause which type of vomiting?
Bilious vomiting
What is the most common cause of effortless vomiting in babies?
Gastro-esophageal reflux
What is the most common symptom of infectious esophagitis?
Odynophagia
Difficulty initiating swallowing is what type of dysphagia?
Oropharyngeal
What are the two subdivisions of esophageal dysphagia?
Mechanical (physical obstruction) & Motility (problem with muscular contraction)
What is the typical dysphagic profile of someone with a Schatzki's ring?
Intermittent dysphagia to solids
Erosive esophagitis with a history of progressive dysphagia and heartburn, but no weight loss is likely what?
Peptic stricture
The upper part of the esophagus is primarily ________ muscle, while the lower part is __________ muscle.
Upper: striated; Lower: smooth
What is the pathophysiology of scleroderma, and how does it affect the esophagus?
Deterioration of smooth muscle. This affects the lower esophageal sphincter by keeping it wide open, causing secondary peptic strictures due to severe GERD.
What is the primary problem in Achalasia (not symptom)?
Lack of relaxation in the lower esophageal sphincter.
"Bird's beak" esophagus is common in which condition?
Achalasia
A 22-year old male is admitted to the ER with food impaction in the esophagous. He has a history of intermittent solid food dysphagia. He has also has asthma. What is a likely diagnosis?
Eosinophilic esophagitis
Trachealization of the esophagus is found in what condition?
Eosinophilic esophagitis
A 55-year old diabetic woman complaining of nausea and occasional vomiting, admits to not being able to finish her meals. What is a likely cause?
Gastroparesis (Prolonged emptying of the stomach)
What is the superior border of the abdominal cavity? What is the inferior border?
Superior: diaphragm; Inferior: Pelvic inlet
What are the three main muscles of the abdominal wall?
External oblique, Internal oblique, Transversus abdominus
The transverse colon and small intestine are covered by what structure?
Greater omentum
The lesser omentum lies mainly between which two organs?
Stomach (lesser curvature) and liver (inferior border)
The lesser sac lies deep to which structure?
Lesser omentum
The ascending and descending colon are _________ structures, while the transverse and sigmoid colon are ___________.
A/D: Retroperitoneal; T/S: Intraperitoneal
What are gastric folds are also known as?
Rugae
The fundus of the stomach lies _________ to the body of the stomach.
Superior
Between the jejunum and the ileum, which has more arterial arcades, and which has longer vasa recta?
The jejunum has longer vasa recta; the ileum has more arterial arcades
What are the borders of the foregut, midgut and hindgut?
- Foregut: Terminal esophagus - 1st part of duodenum
- Midgut: 2nd part of duodenum - right 2/3 of Transverse colon
- Hindgut: left 1/3 of Transverse colon - anal canal (upper 2/3rds)
What are the three branches of the abdominal aorta (in order, of course)?
Celiac trunk; Superior mesenteric artery, Inferior mesenteric artery
What are the three main branches of the celiac trunk?
Hepatic artery; Left gastric artery; Splenic artery
What ligament separates the two areas (not lobes) of the liver?
Falciform ligament
What are the four lobes of the liver (Though some would say there are only two lobes)?
Caudate, quadrate, left, right
Which vessels/structures pass through the porta hepatis?
Hepatic artery, portal vein, common bile duct
What structures merge to form the common bile duct?
Left & Right hepatic ducts merge to form the common hepatic ducts. This merges with the cystic duct to form the common bile duct.
Fat, blood vessels and lymphatics are found in what general 'structure' supplying the intestines?
Mesentery
The inferior mesenteric vein drains into the _______ vein, where it joins the ____________ vein to form the portal vein.
Splenic; Superior mesenteric
Portal-systemic anastomosis hypertension in the rectum can cause what? What about in the esophagus?
Rectum: hemorrhoids; Esophagus: esophageal varices
Which division of the autonomic nervous system have cranio-sacral orgins?
Parasympathetic
Lactate dehydrogenase is an important marker for what?
Hemolysis
What are the two types of gallstones primarily composed of?
Cholesterol; Bilirubin (pigment stones)
Which lymph node is typically enlarged in cholecystitis? Where is it located?
Calot's node. In the triangle of Calot, of course.
The periumbilical pain associated with appendicitis is due to innervation by ____________ nerves, while the localized RLQ pain in the later stage is ___________ pain.
Visceral; Somatic
What is rebound tenderness indicative of (i.e. in appendicitis)?
Aggravation of the parietal layer of the peritoneum by stretching or moving (peritonitis) - removal of pressure rather than application is painful
What is Rovsing's sign?
Pressing on the left side of the abdominal cavity and eliciting pain in the RLQ
Faecoliths are problematic in what GI condition (aside from diverticulitis)?
Appendicitis
Perforated appendicitis is most at risk for infection by which bacteria?
E. Coli
Diarrhea can be classified into which two main types? What are their general pathophysiologies?
- Secretory: Increase in active secretion or decrease in absorption (mainly infective, like Cholera toxin)
- Osmotic: Too much water drawn into the bowels (lactose intolerance, maldigestion)
Why does diarrhea occur in cystic fibrosis?
Blockage of proper pancreatic enzyme secretion due to excess chloride production prevents adequate digestion of food, preventing absorption and causing diarrhea.
What test is done to confirm diagnosis of cystic fibrosis?
Sweat chloride test
- Which sugars require cotransport with sodium into the intestinal enterocytes?
- Which transporter carries absorbed sugars out of the enterocyte and into the portal circulation?
- Glucose and Galactose require cotransport to enter the enterocyte.
- Glucose, Galactose and Fructose all make use of the GLUT2 transporter to enter portal circulation
What is the cotransport ion for single amino acids into the enterocyte? What is the ion for di and tripeptides?
Single: Sodium
Di, Tri: Hydrogen
What are the fat soluble vitamins, and what are some of their functions?
A: Required for retinal production in the eye
D: Promotes bone resorption, Aids in maintaining serum calcium levels
E: Nervous system effects (among a bunch of other stuff)
K: Required for clot formation (X,IX,VII,II)

There is more for each, but whatever.
What three enzymes are replaced in pancreatic enzyme replacement therapy? (E.g. Creon)
Lipase, Protease, Amylase
The cystic fibrosis gene is inherited in an ________ _________ fashion.
Autosomal recessive
What general pharmacological principles apply in patients with cirrhosis (how should drug dosaging be adjusted)?
Cirrhosis slows the metabolization of drugs by CYP enzymes, thus drugs metabolized by these enzymes should be reduced. This may need to be altered if the metabolite is hepatotoxic.
What is the pathophysiology of ascites in patients with cirrhosis?
Portal hypertension prevents effective blood flow, causing fluid buildup and excretion/seepage out of the blood vessels, which collects in the abdominal cavity.
What is the pathophysiology of portal hypertension in patients with cirrhosis?
Cirrhosis causes scarring and stricture of the portal venous system, causing reduced flow and increasing pressure
What is the effect on sodium homeostasis in patients with cirrhosis?
Arterial blood pressure drops, so sodium is retained in order to preserve homeostasis. This causes the kidneys to be relatively hypovolemic. (It's a bit more complicated than this, I think...)
What is the pathophysiology of esophageal varices in patients with cirrhosis?
Some blood from the esophagous is drained into the left gastric vein, which drains into the portal vein. Portal hypertension increases backflow, and causes varices in these esophageal veins (Anastomosis of portal-systemic circulation)
What is the pathophysiology of splenomegaly in patients with cirrhosis?
Portal hypertension causes fluid backup into the splenic vein, causing engorgement of the spleen.
Which two liver markers are indicative of hepatocyte integrity? Which are markers for cholestasis? (AlkP, ALT, AST, GGT)
Hepatocyte integrity: ALT/AST
Cholestasis: AlkP/GGT
A test positive for anti-mitochondrial antibodies (AMA), combined with high immunoglobulin levels is indicative of what condition?
Autoimmune primary biliary cirrhosis
Which chronic liver disease is most commonly associated with inflammatory bowel disease?
Primary sclerosing cholangitis
Describe the metabolism of bilirubin (There's no answer for this one, just a youtube link).
http://www.youtube.com/watch?v=JNbca1vxa5c
A mutation in the bilirubin conjugation enzyme is characteristic of what condition?
Gilbert's syndrome
An elevated alkaline phosphate level during puberty is typically indicative of what?
Normal bone growth
What are the five components of the Child-Pugh score?
INR; Bilirubin; Albumin; Encephalopathy; Ascites
What are the three components of the MELD score?
INR; Bilirubin; Creatinine
What are the two measured components of the Maddrey score/Discriminant function
PT; Bilirubin