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195 Cards in this Set
- Front
- Back
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The celiac artery supplies which structures of the GI tract?
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stomach, proximal duodenum, liver, pancreas, gallbladder
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What parts of the GI tract does the Superior Mesenteric a. supply?
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distal duodenum --> 2/3 of transverse colon
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What organs does the Inferior Mesenteric a. supply?
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distal 1/3 of transverse colon --> upper portion of rectum
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What 3 vessels come off of the celiac trunk?
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1) left gastric a.
2) splenic a. 3) common hepatic a. |
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What does the cystic a. branch off from?
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right hepatic a.
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What 2 arteries feed the greater curvature of the stomach?
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left and right gastroepiploic aa.
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Where does the gastroduodenal a. branch off from?
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common hepatic a.
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Esophageal varices involve distension of which veins?
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left gastric v. --> azygous v.
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External hemorrhoids are due to portal HTN backing up into:
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superior rectal v. --> inferior rectal v.
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A caput medusa is sign of portal HTN involving which veins?
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paraumbilical --> inferior epigastric
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What are the 4 layers of the digestive tract?
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1) mucosa
2) submucosa 3) muscularis externa 4) serosa/adventitia |
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Mucosa is composed of:
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1) absorptive epithelium
2) lamina propria 3) muscularis mucosa |
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Submucosa is composed of:
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Meissner's plexus
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Muscularis externa is composed of:
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1) outer longitudinal layer
2) Auerbach's plexus 3) inner circular layer |
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What does Meissner's submucosal plexus do?
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controls secretions, blood flow, absorption
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What does Auerbach's myenteric plexus do?
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gut motility
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What layer of the digestive tract do you find glands?
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submucosa
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What is the purpose of mesentery?
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binds digestive tract to abdominal wall
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Name the layers of the abdomen (above arcuate line) starting with the Skin and ending with the Peritoneum.
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1) skin
2) superficial fascia 3) external oblique 4) internal oblique * anterior rectus sheath made of ext. obl. + int. obl. fascia 5) rectus abdominus * posterior rectus sheath made of int. obl. + transversalis ab. fascia 6) transversus abdominis 7) transversalis fascia 8) extraperitoneal tissue 9) parietal peritoneum |
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What is the role of Brunner's glands?
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They are found in the duodenal submucosa & secrete alkaline mucus to neutralize acid coming from stomach.
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Why would someone have hypertrophied Brunner's glands?
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peptic ulcer disease
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Which class of immunoglobulins deals with intraluminal antigens?
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secretory IgA - M cells of Peyer's patch take up Ag and stimulate B cells, which then differentiate into IgA-producing plasma cells.
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The sinusoids of the liver have ___ endothelium that lets blood come in direct contact with hepatocytes.
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fenestrated - pores 100-200 nm in diameter
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The ___ duct and ___ duct come together at the ampulla of Vater to secrete into the duodenum.
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common bile duct; pancreatic
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The pectinate line is formed where the ___gut meets ___derm.
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hindgut; ectoderm
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Found above pectinate line =
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adenocarcinoma & internal hemorrhoids - painless, visceral innervation
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Found below pectinate line =
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squamous cell carcinoma & external hemorrhoids - PAINFUL! somatic innervation
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Rectum above the pectinate line is supplied by the ___ artery, which is a branch of the ___.
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superior rectal artery; inferior mesenteric artery
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Venous drainage of rectum above pectinate line is from ___ --> ___ --> portal system.
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superior rectal vein --> inferior mesenteric vein
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Rectum below the pectinate line is supplied by the ___ artery, a branch off the ___ artery.
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inferior rectal artery; internal pudendal artery
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Venous drainage of the rectum below pectinate line is from ___ vein --> ___ vein --> ___ vein --> IVC.
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inferior rectal vein --> internal pudendal vein --> internal iliac vein
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What is in the femoral TRIANGLE? (lateral --> medial)
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femoral nerve, artery, vein, lymphatics
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What is in the femoral SHEATH? (lateral --> medial)
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femoral artery, vein, femoral canal containing deep inguinal lymph nodes
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What IS the femoral sheath anyway?
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Tube of fascia extending 3-4 cm below inguinal ligament, holding the femoral artery, vein, inguinal LNs
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What is a femoral hernia?
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Abdominal contents come out through femoral canal, below & lateral to pubic tubercle
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Name the layers of the spermatic cord:
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1) external spermatic fascia
2) cremaster muscle & fascia 3) internal spermatic fascia |
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An indirect hernia passes through which inguinal structures?
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internal inguinal ring and external inguinal ring, into the scrotum
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A direct hernia protrudes from:
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Hesselbach's triangle through the external inguinal ring only (recall: Hesselbach's triangle is made up of inferior epigastric artery, lateral border of rectus abdominis, inguinal ligament)
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What are the 4 salivary glands?
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- parotid
- submandibular - submaxillary - sublingual (has the most mucus secreting cells) |
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What 3 components of saliva and their functions?
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1) a-amylase/ptyalin: begin starch digestion
2) bicarbonate: neutralizes oral bacterial acids for dental health 3) mucins/glycoproteins: lubricate food |
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Salivary secretion is stimulated by:
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- sympathetics (T1-T3)
- parasympathetics (CN VII, IX) |
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Intrinsic factor:
source action |
parietal cells of stomach
bind B12 for uptake in ileum |
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What enhances secretion of gastric acid by the parietal cells?
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- gastrin
- ACh - histamine |
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What decreases gastric acid secretion by the parietal cells?
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- somatostatin
- prostaglandins - GIP - secretin |
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What does pepsin do, and how is it activated?
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Pepsin is secreted by chief cells of stomach and digests proteins. Its zymogen pepsinogen is cleaved by acid. Its release is stimulated by vagus nerve and local acid.
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How does the stomach protect itself from autodigestion?
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HCO3- secretion by mucosal cells of stomach and duodenum. Enhanced secretion by secretin.
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Gastrin is released by the ___ cells of the stomach.
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G cells
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What GI hormone is secreted in Zollinger-Ellison syndrome (pancreatic tumor)?
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gastrin!!
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What is the action of gastrin?
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- inc. gastric acid secretion
- inc. growth of gastric mucosa - inc. gastric motility |
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What stimulates gastrin release?
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- stomach distention
- AA and peptides (esp. F & W) - vagus |
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What inhibits gastrin release?
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- pH < 1.5 (too much acid)
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Which cells secrete cholecystokinin?
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I cells of duodenum & jejunum
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What does cholecystokinin do?
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- inc. pancreas secretion
- gallbladder contraction - growth of exocrine pancreas & gallbladder - dec. gastric emptying |
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What decreases secretion of CCK?
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- secretin
- pH < 1.5 |
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What increases secretion of CCK?
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fatty acids & AA
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What does secretin do?
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- inc. pancreatic HCO3
- dec. gastric acid secretion |
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Which cells make secretin?
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S cells of duodenum
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What enhances secretin release?
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- acid
- FA in duodenum |
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What is the importance of HCO3 in the duodenum?
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HCO3 neutralizes gastric acid so that pancreatic enzymes have proper pH environment to function.
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What does somatostatin do?
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- dec. gastric acid & pepsinogen secretion
- dec. pancreas & SI fluids - dec. gallbladder contraction - dec. insulin & glucagon *basically, it is the ANTIgrowth hormone!! |
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Which cells make somatostatin?
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D cells of pancreas; GI mucosa
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What is the role of Gastric Inhibitory Peptide?
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- dec. gastric acid
- inc. insulin |
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Which cells make GIP?
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K cells of duodenum & jejunum
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Which hormone is stimulated by FA & AA & glucose?
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GIP
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Where is EtOH absorbed in the GI tract?
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stomach
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Where are water-soluble vitamins absorbed in the GI tract?
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terminal jejunum
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Where are proteins and AA's absorbed in the GI tract?
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proximal jejunum
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Where is iron absorbed in the GI tract?
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duodenum
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Where is calcium absorbed in the GI tract?
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duodenum
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Where is vitamin B12 and bile absorbed in the GI tract?
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ileum
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What is absorbed in the colon?
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- water
- K+ - NaCl - short chain FAs |
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What does the pancreas synthesize to digest starches?
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a-amylase ~ hydrolyzes starch to oligo- and disaccharides
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What does the pancreas make to breakdown fat?
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lipase, colipase, phospholipase A
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What are the proteases that the pancreas makes?
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trypsin, chymotrypsin, elastase, carboxypeptidase (recall: trypsinogen is cleaved first by enterokinase, a brush border enzyme, then cleaves other proenzymes)
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Pancreatic insufficiency is manifested by:
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- steatorrhea
- deficiency in fat soluble vitamins (KADE) - malabsorption |
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Which bonds do salivary amylase break?
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a-1,4 linkages --> disaccharides (maltose, maltotriose, a-limit dextrans)
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Which enzymes break oligo- and disaccharides into monosaccharides?
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Oligosaccharide hydrolases @ brush border of intestine (rate limiting step in carb digestion!)
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In the liver, all blood flows toward the:
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central vein (bile flows AWAY from this direction)
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Direct bilirubin =
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bilirubin conjugated with gluronic acid
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Indirect bilirubin =
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bilirubin complexed with albumin floating around in blood (taken up by liver to be conjugated)
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What is bile made of?
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- bile salts
- bilirubin - cholesterol - phospholipids - water - ions |
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A diaphragmatic hernia is usually due to ___ protruding upward through the ___ hiatus of the diaphragm. (bonus question: at what vertebral level is this hiatus?)
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stomach; esophageal hiatus (T10, along with the 2 vagus nerves)
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A herniation that is medial to the inferior epigastic vessels is a(n) ___ hernia.
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direct - usually older men get these
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A hernia that is lateral to the inferior epigastric vessels is a(n) ___ hernia.
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indirect - occur mostly in male infants due to failure of processus vaginalis to close
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Achalasia is due to loss of ___ plexus --> ___ fails to relax.
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myenteric/Auerbach's; LES
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People with achalasia are at an increased risk for:
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esophageal CA
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Secondary achalasia can be due to:
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Chaga's disease - Trypanosoma cruzi, Reduviid bug, treat w/nifurtimox
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Meckel's diverticulum is persistence of:
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vitelline duct, or yolk stalk (most common congenital anomaly of GI tract)
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What are possible complications of a Meckel's diverticulum?
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- bleeding
- intussusception - volvulus - obstruction |
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What are the five 2's regarding Meckel's diverticulum?
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1) 2 inches long
2) 2 feet from ileocecal valve 3) 2% of population 4) presents w/in 2 yrs of life 5) may have 2 types epithelium |
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What serum enzyme is an indicator of various liver diseases as well as alcohol use?
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GGT - gamma glutamyl transpeptidase
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ALT > AST indicates:
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viral hepatitis
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AST > ALT indicates:
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alcoholic hepatitis
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If only the AST is elevated, this indicates:
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MI
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Increased levels of which 2 serum enzymes indicate acute pancreatitis?
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- amylase (also indicates mumps!!)
- lipase |
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DECREASED levels ceruloplasmin indicate which disease?
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Wilson's disease
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High Alkaline Phosphatase could mean:
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- obstructive liver disease (HCC)
- bone disease |
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In a patient with longstanding acid reflux, you worry about ___ ___, which may lead to what malignancy?
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Barrett's esophagus; adenocarcinoma
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Histologically, what does Barrett's esophagus look like?
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gastric columnar epithelium replacing esophageal nonkeratinized stratified squamous epithelium; squamocolumnar junction moved upwards
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Name 7 risk factors for esophageal cancer:
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1) alcohol
2) Barrett's esophagus 3) cigarettes 4) diverticuli (Zenker's) 5) esophageal webs (Plummer Vinson) 6) esophagitis (reflux, irritants, infection) 7) familial |
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A worried mother brings in her 1 wk old infant whom she says has been vomiting after breastfeeding. He has a palpable mass in the epigastric region. Upon questioning, the mother says the vomited milk is white in color. What does the baby have?
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Congenital pyloric stenosis - 1/600 live births, hypertrophied pylorus, nonbilious projectile vomiting, treatment is surgery
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Celiac sprue =
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autoantibodies to gliadin/gluten, affects proximal SI only - see blunted villi and hyperplasia of crypts!
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Tropical sprue =
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infectious, can affect entire SI, responds to antibiotics
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Whipple's disease is caused by ___. Macrophages seen in the lamina propria & mesenteric LNs stain with ___.
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Tropheryma whippelii; PAS
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Pancreatic insufficiency is commonly due to:
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cystic fibrosis, chronic pancreatitis
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Acute, erosive gastritis can be caused by:
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- NSAIDs
- stress - alcohol - uricemia - burns (Curling's ulcer) - brain injury (Cushing's ulcer) |
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Type A chronic gastritis =
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autoAbs to parietal cells --> pernicious anemia, achlorhydria
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Type B chronic gastritis =
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caused by H. pylori
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Which peptic ulcer has pain that increases with meals and causes weight loss?
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GASTRIC ulcer - H.pylori, chronic NSAID use, DECREASED mucosal protection against gastric acid
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Which peptic ulcer has pain following meals and causes weight gain?
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DUODENAL ulcer - H.pylori infection!!! INCREASED gastric acid or DECREASED mucosal protection
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Which peptic ulcer disease do you see hypertrophied Brunner's glands?
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duodenal
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The incidence of peptic ulcer disease is twice as high in which population?
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SMOKERS!!!
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What does a duodenal ulcer look like grossly?
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clean, punched out margins
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Etiology of Crohn's disease:
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infectious
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Etiology of Ulcerative colitis:
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autoimmune
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Location of Crohn's disease:
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rectal sparing - usually terminal ileum & colon, can be anywhere
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Location of Ulcerative colitis:
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always involves rectum - only large intestine affected
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Which IBD do you see skip lesions and cobblestone mucosa?
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Crohn's disease
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Which IBD has continuous lesions that always involve the rectum, and pseudopolyps of the mucosa?
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Ulcerative colitis
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Which IBD has transmural inflammation?
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Crohn's
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Which IBD only has inflammation of mucosa & submucosa?
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Ulcerative colitis
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Which IBD is associated with noncaseating granulomas?
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Crohn's disease
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Which IBD is associated with crypts, abscesses, bleeding, and ulcers - but NO granulomas?
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Ulcerative colitis
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Which IBD can lead to colorectal carcinoma?
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Ulcerative colitis!!!
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Which IBD can lead to toxic megacolon?
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Ulcerative colitis!!!
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Which IBD can lead to perianal disease, malabsorption, and strictures?
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Crohn's disease
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Which IBD is associated with migratory polyarthritis, ankylosing spondylitis, uveitis, erythema nodosum, and immunologic disorders?
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Crohn's disease
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Which IBD is associated with primary sclerosing cholangitis and pyoderma gangrenosum?
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Ulcerative colitis
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Stomach adenocarcinomas are associated with:
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- nitrosamines in diet
- achlorhydria - chronic gastritis |
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Virchow's node =
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stomach cancer mets to supraclavicular node
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Krukenberg's tumor =
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bilateral mets to ovaries from stomach - see signet ring cells and abundant mucus
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Linitis plastica =
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diffusely infiltrative stomach cancer, thick rigid appearance - very bad!!!
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Appendicitis starts out with diffuse/localized pain, then progresses to diffuse/localized pain.
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diffuse (periumbilical); localized (McBurney's point)
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What else can often present like appendicitis?
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- diverticulitis (old ppl)
- ectopic pregnancy (use b-hCG to rule out) |
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What is a diverticulum?
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Blind pouch off the GI tract - most often in sigmoid colon (true = all 3 gut layers outpouch, false = only mucosa and submucosa outpouch)
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What is diverticulosis and who often gets it?
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50% of ppl over 60 yrs have diverticulosis. Associated with low-fiber diet. Due to increased intraluminal pressure and focal weakness in colonic wall.
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What is diverticulitis?
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Inflamed diverticuli --> LLQ pain!!! Can perforate, cause bowel stenosis, form abscess.
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Hirschsprung's disease is due to lack of which enteric nervous plexus?
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BOTH myenteric and submucosal - failure of neural crest cell migration
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There is an increased risk of Hirschsprung's disease in which population?
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Down's syndrome
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Is the aganglionic segment of bowel in Hirschsprung's the dilated portion or the constricted portion?
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constricted
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What are risk factors for colorectal cancer, the 3rd most common cancer?
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1) colorectal villous adenomas
2) IBD 3) high fat, low fiber diet 4) older age 5) FAP 6) HNPCC 7) deletion DCC gene (18q) 8) deletion APC gene (5q) 9) family, personal Hx |
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How do you screen for colorectal cancer?
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People > 50 yrs do occult blood stool test, colonoscopy.
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What would a barium swallow show in a person with colorectal cancer?
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"apple core" lesion - rule out Entamoeba histolytica!
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What (nonspecific) tumor marker is elevated in colorectal cancer? (also pancreatic, breast, gastric cancers)
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CEA - carcinoembryonic antigen
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Portal shunting between which 2 veins can help relieve portal HTN?
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splenic vein - left renal vein
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Macronodular liver cirrhosis is usually due to:
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- postinfectious
- drug-induced hepatitis |
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Micronodular liver cirrhosis is usually due to:
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- alcohol
- hemochromatosis - Wilson's disease |
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What are some clinical manifestations of liver cell failure? (from the head down)
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- coma
- scleral icterus! - fetor hepaticus - spider nevi - gynectomastia! - jaundice! - lose pubic hair - asterixis tremor - bleeding tendency - anemia - ankle edema |
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What are some manifestations of portal HTN?
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- hematemesis (esophageal varices)
- melena - splenomegaly - caput medusa - ascites - hemorrhoids |
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Histologically, what would you see in alcoholic hepatitis?
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- swollen necrotic hepatocytes
- neutrophil infiltrate - Mallory bodies (eosinophilic inclusions) - fatty change - sclerosis around central v. |
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In alcoholic hepatitis, AST : ALT is > ___.
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1.5
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What is Plummer-Vinson syndrome?
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- atrophic glossitis
- iron deficiency anemia - esophageal webs - higher risk esophageal squamous cell carcinoma |
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What is Budd-Chiari syndrome?
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Occlusion of IVC or hepatic v. --> congestive liver disease (hepatomegaly, ascites, ab pain, liver failure). Associated with polycythemia vera, pregnancy, HCC, oral contraceptives...
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How is Wilson's disease inherited?
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AR
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What is the problem in Wilson's disease?
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Inadequate copper excretion from Liver --> accumulate in brain, liver, kidneys, cornea, joints
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How does Wilson's disease manifest clinically?
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1) asterixis
2) basal ganglia degeneration 3) low ceruloplasmin 4) Kayser-Fleischer rings 5) cirrhosis & HCC 6) chorea 7) dementia |
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How do you Tx Wilson's disease?
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penicillamine to chelate copper
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Wilson's disease is aka:
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hepatolenticular degeneration
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Hemochromatosis =
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Disease caused by iron (hemosiderin) deposition - can be AR or secondary to chronic blood transfusions
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What is the classic triad of hemochromatosis?
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1) skin pigmentation --> bronze
2) pancreatic fibrosis --> diabetes 3) liver cirrhosis 3) |
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Hemochromatosis results in which cardiovascular problem, and increases one's risk for which malignancy?
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CHF; HCC
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What is the level of body iron that can set off airport metal detectors?
|
50 g
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Hemochromatosis:
ferritin - iron - TIBC - transferrin saturation - |
high ferritin
high iron low TIBC high transferrin saturation |
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How do you Tx hemochromatosis?
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desferoxamine, phlebotomy
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Hepatocellular jaundice:
hyperbilirubinemia - urine bilirubin - urine bilinogen - |
both conjugated & unconjugated
increased normal, or decreased |
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Obstructive jaundice:
hyperbilirubinemia - urine bilirubin - urine bilinogen - |
conjugated
increased decreased |
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Hemolytic jaundice:
hyperbilirubinemia - urine bilirubin - urine bilinogen - |
unconjugated
absent increased |
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What is the defect in Gilbert's syndrome?
|
hyperbilirubinemia due to mildly decreased levels of UDP-glucuronyl transferase - asymptomatic but unconjugated bilirubin is elevated
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What is the defect in Crigler-Najjar syndrome type 1?
|
ABSENT UDP-glucuronyl transferase - patients die w/in a few years, see jaundice, kernicterus, high unconjugated bilirubin, treat w/phototherapy and plasmapheresis (Type 2 milder and can be given phenobarbital)
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What is the problem in Dubin-Johnson syndrome?
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conjugated hyperbilirubinemia due to defective liver excretion - black liver (Rotor's syndrome milder and liver is not black)
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Clinical triad of primary sclerosing cholangitis:
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1) jaundice
2) fever 3) RUQ pain |
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Inflammation & fibrosis of intra- and extrahepatic bile ducts, which look "beaded" on ERCP =
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primary sclerosing cholangitis
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Primary sclerosing cholangitis is associated with which other inflammatory disease?
|
ulcerative colitis!
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What can primary sclerosing cholangitis lead to?
|
secondary biliary cirrhosis
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Your patient has elevated ALP, elevated serum mitochondrial antibodies. He also has steatorrhea, pruritus, and xanthomas. Diagnosis?
|
primary biliary cirrhosis - intrahepatic & autoimmune disorder with severe obstructive jaundice in addition to presenting symptoms
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Extrahepatic biliary obstruction -->
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secondary biliary cirrhosis - increased pressure in intrahepatic ducts leads to fibrosis, often complicated by ascending infection, bile stasis/"lakes"
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HCC is associated with:
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- Hep B & C
- hemochromatosis - Wilson's disease - A1AT deficiency - alcoholic cirrhosis - aflatoxin |
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What tumor marker is elevated in HCC?
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aFP
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How does HCC present?
|
- ascites
- TENDER hepatomegaly - polycythemia - hypoglycemia |
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Reye's syndrome can be caused by:
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- VZV
- influenza G - salicylates (aspirin) |
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Findings in Reye's syndrome:
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- fatty liver
- coma - hypoglycemia |
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What are 3 types of gallstones?
|
1) cholesterol - radiolucent
2) mixed cholesterol & bilirubin - radiolucent 3) bilirubin - radiopaque |
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Cholesterol gallstones are associated with:
|
obesity, Crohn's disease, cystic fibrosis, old age, Clofibrate, estrogen, multiparity, rapid wt. loss, Native Americans
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Bilirubin gallstones are associated with:
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chronic RBC hemolysis (sickle cell), alcoholic cirrhosis, old age, biliary infection (Clonorchis sinesis)
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Mixed gallstones are associated with what risk factors?
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female, middle age, fat, multiparity
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Causes of acute pancreatitis: GET SMASHeD
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gallstones, EtOH, trauma, steroids, mumps!, autoimmune, scorpion, hypercalcemia, sulfa drugs!
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How does acute pancreatitis present?
|
epigastric abdominal pain radiating to back; anorexia, nausea
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Labs for acute pancreatitis:
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elevated amylase & lipase (pancreatic enzymes)
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Acute pancreatitis can lead to:
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1) DIC
2) ARDS 3) diffuse fat necrosis --> hypocalcemia! 4) pseudocyst 5) hemorrhage 6) infection |
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An AIDS patient who is a chronic alcoholic recently started a new medication and died suddenly. What was the new medication he took?
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didanosine (ddI)
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Chronic CALCIFYING pancreatitis is associated with:
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alcoholism
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Chronic OBSTRUCTIVE pancreatitis is associated with:
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gallstones
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Pancreatic adenocarcinoma most often presents with what 4 sxs?
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1) ab pain radiating to back
2) wt. loss & malabsorption 3) migratory thrombophlebitis (Trousseau's sign) 4) obstructive jaundice w/palpable gallbladder (Courvoisier's sign) |
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Which part of the pancreas most often gets adenocarcinoma?
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head --> obstructive jaundice!
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What is the Px for pancreatic adenocarcinoma?
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6 months or less
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