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228 Cards in this Set

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baby vomits milk when fed and has a gastric air bubble; what kind of fistula is present?
blind esophagus w/ lower segment of esophagus attached to trachea
After a stressful life event a 30 y/o man has diarrhea and blood per rectum; intestinal biopsy has transmural inflamm. What is teh diagnosis?
Crohns
A young man presents w/ mental deterioratoin and tremors. He has brown pigmentation in a ring aroudn the periphery of his cornea and altered LFTs. What is the treatment?
Wilson's disease
Rx is Penicillamine
What is teh most common cause of idiopathic hyperbilirubinemia in a 20y/o male?
Gilberts
What provides the blood supply for the foregut?
Celiac artery
stomac to proximal duodenum; liver, gallbladder, pancreas
What provides the circulation for the Midgut?
SMA
Distal duodenum to proximal 2/3 of transverse colon
What provides the circulation for the hindgut?
IMA
distal 1/3 of transverse to the rectum
What are the components of the ciliac trunk?
left gastric artery
splenic- left gastroepiploic
common hepatic
What are the branches off of the common hepatic?
gastroduodenal artery-> right gastroepiploic
Right gastric artery
hepatic artery
What are teh branches off of the hepatic artery?
Left hepatic
Right hepatic-> cystic
What are the portal system anastamoses?
1. L. Gastric vein-> azygous (esophageal varices)
2. Superior-> inferior rectal (hemorrhoids)
3. paraumbilical-> inferior epigastric (caput medusae)
4. Retroperitoneal -> renal
5. Retroperitoneal-> paravertebral
Varices of gut, butt, caput w/ portal HTN.
Breakdown the layers of the gut wall (inside to out)
1. Mucosa
2. submucosa
3. Muscularis externa
4. Serosa/adventitia
What are the layers of the mucosa?
epithelium- absorption
lamina propria- support
muscularis mucosa- mucosal motility
What are the layers of the submucosa?
Submucosal nerve plexus (Meissner's): controlss secretions, blood flow, and absorption.
What are the parts of the Muscularis externa?
outer longitudinal layer
inner circular layer
Myenteric nerve plexus
controls motility
What are the layers of the abdomine from inside to out?
Peritoneum
Exraperitoneal tissue
Transversalis fascia
Transversus abdominis
Internal oblique
external oblique
Superficial fascia
skin
What is the role of the myenteric plexus?
Auerbach's
coordinates motility along the gut wall.
Contains cell bodies of some parasympathetic terminal effector neurons. Located between inner and outer layers (longitudinal and circular) of smooth muscle in GI tract wall.
What is the role of the submucosal enteric plexus?
Meissner's
Regulates local Secretions, blood flow, and absorption
cell bodies of some parasymps terminal effector neurons.
located between mucosa and inner layer of smooth muscle in GI tract wall.
What are brunner's glands?
secrete alkaline mucus to neutralize acid contents entering the duodenum from the stomach. Located at the duodenal submucosa
What is the role of Peyer's Patches?
unencapsulated lymphoid tissue found in lamina propria and submucosa of small intesting. COvereted by cuboidal enterocytes. w/ M cells interspersed. M cells take up antigen. Stimeed B cells leave peyers patch adn travel through lymph and blood to lamina propria of intestine to diff into IgA-secreting plasma cells. IgA receives protective secretory component and is then transported across epithelium to gut to deal with intraluminal antigen.
IgA interaGutAb.
WHat is unique about the sinusoids of the liver?
irregular capillaries w/ fenestrated endothelium. No BM. macromolecules of plasma have full access to basal surface of hepatos through the space of Disse.
What are the billiary structures?
gallbladder
cystic duct
Right and left hepatic duct
common duct
pancreatic duct
duodenum
What is the pectinate line?
where hindgut meets ectoderm

Above
internal hmorrhoids- not painful
adenocarcinoma
Visceral innervation
Superior Rectal Artery from IMA
Venous drainage to superior rectal vein-> inferior mesenteric vein-> portal system

Below-
external hemorrhoids (painful)
Squamous cell carcinoma
Somatic innervation- (Pain w/ hemorrhoids)
Arterial supply from inferior rectal off of internal pudendal
venous drainage to inferior rectal vein-> internal pudendal vein-> internal iliac vein-> IVC
What is inside the femoral triangle?
contains the femoral vein, femoral artery, and femoral nerve
Femoral sheath- fascial tube that extends beyond the inguinal ligament
contains femoral artery, vein and femoral canal (deep inguinal lymph nodes)
Lateral to medial- NAVEL
Nerve
Artery
Vein
Empty
Lymph
What is a femoral hernia
Femoral hernia is entrance of abdominal contents through the femoral canal- below and lateral to pubic tubercle
What are the borders of the femoral triangle?
Inguinal ligament
Sartorius muscle
Adductor longus muscle
What are the layers of the inguinal canal?
Inguinal ligament
external oblique
internal oblique
transversus abdominis
deep inguinal ring
transversalis fascia
parietal peritoneum
What are the layers of the spermatic cord?
Internal spermatic fascia
cremasteric muscle and fascia
external spermatic fascia
spermatic cord
What is teh site of indirect hernia?
through the internal inguinal ring
What is the site of a direct hernia?
Abdominal wall:
site of protrusion of direct hernia
Salivary secretion:
what is the source?
What is the function?
source- parotid, submandibular, submaxillary and sublingual glands
Function
alpha-amylase- begins starch
Bicarb- neutralizes bacterial acids, maintains dental health
Mucisn- lubricate food.

low flow- hypotonic
high flow- isotonic

stimmed by symps and paras.
Intrinsic Factor:
What is the source?
What is the action?
What diseases is it associated w/?
Parietal cells, stomach make it.
Vit b12 binding protein, required for uptake
Autoimmune destruction-> chronic gastritis and pernicious anemia
Gastric acid:
What makes it
What is the action
What regulates its secretion?
parietal cells, stomach
decreases the stomach pH
secretion is increased by histamine, ACh, gastrin
Decreased by somatostatin, GIP, Prostaglandin, secretin
Pepsin:
What makes it?
What is the action?
What regulates the secretion?
How is it activated?
Secreted by Chief cells of stomach
Protein digestion- functions best at low pH
Increased secretion w/ vagal stimulation
Pepsinogen cleaved to pepsin in acidic solution
HCO3:
what makes it?
What's it's function?
what regulates its secretion?
made by mucosal cells of the stomach and duodenum
Neutralizes acid; prevents autodigestion
Increased secretion by secretin.
What are the secretory products of the GI tract?
Gastrin
Gastric Acid
Pepsin
HC03
What are the hormones of the GI tract?
Gastrin
CCK
Secretin
Somatostatin
Gastric inhibitory peptide
Gastrin
Where is it made?
What is it's action?
What regulates it?
what disease is it associated w/?
G cells, antrum o fthe stomach
increases gastric H secreasion, growth of gastric mucosa, increased gastric mobility
increased w/ stomach distention, AAs, Peptides, vagal stim;
decreased by H secretion and stomach acid pH<1.5
increased in ZE; phenylalanine adn tryptophan are stimulators
CCK
Where is it made?
What is it's action?
What regulates it?
what disease is it associated w/?
Made in I cells of duodenum and jejunum
increase pancreatic secreation and gallbladder contraction;
Decreases gastric emptying, incrases growth of exocrine pancreas and gallbladder

Decreasaed by secretin and stomach pH less than 1.5
increased by fattys and AAs.

Cholethiasis- pain worsens w/ fatty food from CCK
Secretin
Where is it made?
What is it's action?
What regulates it?
what is it's role w/ pancreatic enzymes?
Made in S cells of duodenum
Increases pancreatic HCO3 secretion, decreases gastric acid secretion. stims growth of exocrine pancreas and stims bile production.

Increased secretion w/ acid, fatty acids in lumen of duodenum.

increase in HCO3 neutralizes gastric acid in duodenum allowing pancreatic enzyme functionality
Gastric inhibitory peptide- GIP
Where is it made?
What is it's action?
What regulates it?
what is it's role w/ pancreatic enzymes?
Made in the K-cells in the duodenum and jejunum
Decreases gastric H secretion
Increases insulin release

Regged by increased by fattys, AAs, oral glucose

GIP is why an oral glucose load is used more rapidly than the equivalent given by IV
Somatostatin
Where is it made?
What is it's action?
What regulates it?
what is it's role w/ pancreatic enzymes?
Made in D cells
pancreatic islets; GI mucosa
Decreases- gastric acid, pepsinogen; pancreatic and small intestine fluid secretion; gallbladder contraction; insulin and glucagon release

Stimmed by acid, inhibbed by vagal

Inhibitory; antigrowth effects from lack of digestion
What is absorbed in the stomach?
EtOH
What is absorbed in the duodenum?
Glucose, via Na co-transport
Vit A and D
Fatty Acids
Fe
Ca
What is absorbed in the proximal jejenum?
Gcose, Glactos, monosaccharides, disaccharides
Vit A and D
Fatts
protein and AAs
What is absorbed in the terminal jejenum?
Water-soluble vitamins
Disaccharides
Fatty acids
Proteins and amino acids
What is absorbed in the Ileum?
Proteins and AAs
B12
Bile salts
- is a reserve, can obsorb more if needed.
What is absorbed in the colon?
H2O
K
NaCl
Short-chain fattys
What is the role of Histamine w/ digestion?
increases gastric H secretion directly
potentiates effects of gastrin and vagal stimulation
What is the role of vasoactive intestinal peptide in digestion?
homologous to secretin
Released by mucosa and smooth muscle
relaxes GI smooth muscle, lower the esophageal sphincter
Stims pancreatic HCO3 secretion
inhibs gastric H secretion
What is the role of GRP (bombesin)?
released from vagus
stims gastrin release
What is teh role of Enkephalins?
met-enkephalin, leu-enkephalin
secreted from nerves in the mucosa and smooth muscle of th eGI tract
Stimulates the contraction of GI smooth muscle-> LES, pyloric and ileocecal sphincters
Inhibit intestinal secretion of fluid and elytes. (opiates in diarrhea)
What is the role of the H/K ATPase on the parietal cell?
proton pump.
inhibbed by PPIs.
What is the roles of the alpha-amylase
starch digestion
secreted active
What is the role of Lipase, Phospholipase A, colipase?
fat digestion
What is teh role of trypsin, chymotrypsin, elastaste, and carboxypeptidases?
Proteases
protein digestion
What is the role of trypsinogen?
inactive trypsin
converted by enterokinase (duodenal brush border)
starts a + feedback loop
What happens in pancreatic insufficiency?
what disease can cause this?
Pts present w/ malabsorption, steatorrhea.
Limit fat intake and watch Vit A,D,E,K levels (fat-soluable)

Seen in cystic fibrosis, alcoholism, other
How does blood and lymph flow through the sinusoids?
blood flows towards the central vein
bile flows away.
What is the composition fo bile?
bile salts- acids conjugated to glycien or taurine to make them water soluble, phospholipids, cholesterol, bilirubin, water, ions
How is bilirubin processed?
product of heme metab
actively taken up by hepatocytes.
Direct- conjugated w/ glucoronic acid; water soluble.
indirect bilirubin- unconjugated; water insoluble. Bound to albumin

Jaundice from elevated bilirubin

urobilirubin is excreted by kidney
urobilinogen is recycled (made by bacteria in colon
Stercobilin gives poo it's color
Where do slow waves originate for gi motility?
interstitial cells of Cajal- pacemaker
depols cells to get them closer to Action Potentials.
frequency is lowest in stomach, highest in duodenum
What is the role of motilin?
regulates the migrating myoelectric complex
What regulates gastric emptying?
fastest when stomach contents are isotonic.
Fat inhibs emptying by stimulating CCK
H in duodenum inhibs gastric emptying via direct neural reflexes.- interneurons
What is the gastroileal reflex? the gastrocolic reflex?
Food in the stomach triggers ileal peristalsis. Increases the frequency of mass movements.
What are Haustra?
sac-like segments of the large intestine
What is Hirschsprung's disease?
Megacolon- no enteric nervous system.
where is the vomiting center?
medulla
Where is the chemoreceptor trigger zone?
fourth ventricle
triggered by emetics, rads, vestibulart stim.
What are the components of saliva?
High K and HCO3
low Na and Cl
Hypotnicity
alpha amylase, lingual lipasae, kallikrein.

at high flow rates, it's like plasma- Na, Cl jump. K drops. HCO3 doesn't change much.
How does pancreatic secretions differe from plasma?
less Cl
more HCO3
low flow- na and cl
high flow- na and hco3
what is the 2nd messenger for secretin?
cAMP
What is the 2nd messenger for CCK?
IP3
What is SGLT1?
Na-dependent cotransporter of glucose and Na.
absorbtion of Gcose from intestine
(Gcose enters blood w/ facilitated diffusion)
How is fructose transported?
facilitated diffusion
What is the difference between endo and exopeptidases?
Endo degrades interior peptide bonds
Exo degrades from C terminus
How are AAs transported?
Na dependent cotransport
Di and Tripeptides w/ H-dependant.
What e-lyte is lost in diarrhea?
K.
What e-lyte is triggered to be secreted in cholera/E.coli?
Cl
How are vits A,D,E,K absorbed?
in micelles (fat soluble)
What is an abdominal hernia?
Protrusions of peritoneum through an opening at sites of weakness
Diaphragmatic
Indirect inguinal
direct inguinal
What is a diaphragmatic hernia?
Abdominal structures enter the thorax; may occur in infants as a result of defective development of pleuroperitoneal membrane.
Most commonly a hiatal hernia, stomach herniates.
What is an indirect inguinal hernia?
Indirect hernia through Internal (deep) inguinal ring and external (superficial) inguinal ring. into the scrote. Indirect hernia enters inguinal ring lateral to inferior epigastrict

MDs don't LIe:
Medial to inferior epigastric artery = Direct hernia
Lateral to inferior epigastric = Indirect hernia
What is a direct inguinal hernia?
Protrudes through the inguinal triangle. Direct hernia bulges directly through abdominal wall medial to inferior epigastric artery. Goes through the external inguinal ring. Usually older men.

MDs don't LIe:
Medial to inferior epigastric artery = Direct hernia
Lateral to inferior epigastric = Indirect hernia
What is Hesselbach's triangle?
Inferior epigastric artery
Lateral border of rectus abdominis
Inguinal ligament.
What is Aphthous stomatitis?
painful recurrent erosive oral ulcerations
What is acute necrotizing ulcerative gingivitis?
Trench mouth, Vincent infection, fusospirochetosis
Sever gingival infection
cuased by fusobacterium and borrelia vencentii infection
Define the following benign lesions:
Papilloma
Fibroma
Hemangioma
Epulis
Papilloma- epithelial- tongue, lips, gingivae, buccal mucosa
Fibroma- non-neoplastic hyperplastic lesion from chronic irritation.
Hemangioma- tongue, lips, buccal mucosa
Epulis- any benign growth of the gingivae; most often a reparative growth
What is leukoplakia?
clinical term of irregular white mucosal patches
- hyperkeratosis 2ry to irritation
benign, but can become carcinoma in situ
What are the odontogenic tumors?
Odontoma
- most common
- hamartoma from odontogenic epithelium; odontoblastic tissue
Ameloblastoma
- epithelial tumor from precursor cells of the enamel organ
- mandible
- before 35
- benign, slow expansion of the jaw from irregular local extension
Oral Cancer
squamous cell carcinoma
tongue in 50%.
mouth tongue, esophagus- tobacco and alcohol
pipe smoking, chewing tobacco or betel nuts
Sialdenitis
Inflam of the salivary glands
caused by infection, immune-mediated mechanims, occlusion of the salivary ducts by stones.
Acute Parotitis
mumps
Sjogren syndrome
autoimmune
keratoconjunctivitis sicca, xerostomia, and CT disease w/ RA
malignant lymphoma
Mucocele
cyst-like pool of mucus, lined by granulation tissue near a minor salivary gland
from mucus leakage of traumatized duct
What is an abdominal hernia?
Protrusions of peritoneum through an opening at sites of weakness
Diaphragmatic
Indirect inguinal
direct inguinal
What is a diaphragmatic hernia?
Abdominal structures enter the thorax; may occur in infants as a result of defective development of pleuroperitoneal membrane.
Most commonly a hiatal hernia, stomach herniates.
What is an indirect inguinal hernia?
Indirect hernia through Internal (deep) inguinal ring and external (superficial) inguinal ring. into the scrote. Indirect hernia enters inguinal ring lateral to inferior epigastrict

MDs don't LIe:
Medial to inferior epigastric artery = Direct hernia
Lateral to inferior epigastric = Indirect hernia
What is a direct inguinal hernia?
Protrudes through the inguinal triangle. Direct hernia bulges directly through abdominal wall medial to inferior epigastric artery. Goes through the external inguinal ring. Usually older men.

MDs don't LIe:
Medial to inferior epigastric artery = Direct hernia
Lateral to inferior epigastric = Indirect hernia
What is Hesselbach's triangle?
Inferior epigastric artery
Lateral border of rectus abdominis
Inguinal ligament.
What is Aphthous stomatitis?
painful recurrent erosive oral ulcerations
What is acute necrotizing ulcerative gingivitis?
Trench mouth, Vincent infection, fusospirochetosis
Sever gingival infection
cuased by fusobacterium and borrelia vencentii infection
Define the following benign lesions:
Papilloma
Fibroma
Hemangioma
Epulis
Papilloma- epithelial- tongue, lips, gingivae, buccal mucosa
Fibroma- non-neoplastic hyperplastic lesion from chronic irritation.
Hemangioma- tongue, lips, buccal mucosa
Epulis- any benign growth of the gingivae; most often a reparative growth
What is leukoplakia?
clinical term of irregular white mucosal patches
- hyperkeratosis 2ry to irritation
benign, but can become carcinoma in situ
What are the odontogenic tumors?
Odontoma
- most common
- hamartoma from odontogenic epithelium; odontoblastic tissue
Ameloblastoma
- epithelial tumor from precursor cells of the enamel organ
- mandible
- before 35
- benign, slow expansion of the jaw from irregular local extension
Oral Cancer
squamous cell carcinoma
tongue in 50%.
mouth tongue, esophagus- tobacco and alcohol
pipe smoking, chewing tobacco or betel nuts
Sialdenitis
Inflam of the salivary glands
caused by infection, immune-mediated mechanims, occlusion of the salivary ducts by stones.
Acute Parotitis
mumps
Sjogren syndrome
autoimmune
keratoconjunctivitis sicca, xerostomia, and CT disease w/ RA
malignant lymphoma
Mucocele
cyst-like pool of mucus, lined by granulation tissue near a minor salivary gland
from mucus leakage of traumatized duct
What is a ranula?
large mucocele, salivary gland origin
floor of the mouth
Pleomorphic adenoma
parotid gland
variable mix of epithelial and mesenchyme elements.
Most common salivary gland tumor
Close to facial nerve
Papillary cystadenoma lymphomatosum
Warthin tumor
Parotid gland
cystic spaces lined by double-layerd eosinophilic epitheilum
embedded in lympoid stroma
benign
Mucoepidermoid tumor
Parotid gland
Comprised of mucus-producing and epidermoid components and cells intermediate between the two.

Behavior varies from benign to highly malignant;
tumors w/ more epidermoid are wordse
Adenoid cystic carcinoma
Minor salivary glands
variable histo
cribriform pattern w/ masses of small dark-staining cells
infiltrates perineural spaces and cause pain
slow-growing
Oncocytoma
paroti
large, granular

benign; peak in elderly
Tracheo esophageal fistula
most common is to have empty esophageal pouch

2nd most common- upper esophagus combines, lower esophagus just hanging

3rd- both complete with a connection between the two
Esophageal diverticula
pulsion- false
traction - true less common; from inflam

Zenker- UES
epiphrenic- LES (near the diaphragm)
Achalasia
loss of gangilon cells in the myenteric plexus
dilation of the esophagus
persistant contraction of LES
bird beak

Chagas-> 2ry achalasia
Esophageal varices
dilated submucosal esophageal veins, 2ry to portal HTN
upper gastrointestinal hemorrhage.

Bleeding ulcer, Mallory-Weiss (tear from retching) are other causes of bleeding
GERD
Reflux
burning that's relieved by antacids
most commonly associated w/ hiatal hernia.
recumbent is bad

also with preggers and scleroderma
alcohol and tobacco

can cause esophagitis, stricture, ulcer, or columnar metaplasia of esophageal squamous epi
Barretts esophagus
glandular/columnar instead of squamous esophagus
Candida esophagitis
w/ abtic therapy, DM, maligs or AIDS
painful difficult swallowing
Herpetic esophagitis
HSV
in immunosupressed
painful difficult swallowing
What are less common forms of esophagitis?
CMV infection, uremia, rads, GVH
Esophageal stricture
from prolonged GERD
also from suicidal or acidental acid
progressive dysphagia
What are the risks of esophageal carcinoma
ABCDEF
Alcohol
Barrets
Cigs
Diverticuli (Zeckers)
Esophageal web
Familial
What do the following GI markers mean?
Aminotransferases
GGT (Gamma-glutamyl transpeptidase)
Alk phos
Amylase
Lipase
Ceruloplsamin
Viral Hep (ALT>AST)
Alcoholic (AST>ALT)
MI (AST)

GGT- various liver disease
Alk phos- obstructed liver, bone disease
Amylase- acute pancreatitis, mumps
Lipase- acute pancreatitis
Ceruloplasmin- Wilson's
Esophageal carcinoma
dysphagia, weight loss, and anorexia; occasional pain or hematemesis

US- equal squamous and adeno
squamous cell is much more frequent world wide

Sqaumous is decreasing from decreased alcohol and cigs

Squamous occurs in upper and middle third of esophagus
Adeno is in lower third
spreads by local extension
Congenital pyloric stenosis
hypertrophy of the circular muscular layer of the pylorus- palpable mass- "olive"
projectile vomiting in first 2 wks of life
more in boys (1st born)
corrected by surgical incision of the hypertrophied muscle
What causes acute erosive gastritis
NSAIDs
Cigs
alcohol
Burn: curling ucler, acute gastric ulcer w/ severe burns
Brain injury: Cushings ulcer
Whas is autoimmune gastritis?
4 As
Abs to parietal cells, Achlorhydria, pernicious Anemia, and Autoimmune diseases like thyroiditis and Addison disease
aging, partial gastrectomy, gastric ulcer and gastric carcinoma
Helobacter
most common form of gastritis
no pernicious anemia
increased gastric acid secreteion
Menetrier disease
- extreme enlargement of gastric rugae and some severe loss of plasma proteins
Peptic ulcers of the stomach
near the lesser curvature in the antral and prepyloric regions
Pain is greater with meals; weight loss

- H. pylori. bacterial ureases and proteases breakdown epithelium
- Increased permeability of mucosa from H ion-> injury
- Bile induced gastritis -> ulcer
- NSAIDS decrease protection
Stomach carcinoma
after age 50, more in men
more frequent in type A blood

H. pylori
Nitrosamines- smoked fish, meat, pickled veggies
Excessive salt and low fruits
-predisposed by Achlorhydria, chronic gastritis
What are teh characteristics of stomach carcinoma
Histo-adeno
distal stomach- along the lesser curvature of the antrum or prepyloric region
Aggressive spread to adjacent organs
Involves distal sites- supraclavicular lymph node- Virchow;
Bilateral ovarian involvement- Krukenberg tumor. Signet-ring cells
What are the mophologic types of stomach carcinoma?
Intestinal
- polypoid, solid mass projecting into the lumen,
- high degree of associaation w/ H. pylori;
- can be ulcerationg

Infiltrating or diffuse-
- not H. pylori
- thickened, rigid wall
- called linitus plastica
Stomach lymphoma
4% of tumors
H. Pylori
MALT
better prognosis
Peptic ulcer of the duodenum
first portion of duodenum
hyper secretion of gastric acid
w/ blood group O
Decreased pain with food
- hemorrhage w/ melena

- aspirin, smokers, ZE, hyperPTH, MEN I
Meckel's Diverticulum
most common congenital anomaly of the small intestine
remnant of vitelline duct (yolk stalk)
distal small bowel
can ulcerate

Intussusception- invagination of proximal segment into a more distal segment. pre-existing bowel path.
Volvulus- twisting of GI tract

5 2's
2 inches
2 years of life
2 feet from ileocecal valve
2% population
2 types of epithelium
What is an omphalomesenteric cyst?
cystic dilation of vitelline duct.
Celiac disease
Flat mucosal surface w/ marked villous atrophy; increased lymphos and plasma cells in lamina propria

Gluten sentitivity
weight loss, weakness, diarrhea w/ pail, bulky, frothy, foul-smelling stools.
- growth retadation and failure to thrive
- symptomatic in infancy w/ ceral

HLA B8 and DW3; Abs against gliandin
can cause T-cell lymphoma
Tropical sprue
Histo findings vary from no changes to abnlties of sprue
Infections
responds to Abtics
Whipple
PAS+ macrophages in mucosa
Tropheryma whippelii bacilli on EM
affects any organ, small intestine is most common
arthralgias, cardiac and neurologic symps are common
Disaccharidase deficiency
No histo changes
lactase deficiency
Abetalipoproteinemia
no Histo
circulating acanthocytes
B-lipoprotien deficiency by hereditary deficiency of apo B
Intestinal lymphangiectasia
dilation of the intestial lymph
marked gastrointestinal protein loss w/ resultant hypoproteinemia and generalized edema
What is Hirschsprungs disease?
congenital megacolon from lack of enteric nervous plexus in segment on biopsy
failure of neural crest cell migration
chronic constipation early in life
dilated portion of the colon proximal to the aganglionic segment-> transisiton
Crohns
Infections
chrnoic inflamm condition
GI tract, distal ileocecum, small intestine, colon
young people in the 2nd or 3rd decades of life.
Jews
Can cause carcinoma (more common in UC)

Transmural
Thickening of segment wall, narrowing of lumen
linear ulceration
Skip lesions
non-caseating granulomas
submucosal fibrosis
coblestone appearance
rectal sparing

pain, diarrhea, malabsorp, fever, obstruction (from stricture), fistulas
Ulcerative colitis
only affects colon
inflam of mucosa, submucosa
cyrpt abscesses and pseudopolyps
increased incidence of cancer
Autoimmune
Diverticula
pockets of mucossa and submucosa herniated
older
sigmoid; multiple

Diverticulosis- multibple w/o inflamm; low fiber
Diverticulitis- inflam, older, perforation, peritonitis, abscess; bright red bleeding; may have signs of acute inflamm
Ischemic bowel disease
mucosal, mural, transmural infarct
atherosclerotic occlusion of two of the major mesentaric vessels
splenic flexure and rectosigmoid junction
Carcinoid
appendix
slow growing, rare mets
can mets to liver-> syndrome
elaboration of vasoactive peptides (serotonin)
- flushing
- diarrhea
- bronchospasm
- valvular lesions fo R side of heart
Angiodysplasia
tortuous dilation of small vessels spanning the intestinal mucosa or submucosa
common cause of unexpliend lower bowel bleeding
Colorectal cancer
3rd most common cancer
RF-
colorectal villous adenomas
ulcerative colitis
high fat, low fiber
age
FAP
HNPCC
DCC gene deletion
FHx
Apple core lesion on barium swallow.
Appendicitis
All ages
diffuse periumbilical pain-> MBurney's point. Nausea, fever; may perforate-> peritonitis
DDx- diverticulits (elderly), ectopic pregs
What polyp has the highest potential for malignancy?
villous
What polyps are the most common?
tubular
What is familial polyposis
AD condition w/ many polyps, will go malig
Gardner syndrome
AD- numerous polyps w/ osteomas and soft tissue tumors
Turcot syndrome
adenomatous polyps w/ tumors of CNS
What is physiologic jaundice of the newborn?
common in the first week of life. chemically unconjugated hyperbilirubinemia
increased production and deficiency of glucoronyl transferase of the immature liver

must be diffed from cholestasis; caused by CMV, alpha-antitrypsin deficiency, other
What is Gilbert syndrome?
common elevated serum unconjugated bilirubin
decreased bili uptake and glucuronyl transferase
What is Crigler-Najjar syndrome?
severe familial disorder characterized by unconjugated hyperbili caused by a deficiency of glucuronyl transferase.
Type I- Leads to early death from kernicterus, damage to the basal ganglia and other parts of the CNS
plasmapharese, phototherapy

Type II- less severe form- responds to phenobarbital, decreases the serum concentration
What is dubin Johsnon syndrome?
AR form of conjugated hyperbillirubinemia w/ defective billirubin transport
brown to black discoloratoin of the liver. Dark pigment, unclear chemical nature

Rotor syndrome is the same, but not as extreme, no black liver.
Hepatocellular jaunidice?
hyper conjugated and unconjugated
increase urine bili
decreased urine urobili

intrahepatic cholestasis -> retention of conjugated bili
enzymes increase: alk phos=obstruction
Obstructive jaundice?
hyper conjugated
increased urine bili
decreased urine urobili

increased alk phos and chol; ALT and AST variable.
Complete obstruction-> plae stools, and clay colored urine
Hemolytic jaundice?
hyper unconjugated
no urine bili
increased urobili

increased hemoglobin catabolism.
HAV
fecal-oral; no parenteral
no chronic carrier
15-45 day incubation
HBV
HBcAg, HBeAg, HBsAg
parenteral, sexual, vertical
60-90 day incubation
HCC
ground glass heptocytes
Carrier state or chronic liver disease
Breakdown the Ags of HBV
HBsAg- serum wks before clinical findings
persists for 3-4 months
Persitance=carrier
Ab will appear, if w/ loss of Ag= recovery and immunity

HBcAg
Anti appears 4 wks after HBsAg. Acute illness and remains elevated for years.
marker of infection between HBsAg and anti-HBsAg

HBeAg- appears after HBsAg and disappears befoer HBsAg
correlates with viral infectivity

HBV DNA- detected in serum and is an index of infectivity
HCV
parenteral
transfusion
carrier and chronic
HCC
HDV
single RNA strand; coinfects with B;
can't replicate alone, needs B
HEV
enterically transmitted
preggers
HGV
some blood doners, but path is unknown
Chronic hepatitis
abnlties for >6mths
etiology- HBV, HCV, other
Autoimmune- 2ry to various immunologic abnlties
hypergammaglobulinemia and anti-smooth muscle Abs.
neonatal hepatitis
unknown etiology
multinucleated giant cells
bile pigment and hemosiderin w/in parenchymal cells
jaundice in first few wks of life
What are other liver viral infections?
EBV
CMV- owl's eye
HSV
Yellow fever- midzonal hepatic necrosis. Councilman bodies
Leptospirosis
weil disease
jaundice, renal failure, and hemorrhagic phenomena
Echinococcus granulosus
tapeworm eggs; dogs and sheep
hydatid disease- parasitic cysts
Schistosomiasis
Schistosoma mansoni
S. Japonicum
portal vein and branches
Eggs are highly Agenic
granuloma
tussue destruction, scarring, portal HTN
Reye syndrome
acute disorder of young children w/ encephalopathy, coma, microvesicular fatty liver, hypoglycemia
aspirin (salycilates) admin to kids w/ acute viral infections; VZV and flu B
Fatty liver of preggers
acute hepatic failure of 3rd trimester w/ microvesicular fatty liver
high mortality
Tetracycline toxicity
unpredictable hypersensitivity w/ microvesicular fatty change
Alcoholic liver
most common liver disease in the U.S.
Fatty change- reversable
Hepatitis- fatty change, focal liver cell necrosis, infiltrates of neutrophils
Mallory bodies.
Irreversible fibrosis around central veins; can cause cirrhosis
Cirrhosis
Cirrhosis is a descriptive term for chronic liver disease characterized by generalized disorganization of hepatic architecture; scarring, nodule formation

caused by - prolonged alcohol, drugs, chemical agents; viral, biliary obstruction, hemochromatosis; Wilson disease

Micronodular- metabolic (alcohol, hemochrom, wilsons)
Macronodular- liver injury, necrosis; increased risk of HCC

Psrtacaval shunt between splenic vein and left renal vein may relieve portal HTN.

Jaundice, hypoalbuminemia, coag deficiencies, hyperestrinism

esophageal varices
rectal hemorrhoids
periumbilical venous collaterals
splenomegaly
edema, ascites, hydrothorax
- increased protal venous pressure, decreased plasma onctoic pressure, Na, H2O retention
Encephalopathy- ammonia; flapping hand tremor (asterixis)
alcoholic cirrhosis
most frwquent; micronodular w/ hobnail liver w/ large, irregular nodules
Postnecrotic cirrhosis
Large, irregular nodules containing intact hepatic lobules; diverse etiologies; end w/ viral hepatitis; HBV
Primary Biliary Cirrhosis
autoimmune; antimitochonidral; obstructive jaundice- itching and hyperchol
middle-aged women
increased parenchymal copper
increased alkphos
Secondary Biliary Cirrhosis
Long-standing obstruction; back-up-> increased pressure, fibrosis
bile stasis and bile lakes

ascending cholangitis from infection
increased alk phos, conjugated bili
Hereditary Hemochromatosis
Familial defect in control of Fe absorpiton (AR); HFe on chrom 6
hemosiderine in hepatic, pancreatic, myocardium and other
triad- cirrhosis, DM, skin pigmentation
micronodular

CHF and HCC
Rx- phlebotomy, deferoxamine
increased ferritin, Fe, decreased TIBC
Wilson disease
AR disorder of copper metab
decreased serum ceruloplasmin
liver, kidney, brain and cornea affected

Kayser-Fleischer ring around the cornea.
What are inborn errors in metabolism that cause cirrhosis?
alpha1-antitrypsin deficiency
Galactos-1-P uridyl transferease deficiency
glycogen storage diseases
What is the difference between Pre, Intra, and Post hepatic portal HTN?
Pre- portal and splenic vein obstruction from thrombosis

Intra- intrahepatic vasc obstruction- cirrhosis or mets, occasionally schistosomiasis

Post- venous congestions in distal hepatic venous circulation. Constrictive pericarditis.
Budd-Chiari syndrome
thrmbotic occulsioin of the major hepatic veins (IVC), ab pain, jaundice, hepatomegaly, ascites, and liver failure

polycythemia vera, HCC, ab neoplasms; preeggers on occasion.
What are the benign tumors of the liver?
Hemangioma- most common
Adenoma
- incidence w/ OCs
- subcapsular in location, may rupture-> intraperitoneal hemorrhage
Liver Mets
majority
HCC
1ry malig
pre-existing cirrhosis
HBV
aflatoxin B1 contam of nuts and grains. p53 point mutation
alpha-FP
invades vascular channels
Cholangiocarcinoma
less common
Far East- Clonorchis sinesis (liver fluke)
intrahepatic billiary epithelium
late complication of thorium dioxide
Hemangiosarcoma
rare malginant vascular tumor
associated w/ toxic exposure to polyvinyl chloride, thorotrast, and arsenic
What aer teh differences between acute and chronic cholecystitis?
acute- inflam of gallbladder, pyogenic; nausea, vomit, fever, leukocytosis; RUQ and epigastric pain.
Chronic- thickening of gallbladder w/ extensive fibrosis. Gallstones
Cholithiasis- what different stones are seen?
more common in chicks
chol stones- too large to enter cystic duct or common bile duct; found in obesity, crohn's, cystic fibrosis, advanced age, clofibrate, estrogens, multiparity, rapid weight loss, and native americans.
Pigment stones- Precipitation of unconjugated bilirubin. Hemolytic anemia. Bacterial infection.
Mixed stones- most; chol and calcium; visualized on x-ray from Ca.

4 Fs
Fat, Female, Forty, Fertile
Cholithiasis- What are the clinical manifestations
can be silent
can lead to food intolerance
Cholithiasis- what complications can arise?
Biliary colic- impaction of gallstone in cystic or common bile duct
Common bile duct obstruction- obstructive jaundice w/ conjugated hyperbilirubinemia, hyperchol, increased alk phos and hyperbilirubinuria
Ascending cholangitis- 2ry bacterial infection facilitated by obstructed bile flow.
Cholecystitis
Acute pancreatitis
Gallstone ileus
Mucocele
Malignancy
Cholesterolosis
Strawberry gallbladder
yellow chol flecks in mucosal surface
no inflamm changes
no special associations w/ cholelithiasis
Tumors of gallblader?
rare benign
Adinocarcinoma is common (w/ gallstones)

extrahepatic biliary ducts and the ampulla of Vater
- less common than carcinoma of the gallbladder
- adenocarcinoma
obstructive jaundice
tumors-> enlarged, distended gallbladder; stones do not
Acute pancreatitis
activation of pancreatic enzymes. Autodigestion; hemorrhagic fat necrosis; calcium soap. Pseudocyts.
-Severe ab pain and prostration; radiates to back, nausea, anorexia
-increased serum amylase, lipase
-hypocalcemia
-can be superimposed onto chronic pancreatitis
DIC, ARDS, diffuse fat necrosis, hypocalcemia, pseudocyst, hemorrhage, infection


Cases-
GET SMASHeD
Galls stones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion sting
Hypercalcemia/Hyperlipidemia
Drugs
Chronic pancreatitis
Progressive parenchymal fibrosis
alcohol
calcification
pseudocysts
ab and back pain, disability, steatorrhea. Decreased ADEK
Pancreatic Carcinoma
common tumor
smokers
adenocarcinoma
- head of pancreas-> obstructive jaundice, less often body or tail.
- if in the tail, can cause 2ry DM
- may have ab pain radiating to the back; weight loss, anorexia, migratory thrombophlebitis
obstruction.
H2 blockers:
mechanism
cliincal use
blocks the H2 receptors, decrease H+ secretion
used for ulcer, gastritis, mild reflux
What are the SEs of Cimetidine
P450
antiandrogenic
decreased creatinine
What are the H2 blockers?
Cimetidine
Ranitidine
Famotidine
Nizatidine
PPIs:
mechanism
cliincal use
block the Na/H pump
peptic ulcer, gastritis, esophageal reflux, ZE
What are the PPIs
Omeprazole
Lansoprazole
H2 Bismuth, sucralfate:
mechanism
cliincal use
Bind to ulcer base, physical protection, allow CHO3 to reestablish pH
ucler healing, diarrhea
What is the triple therapy of H. pylori
Metronidazole
Bismuth
Amoxicillin
Misoprostol:
mechanism
cliincal use
PGE analog. Increased secretions of mucous barrier, decrease acid production

prevent NSAID peptic ulcers; maintenance of patent ductus, labor
What are the SEs of Misoprostol?
Diarrhea. Contraindicated in women of childbearing potential (abortifacent)
muscarinic agonists:
mechanism
cliincal use
Block M1 receptors on ECL cells and M3 receptors on parietal cells
Clinical use- peptic ulcer
Infliximab:
mechanism
cliincal use
monoclonal Ab against TNF-Alpha
used in crohns and RA
What are teh SEs of muscarinic antagonists?
Tox- bradycardia, dry mouth, difficulty focusing eyes
What are the SEs of infliximab?
Resp infection, fever, hypotension
Sulfalazine:
What is the mech
what is the clinical use?
sulfapyridine- antibacterial
mesalamine- antiinflam
combo that's activated by conlonic bacteria
used in UC, Crohns
what are the SEs of Sulfasalazine?
malaise, nausea, sulfonamide tox, reversible oligo spermia
Odansetron:
mech
clinical use?
5-HT3 antag
anit-emetic
post-op, chemo
What are the SEs of Odansetron?
headache, constipation
What happens w/ antacid overuse?
absorp, bioavailability, urineary excretion of other drugs w/ altered gastric/urinary pH and delayed gastric emptying

Aluminum hydroxide- constipation, hypophosphatemia
Mg OH- diarrhea
CaCO3- hyperCa, rebound increased acid.
All cause hypokalemia