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346 Cards in this Set

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Ameloblasoma: MC location?
Mandible

Radiograph: view?
Radiograph shows "soap bubble" appearance
Ameloblastoma arise from ___?
Dentigerous cyst/ enamel organ
Barret's esophagus : Microscopic findings?
Glandular metaplasia in distal esophagus 
1. Gastric type columnar cells
2. Intestinal goblet cells
Barret's esophagus is a complication of_____?
GERD
Barret's esophagus: complications?
1. Ulceration with strictures
2. Distal adenocarcinoma
Basal cell carcinoma associated risk factor?
UV light exposure
Basal cell carcinoma: MC site?
Upper lip
Behcet's syndrome: 
HLA association?
virus association?
HLA-B51, HLA-B27

HSV or parvovirus
Behcet's syndrome: clinical findings?
1. Recurrent aphtous ulcers
2. Recurrent genital ulcers
3. Uveitis
4. Erythema nodosum
Behcet's syndrome: Rx?
1. A/inflammation
2. Corticosteroids
3. Colchicine
4. Thalidomide
Behcet's syndrome?
Immune small vessel vasculitis
Benign salivary gland tumors: Name em
1. Pleomorphic adenoma 
2. Warthin's tumor
(papillary cystadenoma lymphomatosum)
Bochdalek hernia:
Clinical finding?
Radiograph finding?
1. Respiratory distress
2. Radio: Loops of bowel in left pleural cavity

(In sliding hernia- bowel sounds heard in left lower base)
Bochdalek hernia?
'Pleuroperitoneal hernia'

Visceral contents extend into thorax on left side ( thru posterolateral part of diaphragm)---> respiratory distress
Cleft lip/palate: complications?
1. Malocclusion
2. Eustachian tube defect---> Otitis media
3. Speech problems
Cleft lip/palate: Pathogenesis?
Rx?
Failure of fusion of facial processes

Rx: Sx
Corrosive esophagitis: cause?
Akali
Acid: HCl

Complications?
1. Strictures
2. Perforation
3. Squamous cell carcinoma
Dental caries: cause?
Streptococcus mutans
(Acid from sucrose fermentation erodes enamel exposing underlying dentine)
Dental caries: prevention?
Fluoride prevents erosion

Excess fluoride results in ____(teeth)
Fluorosis: chalky discoloration of teeth
Dentigerous cyst?
associations?
1. Epithelial elements of dental origin
2. Associations:
i. Unerupted third molar
ii. Ameloblasts
Erythroplakia/leukoplakia: causes?
1. Dentures
2. Tobacco use
3. Alcohol abuse
4. HPV
Erythroplakia/leukoplakia: locations?
1. MC: Vermilion border of lower lip
2. Buccal mucosa
3. Hard/soft palate
Erythroplakia/leukoplakia: pathology?
Squamous hyperplasia of epidermis
Erythroplakia/leukoplakiaL: important Ix to be carried out?
Biopsy to rule out malignancy- squamous cell carcinoma
Esophageal disorder with: 
1. Heartburn?
2. Dysphagia for solids
3. Dysphagia for solids and liquids
1. GERD
2. Obstructive problems: Name em
3. Motility problems Name em
Obstructive:
1. Esophageal cancer
2. Esophageal webs
3. Strictures

Motility problems:

1. upper esophagus:
a. Dermatomyositis
b. Myasthenia gravis
c. Stroke

2. Lower esophagus:
a. Systemic sclerosis
b. CREST syndrome
c. Achalasia
Esophageal diverticuli: name em?
True: ?
False: ?
Zencker's: ?
1. True: outpouching of mucosa, submucosa and muscularis propria
2. False: outpouching of mucosa and submucosa only
3. Zencker's: Due to waekness of cricopharyngeus muscle
(pulsion type)-
located in upper esophagus
Esophageal varices?
Dilated left gastric veins
**submucosal**

left gastric vein is a branch of ____
Portal vein
GERD : Rx?
Same as hiatal hernia
GERD: associated with what condition in women?
Pregnancy
GERD: clinical findings?
1 Heart burn
2. Nocturnal cough
3. Acid enamel injury
4. Bloating/belching
5. Early satiety
6. Barret's esophagus
GERD: commonly associated with what condition in general?
Hiatal hernia
GERD: dx?
1. 24 hr esophageal pH monitoring
2. Esophageal endoscopy
3. Manometry
**(LES pressure<10mm)**
GERD: pathology?
1. Transient LES relaxation----> acid and bile reflux into distal esophagus
2. Ineffective clearance of esophageal material
GERD: risk factors?
1. Smoking/alcohol (lower LES tone)
2. Caffeine, chocolate (lower LES tone)
3. Pregnancy, obesity (Increased intra-abdominal pressure)
4. Hiatal hernia
GI related AIDS defining lesion?
GI related pre-AIDS lesion?
Infectious esophagitis
Oral thrush
Glossitis: (inflammation of tongue) observed in which conditions?
1. Fe deficiency
2. B12/folate deficiency
3. Vit C deficiency
4. Niacin deficiency
5. Scarlet fever
6. EBV associated hairy leukoplakia
Hiatal hernia: associations?
1. Sigmoid diverticulosis
2. Esophagitis
3. Duodenal ulcers
4. Gallstones
Hiatal hernia: types?
1. Sliding type
2. Rolling type

which is one more common?
Sliding type (90%)
Infectious esophagitis: associated with ___viruses?
1. HSV
2. CMV
3. Candida

Microscopic findings?
1. CMV: Large squamous cells with basophilic intranuclear inclusion
2. HSV: multinucleated squamous cells with intranuclear inclusions
Infectious esophagitis: Associated with ____
AIDS
Leukoplakia/erythroplakia: which of the 2 has a higher chance of turning malignant?
1. Erythroplakia has a higher chance
Lichen Planus: associated with?
Squamous cell carcinoma
Macroglossia observed in which conditions?
1. Myxedema
2. Down syndrome
3. Acromegaly
4. Amyloidosis
5. MEN IIb(III)
Malignant tumors of oral cavity : name em?
1. Squamous cell carcinoma
2. Basal cell carcinoma
3. Verrucous carcinoma
MC benign salivary gland tumor?
Pleomorphic adenoma


Is it male or female dominant?
Female dominant
MC benign tumor of oral cavity?
Squamous papilloma
MC congenital disorder of oral cavity?
Cleft lip/palate
MC gland involved in salivary gland tumors?
Parotid salivary glands
MC infection in HIV?
Candida
MC location of kaposi's sarcoma?
etiologic agent?
Hard palate
HHV8
MC malignant salivary gland tumor?
Mucoepidermoid carcinoma

MC site?
Parotid glands
MC site for squamous cell carcinoma?
other sites?
#1 Upper lip
#2 Floor of mouth
#3 Lateral border of tongue
MCC of odynophagia in AIDS pts?
Infectious esophagitis
Mucoepidermoid carcinoma: histopathology?
Mixture of squamous and mucus secreting cells
Non infectious ulcers in mouth?
1. Pemphigous vulgaris
2. Mucous membrane pamphigoid
3. Erythema multiforme
4. Aphthous ulcer
5. Behcet's syndrome
Oral manifestations in HIV?
1. Candidiasis
2. Kaposi's sarcoma
3. Aphthous ulcers
4. Hairy leukoplakia
Oral pigmentation observed in which conditions?
1. Peutz-Jegher's syndrome(small intestinal polyps) d/t melanin pigmentation on lips
2. Addison's disease
d/t increased ACTH
3. Lead poisoning
d/t lead deposits(gingival margins)
Pleomorphic adenoma: 
gross pathology?
Micro pathology?
Gross: Painless movable mass at angle of jaw

Micro: Epithelial cells intermixed with cartilagenous/myxomatous stroma
Plummer-Vinson syndrome: 
Cause?
Gross findings?
Clinical findings?
Complication?
1. Cause: Fe deficiency
2. Gross: Leukoplakia in oral mucosa and esophagus
3. Clinical findings: Intermittent dysphagia for solids
4. Progression to squamous cell carcinoma (esophagus)
Red/brown deposits (teeth) observed in?
Congenital porphyria
Rolling hernia aka____?
Pathology?
1. Paraesophageal hernia
2. Part of stomach bulges into thoracic cavity
Sjogren's syndrome: associated with ____(which autoimmune dz?)
RA

Sjogren's syndrome involves autoimmune destruction of ____ and ____
Salivary and lacrimal glands
Sliding hernia: rx?
Rx: non pharmacologic:
1. Avoid foods such as chocolate, coffee, CCBs (reduce LES tone)
2. Avoid overeating
3. Sleep with head end of ned elevated

Rx: pharmacologic
1. H2 antagonist
2. PPIs
3. Prokinetic drugs
4. Sx
Sliding type: pathology?
Proximal stomach herniates through hiatus of diaphragm into thorax

Clinical findings?
1. Heartburn
2. Nocturnal epigastric distress
3. Hematemesis
4. Ulceration, strcitures
5. Bowel sounds heard over left lung base
Squamous cancers: rx?
Sx and radiation
Squamous cell carcinoma: metastasis?
Mets to Superior jugular node (tonsillar node)
Squamous cell carcinoma: risk factors?
#1 SMOKING
2. Alcohol
3. HPV
4. Chronic irritation(dentures)
5. Lichen Planus

Smoking has synergistic effect with ____for squamous cell carcinoma?
Alcohol
Squamous papilloma: common sites?
1. Tongue
2. Gingiva
3. Palate
4. Lips
(all mouth except buccal mucosa)
Squamous papilloma: gross pathology?
Exophytic tumor with fibrovascular core
TE fistula : clinical findings?
1. Polyhydroamnios
2. Abdominal distention(infant)
3. Regurgitation--->chemical pnumonia
4. VATER:
Vertebral anomalies
Anal atresia
TE fistula
Renal disease
absent radius

TE fistula: abdominal distention observed due to?
Air in stomach (trachea is connected to stomach)
TE fistula : Gross features?
1. Proximal esophagus ends blindly
2. Distal esophagus arises from _____
Trachea
Thalidomide : uses?
1. MM
2. Behcet's syndrome
Tooth discoloration observed in?
1. Tetracyclines
2. Fluoride(white discoloration)
3. Congenital porphyria- 
red/brown teeth d/t porphyrin deposits
Veruccous carcinoma:
associations?
1. Smokeless tobacco 
2. HPV
Viral risk factor for squamous cell carcinoma?
HPV
Warthin's tumor: micro pathology?
Heterotrophic glands trapped in lymph nodes
What are aphthous ulcers?
Oral ulcers covered with shaggy exudate- painful
What pathologic observation determines increased risk for recurrence?
Tumor projection through capsule
What sign indicates that pleomorphic adenoma has turned malignant?
Facial nerve involvement
Zencker's type: clinical findings?
1. Halitosis
2. Painful swallowing
3. Regurgitation
4. Diverticulitis

Zencker's :rx?
Surgery
Gastric varices: Complication?
1. Hematemesis

Gastric varices commonly associated with ___(liver condition)
Cirrhosis

MCC of death in cirrhosis= rupture of gastric varices
Gastric varices: Dx?
(most important diagnostic procedure)
1. With endoscopy
Gastric varices: prevention of bleeds/rebleeds?
1. B-blockers with isosorbide
2. TIPS
3. Octreotide
4. Endoscopic ligation
5. Endoscopic sclerotherapy
6. Sx with stapling
Mallory-Weiss tears observed in which 2 conditions?
Common site of tears?
Complication?
1. Alcoholics
2. Bulimia

Site: Distal esophagus and proximal stomach

Complication: hematemesis
Boerhaave's syndrome?
Associated with which 3 conditions?
Distal espogeal rupture

Associated with:
1. Endoscopy- majority
2. Bullimics
3. Retching

Complications?
1. Pneumomediastinum (air in mediatinum--> Hamman's crunch on auscultation)
2. Pleural effusion (with food, acid and amylase)
MC neuromuscular disorder of esophagus?
Achalasia
Achalasia: pathology?
Incomplete relaxation of LES

"In aCHalasia esophageal sphincter remains Contracted"
Achalasia : pathogenesis?
1. Myenteric plexus destruction--> Reduced NO producing neurons---->Incomplete relaxation
Achalasia: Etiologic causes?
(HLA association)
1. Chagas disease or
2. Acquired (HLA-DQw1 association)

"In achalasia the esophagus ducks (DQs)"
Achalasia: clinical findings?
1. Difficulty belching
2. Dysphagia for solid and liquid foods
3. Rest all similar to GERD
(nocturnal cough/dysphagia)
Achalasia: Dx?
Abnormal barium swallow:
Dilated Aperistaltic espohagus with a "beak like appearance"

Manometry shows aperistalsis
Achalasia: Rx?
1. Pneumatic dilation
2. Esophageotomy
Pharmacologic:
1. Nitrates
2. CCBs
3. Botulinum
MC benign tumor of esophagus?
Leimyoma
MC primary cancer of esophagus?
Adenocarcinoma
Predisopsing factor for:
1. Adenocarcinoma (esophagus)
2. Squamous cell carcinoma
(esophagus)
Adenocarcinoma: Barret's esophagus (GERD)

Squamous cell carcinoma: Smoking
Squamous cell carcinoma: associations/risk factor?
1. Smoking
2. Alcohol
3. Achalasia
4. Plummer Vinson syndrome
MC location of squamous cell carcinoma of esophagus?
Middle(central) third of esophagus


("SSSquamouscellcarcinoma in SSSenter of esophagus)"
Squamous cell carcinoma: spread/metastasis?
#1 Lymph nodes
2. Lungs
3. Liver
Electrolyte abnormality observed with squamous cell carcinoma?
Hypercalcemia


Why this defect?
Since squamous cell carcinoma secretes PTH like peptide
Adenocarcinoma is associated with GERD such as squamous cell carcinoma is associated with ?
Achalasia
Squamous cell carcinoma: Commonly involved lymph nodes?
1. Supraclavicular nodes(painless enlargement)
Hematemesis:
Causes?
#1 PUD
2. Varices
3. Gastritis
Melena: site of GI pathology?
Proximal to gastro-duodenal junction
Gastric analysis?
Ratio of :
Basal acid output: Maximal acid output
(BAO:MAO)

BAO: basal acid output- acidity of gastric juice on empty stomach
MAO: maximal acid output- acidity of gastric juice after pentagastrin stimulation

Normal ratio of BAO: MAO?
0.2:1 (20%)
Congenital pyloric stenosis: Causes?
1. Genetic basis
2. Chronic duodenal ulcer (leads to scarring)
Congenital pyloric stenosis :
Clinical triad?
1. Non bilous projectile vomiting
2. Olive
3. Hyperperistalsis
Gastroparesis:
Causes?
Clinical findings?
Rx?
Causes:
1. Vagotomy
2. Diabetes

Clinical findings:
1. Early satiety
2. Vomiting
(after few hrs of meal ingestion)

Rx:
1. Small volume feed
2. Metoclopramide
Difference between:
1. Ulcer and
2. Erosion
Erosions involve mucosa only

Ulcers involve mucosa and submucosa
Hemorrhagic gastritis: causes?
#1 NSAIDs
2 Alcohol
3 CMV
4 Burns- Curling's ulcer
5 CNS injury- cushing's ulcer
6. Anisakis
5 CNS injury
6 Uremia
7 Anisakis
Viral cause of hemorrhagic gastritis?
CMV
Parasitic cause of hemorrhagic gastritis?
Anisakis
Hemorrhagic gastritis:
Complication?
Fe deficiency anemia
Hemorrhagic gastritis: rx-pharmacologic?
1. PPIs
2. Misoprostol

(reduce acidity)
Type A chronic atrophic gastritis: MC sites in stomach?
Important association?
MC site: Body and fundus

Associated with perinicious anemia
(Type A: Anemia)
Atrophic gastritis: Type A
Complications?
Lab finding?
Complications:
1. Achlorhydria
2. Megaloblastic anemia

Lab finding:
HYpergastrinemia
Type B chronic atrophic gastritis: MC site in stomach?
Important association?
Sites:
1. Pylorus
2. Antrum

Important association:
Helicobacter pylori
Type B chronic atrophic gastritis: pathophysiology?
Helicobacter pylori contracted by _____ route--->Colonizes mucus layer lining---> produces urease---> breaks down proteins---> NH3

2. Secretes protease---> atrophy
Feco-oral route
Type B chronic atrophic gastritis commonly observed along _____(lesser curvature/greater curvature) of stomach?
Lesser curvature
H.pylori is invasive/non invasive?
Non invasive
Chronic atrophic gastritis: Microscopic finding?
1. Chronic infiltrate(lymphocyte) in all layers of stomach
2. Intestinal metaplasia of stomach(goblet cells etc)
Chronic atrophic gastritis: What is the intestinal metaplasia indicative of?
Progression to adenocarcinoma
Tests to identify H.pylori infection?
1. Urea breath test
2. Stool antigen test
3. Urease activity test(biopsy)
4. Serology (?)
Gold standard test to detect H.pylori?
Urease activity in biopsy


Disadvantage of test?
Invasive
Best screening test for H.pylori?
Stool AG test
Test that is the best indicator of 'active infection'?
Stool AG test
Disadvantage of serologic tests?
Do not distinguish present from past infections
H.pylori infection: Rx?
BMTO regimen:
Bismuth
Metro
Tetracycline
Omepraole

or

Omeprazole
Amoxicillin
Clarithromycin


Test to indicate cure?
Stool AG test -ve
H/pylori disease associations?
1. Gastric/duodenal ulcers
2. Gastric adenocarcinoma
3. MALTOMA
Menetrier's disease?
Hyperplasia of mucus sectreting cells---> giant rugal folds

Complications?
1. Hypoprotenemia
2. Achlorhydria
3. Adenocarcinoma
MCC of PUD?
H.pylori
Which of the two are more common: gastric or duodenal ulcers?
Duodenal ulcers
Duodenal ulcers are more common in ____ (first/second/third) part of duodenum
First part
Gastric ulcers: MC location?
Lesser curvature near incisura angularis
Peptic ulcers: Gross appearance?
1. Clean
2. Sharply demarcated
3. Elevated edges
Peptic ulcers: 4 layers observed histologically?
1. Necrotic debris
2. Neutrophilic inflammation
3. Granulation tissue
4. Fibrosis
Peptic ulcer that has a chance to turn malignant?

Peptic ulcer that has NO CHANCE to turn malignant
MAY turn malignant: Gastric ulcer


NEVER turn malignant: Duodenal ulcers
ZE syndrome: important clinical clues?
1. Multiple resistant ulcers
2. Located distal to 1st portion of duodenum
3. Diarrhea

(PUD + diarrhea)
ZE syndrome: pathology? (triad)
1. Islet cell tumor producing excess gastrin--->
2. hyperacidity (increased HCl production)--->
3. ulceration

Gastrinoma
(Triad)
ZE syndrome: clinical presentation?
1. Multiple resistant ulcers (distal to 1st portion of duodenum)
2. Kidney stones
ZE syndrome: Lab findings?
Gastrin> 1000pg/ml
1. Increased BAO
2. Increased MAO
3. Increased BAO: MAO
(indicates more BAO than MAO)
ZE syndrome: Rx?
1. PPIs
2. Chemotherapy
Gastric ulcers: pathogenesis?
H.pylori infection---> mucosal ischemia--->defective mucosal barrier + reduced PGE--->
bile reflux (?) and delayed gastric emptying
PUD are generally ____(single/multiple) ulcers
Single unless associated with gastrinoma (MENI syndrome)
_____(gastric/duodenal)ulcer is associated with pancreatitis
Duodenal (occurs as a complication following perforation)
Complications of:
1. Gastric
2. Duodenal ulcers?
Perforation
Bleeding
(for both)

Arteries affected in:
1. Gastric ulcers
2. Duodenal ulcers
1. Gastric ulcers: Left gastric artery
2. Duodenal ulcers: Gastroduodenal artery
Gastric/duodenal ulcers- differentiation on basis of clinical findings?
Gastric ulcers: Epigastric pain exacerbated on eating

Duodenal ulcers: Epigastric pain reduced on eating
Ix/Dx for gastric/duodenal ulcers?
Gastric:
1. Endoscopy
2. Biopsy (chance to turn malignant)
3. Upper GI barium study

Duodenal:
1. Endoscopy only (No biopsy)
2. Upper GI barium study

Basically:
endoscopy--->determine location--->if gastric---->biopsy
-->if duodenal---> no need for biopsy

Common complication of endoscopy?
Boerhaave syndrome (esophageal perforation)

other causes:
Retching in bulimics
Vagotomy is commonly indicated for resistant cases of _____(gastric/duodenal) ulcers
Duodenal ulcers

"highly selective vagotomy"
Complications of chronic gastritis and achlorhydria
Gastric polyps
Name one benign gastric polyp
Name one malignant gastric polyp
Benign: Hamartoma
Malignant: Adenomatous polyp

Which of the two is more common?
Hamrtomatous polyp
Gastric tumors: Name em?
Leiomyoma
Adenocarcinoma
MALToma
Leiomyoma: fate?
(Stomach is the most common site for leiomyoma in GI)
Bleeding/ulceration
Primary adenocarcinoma is common in the blood group ____(A/B/AB/O)?
Blood group A
H.pylori infection leading to PUD is more common in blood group ____(A/B/AB/O)?
Blood group O
Gastritis associated with adenocarcinoma stomach: type A or type B?
type A
Bacterial risk factor for adenocarcinoma stomach?
H.pylori
Diet related risk factor for adenocarcinoma stomach?
1. Smoked foods
2. Lack of fiber in diet(fruits/veggies)
3. Nitrosamines (pestidices/cosmetic products)
Disease conditions that are risk factors for adenocarcinoma of stomach
1. PUD(gastric)
2. Menetrier's disease
Types of stomach adenocarcinoma?
1. Polypoid/ulcerated
2. Diffuse
Type of gastric adenocarcinoma not associated with H.pylori infection?
Diffuse type of adenocarcinoma
Diffuse gastric adenocarcinoma: micro pathology?
1. Diffuse involvement of stomach wall
2. "Signet ring cells "
(Mucin pushes nucleus of cancer cells to periphery)
Diffuse gastric adenocarcinoma: spread?
Spread to both ovaries (Krukenberg's tumor)
Diffuse gastric adenocarcinoma: clinical findings?
1. Left supraclavicular LN (Virchow)
2. Acanthosis Nigricans
3. Leser Trelat sign

common ca related signs-
1. Cachexia
2. Wt loss
3. Epigastric pain
4. Vomiting
4. Mets to umbilicus
Diffuse gastric adenocarcinoma: mets?
1. Supraclavicular LN(Virchow)
2. Umbilicus (Sis.Mary-Joseph)
3. Ovaries(Krukenberg)
4. Lungs
5. Liver
Diffuse gastric adenocarcinoma: Skin lesions?
1. Seborrheic keratosis
2. Acanthosis nigricans
Diffuse gastric adenocarcinoma: Rx?
Sx and chemotherapy
MC site for extranodal malignant lymphoma?
Stomach- MALToma
Stomach- MALToma: Important bacterial association?
H.pylori
Gastric lymphoma: MCC?
H.pylori
Malabsorption of:
1. Fe indicates ___?(part of intestine)
2. Folate indicates____
3. B12 indicates ____
Fe: duodenum
Folate: Jejunum
B12: Ileum
Types of diarrhea associated with:
1. Shigella
2. Giardia
3. Disaccharidase deficiency
4. V.cholera
5. C.Jejuni
6. Laxatives
7. Serotonin syndrome
8. MgSO4
9. E.histolytica
10. E.coli
1. Shigella: Invasive
2. Giardia: Osmotic
3. Disaccharidase deficiency: Osmotic
4. V.cholera: Secretory
5. C.jejuni:
Ix for determining type of diarrhea?
Step1: Leukocyte +ve/-ve
Step2: If +ve indicates invasive
Step2: If -ve ---> step3
Step3: Stool osmotic gap test
Step4: Osmotic gap< 50: Secretory
Step4: Osmotic gap> 50:
Osmotic
How do you determine osmotic gap in stools?
300-{2x(Na+k)}
Type of fluid loss in osmotic diarrhea?
Hypotonic
Hypertonic
Isotonic
Hypotonic
Type of fluid loss in osmotic diarrhea?
Hypotonic
Hypertonic
Isotonic
Isotonic
MCC of pancreatic insufficiency?
Alcoholism
Malabsorption in pancreatic insufficiency:
Pathogenesis?
1. Maldigestion of fat
(decreased lipase)
2. Maldigestion of prots
(decreased prots)

CARB DIGESTION NOT AFFECTED
Bile salt/acid deficiency:
Causes?
1. Cirrhosis: insufficient synthesis of bile acids from cholesterol
2. Obstructive jaundice
3. Bacterial overgrowth
4. Cholestyramine
5. Crohn's dz/ileal obstruction(terminal ileal absorption affected)
Small bowel diseases causing malabsorption?
1. Celiac disease
2. Whipple's disease
3. Abetalipoprotenemia(lymphatic obstruction)
Malabsorption: Quantitative stool for fat test?
72 hour collection of stool
>7g of fat/24 hrs indicates malabsorption
Tests for fat malabsorption?
1. Quantitative stool for fat
2. Qualitative stool for fat
3. Serum beta carotene
D-Xylose absorption test?
D-xylose malabsorption indicates small bowel disease

(D-xylose does not require pancreatic enymes for absorption)
Enzyme that is specific for pancreatic insufficiency?
Trypsin

(Sr.immunoreactive trypsin)
Tests for pancreatic insufficiency?
1. Sr.trypsin
2. CT scan (pancreas calcification)
3. Secretin test
4. Bentiromide test
Secretin test: Tests secretion ability
Bentiromide test: Tests pancreatic ability to secrete chymortrypsin
(chymotrypsin cleaves bentiromide into PABA)
PABA- excreted in urine
Pancreatic calcification on CT scan indicates?
Chronic pancreatitis
Bile salts deficiency tests?
Bile breath test(oral radioactive test)

Decreased radioactive cholyl-glycine
Tests for bacterial overgrowth?
Lactulose- H2
C14 xylose test

C14 in CO2 and H2 both measured in breath
Malabsorption: clinical findings?
ADEK deficiency
B12 and folate deficiency
Asictes and hypoproteinemia
Celiac disease: pathology?
Inappropriate immune response to gluten in wheat
Serotonin syndrome: Triad symptoms
Cognitive effects: headache, agitation, hypomania, mental confusion, hallucinations, coma

Autonomic effects: shivering, sweating, hyperthermia, hypertension, tachycardia, nausea, diarrhea.

Somatic effects: myoclonus (muscle twitching), hyperreflexia (manifested by clonus), tremor.
Vesicles/erythema + malabsorption?
Celiac disease
Celiac disease other important associations?
1. Dermatitis herpetiformis
2. DM-type 1
3. Hashimoto's thyroiditis
4. IgA deficiency
5. Down's syndrome
6. Turner's syndrome
Celiac disease: Pathogenesis?
TISSUE GLUTAMINASE breaks down gluten----> immunogenic gluten peptides----> phagocytosed by APC--->
stimulates HLA-DQ2/8 to CD4 cells--> release protease--> cell death and degradation
Celiac disease: diagnostic ABs?
1. Anti-tissue glutaminase
2. Anti-endomyseal IgA AB
3. Antigliadin IgA/IgG ABs
Celiac disease: Microscopic features?
1. Villous atrophy
2. Lengthening of crypts
3. Inflammation in Lamina Propria
Transglutaminase location?
In lamina propria of small intestines
Celiac disease:Rx?
1. Gluen free diet
2. Corticosteroids
Whipple's disease: cause?
Tropheryma whipplei
Serotonin syndrome: Triad symptoms
Cognitive effects: headache, agitation, hypomania, mental confusion, hallucinations, coma

Autonomic effects: shivering, sweating, hyperthermia, hypertension, tachycardia, nausea, diarrhea.

Somatic effects: myoclonus (muscle twitching), hyperreflexia (manifested by clonus), tremor.
Whipple's disease: Dx?
PCR for tropheryma whipplei
Vesicles/erythema + malabsorption?
Celiac disease
Celiac disease other important associations?
1. Dermatitis herpetiformis
2. DM-type 1
3. Hashimoto's thyroiditis
4. IgA deficiency
5. Down's syndrome
6. Turner's syndrome
Celiac disease: Pathogenesis?
TISSUE GLUTAMINASE breaks down gluten----> immunogenic gluten peptides----> phagocytosed by APC--->
stimulates HLA-DQ2/8 to CD4 cells--> release protease--> cell death and degradation
Celiac disease: diagnostic ABs?
1. Anti-tissue glutaminase
2. Anti-endomyseal IgA AB
3. Antigliadin IgA/IgG ABs
Celiac disease: Microscopic features?
1. Villous atrophy
2. Lengthening of crypts
3. Inflammation in Lamina Propria
Transglutaminase location?
In lamina propria of small intestines
Celiac disease:Rx?
1. Gluen free diet
2. Corticosteroids
Whipple's disease: cause?
Tropheryma whipplei
Whipple's disease: Dx?
PCR for tropheryma whipplei
Whipple's disease: Microscopic findings?
Foamy PAS +ve macrophages--->
Obstruct lymphatics and reabsorption of chylomicrons---> Malabsorption of fats

Location of PAS +ve macrophages?
Lamina propria
Whipple's disease: clinical features?
1. Polyarthritis
2. Lymphadenopathy
3. Skin pigmentation
4. Fever
5. Steatorrhea
Small bowel obstruction:
Radiographic findings?
1. Air--fluid level
2. Absence of air distal to obstruction
Bowel obstruction: clinical findings?
1. Colicky pain
(alternating with pain free intervals)
2. Abdominal distention
3. No rebound tenderness
4. High pitched tinkling sound
MCC of small bowel obstruction?
Adhesions/strictures from previous sx

(other causes of adhesions: endometriosis,
radiation)
Crohn's disease: MC location of small bowel obstruction?
1. Terminal ileum (Narrow due to full thickness inflammation of bowel)
Duodenal atresia:
important clinical association?
Radiologic finding?
Clinical finding?
Association: Down syndrome

Radio: Double bubble sign

Clinical finding:
1. Vomiting of bile stained fluid at birth
2. History of maternal polyhydramnios

what is "double bubble" sign?
Double bubble sign:
air in stomach and
air in proximal duodenum
Hirschsprung disease: pathology?
1. Absence of ganglion cells in Meissner's submucosal plexus
Myenteric plexus--->
Aperistalsis--->
(Constant contraction without relaxation)--->
Obstruction
Hirschsprung disease:
Acquired causes?
Important clinical association?
Acquired causes:
Chagas disease(destruction of ganglions by amastigotes)

Clinical association:
Down syndrome
Hirschsprung disease: Common site?
1. Distal sigmoid colon
2. Rectum
Hirschsprung disease: Important clinical clue?
No stool on examining finger
(No stool in rectal vault- collected proximal to the affected segment)
Hirschsprung disease: MCC death?
Entorocolitis of affected segment--->Perforation
Hirschsprung disease: Dx? Rx?
Dx: Rectal biopsy
Rx: Resection
Causes of bowel obsrtuction?
#1 Adhesions
2. Crohn's disease
3. Duodenal Aaresia
4. Gallstone ileus
5. Hirschsprung disease
6. Indirect inguinal hernia
7. Femoral hernia
8. Intussusception
9. Volvulus
10. Meconium ileus
Intussusception: risk factors-
In children?
In adult?
Children: Peyer's patches
Adults: Polyp/cancer

also rota virus vaccine

Intussusception more common in children age 1-5yrs
Intussuscpetion: MC site?
Terminal ileum (invaginates into cecum)
Intussusception: pathology?
Obstruction
Ischemia
Intussusception: Important clinical sign?
Dance's sign: oblong mass palpated in midepigastrium
Meconium ileus occurs as a complication of ____ disease?
Cystic fibrosis
Volvulus: pathology?
Bowel twists around mesenteric root-->obstruction
MC site for volvulus?
Young adults: Cecum
Elderly: Sigmoid colon
Volvulus: risk factors:
1. Chronic constipation
2. Pregnancy
3. Laxatives
MC type of hernia?
Indirect inguinal hernia
Small bowel: blood supplied by?
Superior mesenteric artery
Watershed area of bowel?
Splenic flexure of colon: SMA and IMA
Types of infarction?
1. Transmural: Full thickness
2. Mucosal

causes of both?
Transmural: Occlusion of SMA
Mucosal: Hypotension--> hypoperfusion
Causes of acute small bowel ischemia?
Acute mesenteric ischemia:
1. Embolic from left side of heart
2. Thrombosis
Small bowel ischemia: Clinical findings?
1. Sudden onset pain
2. Bowel distention
3. Bloody diarrhea
4. Absent bowel sounds
Small bowel ischemia: Radiographic findings?
Thumb print sign
Air-fluid
MC site of intestinal infarction?
Splenic flexure since it is a watershed area
Ischemic colitis: cause?
clinical features?
Radiologic findings?
Atherosclerotic narrowing of SMA

Clinical features:
Pain along splenic flexure
Bloody diarrhea(infarction)

Radiologic findings:
Thumb printing
Angiodysplasia:
Pathology?
MC site?
Pathology: Dilation of mucosal veins

MC site: Cecum and right colon
Angiodysplasia:
Pathogenesis?
Clinical findings?
Pathogenesis: Increased wall stress on cecum produces stretching of venules

Clincal findings:
Hematochezia
Angiodysplasia:
important associations?
1. VW factor deficiency
2. Calcific aortic stenosis
Angiodysplasia:
Dx?
Rx?
Colonscopy:
1. Identify
2. Cautery of lesions

Angiography: localize

Rx:
Right hemicolectomy
Correct AS
Meckel's diverticulum:
Rule of 2?
2 inches length
2 feet from ileocecal jn
2% population
2% symptomatic
Meckel's diverticulum contains _____and_____tissue
1. Stomach
2. Pancreatic
Meckel's diverticulum: clinical features?
Clinical features:
1. Bleeding
2. Fecal material in umbilical area
3. Pain in diverticulitis
Meckel's diverticulum: dx?
Tc-99 scan
MC site for diverticuli formation in GI tract?
Sigmoid colon
Sigmoid colon diverticulitis: Disease association?
1. Marfan's syndrome
2. Ehler's Danlos syndrome
3. Adult polycystic kidney disease
Sigmoid diverticulitis: clinical findings?
1. Diverticulitis (stool impaction)
2. Fever
3. Diarrhea followed by constipation
4. Left lwer quadrant pain
5. Tender palpable mass
6. Perforation/abscess
7. hematochezia
Sigmoid diverticulitis is the MCC?
Fistulas
MCC of hematochezia?
Sigmoid diverticulitis
Inflammatory bowel disease: MC IBD?
Ulcerative colitis
Smoking is a risk factor for ____(ulcerative colitis/crohn's disease)
Crohn's disease
Common location for Ulcerative colitis?

Pattern of involvement:
continuous/discontinuous
1. Rectum
2. Extends up into colon

Continuous involvement
No involvement of other areas of GI
Common location for Crohn's disease?

Pattern of involvement:
continuous/discontinuous
1. Terminal ileum
2. Colon + terminal ileum(majority)
3. Ileum

Discontinuous- may involve other areas of GI: mouth
Gross features of ulcerative colitis?
1. Inflammatory pseudopolyps
2. Ulcerating and hemorrhaging mucosa
Gross features of crohn's disease?
Aphthous ulcer in bowel
Skip lesions--> strictures/fistulas

(deep linear ulcers with cobblestone pattern)
Ulcerative colitis: microscopic findings?
Ulcers and crypt abscess
dysplasia likely
Crohn's disease: microscopic pattern?
Non caseating granulomas
Lymphoid aggregates
Dysplasia less likely
Ulcerative colitis: clinical finding?
Left sided pain
Bloody diarrhea
Primary sclerosing cholangitis
erythema nodosum
iritis/uveitis
pyoderma gangrenosum
Arthritis
p-ANCA +ve
Crohn's disease: clinical features?
Right sided pain
Bloody diarrhea
Primary sclerosing cholangitis
erythema nodosum
iritis/uveitis
pyoderma gangrenosum
Arthritis
Ulcerative colitis: complications?
Toxic megaolon
Adenocarcinoma
Crohn's disease: complications?
Fistulas
Obstruction
Colon cancer
Renal calculi
Malabsorption
macrocytic anemia
Inflammatory bowel disease: rx?
Sulfasalazine
Mesalamine
Corticosteroids
Nicotine patch
Azathioprine/cyclosporine
Identify which of these are associated with Crohn's or Ulcerative colitis:
1. Smoking is a risk factor
2. Smoking is protective
3. Transmural inflammation
4. Mucosal inflammation
5. Continuous
6. Discontinuous
7. Obstruction
8. Aphthous ulcers
9. Pseudopolyps
10. Dysplasia
11. Non caseating granuloma
12. Left sided pain
13. Right sided pain
14. Lead pipe sign
15. String sign
16. Toxic megacolon
17. Fistulas
18. Colon cancer
19. Malabsorption
20. Renal stones
21. Cobblestone pattern
1. Smoking is a risk factor: CD
2. Smoking is protective: UC
3. Transmural inflammation: CD
4. Mucosal inflammation: UC
5. Continuous: UC
6. Discontinuous: CD
7. Obstruction: CD
8. Aphthous ulcers: CD
9. Pseudopolyps: UC
10. Dysplasia: UC
11. Non caseating granuloma: CD
12. Left sided pain: UC
13. Right sided pain: CD
14. Lead pipe sign: UC
15. String sign: CD
16. Toxic megacolon: UC
17. Fistulas: CD
18. Colon cancer: UC
19. Malabsorption: CD
20. Renal stones: CD
21. Cobblestone pattern: CD
Irritable bowel disease: triggering factors?
1. Loss of tolerance to bacterial flora
2. Environmental/genetic
Irritable bowel disease: risk factors?
1. Childhood sexual abuse
2. Domestic abuse
3. Stress/depression/personality disorder
MC site of primary adenocarcinoma of small bowel?
Duodenum
MC small bowel malignancy?
Carcinoid tumor
Carcinoid tumor of small bowel: type of tumor?
Neuroendocrine tumor
Carcinoid tumors are ____(benign/malignant)?
Malignant
Features determining metastasis?
1. Size>2cm
2. Invasion depth
Is site of carcinoid tumor associated with metastasis?
Yes


Which sites are associated with metastasis?
1. Midgut tumors Metastasize
(Midgut-Metastasize)
eg.terminal ileum
2. Foregut and hindgut do not metastasize
Foregut: stomach
Hindgut: rectum
Carcinoid tumors of GI: MC site?
MC site:Appendix

Other sites?
1. Terminal ileum
2. Esophagus
3. Stomach
4. Colon
Carcinoid tumor: Gross appearance?
Bright yellow tumor
Carcinoid tumor of small bowel: When do symptoms occur?
Only when they metastasize to the liver
Carcinoid tumor that produces symptoms without metastasis?
Bronchail carcinoid tumor
Carcinoid tumor: serotonin gains access through_____ vein following mets, to gain access to the systemic circulation?
Hepatic vein
Serotonin syndrome: Clinical findings?
Symptom Triad:

1. Cognitive effects: headache, agitation, hypomania, mental confusion, hallucinations, coma

2. Autonomic effects: shivering, sweating, hyperthermia, hypertension, tachycardia, nausea, diarrhea.

3. Somatic effects: myoclonus (muscle twitching), hyperreflexia (manifested by clonus), tremor.

also- wheezing

clues to dx?
Wheezing + diarrhea + increased 5-HIAA(urine)
Serotonin syndrome: associated cardiac effects?
TIPS
Serotonin syndrome: Dx?
Increased 5-HIAA
CT liver to detect liver mets
Carcinoid tumor with serotonin syndrome: Rx?
1. Cyproheptadine(serotonin receptor antagonist)
2. Somatostati analogue
3. Avoid alcohol
4. Chemotherapy
5. Surgical resection
Small bowel malignant lymphoma: type and site?
Type: b-cell type (burkitt's lymphoma)
Peyer's patches : MC site
Carcinoid tumor--> serotonin syndrome: mediators that produce symptoms?
1. Serotonin
2. Histamine
3. Bradykinin
Types of GI polyps?
1. Hyperplastic polyps
2. Juvenile polyps
3. Peutz Jegher's polyposis
4. Neoplastic polyps
MC type of polyp in adults?
MC site?
1. MC type: Hyperplastic polyps
2. MC site: Sigmoid colon

Is it malignant?
Histological appearance?
1. No mets
2. Histo: "Saw tooth" appearance
MC type of polyp in children?
MC site?
Juvenile/retention polyp
MC site: rectum

Gross appearance?
Inheritance pattern?
1. Gross: Cut section shows cystic dilated spaces
2. Inheritance: AD
Peutz-Jegher's polyposis: inheritance pattern?
AD
MC site for Peutz-Jegher's polyps?
Small bowel
Peutz-Jegher's: clinical findings?
Mucosal pigmentation

Hamartomas
Peutz-Jegher's: associated tumor conditions?
1. Colorectal
2. Breast
3. Gynec malignancies
Neoplastic polyps: what type of tumor?
Adenoma:
may turn malignant

Indications that a tumor turn malignant?
1. Adenoma>2cm
2. Multiple polyps
3. Increased villous components
Neoplastic polyps: types?
1. Tubular adenoma
2. Tubulovillous adenoma
3. Villous adenoma
4. Familial polyposis

MC of neoplastic polyps?:
MC site?
Appearance?
1. MC type: Tubular adenoma
2. MC site: Sigmoid colon
3. Appearance:
i. "stalked mushroom"
ii. Cut section: complex branching glands
Neoplastic polyps:
Stalked types?
Sessile types?
Stalked:
i. Tubular adenoma
ii. Tubulovillous

Sessile:
i. Villous
Villous adenoma: MC location?
Rectosigmoid location
Type of adenoma associated with electrolyte disturbances?
Villous adenomas

What are the electrolytic changes?
Electrolytic changes: Hypokalemia
(+ Hypoalbuminemia)

Due to the tumor secreting mucus and potassium rich secretion
Familial polyposis: Inheritance pattern?
Inheritance pattern: AD


Common age group of incidence?
10-20yrs
Familial polyposis syndrome: Pathogenesis?
Inactivation of APC gene
Familial polyposis syndrome: At what age does malignant transformation occur?
35-40yrs age group
Familial polyposis syndrome: Important association?
Congenital pigmental epithelial hypertrophy in RETINA.
Which of the neoplastic polyps have the greatest potency to turn malignant?
Villous adenoma
(maximum villous component)
MC neoplastic polyp?
Tubular polyps
Familai polyposis syndrome exhibits complete/incomplete penetrance?
Complete penetrance

(Implies all patient will be affected)
Gardner's syndrome:
Clinical triad?
1. GI polyps
2. Osteomas
3. Desmoid tumor

Inheritance pattern?
AD
Turcot's syndrome:
Clinical dyad?
1. Polyposis
2. Brain tumors-(astrocytoma/medulloblastoma)

Inheritance pattern?
AR
Colon cancer: peak incidence is observed in ____age groups
7th decade(61-70)
Detection of:
1. Rectal cancer - best done by which screening test
2. Colon cancer- best done by which screening test
1. Rectal: Digital examination
2. Colon: Sigmoidoscopy
Colon cancer risk factors?
1. Age>50
2. Smoking
3. Alcohol
4. Obesity
5. Physical inactivity
6. First degree relative with colon ca
7. Ulcerative colitis
8. Low fiber diet
9. Hereditary polyposis syndrome
10. Hereditary nonpolyposis syndrome
11. Familial cancer syndrome
Colon cancer: carcinogenesis?
1. ADENOMA CARCINOMA SEQUENCE:
Sequential inactivation of the foll.(in order):
APC--->RAS--->TP53

2. Inactivation DNA mismatch genes
Colon cancer: MC site for location?
MC site: Rectosigmoid

other sites in order:
#2 Ascending colon
#3 Descending colon
#4 Transverse colon
#5 Cecum

(keep going in opposite direction)
Screening test for colon cancer?
Fecal occult blood test (stool guiac test)
Guiac----peroxidase----> ox-guiac--> color change

Disadvantages?
Not specific-
1. Does not distinguish myoglobin from hemoglobin
2. False +ve after meat/radish consumption(also contain oxidase)
Gold standard test for colon cancer?
Colonoscopy
Screening for colon cancer: general trend used?
Colonoscopy:
1. Start with age>50 yrs without risk factors
2. Every 3-5yrs if history of polyp removal
3. Begin at 40 if 1st degree relative has history
Pattern of clinical features on basis of location?
Left sided tend to obstruct
Right sided tend to bleed

Gross features on basis of location?
Left sided-napkin ring configuration
Right sided- bleed
Colon cancer: metastasis?
1, Liver
2. Lung
3. Bones
4. Brain
Colon cancer: prevention?
1. Aspirin/ NSAIDs
2. Statins (?)
3. Estrogen/progestins
4. Annual fecal blood test
5. Diet-more fiber
6. Stop smoking
Tumor marker for colon cancer?
CEA

PROGNOSTIC only
Acute appendicitis: pathogenesis in children?
in adults?
Children: Viral infection/vaccine--> lymphoid hyperplasia

Adults: fecaliths-->obstruction

Viral infections associated with appendicitis?
1. Adenovirus
2. Measles virus
3. Measles vaccine
Acute appendicitis: primary microbes in:
Adults?
Children?
Adults:
E.coli
B.fragilis

Children:
Measles
adenovirus
Appendicitis: sequence of events?
1. Peri-umbilical pain
2. Fever
3. Nausea, vomiting
4. Cutaneous hyperaethesia at T12
5. RLQ pain
Appendicitis:
1. Periumbilical pain: due to irritation of which fibers?
2. RLQ pain: due to irritation of which fibers?
3. Blumberg's sign
4. Rovsing's sign
5. Psoas sign
1. Periumbilical pain: C fibers
2. RLQ pain: A-d fibers
3. Blumberg's sign: Rebound tenderness@ Mcburney's point
4. Rovsing's sign: RLQ pain on palpation
5. Psoas sign: Pain on thigh extension
Appendicitis: lab findings?
1. Neutrophilic leukocytosis
2. Increased protein
3. Hematuria
4. Pyuria
Appendicitis: MC complication?
Peri-appendiceal abscess

Complications of peri-appendiceal abscess?
1. Perforation
2. Subphrenic abscess
Appendicitis: subphrenic abscess : associated microbe?
B.fragilis
Appendicitis: All complications?
1. Peri-appendiceal abscess
2. Pyelophlebitis
3. Subphrenic abscess
Appendicitis: gas in portal vein on radiography indicates?
Pyelophlebitis(infection of portal vein)

Complication of pyelophlebitis?
Thrombosis of portal vein
Appendicitis:
Persistent post operative fever indicates?
Subphrenic abscess

Clinical findings?
Right sided pleural effusion
Right sided fixed diaphragm
Tenderness over 7th and 8th ribs
Dx of acute appendicitis?
1. Clinical examination
2. Spiral CT with gastrograffin (since barium may result in spillage if appednix perforated)
3. Ultrasound
Appendicitis: rx?
1. Appendectomy
2. Cefotxitin
Conditions mimicing appendicitis?
1. Viral gastroenteritis
2. Ruptured ectopic pregnancy
3. Ruptured follicular cyst
4. Meckel's diverticulitis
5. Mesenteric lymphadenitis
Internal hemorrhoids: veins affected?
Internal hemorrhoid veins

Location?
Above the pectinate line
Mucosa and submucosa
Internal hemorrhoids: causes?
#1 Straining at stools
2. Pregnancy
3. Obesity
4. Anal intercourse
5. Portal hypertension
Internal hemorrhoid: clinical findings?
1 Bright red blood in stools
2 Painless
3 Prolapse out of rectum
4 Anal pruritis
Internal hemorrhoid: rx?
1. High fiber diet
2. Warm soaks/sitz bath

3. Topical hydrocortisone
4. Stool softeners

sx:
1 rubber band ligation
2 hemorrhoidectomy
3 sclerotherapy
External hemorrhoids: vein affected?
Inferior hemorrhoidal vein

Location?
Located below pectinate line

Painful thrombosis
Rectal prolapse: causes?
Children:
1. Whooping cough
2. Trichuriasis
3. Cystic fibrosis

elderly:
Straining at stools
Pilonidal sinus?
Painful mass in sacrococcygeal area
excess hair in deep gluteal fold

rx:Incision and drainage
Anorectal fistula:
Etiology
Cryptoglandular infection
Trauma
Crohn's disease
Malginancy- anal carcinoma
Anal fissures: MC site of location?
Posterior fissure
If anal fissure is not posteriorly located: what does it indicate?
Indicates crohn's disease
Anal fissure: rx?
Nitroglycerine
Botulinum toxin injection
Anal carcinmoa: types?
1. Basaloid
2. Squamous cell
Anal carcinoma: Basaloid location?
Transitional zone above dentate line
Anal carcinoma: sqaumous cell carcinoma: loaction?
In anal canal

Viral association?
HPV 16 and HPV 18