Block 7

Front 1

what are the four major causes of weight gain?

Back 1

growth
increase in lean body mass
increase in fat
increase in fluid

Front 2

which two elements comprise normal body composition?

Back 2

lean body mass and adipose tissue

Front 3

what is the commonest cause of weight gain?

Back 3

increase in adiposity

Front 4

name some endocrine conditions that cause weight gain

Back 4

hyperinsulinaemia
type 2 diabetes
acromegaly
cushing's
hypothyroidism
raised prolactin levels

Front 5

t/f... extremely high alcohol intake is associated with excess adiposity

Back 5

false

Front 6

what secretes insulin?

Back 6

beta cells of the pancreas

Front 7

what is the main signal for insulin secretion?

Back 7

rise in blood glucose levels above 5 mM

Front 8

what is the effect on cAMP when cells bind insulin?

Back 8

intracellular levels of cAMP are lowered

Front 9

t/f... the brain needs insulin for glucose transport

Back 9

false

Front 10

t/f... insulin inhibits the movement of GLUT-4 glucose transporters from the cell membrane to the Golgi apparatus

Back 10

true

Front 11

t/f... glucose transport into the liver is not possible unless insulin is present

Back 11

false

Front 12

t/f...insulin inhibits lipolysis

Back 12

true

Front 13

how does insulin keep cAMP levels low?

Back 13

by stimulating phosphodiesterase which breaks down cAMP

Front 14

what effect does insulin have on leptin levels?

Back 14

insulin increases leptin levels

Front 15

t/f... leptin acts as a satiety factor in humans

Back 15

false

Front 16

t/f... dietary fibre may lower cholesterol

Back 16

true

Front 17

what is the most effective fatty acid in lowering LDL cholesterol?

Back 17

linoleic acid

Front 18

which racial groups are at higher risk of familial hypercholesterolaemia?

Back 18

Lebanese, South African and French Canadians

Front 19

what has impaired function in familial hypercholesterolaemia?

Back 19

LDL receptors

Front 20

describe the dyslipidaemia in metabolic syndrome

Back 20

raised triglycerides
low HDL
LDL normal or marginally elevated

Front 21

what is the mechanism of action of sulphonylureas?

Back 21

potentiate glucose stimulated insulin release

Front 22

what is the most important side effect of sulphonylureas?

Back 22

hypoglycaemia

Front 23

what is the most important side effect of metformin?

Back 23

lactic acidosis

Front 24

what is the drug of first choice in obese Type 2 diabetes patients?

Back 24

metformin

Front 25

where does the alimentary tract start and end?

Back 25

oral cavity
anus

Front 26

where does the gastrointestinal tract begin?

Back 26

stomach

Front 27

what comprises the small intestine?

Back 27

duodenum
jejunum
ileum

Front 28

name the four parts of the colon

Back 28

ascending colon
transverse colon
descending colon
sigmoid colon

Front 29

which vertebral level does the oesophagus start at?

Back 29

C6

Front 30

t/f... the part of the oesophagus in the abdominal cavity is very long

Back 30

false, it is very short

Front 31

what is the only part of GI tract not in the abdominopelvic cavity?

Back 31

anal canal (in the perineum)

Front 32

what parts of the alimentary tract are derived from the foregut?

Back 32

oesophagus, stomach, proximal duodenum

Front 33

at which point does the foregut end?

Back 33

proximal duodenum (at entry of bile duct)

Front 34

which parts of the alimentary tract are derived from the midgut?

Back 34

distal duodenum
jejunum
ileum
ascending colon
2/3 transverse colon

Front 35

what is the end of the true gut?

Back 35

pectinate line (halfway along anal canal)

Front 36

which organs are associated with the foregut?

Back 36

liver
most of pancreas
spleen

Front 37

which organs are associated with the midgut?

Back 37

lower part of head of pancreas

Front 38

what is the arterial supply to structures derived from the foregut?

Back 38

coeliac trunk

Front 39

what is the arterial supply to structures derived from the midgut?

Back 39

superior mesenteric artery

Front 40

what is the arterial supply to structures derived from the hindgut?

Back 40

inferior mesenteric artery

Front 41

which vein drains the structures derived from the foregut?

Back 41

splenic vein

Front 42

which vein drains structures derived from midgut?

Back 42

superior mesenteric vein

Front 43

which vein drains structures derived from hindgut?

Back 43

inferior mesenteric vein

Front 44

what is the lymphatic drainage of the foregut structures?

Back 44

coeliac nodes

Front 45

what are the ganglia associated with the base of the coeliac trunk?

Back 45

coeliac ganglia

Front 46

t/f... the arteries supplying the GIT are unpaired

Back 46

true, they come off the front of the aorta in the midline

Front 47

the coeliac trunk is at which vertebral level?

Back 47

T12

Front 48

which artery comes off the aorta at vertebral level L1?

Back 48

superior mesenteric artery

Front 49

the inferior mesenteric artery is at which vertebral level?

Back 49

L3

Front 50

which artery comes off the aorta just above the superior border of the pancreas?

Back 50

coeliac trunk

Front 51

which artery comes off the aorta behind the neck of the pancreas?

Back 51

superior mesenteric artery

Front 52

which direction does the inferior mesenteric artery go after branching from the aorta?

Back 52

to the left

Front 53

which branch of the coeliac trunk goes to the right?

Back 53

common hepatic artery

Front 54

which two branches of the coeliac trunk go to the left?

Back 54

left gastric artery
splenic artery

Front 55

what is the arterial supply to the ascending colon?

Back 55

right colic artery

Front 56

which two branches of the superior mesenteric artery travel superiorly?

Back 56

inferior pancreaticoduodenal artery
middle colic artery

Front 57

which artery supplies the descending colon?

Back 57

left colic branch of inferior mesenteric artery

Front 58

what is the name of the inferior mesenteric artery in the pelvic cavity?

Back 58

superior rectal artery

Front 59

what is the marginal artery?

Back 59

anastomoses between colic arteries

Front 60

which two veins form the portal vein?

Back 60

splenic vein
superior mesenteric vein

Front 61

where do the splenic and superior mesenteric veins join to form the portal vein?

Back 61

behind neck of pancreas

Front 62

which vein does the inferior mesenteric vein usually join?

Back 62

splenic vein

Front 63

what does the portal vein travel in?

Back 63

lesser omentum (free edge)

Front 64

what are the sites of portacaval anastomoses?

Back 64

wall of lower oesophagus
wall of rectum and anal canal
umbilicus
retroperitoneal

Front 65

which side of the aorta is the cisterna chyli on?

Back 65

right

Front 66

which vertebral level is the cisternal chyli at?

Back 66

L1-2

Front 67

what is the role of parasympathetic innervation of the GIT?

Back 67

increased peristalsis and secretions

Front 68

what is the effect of sympathetic innervation of GIT?

Back 68

decreased peristalsis and secretions
vasoconstriction

Front 69

what is the parasympathetic supply to foregut and midgut?

Back 69

vagus nerve

Front 70

what is the parasympathetic supply to hindgut?

Back 70

pelvic splanchnic nerves (S2-4)

Front 71

what are the sympathetic splanchnic nerves to the GIT?

Back 71

thoracic
lumbar

Front 72

where does the foregut refer pain to?

Back 72

epigastrium

Front 73

where does the midgut refer pain to?

Back 73

umbilical region

Front 74

where does the hindgut refer pain to?

Back 74

hypogastrium

Front 75

which structures of the GIT may refer pain to the back?

Back 75

secondarily retroperitoneal structures

Front 76

which part of the gut has a ventral mesentery?

Back 76

foregut

Front 77

t/f... all parts of gut have a dorsal mesentery

Back 77

true

Front 78

t/f... all parts of gut have a ventral mesentery

Back 78

false, only the foregut has a ventral mesentery

Front 79

what does the lower free edge of the ventral mesentery become?

Back 79

free edge of falciform ligament and lesser omentum

Front 80

where do the liver and spleen develop?

Back 80

liver - ventral mesentery
spleen - dorsal mesentery

Front 81

which structures are suspended by mesentery?

Back 81

jejunum
ileum

Front 82

which structures are suspended by mesocolon?

Back 82

transverse colon
sigmoid colon

Front 83

which structures are secondarily retroperitoneal?

Back 83

duodenum (except first few cm)
ascending colon
descending colon

Front 84

where is the epiploic foramen?

Back 84

behind free edge of lesser omentum

Front 85

which section of the gut tube elongates quite rapidly?

Back 85

midgut loop

Front 86

where does the midgut loop herniate into?

Back 86

umbilical cord

Front 87

when does the physiological herniation of the midgut loop into the umbilical cord occur?

Back 87

between 6th and 10th week

Front 88

how does the gut tube rotate?

Back 88

270 degrees counterclockwise

Front 89

what stabilises the rotation of the gut tube?

Back 89

fusion of mesenteries

Front 90

how much fluid is contained in the peritoneal cavity?

Back 90

5-10ml

Front 91

where do the greater and lesser sac communicate?

Back 91

epiploic foramen

Front 92

t/f... intraperitoneal structures lie within the peritoneal cavity

Back 92

false, they are almost completely invested by peritoneum

Front 93

what is ascites?

Back 93

pathological accumulation of fluid in peritoneal cavity

Front 94

in what situation is the peritoneal cavity completely closed?

Back 94

male

Front 95

why do ascending infections of peritoneum occur in females?

Back 95

female peritoneal cavity communicates with the exterior via the genital tract

Front 96

what is the rectovesical fossa?

Back 96

fossa between rectum and bladder in peritoneal cavity

Front 97

which layer of peritoneum has somatic dermatomal sensory innervation?

Back 97

parietal peritoneum

Front 98

what divides the supracolic and infracolic compartments?

Back 98

transverse colon

Front 99

t/f... the pancreas is an intraperitoneal organ

Back 99

false, it is a retroperitoneal structure

Front 100

which organs are in the supracolic compartment?

Back 100

liver
gall bladder
spleen
stomach
pancreas
part of duodenum

Front 101

what attaches the liver to the anterior abdominal wall?

Back 101

falciform ligament

Front 102

the median umbilical ligament is the remnant of...

Back 102

the urachus (attaches bladder to umbilicus)

Front 103

the medial umbilical ligaments are...

Back 103

obliterated umbilical arteries

Front 104

what are the sites for internal herniae in the peritoneal cavity?

Back 104

foramen of Winslow
duodenojejunal flexure region
iliocaecal region
sigmoid mesentery region

Front 105

what is zygosis?

Back 105

fusion of two or more layers of peritoneum to form a single layer

Front 106

which structures become secondarily retroperitoneal?

Back 106

right and left colons, pancreas, duodenum

Front 107

what are the lateral umbilical ligaments?

Back 107

inferior epigastric vessels

Front 108

which areas does the oesophagus traverse?

Back 108

neck, thorax, abdomen

Front 109

which muscle prevents food or air from entering the oesophagus except when swallowing?

Back 109

cricopharyngeus (lower part of inferior constrictor muscle)

Front 110

what is the upper oesophageal sphincter?

Back 110

cricopharyngeus

Front 111

where does the pharynx become the oesophagus?

Back 111

lower border of cricoid cartilage (CV6)

Front 112

where does the epithelium of the oesophagus change from stratified squamous to columnar?

Back 112

at the squamo-columnar junction (Z-line)

Front 113

t/f... oesophageal mucosa is tightly connected to muscle

Back 113

false, it is loosely connected to muscle

Front 114

what type of muscle is present in the oesophagus?

Back 114

upper 1/3 - skeletal muscle
middle 1/3 - mixed
middle 1/3 - smooth muscle

Front 115

what is the function of the lower oesophageal sphincter?

Back 115

prevents reflux

Front 116

how long is the oesophagus?

Back 116

25cm

Front 117

what is located posterior to the oesophagus in its upper and lower parts?

Back 117

upper - C7 and thoracic vertebra
lower - thoracic aorta

Front 118

what is anterior to oesophagus?

Back 118

trachea, lymph nodes, pericardium and heart

Front 119

what are the constriction points of the oesophagus?

Back 119

upper oesophageal sphincter
arch or aorta and left principal bronchus
oesophageal hiatus

Front 120

what forms the oesophageal hiatus?

Back 120

encircling fibres of right crus of diaphragm

Front 121

t/f... the oesophagus passes through a tendinous part of the diaphragm

Back 121

false, it passes through a muscular part of the diaphragm

Front 122

what is the blood supply to the oesophagus in the
a) cervical part
b) thoracic part and
c)abdominal part?

Back 122

a) branches of inferior thyroid artery
b) branches of descending thoracic aorta
c) left gastric artery (branch of coeliac trunk)

Front 123

what is the venous drainage of the abdominal oesophagus?

Back 123

portal vein

Front 124

what is the venous drainage of the thoracic oesophagus?

Back 124

azygos vein -> SVC

Front 125

what is the venous drainage to the cervical oesophagus?

Back 125

thyroid veins -> SVC

Front 126

which part of the oesophagus drains to the deep cervical nodes?

Back 126

cervical part

Front 127

which part of the oesophagus drains to the mediastinal nodes?

Back 127

thoracic part

Front 128

which part of the oesophagus drains to the coeliac nodes?

Back 128

abdominal part

Front 129

which nerve forms an oesophageal plexus?

Back 129

vagus

Front 130

what is the innervation of the oesophagus?

Back 130

vagus and sympathetic trunk

Front 131

where does oesophageal pain refer?

Back 131

retrosternally

Front 132

t/f... trachea develops as anterior diverticulum from primitive foregut

Back 132

true

Front 133

what divides the fundus from the body of the stomach?

Back 133

a horizontal line drawn through the cardiac notch

Front 134

what is the part of the stomach distal to the angular notch?

Back 134

pyloric part (pyloric antrum and pyloric canal)

Front 135

what are the folds on the internal surface of the stomach called?

Back 135

rugae

Front 136

how many muscular layers does the stomach have?

Back 136

3 - longitudinal, circular and oblique layers (from superficial to deep)

Front 137

which layer forms the pyloric sphincter?

Back 137

circular layer of muscle

Front 138

which omentum attaches from the lesser curvature?

Back 138

lesser omentum

Front 139

what is the portal triad?

Back 139

portal vein
bile duct
proper hepatic artery

Front 140

what are the two parts of the lesser omentum?

Back 140

hepatogastric ligament
hepoatoduodenal ligament

Front 141

which three ligaments comprise the greater omentum?

Back 141

gastrophrenic ligament
gastrosplenic ligament
gastrocolic ligament

Front 142

what lies anterior to the stomach?

Back 142

liver
diaphragm
anterior abdominal wall

Front 143

what lies posterior to the stomach?

Back 143

lesser sac

Front 144

what is the superior boundary of the epiploic foramen?

Back 144

liver

Front 145

what is the inferior boundary of the epiploic foramen?

Back 145

duodenum

Front 146

what lies anterior to the epiploic foramen?

Back 146

lesser omentum with portal triad

Front 147

what lies posterior to the epiploic foramen?

Back 147

IVC

Front 148

what is the commonest type of hiatal hernia?

Back 148

sliding hiatal hernia

Front 149

how long is the duodenum?

Back 149

25cm

Front 150

which part of the duodenum is mobile?

Back 150

the first few cm (attached to omenta)

Front 151

how many parts does the duodenum have?

Back 151

4

Front 152

what are the parts of the duodenum and at what vertebral level are they situated?

Back 152

superior - L1
descending - L2
horizontal - L3
ascending - L2

Front 153

what side does the duodenum end on?

Back 153

left

Front 154

what side is the duodenum located on?

Back 154

mainly to right of midline

Front 155

which ducts open at the major duodenal papilla?

Back 155

bile duct
main pancreatic duct

Front 156

which duct opens at the minor duodenal papilla?

Back 156

accessory pancreatic duct

Front 157

what is the blood supply to the fundus of the stomach?

Back 157

short gastric arteries

Front 158

what supplies the lesser curvature of the stomach?

Back 158

R and L gastric arteries

Front 159

what supplies the greater curvature of the stomach?

Back 159

R and L gastroepiploic arteries

Front 160

which artery may be eroded by a peptic ulcer on posterior wall of stomach?

Back 160

splenic artery

Front 161

which artery may be eroded by a peptic ulcer on posterior wall of first part of duodenum?

Back 161

gastroduodenal artery

Front 162

what does the gastroduodenal artery branch into?

Back 162

superior pancreaticoduodenal artery
R gastroepiploic artery

Front 163

what is the venous drainage of the stomach and duodenum?

Back 163

portal vein

Front 164

what is the blood supply to the spleen?

Back 164

coeliac trunk

Front 165

what is the venous drainage of the spleen?

Back 165

portal vein

Front 166

what is the largest organ in the body?

Back 166

liver

Front 167

what covers the liver anteriorly in the midline?

Back 167

rectus abdominis

Front 168

how far down does the lung extend in the mid axillary line?

Back 168

rib 8

Front 169

how far down does the pleura extend in the right midaxillary line?

Back 169

rib 10

Front 170

how far down does the liver extend in the right midaxillary line?

Back 170

rib 11

Front 171

what are the two surfaces of the liver?

Back 171

diaphragmatic
visceral

Front 172

what separates the right and left lobes of the liver?

Back 172

falciform ligament (and ligamentum teres)

Front 173

what does the ligamentum teres attach the liver to?

Back 173

umbilicus

Front 174

what delineates the left and right anatomical lobes of the liver posteriorly?

Back 174

fissure for ligamentum teres and fissure for ligementum venosum

Front 175

what is ligamentum teres the remnant of?

Back 175

umbilical vein

Front 176

what divides the liver into its functional lobes?

Back 176

IVC and gall bladder

Front 177

where is the caudate lobe of the liver?

Back 177

between fissure for ligamentum venosum and IVC

Front 178

where is the quadrate lobe of the liver?

Back 178

between fissure for ligamentum teres and gall bladder

Front 179

what forms the falciform ligament?

Back 179

two layers of peritoneum

Front 180

what is the bare area of the liver?

Back 180

the area of the liver between the superior and inferior layers of coronary ligament not covered by peritoneum

Front 181

where does lymph from the bare area of the liver drain?

Back 181

through diaphragm to thoracic nodes

Front 182

what is the lymphatic drainage of the liver?

Back 182

via porta hepatis to coeliac nodes then to cisterna chyli

Front 183

what ligament is formed by the union of the superior and inferior layers of coronary ligament?

Back 183

right triangular ligament

Front 184

what is the most commonly infected area in the abdominal cavity?

Back 184

hepatorenal recess (pouch of Morrison)

Front 185

which structure of the portal triad is most posterior?

Back 185

portal vein

Front 186

which structure lies anteriorly on the left in the free edge of the lesser omentum?

Back 186

proper hepatic artery

Front 187

where is the bile duct located in the free edge of the lesser omentum?

Back 187

anterior and to the right

Front 188

what is another name for the portal triad?

Back 188

hepatic pedicle

Front 189

where does the blood from the portal vein and hepatic artery mix?

Back 189

sinusoids of the liver

Front 190

what is the venous drainage of the liver?

Back 190

hepatic vein -> IVC

Front 191

name some viscera that drain by the portal vein

Back 191

stomach
intestines
pancreas
spleen

Front 192

what forms the common hepatic duct?

Back 192

R and L hepatic ducts

Front 193

what joins the bile duct at the ampulla of Vater?

Back 193

main pancreatic duct

Front 194

where does the bile duct open into the duodenum?

Back 194

major duodenal papilla

Front 195

what is the storage capacity of the gall bladder?

Back 195

40-50ml

Front 196

what allows the release of bile by the gall bladder?

Back 196

contraction of smooth muscle in the wall of the gall bladder and relaxation of sphincters (when food is in the duodenum and cholecystekinin is released)

Front 197

when does the hepatic duct become the bile duct?

Back 197

when the cystic duct joins the hepatic duct

Front 198

t/f... the bile duct passes anterior to the duodenum

Back 198

false, it passes behind the duodenum

Front 199

what gives bile its colour?

Back 199

bile pigments (breakdown products of RBCs)

Front 200

what are bile salts important for?

Back 200

emulsifying fat

Front 201

where does the bile duct travel relative to the pancreas?

Back 201

in or behind the head of pancreas

Front 202

what lies anterior to the gallbladder fundus?

Back 202

anterior abdominal wall

Front 203

which two structures lie inferior to the gallbladder?

Back 203

duodenum and transverse colon

Front 204

why can gallbladder pain refer to the right shoulder region?

Back 204

branches of the phrenic nerve innervate the gallbladder

Front 205

what are the boundaries of Calot's triangle?

Back 205

cystic duct
liver
common hepatic duct

Front 206

where is the pancreas?

Back 206

between duodenum and spleen

Front 207

t/f... head of pancreas is higher than the tail

Back 207

false, the head is lower than the tail

Front 208

where do the superior mesenteric vessels lie relative to the pancreas?

Back 208

superior mesenteric vessels pass anterior to the uncinate process of the pancreas

Front 209

which part of the pancreas is in contact with the spleen?

Back 209

tail

Front 210

t/f... the pancreas is an intraperitoneal structure

Back 210

false, it is retroperitoneal

Front 211

where does the pancreatic duct begin?

Back 211

tail of pancreas

Front 212

where does the accessory pancreatic duct open?

Back 212

minor duodenal papilla

Front 213

what is a cause of jaundice involving the pancreas?

Back 213

cancer of the head of the pancreas

Front 214

where does the splenic artery travel relative to the pancreas?

Back 214

on the superior border of the pancreas

Front 215

where does the splenic vein travel relative to the pancreas?

Back 215

posterior to pancreas

Front 216

which vein is posterior to pancreas and below splenic vein?

Back 216

left renal vein

Front 217

which part of the pancreas is related to the lesser sac?

Back 217

upper part

Front 218

which part of the pancreas is related to the greater sac?

Back 218

lower part

Front 219

which part of the pancreas is not retroperitoneal?

Back 219

tail (in splenorenal ligament)

Front 220

where does pancreatic pain refer?

Back 220

epigastrium
back

Front 221

what is the most easily ruptured structure in the abdominal cavity?

Back 221

spleen

Front 222

where is the spleen located?

Back 222

left hypochondrium, posterior to midaxillary line, related to R9-11 (parallel to R10)

Front 223

t/f... spleen is intraperitoneal

Back 223

true

Front 224

what are the three impressions on the visceral surface of the spleen?

Back 224

gastric
renal
colic

Front 225

which ligament contains the splenic vessels?

Back 225

splenorenal ligament

Front 226

which ligament contains the short gastric and gastroepiploic vessels?

Back 226

gastrosplenic ligament

Front 227

where is the root of the mesentery?

Back 227

between the duodenojejunal junction and the ilioceacal junction

Front 228

which of the jejunum and ileum is more vascular?

Back 228

jejunum

Front 229

what are Peyer's patches?

Back 229

aggregated lymph follicles

Front 230

which of the jejunum and ileum is associated with more numerous arterial arcades

Back 230

ileum

Front 231

which of the jejunum and ileum has longer vasa recta?

Back 231

jejunum

Front 232

which part of the small intestine is associated with more arterial arcades and shorter vasa recta?

Back 232

ileum

Front 233

which colic flexure is higher and more fixed?

Back 233

left colic flexure

Front 234

which is longer and narrower, the ascending or descending colon?

Back 234

descending colon

Front 235

which parts of the large intestine are mobile?

Back 235

transverse and sigmoid

Front 236

which three structures characterise the colon?

Back 236

taeniae coli
haustrations
appendices epiploica

Front 237

what holds the left colic flexure in position?

Back 237

phrenocolic ligament

Front 238

how does the rectum curve (looking anteriorly)?

Back 238

right, left, right

Front 239

where does the rectum start and end?

Back 239

starts at SV3
ends at levator ani

Front 240

t/f... the rectum is entirely within the pelvic cavity

Back 240

true

Front 241

t/f... the upper 1/3 of rectum has peritoneum on front and sides

Back 241

true

Front 242

t/f... the lower 1/3 of rectum has peritoneum on its anterior surface

Back 242

false, the middle 1/3 has peritoneum on its front but the lower 1/3 has no peritoneum

Front 243

what are the anal valves?

Back 243

mucous membranes joining lower ends of anal columns

Front 244

what is the embryologic origin of the GIT below the pectinate line?

Back 244

skin-derived (cf hindgut derived)

Front 245

where do mucous glands open into the anus?

Back 245

anal sinuses

Front 246

what type of epithelium lines the anal canal above and below the pectinate line?

Back 246

above - columnar epithelium
below - stratified squamous epithelium

Front 247

what is the blood supply to the anal canal above the pectinate line?

Back 247

superior rectal artery (a branch of inferior mesenteric artery)

Front 248

what is the blood supply to the anal canal below the pectinate line?

Back 248

inferior rectal artery (branch of internal iliac artery)

Front 249

what is the venous drainage of the anal canal above and below the pectinate line?

Back 249

above - superior rectal vein -> portal vein
below - inferior rectal vein -> internal iliac vein

Front 250

what is the lymphatic drainage of the anal canal above the pectinate line?

Back 250

pararectal lymph nodes along superior rectal artery (eventually to inferior mesenteric lymph nodes)

Front 251

what is the lymphatic drainage of the anal canal below the pectinate line?

Back 251

superficial inguinal lymph nodes

Front 252

which anal sphincter is under voluntary control?

Back 252

external sphincter

Front 253

what is the true pelvis?

Back 253

the pelvis between the pelvic inlet and outlet

Front 254

what is the false pelvis?

Back 254

pelvis above pelvic inlet to the top of iliac crest

Front 255

t/f... the false pelvis is part of the abdominal cavity

Back 255

true

Front 256

what are the boundaries of the pelvic cavity?

Back 256

pelvic inlet to pelvic diaphragm

Front 257

what is the perineum?

Back 257

region below pelvic diaphragm to skin of lower trunk

Front 258

what shape is the pelvic inlet in males?

Back 258

heart shaped

Front 259

what separates the pelvic cavity from the perineum?

Back 259

pelvic diaphragm

Front 260

which pelvic opening is bony and ligamentous?

Back 260

pelvic outlet

Front 261

what is the widest orientation of the pelvic inlet?

Back 261

transverse

Front 262

what is the widest orientation of the pelvic outlet?

Back 262

anterioposterior

Front 263

what are the differences between the male and female bony pelvis?

Back 263

male - heart shaped pelvic inlet, small pelvic outlet, true pelvis narrows, subpubic angle sharp
female - oval shaped pelvic inlet, large pelvic outlet, wide and parallel true pelvis, rounded subpubic angle

Front 264

the greater sciatic notch is broader in males or females?

Back 264

females

Front 265

which ligaments stabilise the sacroiliac joint?

Back 265

sacrotuberous and sacrospinous ligaments

Front 266

which muscle passes through the greater sciatic foramen?

Back 266

piriformis

Front 267

where does the pudendal nerve pass out of the pelvis?

Back 267

greater sciatic foramen

Front 268

where does the pudendal nerve pass to enter the perineum?

Back 268

through the lesser sciatic foramen

Front 269

what are the two parts of the pelvic diaphragm?

Back 269

coccygeus
levator ani

Front 270

which part of levator ani is important in foecal continence?

Back 270

puborectalis

Front 271

what are the parts of levator ani?

Back 271

pubococcygeus
puborectalis
iliococcygeus

Front 272

where do both pubococcygeus and ileococcygeus attach?

Back 272

levator plate

Front 273

what lies immediately behind the pubic bone?

Back 273

bladder

Front 274

what lies immediately in front of the sacrum?

Back 274

rectum

Front 275

what are the peritoneal pouches in the pelvic cavity in males and females?

Back 275

males - rectovesical
females - rectouterine (Pouch of Douglas) and uterovesical

Front 276

what are the two triangles that make up the diamond shaped perineum?

Back 276

urogenital triangle and anal triangle

Front 277

what are the contents of the anal triangle?

Back 277

anal canal, anal sphincters, ischioanal fossa, pudendal canal

Front 278

what are the two layers of the urogenital triangle?

Back 278

perineal membrane (deep)
superficial perineal fascia

Front 279

where is the deep perineal pouch?

Back 279

between pelvic diaphragm and perineal membrane

Front 280

where is the superficial perineal pouch?

Back 280

between perineal membrane and superficial fascia of perineum

Front 281

what lies in front of the anal canal in both sexes?

Back 281

perineal body

Front 282

what is the main artery supplying the perineum?

Back 282

internal pedundal artery

Front 283

what is the main artery supplying the pelvic viscera?

Back 283

internal iliac artery

Front 284

what is the venous drainage of the pelvis and perineum?

Back 284

valveless venous plexus -> internal iliac veins (some drainage to internal vertebral venous plexus via sacral veins)

Front 285

what is the lymphatic drainage of the skin of the perineum?

Back 285

superficial inguinal nodes

Front 286

what innervates the pelvic viscera?

Back 286

inferior hypogastric plexuses (lateral to pelvic viscera below peritoneum)

Front 287

which nerve supplies the muscles of the perineum?

Back 287

pudendal nerve

Front 288

what is the parasympathetic supply to the pelvic viscera?

Back 288

S2-4 via pelvic splanchnic nerves

Front 289

pain afferents travel with which nerves is viscus is above the pelvic pain line?

Back 289

sympathetics (T1-L2) - referred to dermatomes

Front 290

pain afferents travel with which nerves if viscus is below pelvic pain line?

Back 290

parasympathetics (S2-4)

Front 291

where is the pelvic pain line?

Back 291

halfway along sigmoid colon in GIT
lower limit of peritoneum

Front 292

what is the general function of epithelium?

Back 292

separate inside world from outside world

Front 293

what makes up the basolateral membrane?

Back 293

basal membrane and lateral membrane

Front 294

t/f... basal and lateral membranes are physiologically indistinguishable

Back 294

true

Front 295

which epithelial membrane contains the microvilli?

Back 295

apical membrane

Front 296

which epithelial membrane has higher concentrations of cholesterol?

Back 296

apical membrane

Front 297

where is the Na/K ATP-ase (sodium pump) found?

Back 297

basolateral membrane

Front 298

what are two functions of tight junctions?

Back 298

cell-to-cell adhesion
barrier

Front 299

are tight junctions located closer to the apical or basal membrane?

Back 299

apical

Front 300

what is the intercellular space?

Back 300

space between two lateral membranes of neighbouring cells

Front 301

what is the direction of secretion?

Back 301

inside world to outside world

Front 302

what process occurs across epithelium from outside world to inside world?

Back 302

absorption

Front 303

what type of transport occurs between cells across tight junctions?

Back 303

paracellular transport

Front 304

what type of transport occurs through cells?

Back 304

transcellular

Front 305

what are the two types of transcellular transport?

Back 305

active and passive

Front 306

t/f... paracellular transport is always active

Back 306

false, it is always passive

Front 307

is water transport ever active?

Back 307

usually passive following solute transport but some transporters move water and solute at the same time driven by the sodium gradient

Front 308

what is the major mechanism by which water transport occurs in the gut?

Back 308

NaCl absorption

Front 309

what is the mechanism of NaCl absorption that occurs in villous cells in small intestine?

Back 309

electroneutral

Front 310

which two exchangers act as if they are coupled during electroneutral NaCl absorption?

Back 310

Na/H exchanger
Cl/HCO3 exchanger

Front 311

what pushes the chloride out of the cell in electroneutral NaCl absorption?

Back 311

HCO3 gradient out of the cell

Front 312

why is electroneutral NaCl absorption called "electroneutral"?

Back 312

there is no net movement of charge across the apical membrane

Front 313

how does sodium cross the basolateral membrane?

Back 313

sodium pump (3Na/2K)

Front 314

how does chloride cross the basolateral membrane?

Back 314

partially by KCl cotransport
partially by chloride channels

Front 315

where does electroneutral NaCl absorption occur?

Back 315

from duodenum to halfway along colon

Front 316

where does the electrogenic mechanism of NaCl absorption occur?

Back 316

distal colon

Front 317

how does sodium enter the cell in electrogenic NaCl absorption?

Back 317

epithelial Na channels

Front 318

how does sodium leave the cell in electrogenic NaCl absorption?

Back 318

sodium pump

Front 319

t/f... K is lost partially across the apical and partially across the basolateral membrane in electrogenic NaCl absorption

Back 319

true

Front 320

what drives the movement of chloride out of the lumen and K into the cell in electrogenic NaCl absorption?

Back 320

the large negative charge generated by the movement of sodium out of the lumen

Front 321

what drug blocks epithelial Na channels?

Back 321

amiloride

Front 322

which mechanism of NaCl absorption tends not to transport water?

Back 322

electrogenic

Front 323

what is the usual role of the NaK2Cl cotransporter?

Back 323

volume control

Front 324

what is the role of the NaK2Cl cotransporter in epithelial cells?

Back 324

drive Na and Cl secretion

Front 325

what keeps the sodium concentration inside the cell low?

Back 325

NaKATPase

Front 326

what keeps intracellular chloride high?

Back 326

NaK2Cl cotransporter

Front 327

what draws Na (and a bit of K) across the tight junctions in NaCl secretion?

Back 327

the negative charge created by chloride exiting cells through Cl channels

Front 328

t/f... tight junctions are selective for Na and K over Cl

Back 328

true

Front 329

what type of chloride channel is activated by protein kinase A?

Back 329

CFTR channels (found in human crypts)

Front 330

what type of chloride channel is activated by intracellular calcium?

Back 330

Ca activated Cl channels (salivary, sweat glands)

Front 331

where does NaHCO3 secretion occur?

Back 331

bile ducts
pancreatic ducts
duodenal mucosa

Front 332

t/f... intracellular concentration of HCO3 is high

Back 332

true

Front 333

which three proteins are used to maintain intracellular bicarb concentration?

Back 333

NaH exchanger
NaHCO3 cotransporter
H ATPase

Front 334

what is the role of SGLT1?

Back 334

cotransports Na and glucose

Front 335

t/f... GLUT2 is highly selective

Back 335

false

Front 336

t/f... SGLT1 is highly selective

Back 336

true

Front 337

does fructose enter cells actively or passively?

Back 337

passively via GLUT5

Front 338

what transports ACE inhibitors and cephalosporins?

Back 338

PepT1

Front 339

what does the PepT1 transporter transport?

Back 339

proton and a peptide (di and tri amino acids)

Front 340

what is wasting?

Back 340

weight is 20% or more below ideal weight for height

Front 341

what are the five basic mechanisms of failure to thrive?

Back 341

inadequate intake
decreased absorption
excessive losses
abnormal utilisation
increased need

Front 342

t/f... the yolk sac becomes part of the umbilical cord

Back 342

true

Front 343

t/f... the gut and its derivatives are derived from endoderm

Back 343

true

Front 344

which parts of the gut have a dorsal mesentery?

Back 344

all parts

Front 345

which parts of the gut have a ventral mesentery?

Back 345

foregut only

Front 346

what is mesentery?

Back 346

double fold of mesoderm

Front 347

which organs are foregut derived?

Back 347

liver, gallbladder, pancreas

Front 348

when does the stomach develop?

Back 348

between the 4th and 8th week

Front 349

which wall of the stomach grows faster?

Back 349

dorsal wall

Front 350

when does the stomach undergo a 90 degree rotation?

Back 350

7th week

Front 351

which mesentery does the liver develop in?

Back 351

ventral mesentery

Front 352

which structures of the GIT are initially retroperitoneal?

Back 352

thoracic oesophagus
rectum

Front 353

which structures of the GIT are secondarily retroperitoneal?

Back 353

duodenum
pancreas
descending colon
ascending colon

Front 354

when do the liver, gallbladder and pancreas develop?

Back 354

4th to 6th week

Front 355

t/f... the pancreas bud sprouts first

Back 355

false, the liver bud sprouts first

Front 356

what is the endodermal thickening that will form the gallbladder and cystic duct called?

Back 356

cystic diverticulum

Front 357

which viscus forms through the fusion of a ventral and dorsal bud?

Back 357

pancreas

Front 358

what does the dorsal pancreatic bud become?

Back 358

uncinate process of pancreas

Front 359

what is the effect of thyroid hormone on mitochondria?

Back 359

increase size and number

Front 360

what is the normal homeostatic range for blood glucose?

Back 360

3-5 mmol/L

Front 361

what hormone is stimulated by fasting to make nutrients available for cells?

Back 361

glucagon (and other counter-regulatory hormones - cortisol, GH and adrenaline)

Front 362

what stimulates insulin secretion?

Back 362

increased glucose concentration
increased amino acid concentration
food intake (-> GI hormones, parasympathetic stimulation)

Front 363

what is the major control of insulin release from the beta islet cells of the pancreas?

Back 363

increased blood glucose concentration

Front 364

which hormone/drugs inhibit the secretion of insulin?

Back 364

somatostatin
phenytoin
thiazide diuretics

Front 365

which organ is exposed to a higher concentration of insulin (and glucagon) than peripheral tissues?

Back 365

liver (insulin released to portal circulation)

Front 366

what are the effects of insulin on glucose?

Back 366

increase uptake (especially by muscle, fat)
increase glycogen synthesis
decrease glycogenolysis

Front 367

what are the effects of insulin on fat?

Back 367

increase uptake (increase LDL receptor)
increased triglyceride
inhibits lipolysis

Front 368

what are the effects of insulin on proteins?

Back 368

increase amino acid uptake
increase protein synthesis
decrease protein breakdown

Front 369

in which part of the brain is glucose transport insulin dependent?

Back 369

satiety centre

Front 370

where is glucose absorption insulin independent?

Back 370

intestine

Front 371

when is glucose uptake into muscle insulin independent?

Back 371

during exercise

Front 372

what stimulates release of counter regulatory hormones (to insulin)?

Back 372

fasting

Front 373

t/f... all the counter-regulatory hormones increase protein breakdown

Back 373

false, growth hormone does not

Front 374

which cells release glucagon?

Back 374

alpha cells

Front 375

what stimulates glucagon release?

Back 375

decreased glucose
increased amino acids
decreased fatty acids

Front 376

what are the effects of glucagon on carbohydrate?

Back 376

increase glycogen breakdown
increase gluconeogenesis

Front 377

what is the effect of glucagon on protein?

Back 377

protein breakdown (amino acids to liver for gluconeogenesis)

Front 378

what are the effects of glucagon on fats?

Back 378

lipolysis
ketogenesis (liver)

Front 379

what is the mechanism of blurred vision in diabetes?

Back 379

hyperglycaemia and sorbitol accumulation

Front 380

t/f... type 1 DM patients develop complications earlier than T2 patients

Back 380

false, it is unusual for complications to be clinically significant in the first five years in T1 whereas complications may be present from diagnosis in T2

Front 381

when do patients experience symptoms of diabetic retinopathy?

Back 381

when there is macular involvement or if new vessels bleed

Front 382

what are the two types of diabetic retinopathy?

Back 382

non-proliferative
proliferative

Front 383

when will diabetic nephropathy be symptomatic?

Back 383

when creatinine is much elevated

Front 384

how are the early stages of diabetic nephropathy detected?

Back 384

microalbuminuria and proteinuria

Front 385

what is the first clinical sign of diabetic damage to the kidney?

Back 385

microalbuminuria

Front 386

what will help slow the progression of diabetic nephropathy in hypertensive diabetics?

Back 386

effective antihypertensive treatment

Front 387

what is seen histologically in diabetic nephropathy?

Back 387

basement membrane thickening
deposition of matrix in glomerulus
glomerular sclerosis

Front 388

what can artificially elevate microalbumin?

Back 388

exercise
fever

Front 389

which antibodies might be present in T1DM?

Back 389

islet cells
GAD (glutamic acid decarboxylase)
IA2
insulin

Front 390

t/f... most patients with T1DM will have a positive family history

Back 390

false

Front 391

t/f... unsaturated fatty acids are liquids at body temperature

Back 391

true

Front 392

what comprises triglycerides?

Back 392

glycerol + fatty acids

Front 393

what is the major form of fat in diet and fat stores?

Back 393

TAGs

Front 394

what activates hormone-sensitive lipase?

Back 394

adrenaline
glucagon

Front 395

what inhibits hormone-sensitive lipase?

Back 395

insulin

Front 396

t/f... insulin inhibits glucagon secretion

Back 396

true

Front 397

what is the primary effect of insulin on protein?

Back 397

reduced proteolysis

Front 398

what is the action of cortisol on muscle?

Back 398

promotes proteolysis and transfer of amino acids to liver
promotes conversion of amino acids to glucose

Front 399

what is the effect of insulin on fatty acids after hepatic uptake in DKA?

Back 399

insulin blocks transfer of fatty acids into mitochondrial matrix

Front 400

what biochemical change will be present early in DKA?

Back 400

high potassium early (but intracellular K depletion)

Front 401

t/f... low GI meals reduce postprandial insulin

Back 401

true

Front 402

t/f... low GI diets improve insulin sensitivity

Back 402

true

Front 403

will a meal that is slowly digested induce more or less satiety than a meal that is rapidly digested?

Back 403

more satiety

Front 404

what type of diet helps prevent T2DM?

Back 404

low fat

Front 405

which type of carbs improve glycaemic control?

Back 405

low GI

Front 406

which type of diet improves lipids?

Back 406

mediterranean-style diets

Front 407

which primary pathogens are associated with cellulitis?

Back 407

S. pyogenes
S. aureus

Front 408

where are insulin receptors found?

Back 408

hepatocytes
skeletal muscle
fat cells

Front 409

which IRS isoforms are major mediators of insulin action?

Back 409

IRS 1
IRS 2

Front 410

how can insulin resistance be reversed?

Back 410

weight loss and exercise

Front 411

what do adipocytes release at extreme TAG levels?

Back 411

monocyte chemotactic protein-1

Front 412

what do adipose macrophages release?

Back 412

TNF alpha

Front 413

what is the effect of TNF alpha on PPARgamma function in fat?

Back 413

suppression

Front 414

what is the role of PPARgamma modulators in fat and muscle?

Back 414

upregulate insulin sensitivity

Front 415

what do PPARs respond to?

Back 415

eicosanoids and in some cases FAs

Front 416

what are the therapeutic PPARgamma modulators?

Back 416

thiazolidinediones (e.g. rosiglitazone)

Front 417

what triggers release of ADH from posterior pituitary?

Back 417

serum osmolality

Front 418

what are the two types of diabetes insipidus and the differences between them?

Back 418

cranial DI - failure of ADH secretion by posterior pituitary
nephrogenic DI - resistance to action of ADH at kidney

Front 419

what are the phenotypic features of pseudohypoparathyroidism?

Back 419

short stature
shortened metacarpals/metatarsals
deformities of hands and feet

Front 420

what are the features of metabolic syndrome?

Back 420

insulin resistance or T2DM
central obesity
hypertension
dyslipidaemia
atherosclerosis and CV disease

Front 421

what are the two theories explaining insulin deficiency in T2DM?

Back 421

glucose toxicity
amylin

Front 422

what are the monozygotic twin concordance rates for both types of diabetes?

Back 422

T1 - 15-50%
T2 - >90%

Front 423

what percentage of diabetes is caused by a single gene defect?

Back 423

1-2%

Front 424

what deformity is associated with diabetic foot disease?

Back 424

Charcot's joint

Front 425

what is the treatment for hyperosmolar coma?

Back 425

rehydration
careful infusion of insulin
potassium

Front 426

which oral hypoglycamics increase insulin release?

Back 426

sulfonylureas
insulin secretagogues

Front 427

which oral hypoglycaemics increase insulin sensitivity?

Back 427

biguinides (metformin)
thiozoladinediones

Front 428

which oral hypoglycaemic decreases sugar absorption from gut?

Back 428

acarbose

Front 429

what is a normal HbA1c?

Back 429

3.5-6%

Front 430

what is the BSL for a hypo?

Back 430

<3.7

Front 431

what percentage of genetic contribution is associated with obesity?

Back 431

30-70%

Front 432

which lipoproteins are the largest?

Back 432

chylomicrons

Front 433

which apoprotein on chylomicrons promotes LPL activity?

Back 433

Apo CII

Front 434

what converts chylomicrons to chylomicron remnants?

Back 434

action of lipoprotein lipase (depletes TAGs)

Front 435

where are VLDLs synthesised?

Back 435

liver

Front 436

what happens to VLDL remnants?

Back 436

taken up by liver or converted to LDL in circulation

Front 437

familial hypercholesterolaemia is associated with deficiency of what?

Back 437

LDL receptors

Front 438

how do statins lower LDL levels?

Back 438

suppress cholesterol synthesis (esp. in liver)
hepatocytes - increased expression of LDL receptors
LDLs taken up from plasma

Front 439

what are the statins?

Back 439

HMG CoA reductase inhibitors

Front 440

what does HMG CoA reductase do?

Back 440

catalyses a key step in cholesterol synthesis

Front 441

what is the effect of diabetes on VLDLs?

Back 441

elevated VLDLs resulting in increased serum TAGs

Front 442

what is the effect of diabetes on lipoprotein lipase activity?

Back 442

reduced activity

Front 443

what is the mechanism of action of fibrates?

Back 443

activate PPARalpha (suppresses VLDL production, enhances activity of LPL, TAGs fall)

Front 444

what percentage of anterior pituitary cells are corticotrophs?

Back 444

20%

Front 445

which zone of the adrenal gland secretes mineralocorticoids?

Back 445

zona glomerulosa

Front 446

which zones of the adrenal cortex secrete glucocorticoids and androgens?

Back 446

zona fasciculata
zona reticularis

Front 447

t/f... cortisol has a maximum output beyond which higher concentrations will not be achieved despite ACTH

Back 447

true

Front 448

what are the effects of cortisol on carbohydrate metabolism?

Back 448

gluconeogenesis
reduces rate of glucose utilisation by cells
increased glucose in blood

Front 449

what are the effects of cortisol on protein metabolism?

Back 449

reduced protein in cells (except for liver where protein is increased)

Front 450

what is the effect of cortisol on fat metabolism?

Back 450

increased lipolysis (in presence of GH and ACTH)

Front 451

what are the pharmacological actions of cortisol?

Back 451

anti-inflammatory
immunity

Front 452

what stimulates secretion of cortisol?

Back 452

hypoglycaemia
emotional stresses
drive for diurnal rhythm
trauma

Front 453

which happen first in glucocorticoid excess, tissue or metabolic changes?

Back 453

metabolic changes

Front 454

what is the rate limiting step in steroid synthesis?

Back 454

conversion of cholesterol to pregnenolone

Front 455

how is cortisol transported in plasma?

Back 455

bound to cortisol binding globulin (transcortin) and albumin

Front 456

which steroid has the highest glucocorticoid activity?

Back 456

dexamethasone

Front 457

what is inflammation of
a) small bowel
b) large bowel
c) gall bladder?

Back 457

a) Crohn's disease
b) ulcerative colitis
c) cholecystitis

Front 458

how will the pancreas appear on CT/MRI if there is
a) acute inflammation
b) chronic inflammation?

Back 458

a) swollen
b) shrunken

Front 459

what might a mass at the head of pancreas obstruct?

Back 459

bile duct

Front 460

what other organ might be affected by a mass at the tail of the pancreas?

Back 460

spleen

Front 461

what is the normal span of a spleen?

Back 461

11+/-2cm

Front 462

what is the endocrine component of the pancreas?

Back 462

islets of Langerhans

Front 463

which hormones are secreted by the islets of Langerhans?

Back 463

insulin
glucagon
somatostatin

Front 464

what percentage of the weight of the pancreas is made up of islets of Langerhans?

Back 464

2%

Front 465

what percentage of the weight of the pancreas is made up of the exocrine component?

Back 465

96%

Front 466

how much pancreatic juice does the exocrine pancreas produce each day?

Back 466

approx 2L

Front 467

what do the pancreatic acini secrete?

Back 467

isotonic NaCl rich fluid and a wide range of proteins

Front 468

what are the precursors of digestive enzymes called?

Back 468

zymogens

Front 469

where are the zymogens normally acivated?

Back 469

gut lumen

Front 470

what activates zymogens in the gut lumen?

Back 470

activation of trypsinogen by enteropeptidase (a brush border protease)

Front 471

t/f... colipase is an enzyme

Back 471

false, it is a cofactor required for efficient binding of pancreatic lipase to micelles

Front 472

how is colipase secreted?

Back 472

as a precursor - procolipase

Front 473

what does pancreatic secretory trypsin inhibitor (PSTI) do?

Back 473

prevents premature activation of zymogens by any active trypsin formed prior to their secretion

Front 474

what is required for maximal activity of pancreatic lipase in hydrolysing triglycerides?

Back 474

colipase

Front 475

what stimulates pancreatic acinar fluid and electrolyte secretion?

Back 475

cholecystokinin and acetylcholine

Front 476

how do both cholecystekinin and acetylcholine act?

Back 476

by increasing intracellular free calcium

Front 477

what is secreted by pancreatic ducts?

Back 477

NaHCO3 rich fluid and low amounts of mucoprotein

Front 478

what stimulates the secretion of NaHCO3 by pancreatic ducts?

Back 478

secretin

Front 479

how does secretin act?

Back 479

increasing intracellular cAMP

Front 480

malabsorption of which nutrient will occur first?

Back 480

fat

Front 481

fat malabsorption does not occur until lipase and colipase secretion are less than ... of average normal values?

Back 481

2%

Front 482

at what pH is pancreatic lipase active?

Back 482

alkaline pH

Front 483

why does failure of bicarb secretion (e.g. in CF) exacerbate fat malabsorption?

Back 483

pancreatic lipase is strongly pH sensitive and is only active at alkaline pH

Front 484

name some congenital conditions in which protein malabsorption can occur due to pancreatic insufficiency

Back 484

CF
Schwachman syndrome (congenital hypoplasia of the pancreas)
congenital trypsinogen deficiency

Front 485

t/f... fat digestion is impaired in coeliac disease

Back 485

false, fat digestion is unimpaired but there is impairment of absorption of products of digestion, fatty acids and monoglycerides

Front 486

what are the major carbohydrates that can be digested by humans?

Back 486

starch
disaccharides
monosaccharides

Front 487

what do salivary and pancreatic amylase do?

Back 487

attack starch by attacking linear chains of at least 6 glucose moieties linked by alpha-1,4 bonds

Front 488

what inactivates salivary amylase?

Back 488

low pH in stomach

Front 489

what is released when pancreatic amylase attacks starch?

Back 489

maltose
maltotriose
alpha-limit dextrins (contain alpha-1,6 bonds that cannot be attacked by amylase)

Front 490

which digestive enzyme cleaves alpha-1,4 bonds to release glucose?

Back 490

glucoamylase

Front 491

which digestive enzyme cleaves alpha-1,6 bonds and glucose-alpha-1,2-fructose bonds?

Back 491

sucrase-isomaltase

Front 492

what does lactase break down?

Back 492

glucose-beta-1,4-galactose bonds to break down lactose

Front 493

what are the small intestine brush border enzymes involved in the digestion of carbohydrates?

Back 493

glucoamylase
sucrase-isomaltase
lactase
and others

Front 494

what happens to dietary fibre?

Back 494

reaches the large bowel intact
fermented by colon microflora releasing short chain fatty acids and gases

Front 495

what is the initial enzyme involved in the digestion of protein?

Back 495

pepsin

Front 496

what secretes the endopeptidase pepsin?

Back 496

chief cells of the gastric mucosa

Front 497

what is the inactive precursor of pepsin?

Back 497

pepsinogen

Front 498

what activates pepsinogen?

Back 498

low pH (<3)

Front 499

what degrades proteins to oligopeptides in the small intestine?

Back 499

exopeptidases and endopeptidases

Front 500

when are exopeptidases and endopeptidases activated?

Back 500

when they reach the duodenal lumen

Front 501

what activates trypsinogen?

Back 501

brush border enzyme enteropeptidase

Front 502

what activates most of the proenzymes in the duodenal lumen involved in protein digestion?

Back 502

trypsin

Front 503

what degrades oligopeptides to their constituent amino acids?

Back 503

brush border enzymes including endopeptidases, aminopeptidases, carboxypeptidases and dipeptidases

Front 504

t/f... oligopeptides are either fully degraded by brush border enzymes or transported into enterocytes and then degraded to amino acids

Back 504

true

Front 505

what secretes bile salts?

Back 505

liver

Front 506

what is required for the formation of micelles?

Back 506

presence of bile salts

Front 507

the formation of what is required for digestion of lipids?

Back 507

micelles

Front 508

where do micelles form?

Back 508

lumen of small intestine

Front 509

what breaks down triglycerides?

Back 509

pancreatic lipase in the presence of colipase

Front 510

what is released when trigylcerides are broken down?

Back 510

2-monoacylglycerol and fatty acids

Front 511

how are cholesterol esters digested?

Back 511

hydrolysed by pancreatic enzyme cholesterol esterase

Front 512

what breaks down phospholipids?

Back 512

phospholipase A2

Front 513

what is released when phospholipids are broken down?

Back 513

fatty acids and lysophospholipids

Front 514

what transports glucose and galactose across the apical membrane of small intestinal villous cells?

Back 514

sodium glucose cotransporter SGLT1

Front 515

what transports fructose across the apical membrane of small intestinal villous cells?

Back 515

GLUT5

Front 516

t/f... fructose transport across the apical membrane is active

Back 516

false, it is passive

Front 517

what transports the monosaccharides out of the small intestinal villous cells?

Back 517

GLUT2

Front 518

where are monsaccharides metabolised?

Back 518

liver

Front 519

what are the products of carbohydrate digestion?

Back 519

glucose (80%)
fructose (14%)
galactose (5%)

Front 520

what are the products of protein digestion?

Back 520

di- and tri-peptides and amino acids

Front 521

in general, the transporters for which amino acids are Na-coupled?

Back 521

acidic and dipolar amino acids

Front 522

which amino acids are associated with transporters that are not sodium-coupled?

Back 522

basic amino acids

Front 523

what transports small peptides across the apical membrane of small intestinal villous cells?

Back 523

a variety of secondary active transporters that cotransport them with H

Front 524

what happens to peptides inside small intestinal villous cells?

Back 524

peptides are broken down by cytosolic hydrolases to amino acids

Front 525

what transmits amino acids to the liver?

Back 525

portal vein

Front 526

what are the products of triglyceride digestion?

Back 526

monoglyceride and two fatty acids

Front 527

what is the role of micelles in triglyceride absorption?

Back 527

maintain the concentration of MG and FA in the unstirred aqueous fluid layer in contact with apical membrane

Front 528

what happens to monoglyceride and long chain fatty acids in the enterocyte?

Back 528

they are resynthesised in the er into triglycerides and bound to specific apolipoproteins to form chylomicrons which are then secreted and enter the lymphatics

Front 529

what happens to medium chain fatty acids following absorption?

Back 529

transported to liver via portal circulation

Front 530

how does cholesterol cross the apical membrane?

Back 530

specific carrier protein

Front 531

what happens to cholesterol in the enterocyte?

Back 531

re-esterified and secreted as a cholesterol ester into lymphatics

Front 532

what are the products of phospholipid digestion?

Back 532

FA
lyso-phospholipids

Front 533

what happens to lyso-phospholipid in the enterocyte?

Back 533

some is used to reform phospholipids which are incorporated into chylomicrons and VLDLs
remainder is broken down to water soluble metabolites and transported to liver via portal circulation

Front 534

which grains should be avoided on a gluten free diet?

Back 534

wheat
barley
rye

Front 535

what structure will perform jejunal functions following resection of the jejunum?

Back 535

ileum

Front 536

what is generally expected if more than 100cm of ileum is removed?

Back 536

malabsorption

Front 537

t/f... feeding is not recommended in the case of a true small bowel obstruction

Back 537

true

Front 538

how is thiamine absorbed in the small intestine?

Back 538

active sodium and energy dependent carrier mechanism or by passive diffusion

Front 539

where are riboflavin and the flavine nucleotides absorbed?

Back 539

proximal jejunum

Front 540

how are riboflavin and the flavine nucleotides absorbed?

Back 540

saturable transport system following release from food proteins by gastric acidification

Front 541

t/f... B-6 undergoes dephosphorylation before absorption

Back 541

true

Front 542

where are niacin and B-6 assimilated?

Back 542

jejunum

Front 543

how are niacin and B-6 assimilated?

Back 543

facilitated and/or passive diffusion

Front 544

how happens to ascorbic acid before it is transported across the enterocyte membrane by an energy dependent process?

Back 544

undergoes conversion to the dihydro derivative

Front 545

which two vitamins have specific intestinal transport mechanisms?

Back 545

B-12 and folate

Front 546

describe the steps leading up to the absorption of vitamin B-12 in the ileum

Back 546

B-12 is freed from food linkages by gastric acid and then binds to salivary R polypeptides.
the R polypeptides are hydrolysed from B-12 by pancreatic proteases, enabling B-12 to bind to IF secreted from gastric parietal cells which bond to specific ileal receptors where B-12 is absorbed

Front 547

what transports B-12 through the mucosal cell?

Back 547

carrier protein - transcobalamin II

Front 548

what process is required before folate can be absorbed?

Back 548

cleavage from polyglutamates in food by upper jejunal brush border conjugases

Front 549

in what situations is conjugase action impaired?

Back 549

coeliac disease
drug exposure (salazopyrine, dilantin, alcohol)

Front 550

how are fat soluble vitamins absorbed?

Back 550

incorporated in bile salt micelles in upper jejunum

Front 551

which fat soluble vitamins require prior hydrolysis to enhance their absorption?

Back 551

retinyl esters

Front 552

which fat soluble vitamin requires both bile and pancreatic enzymes for absorption?

Back 552

Vitamin K

Front 553

how are most trace metals absorbed?

Back 553

passive diffusion

Front 554

in what form is iron absorbed?

Back 554

ferrous

Front 555

how is ferrous iron absorbed?

Back 555

via brush border of upper SI cells: it bonds to a membrane receptor protein and absorption may be facilitated by a cytosolic apotransferrin

Front 556

which foods impair iron absorption?

Back 556

milk protein, tea, coffee, phytates

Front 557

what is lactose?

Back 557

disaccharide found in mammalian milk

Front 558

t/f... lactose is absorbed by small bowel after it is hydrolysed into galactose and glucose

Back 558

true

Front 559

what catalyses the hydrolysis of lactose?

Back 559

lactase

Front 560

where is lactase expressed?

Back 560

in brush border of small intestinal (especially jejunal) villous epithelial cells

Front 561

what does maltase act on?

Back 561

maltose
maltotriose

Front 562

what does sucrase act on?

Back 562

sucrose

Front 563

what does isomaltase act on?

Back 563

branched chain units of glucose derived by the action of alpha-amylase on glycogen or amylopectin

Front 564

what is maltose?

Back 564

glucose-glucose (alpha-1,4 linkage)

Front 565

what is maltotriose?

Back 565

glucose trisaccharide (alpha-1,4 linkage)

Front 566

what is starch?

Back 566

straight chain alpha-1,4 polymer of glucose

Front 567

what breaks down starch?

Back 567

salivary and pancreatic alpha-amylase

Front 568

what happens to lactose in the colon?

Back 568

lactose is metabolised by bacteria yielding hydrogen gas

Front 569

what are the symptoms of lactose malabsorption?

Back 569

abdominal pain
abdominal distension
increased flatus
audible borborygmi
watery diarrhoea

Front 570

what is the mechanism of the symptoms of lactose malabsorption?

Back 570

osmotic effect of unabsorbed lactose and fermentation of unabsorbed carbohydrates by colonic bacteria

Front 571

t/f... malabsorption of carbohydrates diminishes the nutritional value of milk

Back 571

true

Front 572

what is the result of severe lactose intolerance in infants?

Back 572

failure to thrive

Front 573

describe the stool of lactose malabsorption

Back 573

watery
acidic
contain reducing substances

Front 574

what is the osmotic gap of osmotic diarrhoea?

Back 574

100 or more

Front 575

what is the osmotic gap of secretory diarrhoea?

Back 575

less than 50

Front 576

how is stool osmotic gap calculated?

Back 576

stool osmolality minus 2x(stool Na+stool K)

Front 577

which infants are unable to digest lactose in breast milk?

Back 577

those with congenital lactase deficiency

Front 578

in what percentage of the world's population does lactase activity persist into adult life?

Back 578

30%

Front 579

what will a small intestinal biopsy show in non-persistence of lactase?

Back 579

normal except for low levels of lactase (normal levels of other disaccharidases)

Front 580

t/f... secondary lactase deficiency is irreversible

Back 580

false, it is usually a transient and reversible disorder

Front 581

name one of the most common causes of secondary lactase deficiency and lactose intolerance in children

Back 581

viral gastroenteritis

Front 582

where is lymphoid tissue found in the gastrointestinal, respiratory and genitourinary tracts?

Back 582

lamina propria and submucosa

Front 583

how is lymphoid tissue arranged in the bronchi?

Back 583

diffuse lymphoid aggregates

Front 584

which cells are present in respiratory epithelium for processing of antigens?

Back 584

dendritic cells

Front 585

how is lymphoid tissue arranged in the lamina propria of the intestinal wall?

Back 585

diffuse accumulations

Front 586

where are Peyer's patches?

Back 586

lower ileum

Front 587

humoral immune response at the mucosal level are mostly of which isotype?

Back 587

IgA

Front 588

what is actively transported across mucosal membranes to heplp prevent entry or infectious organisms?

Back 588

IgA

Front 589

what protects secretory IgA from proteolytic digestion in the gut lumen?

Back 589

presence of secretory component

Front 590

how do IgA dimers secreted by submucosal cells reach the gut lumen?

Back 590

bind to poly-Ig receptors on internal surface of epithelial cells
the complex is then endocytosed and transported across the cell to fuse with plasma membrane at luminal surface
receptor is then cleaved, releasing IgA dimers bound to secretory component

Front 591

what type of lymphocytes are present in the lamina propria?

Back 591

activated T cells
activated B cells
plasma cells

Front 592

what type of lymphocytes are present in the epithelial layer?

Back 592

CD8 T cells

Front 593

what synthesises secretory component?

Back 593

intestinal epithelial cells

Front 594

t/f... MALT consists of encapsulated lymphoid tissue

Back 594

false, it consists of non-encapsulated lymphoid tissue

Front 595

what do microfold cells in the epithelium of the small intestine do?

Back 595

transport antigens from the gut to Peyer's patches

Front 596

what is the function of poly-Ig receptors on gut epithelial cells?

Back 596

to bind IgA dimers and transport them to the gut lumen

Front 597

what damage to the small intestine occurs in Coeliac disease?

Back 597

villous atrophy
crypt hyperplasia

Front 598

which two HLA types are associated with Coeliac disease?

Back 598

HLA-DQ2 and HLA-DQ8

Front 599

what fraction of people with HLA types DQ2 or 8 develop CD?

Back 599

1 in 30

Front 600

which enzyme deamidates gluten peptides in the enterocyte?

Back 600

tissue transglutaminase

Front 601

what is the prevalence of CD?

Back 601

1:250 to 1:75

Front 602

what is the classical presentation of CD in childhood?

Back 602

toddler presents with anorexia, diarrhoea, irritability, malnourished, pallor, buttock wasting, pot-bellied appearance

Front 603

what percentage of toddlers presenting with CD have clubbing?

Back 603

30%

Front 604

what percentage of toddlers presenting with CD have constipation?

Back 604

20%

Front 605

which deficiencies are common in toddlers presenting with CD?

Back 605

iron and folate

Front 606

in what percentage of first degree relatives is asymptomatic CD found?

Back 606

33%

Front 607

how is CD diagnosed?

Back 607

small bowel biopsy demonstrating subtotal villous atrophy and crypt hyperplasia

Front 608

what is the most sensitive and specific test for CD?

Back 608

IgA antiendomyseal antibodies against reticulin in monkey oesophageal smooth muscle

Front 609

what is the sensitivity and specificity of IgA tissue transglutaminase antibodies?

Back 609

sensitivity - 92%
specificity - 98%

Front 610

how is CD treated?

Back 610

gluten free diet

Front 611

what are the possible consequences of persistent non-compliance with gluten free diet in CD?

Back 611

small bowel malignancy
higher incidence of autoimmune disease

Front 612

t/f...most cases of CD will present with fat malabsorption

Back 612

false

Front 613

t/f... the anaemia that occurs in CD is most commonly due to B-12 deficiency

Back 613

false, it is due to iron and/or folate deficiency

Front 614

what is the mechanism of small intestinal injury in viral infections?

Back 614

virus particles invade mature enterocytes and cause them to desquamate

Front 615

what do crypt cells do in the case of rotavirus?

Back 615

crypt cells (not infected by virus) proliferate and cover the injured villus but fail to differentiate normally

Front 616

what happens to villi when covered with crypt cells for defence against viral invasion?

Back 616

the villus becomes covered with immature cells which lack the normal brush border enzymes such as lactase and SGLT1

Front 617

what type of diarrhoea occurs with malabsorption?

Back 617

osmotic diarrhoea

Front 618

what may induce abnormal secretion of water and electrolytes resulting in secretory diarrhoea?

Back 618

bacterial toxins in the gut lumen e.g. heat labile toxin of Vibrio cholera and the heat stable toxin of enterotoxigenic E coli

Front 619

how do bacterial toxins stimulate chloride secretion from enterocytes?

Back 619

a) altering cell regulation events in enterocytes
b) modulating enteric nerves and enteroendocrine cells which have a role in modulating secretion

Front 620

t/f... intestinal secretion can be stimulated by immunocytes in the mucosa/lamina propria

Back 620

true

Front 621

how does rotavirus stimulate enterocyte secretion?

Back 621

produces a capsid protein that alters intracellular calcium levels

Front 622

t/f... mast cell degranulation induces profuse secretion

Back 622

true

Front 623

what is the major mechanism for expulsion of intestinal helminths?

Back 623

mast cell degranulation

Front 624

which inflammatory mediators are released by neutrophils in the gut that induce water secretion?

Back 624

arachadonic acid metabolites
TNF
5'-AMP

Front 625

which cells in the mucosa produce secretagogues?

Back 625

fibroblasts
endothelial cells
lymphocytes
macrophages

Front 626

what are the main phagocytes in the gut?

Back 626

neutrophils

Front 627

which products of maldigestion can stimulate colonic secretion?

Back 627

dihydroxy fatty acids

Front 628

t/f... infectious gastroenteritis is usually associated with steatorrhoea

Back 628

false

Front 629

what contributes to the abdominal pain frequently associated with gastroenteritis?

Back 629

altered motility

Front 630

what disturbance of motor activity occurs with intestinal anaphylaxis?

Back 630

rapidly migrating high pressure peristaltic waves which move aborally

Front 631

t/f... cholera does not inhibit the glucose coupled sodium transporter in the small intestine

Back 631

true

Front 632

how does cholera stimulate secretion in enterocytes?

Back 632

via a cAMP mediated chloride channel

Front 633

how much fluid enters the GIT of a normal adult per day?

Back 633

9L (2L ingested, 7L endogenous and electrolytes)

Front 634

what comprises endogenous fluid and electrolytes entering the GIT?

Back 634

salivary, gastric secretions, bile, pancreatic secretions, endogenous small intestinal secretion

Front 635

how much fluid enters the colon per day?

Back 635

1.5L

Front 636

how much fluid exits the GIT in stool per day?

Back 636

0.1-0.2L

Front 637

what increase in stool volume occurs with diarrhoea?

Back 637

>0.1L

Front 638

what are the 4 major cell populations arising from intestinal epithelium?

Back 638

enterocytes
paneth cells
goblet cells
enteroendocrine cells

Front 639

which layer lies beneath the intestinal epithelium?

Back 639

lamina propria

Front 640

what is the pH of the small bowel?

Back 640

8

Front 641

what is the pH of the stomach?

Back 641

2

Front 642

what protects the small bowel from bacterial invasion?

Back 642

low pH

Front 643

what protects the colon from bacterial invasion?

Back 643

normal flora (compete with pathogens for adherence to mucosal surface)

Front 644

t/f... fever is slight or absent in food poisoning

Back 644

true

Front 645

food poisoning with which pathogen does not have a rapid onset of diarrhoea and vomiting?

Back 645

botulism (takes 12-18 hours to produce paralysis)

Front 646

which pathogen is responsible for food poisoning of egg dishes?

Back 646

staph aureus

Front 647

which foods are at danger of food poisoning with clostridium perfringens when reheated?

Back 647

meat and gravy

Front 648

what is the pathogen associated with rice food poisoning?

Back 648

bacillus cereus

Front 649

how does staph aureus cause food poisoning?

Back 649

enterotoxins (proteins) secreted by Staph aureus
resist hydrolysis by gastric and jejunal enzymes
are stable to 100 degrees for 30 minutes
strong inducers of cytokine formation esp IL-1

Front 650

which cytokine is strongly induced by enterotoxins of S aureus?

Back 650

IL-1

Front 651

how do enterotoxins of staph aureus cause nausea and vomiting?

Back 651

peripheral stimulation of vomiting centre

Front 652

when do symptoms occur following ingestion of enterotoxins of staph aureus?

Back 652

within 1-6 hours of ingestion

Front 653

how long do symptoms of food poisoning with staph aureus last?

Back 653

less than 12 hours

Front 654

what is the origin of clostridium perfringens?

Back 654

animal faeces

Front 655

what is the incubation period of clostridium perfringens?

Back 655

8-14 hours

Front 656

what are the two forms of bacillus cereus?

Back 656

emetic (staph aureus like) and diarrhoeal (clostridial)

Front 657

list some non-microbial causes of food poisoning?

Back 657

heavy metals
mutant zucchinis
reef fish (ciguatera poisoning)
mushrooms
blue-green algae
methanol

Front 658

which mushroom can cause fatal hepatotoxicity?

Back 658

amanita phylloides (death cap)

Front 659

what are ciguatoxins?

Back 659

heat-stable, lipid-soluble polyethers which accumulates in the muscles of tropical fish

Front 660

what are the symptoms of ciguatera poisoning?

Back 660

begins with vomiting, diarrhoea, abdominal pain
followed by parasthesia, dysthesia, myalgia, muscle cramps and weakness

Front 661

when may neurological symptoms of ciguatera poison recur?

Back 661

during exercise or alcohol comsumption

Front 662

which blood group is associated with greater risk of cholera, EHEC and norovirus infections?

Back 662

O (receptor for the pathogens)

Front 663

what age group gets rotaviruses?

Back 663

infants

Front 664

why does lactose intolerance develop with viral diarrhoea?

Back 664

infected cells are damaged and lost leaving immature cells with reduced absorptive capacity and lack of disaccharidases

Front 665

how do viruses cause diarrhoea?

Back 665

ingested virus infects cells at top of villi in small intestine
spreads to infect large numbers of these cells
release of virus particles into lumen
infected cells are damaged and lost leaving immature cells with reduced absorptive capacity
fluid accumulation in lumen
diarrhoea and dehydration

Front 666

when does rotavirus become very common?

Back 666

post-weaning

Front 667

what is the incubation period of Norwalk virus infection?

Back 667

24--48 hours

Front 668

what is the duration of illness of Norwalk virus infection?

Back 668

12-60 hours

Front 669

where do outbreaks of norovirus occur?

Back 669

in closed communities (cruise ships, barracks, nursing homes)

Front 670

what are the two types of bacterial enteritis?

Back 670

enterotoxic
enteroinvasive

Front 671

what are the two major enterotoxigenic bacteria?

Back 671

cholera
E coli

Front 672

what are the features of toxigenic diarrhoea?

Back 672

watery, profuse diarrhoea
fever low or absent
no foecal leucocytes

Front 673

descibe the cholera organism

Back 673

gram negative curve rods with a single flagellum on one end

Front 674

where do cholera toxins adhere?

Back 674

proximal small bowel cells

Front 675

t/f... cholera toxins adhere to small bowel cells and then enter the cells

Back 675

false, they do not enter cells

Front 676

which component of the cholera toxin attaches to the cell receptor?

Back 676

B component

Front 677

which receptor does cholera bind to?

Back 677

GM1 - ganglioside receptor

Front 678

what activates adenyl cyclase in cholera infection?

Back 678

A1 subunit of cholera toxin

Front 679

where does cAMP accumulate in cholera infection?

Back 679

along the cell membrane

Front 680

what does the accumulation of cAMP along the cell membrane do in cholera infection?

Back 680

causes active secretion of sodium, chloride, potassium, bicarbonate and water into the intestinal lumen

Front 681

where do enteroinvasive bacteria invade the bowel?

Back 681

distal small bowel

Front 682

what are the classic organisms causing invasive diarrhoea?

Back 682

campylobacter
salmonella
yersinia

Front 683

what are the features of invasive diarrhoea?

Back 683

moderate stool volume
fever
colicky abdominal pain
foecal leucocytes

Front 684

what are the two commonest causes of protozoan enteropathy?

Back 684

giardia intestinalis
cryptosporidium parvum

Front 685

which patients may get relapsing infections of giardia?

Back 685

patients with IgA deficiency

Front 686

which patients experience persistent infection with cryptosporidium parvum?

Back 686

patients with AIDS

Front 687

which form of giardia survives chlorination and heating?

Back 687

cyst form

Front 688

what is the main function of the intestinal mucosa?

Back 688

transport of water, electrolytes, nutrients and other substances important for maintaining mucosal integrity

Front 689

how is water absorbed in the GIT?

Back 689

paracellularly and transcellularly

Front 690

how are ions and other small molecular weight solutes absorbed?

Back 690

passively through the paracellular pathway
dissolved in water
transcellularly via specific ion transporters

Front 691

what is the main basolateral transporter creating the internal concentration and electrical gradients to facilitate ion transport?

Back 691

basolateral Na/K ATPase

Front 692

where is K absorbed passively?

Back 692

small intestine

Front 693

where is K absorbed actively and secreted?

Back 693

colon

Front 694

what happens to undigested carbohydrate in the colon?

Back 694

fermented to short chain fatty acids by colonic bacteria and then absorbed coupled to Na or via anion exchangers

Front 695

how is secretion of fluid by the intestinal epithelium facilitated?

Back 695

apical secretion of Cl via specific Cl channels

Front 696

what happens to Na absorption when Cl secretion is stimulated?

Back 696

Na absorption is inhibited

Front 697

which biochemical abnormalities indicate dehydration?

Back 697

high urea and creatinine

Front 698

which biochemical abnormalities indicate depleted intravascular volume?

Back 698

matabolic acidosis (low pH, low HCO3)

Front 699

which biochemical abnormalities may indicate chronic diarrhoea?

Back 699

low potassium and magnesium

Front 700

t/f... the acidosis associated with acute diarrhoea is usually corrected with rehydration and bicarbonate therapy

Back 700

false, bicarbonate therapy is rarely required

Front 701

what can cause watery (osmotic) diarrhoea?

Back 701

malabsorption (or excessive ingestion) or osmotically active substances such as carbohydrate
diseases that damage the small intestinal mucosa (e.g. viral gastroenteritis, some bacterial and parasitic infections)

Front 702

what is the cause of mucosal damage in regions where malnutrition is endemic?

Back 702

tropical enteropathy
infestation with parasites and pathogenic bacteria
nutritional deficiencies such as zinc and vitamin A

Front 703

what is the most common cause of watery (secretory) diarrhoea?

Back 703

infection e.g. cholera

Front 704

what type of chloride secretion occurs with cholera?

Back 704

electrogenic

Front 705

what is the commonest cause of travellers diarrhoea?

Back 705

E coli

Front 706

t/f... mast cell degranulation can cause excessive intestinal secretion

Back 706

true

Front 707

t/f... intestinal inflammation does not cause excessive intestinal secretion

Back 707

false

Front 708

what are the causes of steatorrhoea?

Back 708

inadequate bile salt concentration
reduced pancreatic lipase secretion (e.g. CF)
damage to mucosal surface
abnormal chylomicron formation
blocked intestinal lymphatics

Front 709

what are the features of the stool in colonic inflammation?

Back 709

bloody stools
excessive white cells

Front 710

what are the causes of bloody stools?

Back 710

bacterial infection
food allergies
viral infections in immunosuppressed individuals
chronic inflammatory bowel disease

Front 711

t/f... diarrhoea usually occurs via a single mechanism

Back 711

false, diarrhoea usually results from a complex interplay of many factors

Front 712

what are the three gastrointestinal processes required for digestion?

Back 712

gut motility
absorption
secretion

Front 713

where do phasic contractions occur in the GIT?

Back 713

small intestine

Front 714

where do tonic contractions occur in the GIT?

Back 714

gastric fundus
colon (particularly sigmoid)

Front 715

t/f... the ileocaecal valve prevents contents in the caecum from reluxing into ileum

Back 715

true

Front 716

which motor functions are important in the oesophagus?

Back 716

propulsion

Front 717

which motor functions are important in the stomach?

Back 717

temporary storage
mixing
propulsion

Front 718

which motor functions are important in the small intestine?

Back 718

propulsion
mixing
some storage

Front 719

which motor functions are important in the colon?

Back 719

propulsion
mixing
storage

Front 720

which pattern of digestive tract motility is a response to swallowing?

Back 720

primary peristalsis

Front 721

which pattern of digestive tract motility is a response to unconscious swallowing or reflux?

Back 721

secondary peristalsis

Front 722

which patterns of digestive tract motility occur in the proximal stomach?

Back 722

proximal stomach: tonic receptive relaxation to accomodate food; subsequent tonic contraction to facilitate emptying

Front 723

which pattern of digestive tract motility occur in the distal stomach?

Back 723

phasic antral contractions (grind and empty contents)

Front 724

what size are the particles ground by the antral pump?

Back 724

0.5-1.5mm

Front 725

what are the two functional motor regions of the stomach?

Back 725

gastric reservoir
antral pump

Front 726

what are the patterns of digestive tract motility in the small intestine?

Back 726

interdigestive motor activity (migrating motor complex)
degestive motor pattern (irregular mixing contractions)

Front 727

where does the migrating motor complex occur?

Back 727

stomach and small intestine

Front 728

what are the patterns of digestive tract motility in the colon and ano-rectum?

Back 728

phasic and tonic contractions (mixing and propulsion)
gastro-colic reflex (increased contractile activity after eating
defaecation

Front 729

t/f... in the colon, non-propogating contractions increase during sleep and decrease on waking

Back 729

false, the opposite is true

Front 730

when are high amplitude propogated contractions triggered in the colon?

Back 730

waking from sleep
prior to defaecation

Front 731

using the barsotat technique, what does a decreased balloon volume indicate?

Back 731

increased colonic tone

Front 732

what is the role of the MMC in the small bowel during fasting?

Back 732

prevents stasis and bacterial overgrowth

Front 733

what is the fed pattern of the small bowel?

Back 733

irregular mixing contractions

Front 734

what percentage increase is there in colonic tone following a meal?

Back 734

30%

Front 735

which components of the GIT are under conscious influence?

Back 735

mouth
upper oesophageal sphincter
striated muscle of proximal oesophagus
anus

Front 736

what controls gut motility?

Back 736

autonomic nervous system
enteric nervous system

Front 737

what is the enteric nerve system?

Back 737

network of cells in gut wall comprising the myenteric plexus (between longitudinal and circular muscle) and submucosal plexus

Front 738

what are the three main types of chemical signalling in the enteric nervous system?

Back 738

synaptic transmission (neuron to neuron)
endocrine (enteroendocrine cell)
paracrine (enterochromaffin cell or enteric mast cell)

Front 739

what is released by enteroendocrine cells to produce the peristaltic reflex?

Back 739

5-HT

Front 740

what do excitatory interneurons associated with the peristaltic reflex release?

Back 740

ACh
SP

Front 741

what is released by inhibitory interneurons associated with the peristaltic reflex?

Back 741

VIP

Front 742

t/f... during the peristaltic reflex, there is relaxation distally and contraction proximally

Back 742

true

Front 743

what is the paraympathetic supply to the GIT from the oesophagus to the ascending colon?

Back 743

vagus

Front 744

what is the parasympathetic supply to the distal colon and rectum?

Back 744

pelvic splanchnic nerves (sacral spinal cord)

Front 745

what neurotransmitter is involved in the parasympathetic supply to the GIT?

Back 745

ACh

Front 746

what is the most important neurotransmitter in sympathetic control of the GIT?

Back 746

noradrenaline

Front 747

what is the sympathetic supply to the GIT?

Back 747

thoracolumbar spinal cord (sympathetic ganglia/intramural plexus)

Front 748

what are the symptoms of oesophagus dysmotility?

Back 748

heartburn
dysphagia
regurgitation
chest pain

Front 749

what are the symptoms of stomach dysmotility?

Back 749

dyspepsia
nausea
vomiting
anorexia
early satiety

Front 750

what are the symptoms of small intestine dysmotility?

Back 750

abdominal pain
bloating
abdominal distension

Front 751

what are the symptoms of colon dysmotility?

Back 751

abdominal pain
diarrhoea
constipation

Front 752

what are the symptoms of anorectum dysmotility?

Back 752

urgency
incomplete evacuation
incontinence
straining

Front 753

is typhoid associated with constipation or diarrhoea?

Back 753

constipation

Front 754

what are the clinical features of typhoid?

Back 754

persistent continuous fever
travel
weight loss
constipation
splenomegaly

Front 755

where are the Peyer's patches?

Back 755

ileum

Front 756

what is the incubation period of typhoid?

Back 756

7-15 days

Front 757

what is the relapse rate of typhoid?

Back 757

10%

Front 758

how is typhoid diagnosed?

Back 758

blood culture

Front 759

when will the urine be positive for typhoid?

Back 759

after the second week of infection

Front 760

what are the major complications of typhoid?

Back 760

perforation
haemorrhage

Front 761

what is the antibiotic treatment of first choice for typhoid?

Back 761

ceftriaxone, cefotaxime

Front 762

which macrolide has useful activity against typhoid?

Back 762

azithromycin

Front 763

which organisms cause dysentery?

Back 763

shigella
campylobacter jejuni
E coli
Entamoeba histolytica
Clostridium difficile

Front 764

which organism causes psuedomembranous colitis?

Back 764

clostridium difficile

Front 765

what is the incubation period of dysentery?

Back 765

1-3 days

Front 766

what are the symptoms of dysentery?

Back 766

fever
colicky pain in lower abdomen
rectal urgency
tenesmus

Front 767

what it the duration of dysentery?

Back 767

2-20 days

Front 768

dysentery due to which organism has the longest duration?

Back 768

shigella

Front 769

what is the taxonomy of shigella?

Back 769

gram negative rod

Front 770

what is the taxonomy of campylobacter?

Back 770

gram negative spiral bacillus

Front 771

how is shigella treated?

Back 771

quinolones
cotrimoxazole

Front 772

what is the treatment of campylobacter?

Back 772

quinolones
macrolides

Front 773

what is the pathogenesis of EHEC?

Back 773

bacterial cells attach to, and efface gut epithelial cells
production and absorption of shiga (vero) toxin
damage to vascular endothelium, especially glomeruli

Front 774

what are the clinical features of EHEC?

Back 774

haemorrhagic colitis
intravascular haemolysis
renal failure

Front 775

how is EHEC diagnosed?

Back 775

faecal detection of associated serotypes (e.g. O157, O111)

Front 776

which form of colitis occurs following antibiotic treatment?

Back 776

clostridium difficile

Front 777

how is C. difficile diagnosed?

Back 777

detection of toxins in stools or culture

Front 778

how is C difficile treated?

Back 778

cessation of antibiotics
administration of oral metronidazole (or vancomycin)

Front 779

which antibiotics never cause colitis due to clostridium difficile?

Back 779

aminoglycosides

Front 780

which antibiotics are most commonly associated with clostridium difficile colitis?

Back 780

clindamycin
beta-lactams

Front 781

what is the most common cause ot diarrhoea in hospital?

Back 781

antibiotics (including C. difficile colitis)

Front 782

what are the causes of diarrhoea in hospital?

Back 782

antibiotics
noroviruses
hyperosmolar solutions
elixirs containing sorbitol or mannitol
drugs e.g. colchicine
ischaemic colitis

Front 783

what are the side effects of dopamine receptor antagonists?

Back 783

dystonia
dyskinesia

Front 784

how does ondansetron work?

Back 784

5-HT3 receptor antagonist

Front 785

why are opiates avoided in shigellosis, c.difficile and EHEC?

Back 785

can cause toxic megacolon

Front 786

what nerve triggers the fed pattern?

Back 786

vagus

Front 787

what mediates tonic inhibition in the gut?

Back 787

sympathetic system

Front 788

what is the origin of the external oblique?

Back 788

lower 8 ribs (interdigitating with serratus anterior)

Front 789

where does external oblique insert?

Back 789

anterior half of outer lip of iliac crest and ASIS, pubic tubercle, pubic crest, pubic symphysis, pectineal line, linea alba, xiphoid process

Front 790

where is the free posterior border of external oblique?

Back 790

from R12 to middle of iliac crest

Front 791

where is the free lower border of the external oblique?

Back 791

from ASIS to pubic tubercle as inguinal ligament

Front 792

what is the origin of the internal oblique?

Back 792

lumbar fascia, anterior 2/3 iliac crest, lateral 2/3 inguinal ligament

Front 793

where does internal oblique insert?

Back 793

12, 11, 10 ribs and costal cartilages
9, 8, 7 costal cartilages
xiphoid process, linea alba, pubic crest, pectineal line

Front 794

what is the free border of the internal oblique?

Back 794

conjoint tendon

Front 795

where does transversus abdominis originate?

Back 795

inner surface of costal cartilages to 12 (interdigitating with diaphragm), lumbar fascia, anterior 2/3 iliac crest, lateral 1/3 inguinal ligament

Front 796

where does transversus abdominis insert?

Back 796

xiphoid process, linea alba, pubic crest, pectineal line

Front 797

what does the free border of the transversus abdominis form?

Back 797

conjoint tendon

Front 798

what forms the conjoint tendon?

Back 798

free borders of internal oblique and transversus abdominis

Front 799

which muscle arises from the outer surface of the ribs, interdigitating with serratus anterior?

Back 799

external oblique

Front 800

which muscle arises from the inner surface of the costal cartilage, interdigitating with the diaphragm?

Back 800

transversus abdominis

Front 801

where is the origin of rectus abdominis?

Back 801

pubic crest, anterior ligament of pubic symphysis

Front 802

what is the insertion of rectus abdominis?

Back 802

anterior surface of xiphoid process, costal cartilages 5,6, 7

Front 803

what is the origin of pyramidalis?

Back 803

pubic crest

Front 804

where does pyramidalis insert?

Back 804

linea alba

Front 805

where does the posterior rectus sheath end?

Back 805

arcuate line

Front 806

what is the blood supply of the rectus abdominis muscle?

Back 806

superior and inferior epigastric arteries

Front 807

where is the neurovascular plane of the anterior abdominal wall?

Back 807

between transversus abdominis and internal oblique

Front 808

what forms the lateral umbilical ligament?

Back 808

inferior epigastric artery

Front 809

what forms the median umbilical ligament?

Back 809

urachus

Front 810

what forms the medial umbilical ligament?

Back 810

obliterated umbilical artery

Front 811

what is the nerve supply to the muscles of the anterior abdominal wall?

Back 811

muscles supplied segmentally by intercostal nerves 7-11, subcostal nerve, iliohypogastric and ilioinguinal nerves

Front 812

what is the nerve supply to pyramidalis?

Back 812

subcostal nerve

Front 813

where does a femoral hernia arise relative to the pubic tubercle?

Back 813

below and lateral

Front 814

where does an inguinal hernia arise relative to the pubic tubercle?

Back 814

above and medial

Front 815

what percentage of all hernias are inguinal?

Back 815

73%

Front 816

what percentage of hernias are femoral?

Back 816

17%

Front 817

what percentage of hernias are umbilical/paraumbilical?

Back 817

9%

Front 818

where is the supracolic compartment?

Back 818

above the transverse colon

Front 819

where is the infracolic compartment?

Back 819

below the transverse colon

Front 820

what is the blood supply to the greater omentum?

Back 820

gastroepiploic arch

Front 821

how many subphrenic spaces are there?

Back 821

6

Front 822

what are the subphrenic spaces?

Back 822

right anterior subphrenic space
right posterior subphrenic space
superior recess of lesser sac
left anterior subphrenic space
left posterior subphrenic space
hepatorenal pouch

Front 823

what is the ligamentum teres?

Back 823

remnant of umbilical vein

Front 824

what separates the right and left anatomical lobes of the liver?

Back 824

groove for IVC and fundus of gall bladder

Front 825

how many segments does the liver have?

Back 825

8

Front 826

what sign on x-ray indicates a perforated peptic ulcer?

Back 826

gas under the diaphragm

Front 827

describe Calot's triangle

Back 827

right-angled triangle: hypotenuse - gall bladder & cystic duct
lower border of liver
common hepatic duct, right hepatic duct and right hepatic artery

Front 828

what is located at each of the corners of a hepatic lobule?

Back 828

bile duct
portal vein
hepatic artery

Front 829

where does blood flow from the portal vein and hepatic artery?

Back 829

into sinusoids to central vein

Front 830

what separates sinusoids in the liver?

Back 830

single layer of hepatocytes (covered by the endothelium of the sinusoids)

Front 831

what percentage of cells in the liver are hepatocytes?

Back 831

94%

Front 832

what are hepatocytes?

Back 832

epithelial cells with apical membranes opposing each other

Front 833

what cells are present in the liver?

Back 833

hepatocytes (94%)
Kupffer cells (2%)
endothelial cells (2.5%)
ito (stellate) cells (1.4%)
pit cells (0.1%)

Front 834

where are kupffer cells located?

Back 834

sinusoidal lumen

Front 835

how do liver endothelial cells differ from other endothelial cells?

Back 835

they have spaces between them (fenestrations)

Front 836

what is the name of the thin layer of connective tissue between the hepatocytes and the endothelium?

Back 836

space of disse

Front 837

what type of cell is located in the space of disse?

Back 837

stellate cells

Front 838

where are pit cells?

Back 838

in the sinusoids

Front 839

what is the function of endothelium in the liver?

Back 839

physical barrier
uptake of HDL, LDL
hydrolysis of lipoproteins due to lipoprotein lipase activity

Front 840

what type of cell is responsible for hydrolysis of lipoproteins?

Back 840

endothelial cells

Front 841

which cell contains lipoprotein lipase?

Back 841

endothelium

Front 842

what enables endothelial cells to take triglycerides out of chylomicrons in blood?

Back 842

lipoprotein lipase

Front 843

what is the function of Kupffer cells in the liver?

Back 843

phagocytosis and endocytosis of micro-organisms, cell debris, tumour cells etc.
defence
clearing endotoxins
production of chemokines and cytokines

Front 844

why do patients with liver failure have a constant state of inflammation?

Back 844

failure of Kupffer cells to clear endotoxins

Front 845

what is the function of stellate cells in the liver?

Back 845

fat storage
storage of vitamin A
contractile (regulate blood flow through sinusoids)
synthesise connective tissue
secrete growth factors

Front 846

what is the function of pit cells in the liver?

Back 846

natural killer cells
directed against viruses, bacteria and tumour cells

Front 847

what are the functions of hepatocytes (8)?

Back 847

glucose and carbohydrate metabolism
protein and amino acid metabolism
acid base balance
lipid metabolism
clearing/excretory functions - clearing peptide and other hormones
excreting and detoxifying organic molecules (endogenous and exogenous)
homeostasis of trace metals
bile production

Front 848

what does hepatocyte cell volume indicate?

Back 848

availability of metabolic substrates from the gut

Front 849

what happens to the volume of hepatocytes during starvation?

Back 849

hepatocytes shrink

Front 850

what happens to hepatocytes after a meal?

Back 850

hepatocytes swell

Front 851

what is stimulated by an increase in hepatocyte cell volume?

Back 851

protein synthesis
glycogen synthesis

Front 852

what is inhibited by an increase in hepatocyte cell volume?

Back 852

proteolysis
glycogenolysis
glycolysis

Front 853

what percentage of dietary carbohydrate is glucose?

Back 853

70%

Front 854

what percentage of dietary carbohydrate are monosaccharides?

Back 854

30%

Front 855

what happens to glucose in the hepatocyte?

Back 855

converted to glycogen and stored
converted by glycolysis to acetyl CoA
exported into circulation

Front 856

in a well fed person, what percentage of liver weight is stored glycogen?

Back 856

10%

Front 857

what is the non-dietary source of glucose?

Back 857

gluconeogenesis (from metabolism of amino acids)

Front 858

what is the source of amino acids for gluconeogenesis?

Back 858

diet
proteolysis in liver
proteolysis in muscle (in times of starvation)

Front 859

what is the effect of insulin on carbohydrate metabolism in the liver?

Back 859

increase in glycogen synthesis
increased glycolysis
net effect -> storage of glucose as glycogen or fat

Front 860

what is the effect of glucagon on carbohydrate metabolism in the liver?

Back 860

glycogen breakdown
gluconeogenesis
net effect -> release of glucose from stores in liver

Front 861

what is the effect of catecholamines on carbohydrate metabolism in the liver?

Back 861

glycogen breakdown

Front 862

t/f... GLUT2 uses an active mechanism

Back 862

false, it is a diffusion mechanism

Front 863

what stimulates conversion of glucose into glycogen in the hepatocyte?

Back 863

plasma glucose
amino acids
insulin
parasympathetic NS
cell swelling

Front 864

what inhibits conversion of glucose into glycogen?

Back 864

starvation
glucagon

Front 865

what stimulates conversion of glycogen into glucose?

Back 865

glucagon
cAMP
catecholamines
sympathetic NS
cell shrinkage
starvation

Front 866

what inhibits conversion of glycogen into glucose?

Back 866

glucose
insulin

Front 867

how does glucagon stimulate the breakdown of pyruvate?

Back 867

inhibiting enzymes that regulate glycolysis (6-phosphofructokinase and pyruvate kinase)
stimulating enzymes that regulate gluconeorgenesis (fructose 1,6-diphosphotase, phosphoenolpyruvate carboxykinase)

Front 868

what is the function of albumin in plasma?

Back 868

maintains oncotic pressure

Front 869

what is bound to bilirubin in the plasma?

Back 869

albumin

Front 870

which coagulation factors are synthesised by the liver?

Back 870

all except factor VIII
fibrinogen

Front 871

t/f... anticoagulation factors are synthesised by the liver

Back 871

true

Front 872

what are the two ways to get rid of ammonium?

Back 872

conversion to amino acid
conversion to urea

Front 873

what is produced by the interaction of bicarbonate and ammonium?

Back 873

carbomoyl phosphate

Front 874

under normal pH, what happens to ammonium ions?

Back 874

converted to urea and excreted

Front 875

during acidosis, what happens to ammonium?

Back 875

excreted by kidneys as glutamine

Front 876

what is heme converted to before reduction to bilirubin?

Back 876

biliverdin

Front 877

how is bilirubin excreted from the liver?

Back 877

bound to albumin

Front 878

how are peptide hormones inactivated by liver?

Back 878

proteolysed by endothelial enzymes

Front 879

how are steroid hormones inactivated by the liver?

Back 879

taken up by hepatocytes and secreted into bile

Front 880

how is thyroid hormone activated by the liver?

Back 880

T4 converted to T3 by endothelium

Front 881

how is vitamin A stored by liver?

Back 881

in fat globules of stellate cells

Front 882

how are xenobiotics eliminated by liver?

Back 882

physical removal from blood (Kupffer cells)
biocemical (metabolism by hepatocytes)

Front 883

what are the two phases of hepatocyte metabolism of xenobiotics?

Back 883

phase I - generation of a more polar product
phase II - conjugation to increase water solubility

Front 884

what are the sources of cholesterol in the liver?

Back 884

intestinal absorption of chylomicrons (0.1-0.5 g/day)
synthesis in liver (1g/day)

Front 885

how is lipid excreted from the liver?

Back 885

secreted in bile
bile salts produced from cholesterol
secreted in VLDLs

Front 886

what produces chylomicrons?

Back 886

intestine

Front 887

what are the two types of liver failure?

Back 887

acute liver failure (sudden massive hepatocyte destruction)
chronic liver failure

Front 888

what is the usual cause of chronic liver failure?

Back 888

cirrhosis

Front 889

what is the hallmark of cirrhosis?

Back 889

nodularity

Front 890

what are the pathological features of cirrhosis?

Back 890

extensive fibrosis
formation of regenerative nodules
hepatocyte necrosis
collapse of supporting reticulin network
connective tissue deposition
distortion of vascular bed
nodular regeneration of remaining liver parenchyma

Front 891

what are the two key steps in cirrhosis?

Back 891

hepatocyte/biliary cell injury
activation of hepatic stellate cells

Front 892

what drives HSC activation?

Back 892

TGF beta
PDGF

Front 893

what is the effect of TGF beta and PDGF in cirrhosis?

Back 893

fibrosis and ECM deposition

Front 894

what is the mechanism of regenerative nodules in cirrhosis?

Back 894

hepatocyte proliferation and apoptosis

Front 895

t/f... regenerative nodules contain a central vein

Back 895

false

Front 896

what are the two clinical hallmarks of cirrhosis?

Back 896

failure of hepatocytes to function
development of portal hypertension

Front 897

why does portal hypertension occur with cirrhosis?

Back 897

scar tissue in vascular bed

Front 898

what are the causes of chronic liver disease?

Back 898

viral hepatitis (HBV, HCV), alcoholic liver disease, NASH, autoimmune, metabolic, alpha-1 antitrypsin deficiency, toxins, drugs, budd-chiari syndrome, chronic biliary obstruction, cryptogenic

Front 899

what is Budd-Chiari syndrome?

Back 899

vascular obliteration of hepatic veins

Front 900

what are the major complications of liver failure?

Back 900

ascites and oedema
spontaneous bacterial peritonitis
hepatorenal syndrome
hepatic encephalopathy
portal hypertensive syndrome
hepatopulmonary syndrome
hepatocellular carcinoma
malnutrition
bone disease

Front 901

what lung pathology is associated with ascites?

Back 901

hepatic hydrothorax (pleural effusion associated with cirrhosis and portal hypertension, usually right-sided)

Front 902

what side is affected by the pleural effusion associated with ascites?

Back 902

right

Front 903

how is cirrhotic ascites differentiated from malignant ascites?

Back 903

serum-ascitic fluid albumin gradient (>11g/L cirrhosis, <11 g/L malignancy)

Front 904

t/f... sodium retention occurs before ascites

Back 904

true

Front 905

what is the pathogenesis of ascites?

Back 905

portal HTN -> NO production in splanchnic vessels -> splanchnic arterial vasodilatation -> decreased effective blood volume -> activation of RAAS, sympathetic nervous system and ADH -> Na and water retention -> increase in plasma volume -> continous Na and water retention (increase in plasma volume is inadequate to normalise circulatory homeostasis)

Front 906

what is the minor pathway in the pathogenesis of ascites?

Back 906

lymph formation exceeds lymph return

Front 907

what will be the result of increased pressure and decreased albumin?

Back 907

ascites

Front 908

what are the three major contributing factors to ascites?

Back 908

increased pressure
decreased albumin
sodium retention

Front 909

what is the mechanism of renal sodium and water retention in cirrhosis?

Back 909

increased antinatriuretic and antidiuretic factors (NA, RAAS, ADH)
decreased natriuretic factors (ANP, PGs)

Front 910

what is the one year survival rate of ascites?

Back 910

60%

Front 911

how does refractory ascites affect survival?

Back 911

60% survival at 6 months (cf 60% at 1 year with ascites)

Front 912

what are the complications of diuretics in cirrhosis?

Back 912

hyponatraemia
hyperkalaemia
hepatic encephalopathy
renal impairment
gynaecomastia
muscle cramps

Front 913

what percentage of hospitalised cirrhosis patients develop spontaneous bacterial peritonitis?

Back 913

10-30%

Front 914

what is the mechanism of spontaneous bacterial peritonitis?

Back 914

bacterial translocation from intestinal lumen to systemic circulation
bacteraemia secondary to impaired RES phagocytic activity
defective antimicrobial activity of ascitic fluid leads to ascitic infection

Front 915

how is spontaneous bacterial peritonitis diagnosed?

Back 915

>300 WCC in ascites
culture ascites into BC bottles

Front 916

what percentage of organisms causing SBP are gram negative?

Back 916

70%

Front 917

what percentage of organisms causing SBP are strep?

Back 917

30%

Front 918

what is given as a prophylactic for SBP?

Back 918

norfloxacin (quinolone antibiotic)

Front 919

what is the 6 month survival of SBP?

Back 919

50%

Front 920

what is the hepatorenal syndrome?

Back 920

progressive renal failure associated with advanced cirrhosis and ascites without intrinsic renal disease

Front 921

what does a gradual rise in creatinine while urine output falls indicate?

Back 921

hepatorenal syndrome

Front 922

which type of hepatorenal syndrome has a rapid onset?

Back 922

type 1

Front 923

t/f... severe hyponatraemia indicates a poor prognosis

Back 923

true

Front 924

how is dilutional hyponatraemia treated?

Back 924

limit diuretics
fluid restriction
no current pharmacological treatment

Front 925

what percentage of blood supply to the liver is arterial?

Back 925

30%

Front 926

t/f... the portal venous system operates under high pressure

Back 926

false

Front 927

how many connections are there from the portal to the systemic systems?

Back 927

5

Front 928

what percentage of patients with cirrhosis will develop oesophageal varices?

Back 928

35-80%

Front 929

what percentage of patients with oesophageal varices bleed?

Back 929

25-40%

Front 930

what is the mortality of bleeding from oesophageal varices?

Back 930

20-50%

Front 931

at what pressure is there established portal hypertension?

Back 931

10 mm Hg

Front 932

what pressure is the threshold for oesophageal variceal haemorrhage?

Back 932

12 mm Hg

Front 933

why is splenomegaly a feature of portal hypertension?

Back 933

high pressure in splenic vein

Front 934

what are the two main effects of lactulose?

Back 934

reduced ammonia absorption
increased nitrogen excretion

Front 935

what are the five factors considered in the Child-Turcotte Pugh grading system for cirrhosis?

Back 935

ascites
encephalopathy
bilirubin
serum albumin
INR

Front 936

which parameters are used in the MELD score?

Back 936

creatinine
bilirubin
INR

Front 937

at which MELD score does a transplant become necessary?

Back 937

20-29

Front 938

which hepatitis viruses cause chronic hepatitis?

Back 938

B, C, D

Front 939

which hepatitis virus can become part of the host's genome?

Back 939

HBV (it is a DNA virus)

Front 940

how are HAV and HEV transmitted?

Back 940

foecal oral (contaminated food or water)

Front 941

when may HAV be transmitted via blood transfusion?

Back 941

if blood donor is viraemic at time of donation

Front 942

which liver enzymes will be elevated in acute Hep A?

Back 942

AST, ALT

Front 943

what is the laboratory criteria for diagnosis of acute hepatitis A?

Back 943

IgM antibody to hepatitis A virus (anti-HAV IgM) positive

Front 944

what does anti-HAV IgG indicate?

Back 944

patient has been infected or vaccinated in the past

Front 945

t/f... jaundice is very unusual in children infected with hepatitis A

Back 945

true

Front 946

what fraction of the world's population has been infected with Hepatitis E?

Back 946

1/3

Front 947

what is the case fatality rate for hepatitis E overall and for pregnant women?

Back 947

1-3%
15-25% for pregnant women

Front 948

t/f... immunoglobulin is effective against hep E

Back 948

false

Front 949

what type of virus is HCV?

Back 949

RNA flavivirus

Front 950

how does HCV replicate?

Back 950

RNA dependent RNA polymerase

Front 951

which genotypes of HCV are seen in Australia?

Back 951

1b and 3a

Front 952

what percentage of people infected with HCV will clear the virus?

Back 952

15-30%

Front 953

which populations in Australia have HCV?

Back 953

migrants
IVDU

Front 954

how is HCV transmitted?

Back 954

parenteral (major form of transmission)
mother-to-child (2% risk)
sexual (1-2% risk)

Front 955

what percentage chance is there of transmitting HCV from a person with HCV following a needlestick injury?

Back 955

3%

Front 956

what does anti-HCV antibody indicate?

Back 956

either have infection or have been exposed in the past

Front 957

how is HCV viraemia confirmed following a positive anti-HCV antibody?

Back 957

PCR

Front 958

how many genotypes of HCV exist?

Back 958

6

Front 959

what is the average incubation period for HCV?

Back 959

6-7 weeks

Front 960

what percentage of HCV-infected persons develop chronic infection?

Back 960

60-85%

Front 961

what are the causes of flares of ALT elevation in HCV positive patients?

Back 961

natural history of infection
viral superinfection
drug hepatotoxicity
herbal hepatotoxicity
fatty liver
alcohol

Front 962

t/f... a liver biopsy is required before treatment of HCV can be commenced

Back 962

false

Front 963

what percentage of HCV infected patients will develop extrahepatic manifestations?

Back 963

1-2%

Front 964

what is the success rate for treatment of genotype 1 or 4 of HCV?

Back 964

50% with 12 months therapy

Front 965

what is the success rate of treatment fro genotype 2/3 of HCV?

Back 965

80%

Front 966

when is treatment of chronic HCV contraindicated?

Back 966

decompensated liver disease

Front 967

how does most transmission of HBV occur in Asia and Africa?

Back 967

mother to child

Front 968

how does most transmission of HBV occur?

Back 968

perinatal/vertical

Front 969

how does most transmission of HBV in adults in areas of low endemicity occur?

Back 969

parenteral or sexual

Front 970

what is the fatality rate of hepatitis B?

Back 970

0.5-1%

Front 971

what is the hallmark of acute hep B?

Back 971

IgM anti-HBc

Front 972

what are the major sequelae of HBV infection?

Back 972

cirrhosis
liver failure
HCC

Front 973

what serological pattern is seen in replicative HBV?

Back 973

positive HBsAg
positive HBeAg
positive IgG anti-HBc
negative anti-HBs
negative anti-HBe
positive HBV DNA

Front 974

what serological pattern is seen in non replicative HBV?

Back 974

positive HBsAg
neg HBeAg
positive anti-HBc IgG
neg anti-HBs
positive antiHBe
neg HBV DNA

Front 975

what serological pattern is seen in cleared HBV infection?

Back 975

pos anti-HBc IgG
pos anti-HBs
pos anti-HBe

Front 976

what serological pattern is seen with HBV vaccination?

Back 976

pos anti-HBs

Front 977

why does HDV need HBV to replicate?

Back 977

HDV requires HBV for synthesis of envelope protein composed of HBsAg which is used to encapsulate the HDV genome

Front 978

what are the two clinical situations in which patients get HDV?

Back 978

coninfection with HBV
superinfection on top of HBV

Front 979

how is HDV transmitted?

Back 979

percutaneous (IVDU)
transmucosal (sexual)

Front 980

for which hepatitis virus is there no IgM to determine acute infection?

Back 980

HCV

Front 981

which two responses to foreign compounds comprise hepatic adaptation?

Back 981

hypertrophy of sER
induction and release of enzymes (GGT, alkaline phosphatase)

Front 982

which drugs are common enzyme inducers in the liver?

Back 982

alcohol
phenytoin
phenobarbitol

Front 983

what are the clinical features of severe drug induced liver disease?

Back 983

jaundice
PT >50%
hepatic encephalopathy
fulminant rapid development of HE or severe coagulation abnormalities

Front 984

what dose of paracetamol is required for hepatotoxicity?

Back 984

>12g

Front 985

what is the toxic metabolite of paracetamol?

Back 985

NAPQI

Front 986

which enzymes are involved in the metabolism of paracetamol to NAPQI?

Back 986

CYP2E1, CYP3A4

Front 987

why do chronic alcoholics require less paracetamol for hepatotoxicity to occur?

Back 987

CYP2E1 is upregulated (it has already been induced by alcohol intake)

Front 988

if alcohol and paracetamol are taken at the same time, what happens to paracetamol toxicity?

Back 988

toxicity is reduced (alcohol competes for CYP2E1)

Front 989

why does fasting increase paracetamol toxicity?

Back 989

fasting reduces GSH (enzyme required to detoxify NAPQI)

Front 990

what is the commonest cause for liver transplant due to acute liver failure?

Back 990

paracetamol toxicity

Front 991

what does N-acetylcysteine (Parvolex) do?

Back 991

replenishes GSH

Front 992

what type of hepatotoxicity may occur with methotrexate, arsenic and hypervitaminosis A?

Back 992

hepatic fibrosis

Front 993

which component of the OCP is most likely responsible for pill-induced cholestasis?

Back 993

oestrogen

Front 994

what separates the caudate lobe from the quadrate lobe of the liver?

Back 994

porta hepatis

Front 995

what divides the left and right anatomical lobes of the liver?

Back 995

falciform ligament and fissures for ligamentum venosum and teres

Front 996

what divides the functional lobes of the liver?

Back 996

a line passing through the fossae for the gall bladder and IVC

Front 997

what is the ligamentum teres a remnant of?

Back 997

umbilical vein

Front 998

what is the ligamentum venosum a remnant of?

Back 998

ductus venosus

Front 999

what covers the surface of hepatocytes adjacent to the space of Disse?

Back 999

microvilli

Front 1000

where is bile produced and secreted?

Back 1000

bile is produced by hepatocytes and secreted into bile canaliculi

Front 1001

where does the lesser omentum attach to the liver?

Back 1001

at the fissure for ligamentum teres and the porta hepatis

Front 1002

how much blood does the liver receive per minute?

Back 1002

1.5L

Front 1003

which structures enter the liver at the porta hepatis?

Back 1003

L and R branches of portal vein
L and R branches of proper hepatic artery
efferent autonomic nerves

Front 1004

which structures exit the liver at the porta hepatis?

Back 1004

L and R hepatic ducts
lymphatic vessels
visceral afferents

Front 1005

what is the venous drainage of the liver?

Back 1005

2-3 large hepatic veins -> IVC

Front 1006

what is the lymphatic drainage of the liver?

Back 1006

through porta hepatis to the thoracic duct

Front 1007

how big is a liver lobule?

Back 1007

1 mm diameter

Front 1008

what is contained in portal triads which lie between liver lobules?

Back 1008

branches of hepatic artery and portal vein, tributaries of hepatic duct and lymph vessels

Front 1009

where is oxygen tension greatest and lowest in the liver lobule?

Back 1009

greatest near portal triad
lowest near central vein

Front 1010

t/f... toxins entering liver will tend to damage cells close to central vein

Back 1010

false, cells near portal triad are damaged first

Front 1011

which cells are affected first by slowing of the hepatic circulation?

Back 1011

cells near the central vein

Front 1012

when is the space of Disse one of the sites of haemopoiesis?

Back 1012

foetus
anaemic adult

Front 1013

where does the proper hepatic artery arise from?

Back 1013

coeliac trunk

Front 1014

where do the hepatic veins drain?

Back 1014

IVC

Front 1015

what happens to excess glucose once hexokinase capacity is exceeded?

Back 1015

liver glucokinase phosphorylates the glucose to produce G 6-P which is converted into glycogen

Front 1016

why does the process of glycolysis rarely occur in the liver?

Back 1016

high concentration of ATP inhibits phosphofructokinase

Front 1017

what controls the conversion of liver glycogen to glucose?

Back 1017

glucagon

Front 1018

once sufficient glycogen is synthesised following carbohydrate intake, what happens to excess carbohydrate?

Back 1018

it is channeled through the glycolytic pathway in the liver and converted into acetyl CoA which is converted into long chain fatty acids

Front 1019

what happens to ingested LCFAs?

Back 1019

converted into triglycerides which are transported to adipose tissue as VLDLs for storage

Front 1020

what happens to acetyl coA derived from adipocytes?

Back 1020

may be completely oxidised by citric acid cycle to produce ATP or may be converted into 3-hydroxy-3-methylglutaryl CoA

Front 1021

what happens to amino acids in the liver?

Back 1021

deaminated and converted to glucose or acetyl CoA

Front 1022

what is lactate?

Back 1022

end-product of glucose metabolism by erythrocytes and active white muscle

Front 1023

what happens to lactate in the liver?

Back 1023

30% is processed by oxidation
70% converted to glucose

Front 1024

how is autoimmune hepatitis recognised on liver biopsy?

Back 1024

inflammatory portal tract infiltrate enriched in plasma cells

Front 1025

what type of inflammatory infiltrate is associated with alcoholic liver disease?

Back 1025

neutrophil

Front 1026

where does HBV replication occur?

Back 1026

mainly in the hepatocyte
also in salivary glands, pancreas, testis

Front 1027

what does the presence of HBeAg in serum indicate?

Back 1027

active virus synthesis is occurring in the liver

Front 1028

what does lamividine target?

Back 1028

the viral RT enzyme

Front 1029

what ALT and AST values occur in alcoholic hepatitis?

Back 1029

AST>ALT and values are rarely 10xN elevated

Front 1030

where are alkaline phosphatase and GGT present?

Back 1030

hepatocyte plasma membrane

Front 1031

what is a common cause of raised plasma levels of alkaline phosphatase and GGT?

Back 1031

cholestasis

Front 1032

what type of hyperbilirubinaemia is associated with liver disease?

Back 1032

mixed conjugated and unconjugated

Front 1033

what type of hyperbilirubinaemia is associated with cholestasis?

Back 1033

conjugated

Front 1034

what is commonest cause of mild unconjugated hyperbilirubinaemia?

Back 1034

Gilbert's syndrome

Front 1035

what is the most useful test of impaired liver function in acute liver failure?

Back 1035

PT

Front 1036

t/f... a prolonged PT in acute liver failure will correct with vitamin K

Back 1036

false

Front 1037

t/f... a prolonged PT associated with cholestasis will correct with vitamin K

Back 1037

true

Front 1038

in which situations may alpha-fetoprotein be raised?

Back 1038

HCC
active cirrhosis

Front 1039

which genetic disorders may cause cirrhosis?

Back 1039

haemachromatosis
Wilson's disease
alpha-1 antitrypsin deficiency

Front 1040

which autoimmune diseases cause chronic cholestasis?

Back 1040

primary biliary cirrhosis
primary sclerosing cholangitis

Front 1041

which drugs may damage the biliary system?

Back 1041

anti-psychotic drugs
antibiotics

Front 1042

what is the main source of extracellular matrix production in the liver?

Back 1042

stellate cell

Front 1043

which liver enzyme is elevated in chronic hepatitis?

Back 1043

ALT

Front 1044

what causes acute liver failure?

Back 1044

hepatitis viruses (particularly HBV)
toxins (paracetamol overdose, mushroom poisoning)

Front 1045

what percentage of cases of acute liver failure are idiopathic?

Back 1045

up to 30%

Front 1046

how is autoimmune hepatitis recognised?

Back 1046

presence of various autoantibodies in serum (ANA, SMA)
significant increase in total serum IgG levels

Front 1047

how is genetic haemachromatosis detected?

Back 1047

increased serum iron, percentage transferrin saturate, ferritin

Front 1048

who gets PBC?

Back 1048

middle aged women

Front 1049

which disease is associated with a characteristic anti-mitochondrial antibody (AMA) directed at the pyruvate dehydrogenase complex on the inner mitochondrial membrane?

Back 1049

PBC

Front 1050

in what percentage of cases is PSC associated with inflammatory bowel disease?

Back 1050

70%

Front 1051

what does PSC involve?

Back 1051

destruction and damage to the biliary system at all levels

Front 1052

what is characteristically seen on imaging in PSC?

Back 1052

strictures and dilatation throughout the liver

Front 1053

what characterises liver failure in cirrhosis?

Back 1053

effects of portal hypertension: development of portosystemic shunts, hepatic encephalopathy, spontaneous bacterial peritonitis, ascites

Front 1054

which patients are particularly at risk of HCC development?

Back 1054

patients with HBV, HCC, haemachromatosis

Front 1055

what is the treatment for HCV?

Back 1055

interferon-alpha plus ribavirin

Front 1056

what treatment for autoimmune hepatitis improves 5 year mortality from 40% to below 10%?

Back 1056

corticosteroids given with azathioprine

Front 1057

how is ascites managed?

Back 1057

salt restriction
aldosterone antagonist diuretic (1st choice)
loop diuretic (2nd choice)
paracentesis

Front 1058

how is encephalopathy treated?

Back 1058

lactulose

Front 1059

what are the survival rates for liver transplantation in adults and children?

Back 1059

adults - 80%
children - 90%

Front 1060

which has a wider lumen, jejunum or ileum?

Back 1060

jejunum

Front 1061

which has a thicker wall, jejunum or ileum?

Back 1061

jejunum

Front 1062

which of the jejunum and ileum has very long vasa recti with few arcades?

Back 1062

jejunum

Front 1063

which of the jejunum and ileum has shorter vasa recti with many arcades?

Back 1063

ileum

Front 1064

where in the small bowel is there more fat in the mesentery?

Back 1064

distally, ie ileum

Front 1065

what is a volvulus?

Back 1065

bowel twisted on its mesentery

Front 1066

what is the widest part of the large bowel?

Back 1066

caecum

Front 1067

what is indicated by a sawtooth pattern on barium enema?

Back 1067

diverticular disease

Front 1068

what is the white line of Hilton?

Back 1068

groove between internal and external sphincter

Front 1069

what fills the ischiorectal fossa?

Back 1069

loose fat

Front 1070

where on a clock face do haemorrhoids occur?

Back 1070

3, 7 and 11 o'clock

Front 1071

by how much does does alcohol dependence increase all-cause mortality?

Back 1071

2-5 times

Front 1072

what are the three phases of alcoholic liver disease?

Back 1072

steatosis
alcoholic hepatitis/steatohepatitis
fibrosis/cirrhosis

Front 1073

what are the cells around the portal tracts called?

Back 1073

acinar zone 1

Front 1074

what are the cells surrounding the central vein called?

Back 1074

acinar zone 3

Front 1075

where does acinar zone 3 steatosis occur?

Back 1075

around central veins

Front 1076

t/f... ethanol toxicity moves from acinar zone 1 to 2 to 3

Back 1076

true

Front 1077

what induces MEOS?

Back 1077

chronic ethanol consumption

Front 1078

t/f... alcohol dehydrogenase is inducible

Back 1078

false, it is constitutively present

Front 1079

which ALDH polymorphism confers reduced capacity to metabolise acetaldehyde?

Back 1079

ALDH2*2

Front 1080

which cytokines are instrumental in enhancing cellular injury in alcoholic liver disease?

Back 1080

TNF
TGF-beta

Front 1081

where is the CYP2E1 system active?

Back 1081

endoplasmic reticulum

Front 1082

where does ADH act in the hepatocyte?

Back 1082

cytosol

Front 1083

where does catalase act in the hepatocyte?

Back 1083

peroxisomes

Front 1084

which pathways producing acetaldehyde produce other toxic and metabolic distrubances causing cellular injury in ALD?

Back 1084

MEOS
ADH

Front 1085

what decreases the first pass metabolism of alcohol by gastric ADH?

Back 1085

fasting (accelerated gastric emptying)
gastrectomy
H2 receptor antagonists

Front 1086

why does the CYP2E1 system play a role in ALD?

Back 1086

generates a high rate of lipid peroxidation and the formation of ROS

Front 1087

what is the major intracellular hepatic antioxidant?

Back 1087

reduced glutathione (GSH)

Front 1088

how does chronic alcohol exposure affect mitochondrial GSH?

Back 1088

reduces mitochondrial GSH

Front 1089

what is the role of protein adducts (of acetaldehyde) in ALD?

Back 1089

adducts act as neoantigens to incite humoral and cytotoxic immune responses

Front 1090

how does ethanol generate oxidative stress?

Back 1090

peroxidation of lipid membranes

Front 1091

how does oxidative stress cause cellular injury?

Back 1091

formation of adducts
generation of cytokines (TNF, TGF-beta) and stimulation of Kupffer cells
peroxidation of cellular membranes
oxidation of DNA

Front 1092

what is the major site of early lesions and fibrosis in ALD?

Back 1092

acinar zone 3 (centrilobular zone)

Front 1093

where are CYP2E1 and GSH located in the liver lobule?

Back 1093

acinar zone 3

Front 1094

what is the role of endotoxin in alcoholic liver disease?

Back 1094

may enter portal and systemic circulation, generating TNF-alpha leading to oxidative stress

Front 1095

where does fibrosis start in alcohol consumers?

Back 1095

acinar zone 3

Front 1096

what is the major source of collagen in liver fibrosis?

Back 1096

hepatic stellate cells

Front 1097

what causes the impairment of hepatic regeneration in ALD?

Back 1097

altered transmission of growth signals

Front 1098

what is the effect of nutritional deficiencies on hepatic regeneration?

Back 1098

impairment of regeneration

Front 1099

what is the major factor in carcinogenesis in alcoholics?

Back 1099

induction of CYP2E1

Front 1100

t/f... the prognosis of alcoholic hepatitis is worse for men than for women

Back 1100

false, prognosis is worse for women

Front 1101

t/f... steatosis is a characteristic histological feature of alcoholic liver disease

Back 1101

true

Front 1102

t/f... hepatic granulomas are a characteristic histological feature of alcoholic liver disease

Back 1102

false

Front 1103

t/f... fibrosis in acinar zone 3 is a characteristic histological feature of alcoholic liver disease

Back 1103

true

Front 1104

t/f... ground glass hepatocytes are a characteristic histological feature of alcoholic liver disease

Back 1104

false, these are characteristic for HBV

Front 1105

t/f... pericholangitis is a characteristic finding in alcoholic liver disease

Back 1105

false, pericholangitis is typically seen in cirrhosing cholangitis or ulcerative colitis

Front 1106

t/f... in chronic alcohol consumers ADH is the major hepatic pathway of alcohol metabolism

Back 1106

false, this is true for people who are small alcoholic consumers

Front 1107

t/f... in women an average daily consumption of 60g is regarded as safe

Back 1107

false

Front 1108

t/f... patients with alcoholic cirrhosis are at increased risk of HCC

Back 1108

true

Front 1109

t/f... acetaldehyde dehyrogenase is inducible by chronic alcohol consumption

Back 1109

false

Front 1110

t/f... GSH is the most important antioxidant mechanism within hepatocytes

Back 1110

true

Front 1111

t/f... in the context of chronic alcohol consumption, increased lipopolysaccharide levels cause protein adducts

Back 1111

false, acetaldehyde and 2E1 cause the adducts

Front 1112

t/f... increased levels of cytochrome P450 2E1 promotes lipid peroxidation within hepatocytes

Back 1112

true

Front 1113

what causes pruritis?

Back 1113

bile salts deposited under the skin

Front 1114

where does bile drain into the deodenum?

Back 1114

ampulla of vater

Front 1115

what is bilirubin?

Back 1115

breakdown product of haem

Front 1116

what is the main source of bilirubin?

Back 1116

haemoglobin from RBC

Front 1117

what are the sources of bilirubin?

Back 1117

main source is Hb
other sources - catalase, cytochromes

Front 1118

t/f... bilirubin is bound irreversibly to albumin during plasma transport

Back 1118

false, it is bound reversibly

Front 1119

what happens to bilirubin before it is excreted into bile?

Back 1119

conjugated with glucuronide

Front 1120

t/f... unconjugated bilirubin cannot be secreted into canaliculi

Back 1120

true

Front 1121

where does bilirubin conjugation occur?

Back 1121

hepatocytes

Front 1122

t/f... unconjugated bilirubin can be excreted in urine

Back 1122

false

Front 1123

what do bile salts do to cholesterol?

Back 1123

keep cholesterol in a soluble state

Front 1124

what is caused by insufficient excretion of bile salts?

Back 1124

ineffective fat digestion and absorption
malabsorption of fat soluble vitamins (ADEK)

Front 1125

which causes of cholestasis cause the most marked bile salt excess?

Back 1125

post-hepatic causes

Front 1126

what are the symptoms of cholestasis?

Back 1126

jaundice
pruritis
dark urine
pale stool

Front 1127

t/f... bilirubin in urine is abnormal

Back 1127

true

Front 1128

what is the hepatitic pattern of LFT abnormalities?

Back 1128

elevated ALT, AST

Front 1129

what is the cholestatic pattern of LFTs?

Back 1129

elevated GGT, alkaline phosphatase and bilirubin

Front 1130

t/f... colicky pain is suggestive of small bowel pain

Back 1130

true

Front 1131

t/f... ulcerative colitis involves the large bowel only

Back 1131

true

Front 1132

t/f... crohn's disease involves the small bowel only

Back 1132

false, it can involve small and large bowel

Front 1133

which part of the bowel is most commonly involved in crohn's disease?

Back 1133

terminal ileum

Front 1134

what is the most common cause of gastroenteritis in Australia?

Back 1134

campylobacter (followed by salmonella)

Front 1135

t/f... swinging fever is characteristic of intra abdominal sepsis

Back 1135

true

Front 1136

t/f... leukopenia is a good prognostic feature for intra abdominal sepsis

Back 1136

false, leukopenia indicates a poor prognosis

Front 1137

what is peritonitis?

Back 1137

inflammation of peritoneal cavity

Front 1138

what is indicated by a history of colicky central pain that progresses to constant right iliac fossa pain?

Back 1138

appendicitis

Front 1139

what is the most common presentation of cholecystitis?

Back 1139

biliary colic

Front 1140

what is Murphy's sign?

Back 1140

pain in right upper quadrant on inspiration (as gallbladder hits examiner's hand)

Front 1141

what condition is indicated by sudden onset of severe upper abdominal pain accompanied by board like rigidity?

Back 1141

ruptured peptic ulcer

Front 1142

what clinical presentation suggests bowel obstruction and infarction?

Back 1142

colicky abdo pain and vomiting
distension, localised tenderness, toxic
hernial orifices

Front 1143

what pain pattern occurs with pancreatitis?

Back 1143

severe central abdo pain radiating through to back

Front 1144

where do intra abdominal abscesses occur?

Back 1144

subphrenic
pelvic
retroperitoneal
between loops of bowel

Front 1145

what moves to wall off a noxious process in abdominal cavity?

Back 1145

omentum

Front 1146

what contributes to the walling off of intra abdominal abscesses?

Back 1146

omentum
adjacent bowel and mesentery
fibrinous exudate

Front 1147

what is the first response to noxious stimuli in the abdomen?

Back 1147

outpouring of peritoneal fluid

Front 1148

how does peritoneal fluid enter the systemic circulation?

Back 1148

via lymphatics (thoracic duct -> subclavian vein)

Front 1149

what is the result of entry of toxins into the systemic circulation?

Back 1149

septicaemia and shock

Front 1150

t/f... the most common type of peritonitis is primary (blood-borne) peritonitis

Back 1150

false, this is a very rare form of peritonitis

Front 1151

which bacteria are most commonly the cause of primary peritonitis?

Back 1151

pneumococcus
streptococcus
E coli

Front 1152

t/f... secondary peritonitis is usually caused by multiple gut organisms

Back 1152

true

Front 1153

what has the most impact on outcome of peritonitis?

Back 1153

promptness and efficacy of treatment

Front 1154

how much bile is produced by the liver each day?

Back 1154

900mL

Front 1155

what are the sources of bile?

Back 1155

hepatocytes
bile ducts

Front 1156

t/f... bile ducts are similar to pancreatic ducts

Back 1156

true

Front 1157

what do bile ducts produce?

Back 1157

isotonic NaHCO3

Front 1158

what do hepatocytes produce?

Back 1158

a fluid rich in organic molecules and relatively poor in bicarbonate

Front 1159

what is extrahepatic bile?

Back 1159

modified intrahepatic bile

Front 1160

what makes up intrahepatic bile?

Back 1160

bile from hepatocytes and intrahepatic bile ducts

Front 1161

how much bile is stored by gallbladder per day?

Back 1161

500mL

Front 1162

what are the functions of the gallbladder?

Back 1162

storage of bile
concentration of bile (up to 10 fold)

Front 1163

what is the range for sodium in hepatic bile?

Back 1163

141-164

Front 1164

what is the concentration of Na in gallbladder bile?

Back 1164

220

Front 1165

what is the concentration of K in hepatic bile?

Back 1165

2.7-6.7

Front 1166

what is the concentration of K in gallbladder bile?

Back 1166

14

Front 1167

what is the concentration of Ca in hepatic bile and gallbladder bile?

Back 1167

hepatic: 1.2-3.2
gallbladder: 15

Front 1168

what is the concentration of HCO3 in hepatic and gallbladder bile?

Back 1168

hepatic: 12-55
gallbladder: 19

Front 1169

what is the concentration of Cl in hepatic and gallbladder bile?

Back 1169

hepatic: 77-117
gallbladder: 31

Front 1170

what is the concentration of bile acids in hepatic and gallbladder bile?

Back 1170

hepatic: 3-45
gallbladder: 45

Front 1171

what is the concentration of total fatty acids in hepatic and gallbladder bile?

Back 1171

hepatic: 2-7
gallbladder: 24

Front 1172

what is the concentration of bilirubin in hepatic and gallbladder bile?

Back 1172

hepatic: 1-2
gallbladder 3

Front 1173

what is the concentration of phospholipid in hepatic and gallbladder bile?

Back 1173

hepatic: 1.4-8.1
gallbladder: 34

Front 1174

what is the concentration of cholesterol in hepatic and gallbladder bile?

Back 1174

hepatic: 1-3.2
gallbladder: 6.3

Front 1175

what are the two forms of bile production?

Back 1175

bile salt dependent
bile salt independent

Front 1176

what is bile salt dependent bile production?

Back 1176

bile produced by transporting bile acids/bile salts from the circulation into the bile

Front 1177

what is enterohepatic recirculation?

Back 1177

bile salts in ileum are transported into portal circulation

Front 1178

t/f... bile acids are derived from cholesterol

Back 1178

true

Front 1179

what is the role of NTCP?

Back 1179

transports sodium and bile salts/acids

Front 1180

what gives bile its colour?

Back 1180

bilirubin

Front 1181

which syndrome presents as severe neonatal jaundice with high levels of unconjugated bilirubin?

Back 1181

Crigler-Najjar syndrome

Front 1182

which enzyme is missing in Crigler-Najjar syndrome?

Back 1182

UGT1A1

Front 1183

what are the health benefits to infants of breastfeeding (strong evidence)?

Back 1183

protects against GI infection, otitis media, lower respiratory tract infection, necrotising enterocolitis

Front 1184

t/f... there is some evidence that breastfeeding protects against UTIs and SIDS and reduces chronic diseases in childhood and later in life

Back 1184

true

Front 1185

what are the benefits of breastfeeding to mothers?

Back 1185

reduced postpartum bleeding
more rapid uterine involution
reduced risks pre-menopausal breast cancer
probable reduced post-menopausal breast cancer and ovarian cancer

Front 1186

which mothers have lower breastfeeding rates?

Back 1186

without tertiary qualifications
aged less than 25
living in the most disadvantaged areas
some rural AHSs

Front 1187

how common is mastitis?

Back 1187

up to 25% breastfeeding women

Front 1188

t/f... antibiotics are firstline treatment for mastitis

Back 1188

false

Front 1189

what is the commonest causative organism of mastitis?

Back 1189

staph aureus

Front 1190

how many mothers return to work before 6 and 12 months?

Back 1190

25% before 6 months
40% before 12 months

Front 1191

where are the paravertebral gutters?

Back 1191

either side of vertebral bodies

Front 1192

where are the abdominal aorta and IVC closest to anterior abdo wall?

Back 1192

just above umbilicus

Front 1193

at which vertebral level is the umbilicus?

Back 1193

L3/4

Front 1194

what are the layers of the anterior abdo wall in the midline?

Back 1194

skin
superficial fascia
deep fascia (very thin)
linea alba
transversalis fascia
extraperitoneal fat
parietal peritoneum

Front 1195

what are the layers of the anterolateral abdo wall laterally?

Back 1195

skin
superficial fascia
deep fascia
external oblique
internal oblique
transversus abdominis
transversalis fascia
extraperitoneal fat
parietal peritoneum

Front 1196

where do the layers of the anterolateral abdo wall fuse?

Back 1196

at the umbilicus

Front 1197

what is the deepest part of the superficial fascia?

Back 1197

membranous layer

Front 1198

what forms the self-contained pouch that may fill with urine from a ruptured urethra?

Back 1198

membranous layer of superficial fascia

Front 1199

what provides support to the viscera?

Back 1199

resting abdo wall muscle tone

Front 1200

when do abdominal wall muscles contract?

Back 1200

forced expiration
to increase intra-abdo pressure
to move trunk
to protect viscera against injury

Front 1201

what forms the anterior rectus sheath above the arcuate line?

Back 1201

1 1/2 aponeuroses

Front 1202

what forms the anterior layer the rectus sheath below the arcuate line?

Back 1202

3 aponeuroses

Front 1203

what is related to the rectus abdominis posteriorly below the arcuate line?

Back 1203

transversalis fascia

Front 1204

where do the superior and inferior epigastric arteries anastomose?

Back 1204

posterior to rectus abdominis muscles

Front 1205

where is the neurovascular plane in the anterior abdominal wall?

Back 1205

between transversus abdominis and internal oblique

Front 1206

t/f... L1 does not pierce the rectus sheath

Back 1206

true

Front 1207

where is the deep inguinal ring?

Back 1207

mid point of inguinal ligament

Front 1208

what is contained in the inguinal canal?

Back 1208

spermatic cord (male)/round ligament (female)
ilioinguinal nerve

Front 1209

an opening in which layer of the abdo wall forms the deep inguinal ring?

Back 1209

transversalis fascia

Front 1210

what is the superficial inguinal ring?

Back 1210

opening in external oblique aponeurosis

Front 1211

where is the superficial inguinal ring in relation to the pubic tubercle?

Back 1211

superior and medial

Front 1212

what attaches to the lateral 2/3 of inguinal ligament?

Back 1212

internal oblique

Front 1213

what attaches to the lateral 1/2 of inguinal ligament?

Back 1213

transversus abdominis

Front 1214

what forms the floor of the inguinal canal?

Back 1214

inguinal ligament

Front 1215

what forms the roof of the inguinal canal?

Back 1215

internal oblique and transversus abdominis

Front 1216

what forms the anterior wall of the inguinal canal?

Back 1216

external and internal oblique

Front 1217

what forms the posterior wall of the inguinal canal?

Back 1217

transversalis fascia and conjoint tendon

Front 1218

what forms Hesselbach's triangle?

Back 1218

rectus abdominis
inferior gastric artery
inguinal ligament

Front 1219

where does a femoral hernia pass?

Back 1219

through femoral ring into upper medial thigh

Front 1220

what are the boundaries of the femoral ring?

Back 1220

femoral vein
inguinal ligament
pectineus muscle and fascia
lacunar ligament

Front 1221

what is the foregut?

Back 1221

oesophagus to prox duodenum (entry bile duct)

Front 1222

what is the midgut?

Back 1222

distal duodenum to 2/3 transverse colon

Front 1223

what is the hindgut?

Back 1223

distal 1/3 transverse colon to upper 1/2 anal canal

Front 1224

which organs are associated with the foregut?

Back 1224

liver
most of pancreas
spleen

Front 1225

which organs are associated with the midgut?

Back 1225

remainder of pancreas

Front 1226

what is the arterial supply and venous drainage of the foregut?

Back 1226

coeliac trunk
splenic vein

Front 1227

what is the arterial supply and venous drainage of midgut?

Back 1227

superior mesenteric artery and vein

Front 1228

what is the arterial supply and venous drainage of the hindgut?

Back 1228

inferior mesenteric artery and vein

Front 1229

what is the parasympathetic supply to the foregut, midgut and hindgut?

Back 1229

foregut - vagus
midgut - vagus
hindgut - S2-4

Front 1230

what is the sympathetic supply to the foregut, midgut and hindgut?

Back 1230

foregut - thoracic splanchnic nerves
midgut - thoracic splanchnic nerves
hindgut - lumbar splanchnic nerves

Front 1231

where do the coeliac truck and superior and inferior mesenteric arteries leave the aorta?

Back 1231

Tv12
Lv1
Lv3

Front 1232

which arteries arise from the coeliac trunk?

Back 1232

left gastric
splenic
common hepatic

Front 1233

which arteries arise from the superior mesenteric artery?

Back 1233

inferior pancreaticoduodenal
jejunal and ileal branches
ileocolic
right colic
middle colic

Front 1234

which arteries arise from the inferior mesenteric artery?

Back 1234

left colic
sigmoidal
superior rectal

Front 1235

where does the portal vein travel in relation to the duodenum?

Back 1235

posterior to first part of duodenum

Front 1236

what are the retroperitoneal parts of the gut tube?

Back 1236

duodenum (except first few cm)
ascending colon
descending colon

Front 1237

what is the epiploic foramen?

Back 1237

opening into lesser sac behind free edge of lesser omentum

Front 1238

what is the greater omentum fused with posteriorly?

Back 1238

transverse colon and its mesocolon

Front 1239

where do the greater and lesser sac communicate?

Back 1239

epiploic foramen

Front 1240

what attaches the jejunum and ileum to the posterior abdominal wall?

Back 1240

mesentery

Front 1241

where does the oesophagus commence?

Back 1241

lower border of cricoid cartilage (Cv6)

Front 1242

which muscle forms the upper oesophageal sphincter?

Back 1242

cricopharyngeus (lower part of inferior constrictor)

Front 1243

where does oesophageal epithelium change from stratified sqamous to columnar?

Back 1243

Z line

Front 1244

what are the layers of muscle in the oesophagus?

Back 1244

outer longitudinal
inner circular

Front 1245

what are the constriction points of the oesophagus?

Back 1245

upper oesophageal sphincter
arch of aorta and left main bronchus
oesophageal hiatus (Tv10)

Front 1246

what is the venous drainage of the three parts of the oesophagus?

Back 1246

cervical: thyroid vv->SVC
thoracic: azygos vv->SVC
abdominal: portal vein

Front 1247

what is the lymphatic drainage of the three parts of the oesophagus?

Back 1247

cervical: deep cervical nodes
thoracic: mediastinal nodes
abdominal: coeliac nodes

Front 1248

what is the arterial supply of the three parts of the oesophagus?

Back 1248

cervical: branches of inferior thyroid artery
thoracic: direct/indirect branches of descending thoracic aorta
abdominal: left gastric artery

Front 1249

what is the innervation of the oesophagus?

Back 1249

left and right vagus nn (form plexus then ant and post vagal trunks which pass through oesophageal hiatus)
sympathetic trunk

Front 1250

where does pain referral occur from the oesophagus?

Back 1250

substernal pain +/- epigastric pain

Front 1251

what are the four parts of the stomach?

Back 1251

cardia
fundus
body
pyloric part

Front 1252

what are the muscular layers of the stomach?

Back 1252

deep: oblique
middle: circular
superficial: longitudinal

Front 1253

what are the folds on the interior of the stomach?

Back 1253

rugae

Front 1254

what thickens to form the pyloric sphincter?

Back 1254

circular layer of muscle

Front 1255

what does the lesser omentum attach to?

Back 1255

lesser curvature of stomach and first few cm of duodenum to liver

Front 1256

what is contained in the greater omentum?

Back 1256

blood vessels
lymph vessels
variable amount of fat

Front 1257

what are the anterior relations of the stomach?

Back 1257

liver
diaphragm
ant abd wall

Front 1258

what are the posterior relations of the stomach?

Back 1258

diaphragm
left suprarenal gland and kidney
pancreas
splenic artery
transverse colon and mesocolon

Front 1259

at what vertebral levels is the duodenum?

Back 1259

Lv1-3

Front 1260

what are the folds on the interior surface of the duodenum?

Back 1260

circular folds (plicae circulares) in all but first few cm

Front 1261

what is the blood supply to the stomach?

Back 1261

branches of coeliac trunk:
lesser curvature - L and R gastric aa
greater curvature - L and R gastroepiploic arteries
fundus - short gastric arteries

Front 1262

what is the blood supply to the duodenum?

Back 1262

sup and inf pancreaticoduodenal aa (from coeliac a and SMA)

Front 1263

which artery may be eroded by a peptic ulcer on the posterior wall of the stomach?

Back 1263

splenic artery

Front 1264

which artery may be eroded by a peptic ulcer on the posterior wall of first part of duodenum?

Back 1264

gastroduodenal artery

Front 1265

what does the gastroduodenal artery branch into?

Back 1265

gastroepiloic and superior pancreaticoduodenal arteries

Front 1266

where is the vena caval hiatus?

Back 1266

Tv8

Front 1267

where is the oesophageal hiatus?

Back 1267

Tv10

Front 1268

where is the aortic hiatus?

Back 1268

Tv12

Front 1269

what makes up the posterior abdominal wall?

Back 1269

lumbar vertebrae and intervening discs
crura and arcuate ligaments of diaphragm
psoas major
quadratus lumborum
iliacus
aponeurosis of transversus abdominis

Front 1270

where does the abdominal aorta start and end?

Back 1270

aortic hiatus (Tv12 in diaphragm)
Lv4

Front 1271

which paired branches of arteries arise from the abdominal aorta?

Back 1271

suprarenal
renal
gonadal (ovarian, testicular)

Front 1272

which branches of the abdominal aorta supply the body wall?

Back 1272

inferior phrenic
lumbar branches
median sacral

Front 1273

where does the IVC commence?

Back 1273

Lv5 bu union of L and R common iliac veins

Front 1274

what are the major tributaries of the IVC?

Back 1274

L and R renal
hepatic veins
lumbar veins
R gonadal
R suprarenal

Front 1275

t/f... the valves in the trunk are valveless

Back 1275

true

Front 1276

how do the SVC and IVC anastomose?

Back 1276

via veins on anterior trunk wall, via the ascending lumbar/azygos system, vertebral venous plexus and portal system

Front 1277

where do the unpaired viscera drain to (lymph)?

Back 1277

preaortic nodes

Front 1278

where do the structures below the diaphragm excluding unpaired viscera drain to?

Back 1278

para-aortic nodes

Front 1279

where do the pre and para-aortic nodes drain to?

Back 1279

cysterna chyli->thoracic duct->drains to junction L subclavian and L int jug

Front 1280

palpation of which node is indicated in a routine examination of the abdomen?

Back 1280

left supraclavicular node (Virchow's node)

Front 1281

what is Troisier's sign?

Back 1281

hard and enlarged Virchow's node

Front 1282

where does lymph return to veins?

Back 1282

root of neck

Front 1283

what are the somatic nerves to the posterior abdominal wall?

Back 1283

subcostal nerve (T12 ventral ramus)
branches of lumbar plexus (forms in psoas major from ventral rami of L1-4)

Front 1284

where are the sympathetic trunks?

Back 1284

in groove between vertebral bodies and psoas major

Front 1285

where is the right symp trunk relative to IVC?

Back 1285

posterior

Front 1286

how do L and R symp trunks unite?

Back 1286

anterior to coccyx as ganglion impar

Front 1287

how do thoracic splanchnic nerves pass through the diaphragm?

Back 1287

pierce the crura

Front 1288

what are the retroperitoneal structures?

Back 1288

suprarenal glands
kidneys
ureters
pancreas (except tail)
duodenum (except first few cm)
ascending and descending colon
abdo aorta
IVC
assoc LN and autonomic nn

Front 1289

what is the arterial supply to the suprarenal glands?

Back 1289

superior, middle and inferior suprarenal aa

Front 1290

which cells release adrenaline and noradrenaline into circulation via suprarenal veins?

Back 1290

chromaffin cells of adrenal medulla

Front 1291

what is the venous drainage of the suprarenal veins?

Back 1291

R suprarenal vein->IVC
L suprarenal vein->left renal v

Front 1292

which features distinguish the colon?

Back 1292

taeniae coli
haustrations
epiploic appendages

Front 1293

what percentage of appendices are retrocaecal? pelvic?

Back 1293

64%
32%

Front 1294

what is a positive psoas sign?

Back 1294

pain on passive extension of right hip joint with knee extended (indicates appendicitis)

Front 1295

what is the obturator sign?

Back 1295

pain on internal rotation of flexed right hip (indicates appendicitis)