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USMLE GI

Instructions:

Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. malnutrition - toxic megacolon - colorectal carcinoma
Complications of UC
Gardner's syndrome
PAS- positive globules in liver -
Complications of crohns

2. What is indirect bilirubin
Unconjugated - water insoluble
LLQ - fever - leukocytosis - can perforate leading to peritonitis - abscess formation - bowel stenosis - give antiobiotics
Phenobarbital - inc liver enzyme synthesis
Tropical sprue

3. What structures feed into the common bile duct
Iron def anemia in older pts - screening of pts >50 with stool occult blood test and colonscopy - apple core lesion on barium enema xray - CEA tumor marker
Mitochondrial abnl - fatty liver - hypoglycemia - coma
Cystic duct and common hepatic duct
Via the superior pancreaticduodenal

4. What receptors does gastrin bind on the parietal cell and What does it activate
H pylori (almost 100%)
Gastrin secreting tumor that causes continuous high levels of acid secretion and ulcers
CCK8 receptor - Gq inc IP3/Ca
Adhesion

5. Why would a self - limited lactase def occur following an injury (viral diarrhea)
Duodenum - 2nd - 3rd and 4th parts
Antrum - H.pylori - inc risk of MALT lymphoma
Right and left hepatic duct
Lactase is located at the tips of intestinal villi

6. What are esophageal strictures associated with
<3mm nodules - metabolic - etoh - hemochromatosis - wilsons
Lye ingestion and acid reflux
Celiac sprue
Primarly through ECL leading to histamine release

7. What causes hirschsprungs
Hernia
Failure of neural crest migration
Gardner's syndrome
Squamous - upper 1/3 - adeno - lower 1/3

8. What is the TX of physiologic neonatal jaundice
Primarly through ECL leading to histamine release
Phototherapy
Black - rotors syndrome
Left gastric vein and esophogeal vein - esophagus

9. Which IBD usually has transmural inflammation and which has mucosal and submucosal inflammation and What are the characteristic signs of each
Crohns = transmural (cobblestone mucosa - creeping fat - string sign - linear ulcers fissures - fistulas) UC = mucosal and submucosal (friable mucosal pseudopolyps with freely hanging mesentary - loss of haustra - lead pipe appearance on imaging
Achalasia due to loss of myenteric plexus (auberach)
NAV = nerve artery vein - venous near the penis (NAVEL)
Ampulla of vater

10. What receptors does ACH bind on the parietal cells and What does it activate
Sympathetic (T1- T3 superior cervical ganglion) and parasympathetic (facial and glossopharyngeal nerve)
M3 - Gq - inc IP3/Ca
Reye's syndrome
DNA mistmatch repair gene mutations lead to sporadic and HNPCC syndrome - mutations accumulate but not define morphologic correlates

11. What does autoimmune destruction of parietal cells lead to...
90%
Lipase - phospholipase A - colipase
Chronic gastritis and pernicious anemia
Diverticulum

12. What causes nutmeg liver
Upregulated intracellular signal transduction
Punched out - clean margins - carcinoma =raised irregular margins
DIC - ARDS - diffuse fat necrosis - hypcalcemia - pseudocyst formation - hemorrhage - infxn - multiorgan failure
Backup of blood into the liver - RHF - budd chiari

13. What are the main components of bile
Gastrin stimulating ECL cells to release histamine - histamine stimulation on parietal cells
Peptic ulcer disease
Bile salts (bile conjugated to glycine or taurine) phospholipids - cholesterol - bilirubin - water and ions
Failure of neural crest migration

14. How do burns cause acute gastritis and What is it called

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15. What are the histological findings in the duodenum

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16. What are the effects of atropine on parietal cells and G cells
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood
Neutralizes gastric acid allowing pancreatic enzymes to fxn
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
Portal HTN

17. What commonly leads to appendicity in kids vs adults
Centrilobular leading to congestive liver disease
Trypsin - chymotrypsin - elastase - carboxypeptidases
No - chronic - can present with diarrhea or constipation or alternation - treat sx
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith

18. Which serum enzyme increases with heavy EtOH consumption
Primary sclerosing cholangitis
Gamma glutamyl transferase GGT
Hirschsprungs
Brush border of intestine - produce monosaccharides from oligo and di

19. absent UDPGT - presents early in life - early mortality
Crigler - najjar type 1
Left gastric vein and esophogeal vein - esophagus
Myenteric nerve plexus - aurbach
Conj - inc - dec

20. What is the prognosis of adenocarcinoma
Averages 6 months - very aggressive - usually already metastasized at presentation
Antrum - H.pylori - inc risk of MALT lymphoma
Epigastric abdominal pain radiating to back - anorexia - nausea
Bleeding - penetration into pancreas - perforation - obstruction

21. Where is the arterial supply from above the pectinate line - and What is the venous drainage
Superior rectal from IMA - superior rectal vein to inf mesenteric to portal system
CCK8 receptor - Gq inc IP3/Ca
Superior rectal
Peptic ulcer disease

22. Is there any structural abnl with IBS - What is the course of disease and presentation
Alfatoxin in peanuts
Distal 1/3 of transverse colon to supper portion of rectum - IMA - and PANS
Alpha amylase
No - chronic - can present with diarrhea or constipation or alternation - treat sx

23. signet ring cells - acanthosis nigracans - dz - character/association - spread
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood
The femoral nerve - only the vein artyer and canal (with deep inguinal lymph nodes)
So hypertrophied they look like brain gyri
Positive

24. How is the diagonsis of CRC made
Krukenbergs tumor
Iron def anemia in older pts - screening of pts >50 with stool occult blood test and colonscopy - apple core lesion on barium enema xray - CEA tumor marker
No
Pancreatic insuff - steatorrhea - fat soluble vitamin def - DM

25. What are the signs of peutz jehgers
Nonkeritinized stratified sqamous epithelium
Striated and smooth
Mucosal cells in the stomach - duod - salivary glands - pancreas - brunners glands in the duod - neutralizes acid - inc by pancreatic and biliary secretion with secretin
Hyperpigmented mouth - lips - hands - genitalia

26. blind pouch protruding from alimentary tract that communicates with lumen of the gut
Diverticulum
Chief cells of the stomach - protein digestion - inc by vagal stimulation local acid
Lack or have an attenuated muscularis externa - often in the sigmoid colon
Pleomorphic adenoma

27. What kind of muscle is in the lower 1/3 of the esophagus
Unconjugated - water insoluble
Smooth
Goes through deep inguinal ring - external inguinal ring and into the scrotum
Dilated esophagus with an area of distal stenosis - birds beak

28. How many layers outpouch in a false diverticula and they occur At what point of weakness and what?
T12
Antrum - H.pylori - inc risk of MALT lymphoma
Only mucosa or submucosa - occur where vasa recta perforate muscularis externa
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin

29. What does a low flow rate mean for saliva
Inspiratory arrest on deep palpation due to pain
Hypotonic because of more time to reabsorb NaCl
Neutralizes gastric acid allowing pancreatic enzymes to fxn
Inferior epigastric artery - lateral border of rectus abdominis - inguinal ligament

30. What are the structures of the femoral triangle and how are they organized
Increase tumorigenesis
NAV = nerve artery vein - venous near the penis (NAVEL)
Alfatoxin in peanuts
Mucosa - submucosa - muscularis externa - serosa/adventitia

31. This disease commonly presents as heartburn and regurg when lying down - What is another common presentation
Striated and smooth
Osmotic
GERD - may also present with nocturnal cough and dyspnea
Inc size - villous histology - inc epithelial dysplasia - precursor to CRC

32. which pancreatic enzyme - secreted in its active form - is responsible for starch digestion
12 waves/min
GLUT 2
Alpha amylase
Aspirin metabolites dec beta oxidation by reversible inhibition of mitocondrial enzyme - ASPIRIN Not RECOMMENDED FOR CHILDREN

33. inc cholesterol and/or bilirubin - dec bile salts and gallbladder stasis
Fasting and stress
Esophageal varices
All 3 gut layers outpouch as in Meckels
Causes of gall stones

34. What does GET SMASHED stand for in acute pancreatitis
The femoral nerve - only the vein artyer and canal (with deep inguinal lymph nodes)
CCK8 receptor - Gq inc IP3/Ca
Lack or have an attenuated muscularis externa - often in the sigmoid colon
Gallstones - EtOH - trauma - steroids - mumps - autoimmune - scorpion sting - hypercalcemia/hyperlipidemia - ERCP - Drugs (sulfa)

35. How is bilirubin carried in the blood
HPNCC
Cirrhosis - DM - skin pigmentation - 'bronze diabetes'
With albumin
External - receive somatic innervation - internal receive visceral innervation - not painful but sign of portal HTN

36. FAP + osseous and soft tissue tumors - retinal hyperplasia

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37. What is the most important mechanism in gastric acid secretion
Gastrin stimulating ECL cells to release histamine - histamine stimulation on parietal cells
Copious diarrhea - non alpha - non beta cell pancreatic tumor
T12
Glucose dependent insulinotropic peptide

38. What are the histological findings in the jejunum
Volvulus
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Cigarettes and chronic pancreatitis - not EtOH

39. What is biliary colic
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
Liver metabolizes 5HT
Dubin johnson
Dense core bodies

40. What are the treatmet options for crohns
Corticosteroids - infliximab
Hematogenous - alpha fetoprotein - budd chiari (hepatic vein blockage)
Source - D cells (pancreatic islets - GI mucosa) - action - dec gastric acid and pepsinogen secretion - dec pancreatic and small intestine fluid secretion - dec gallbladder contraction - dec insulin and glucagon release
Antrum - H.pylori - inc risk of MALT lymphoma

41. bilateral mets to ovaries with abundant mucus - signet ring cells
Smooth
Krukenbergs tumor
Inc risk of CRC and other visceral malignancies
Superior rectal and middle and inferior rectal - rectum

42. If the abdominal aorta is blocked - How does blood get to the middle rectal artery
Superior rectal
Positive
Fasting and stress
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid

43. misfolded gene product protein accumulates in hepatocellular ER - dec in elastic tissu in lungs leading panacinar emphysema
Alpha1 antitrypsin def - codominant trait
Alternating strictures and dilation with beading of intra and extrahepatic bile ducts on ERCP
Low pressure proximal to LES
VZV and influenza B treated with salicylates

44. Autodigestion of pancreas by pancreatic enzymes
Acute pancreatitis
The gastroduodenal
Autoimmune rxn leading to lymphcytic infiltrate + granulomas
GERD - may also present with nocturnal cough and dyspnea

45. To what substance is bilirubin conjugated and why
Lubricate food (glycoprotiens)
Glucouronate - water soluble (direct)
Conj - inc - dec
Crohns = transmural (cobblestone mucosa - creeping fat - string sign - linear ulcers fissures - fistulas) UC = mucosal and submucosal (friable mucosal pseudopolyps with freely hanging mesentary - loss of haustra - lead pipe appearance on imaging

46. internal hemorrhoids and adenocarcinoma occur above or below pectinate line?
Repeated phlebotomy - deferoxamine - HLA- A3
Can lead to hematemesis - found in EtOHics and bulimics
Mucoepidermoid carcinoma
Above

47. In PUD with a duodenal ulcer does pain inc or dec with meals
Zenkers - halitosis - dysphagia and obstruction
Decrease - weight gain
Bleeding - intussusception - volvulus - obstruction near terminal ileum
Source - SI - action - produces migrating motor complexes - regulation - inc in fasting state

48. What kind of diarrhea is produced from a disaccharide def
5HT - wheezing - right sided heart murmurs - diarrhea - flushing -
L/R renal artery around L1
Conj/unconj - inc - nl to dec
Osmotic

49. What structures feed into the common hepatic duct
Colonic polyps
Pancreatic insuff - steatorrhea - fat soluble vitamin def - DM
Smooth
Right and left hepatic duct

50. What are the common causes of gastric ulcers - What causes gastric ulcer
90%
Source - I cells (duod - jej - action - inc pancreative secretion - inc gallbladder contraction - dec gastric emptying - sphincter of Oddi relaxation - regulation - inc by fatty acids and amino acids
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation