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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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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. Which area of the hindgut is a watershed area
Portal HTN
Splenic flexure
HSV-1 - CMV - Candida
12 waves/min

2. Where does inflammation in diverticula likely cause pain - what other signs/symptoms are present and What are the complications
CEA - CA-19-9
In the ileum with bile acids - requires IF
LLQ - fever - leukocytosis - can perforate leading to peritonitis - abscess formation - bowel stenosis - give antiobiotics
Pyoderma gangrenosum - primary sclerosing cholangitis

3. What are the borders of Hesselbach's triangle
Inferior epigastric artery - lateral border of rectus abdominis - inguinal ligament
Inguninal ligament - sartorius muscle - adductor longus
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
Dissaccharidase def - most commonly lactase

4. glandular metaplasia - replacement of nonkeratinized (stratified) squamous epithelium with intestinal (columnar) epithelium in the distal esophagus

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5. FAP + malignant CNS tumor
Turcot
Primarly through ECL leading to histamine release
Lack or have an attenuated muscularis externa - often in the sigmoid colon
Lateral to the inferior epigastric artery

6. inflammatino of gallbadder
Cholecystitis - usually from gallstones rarely ischemia or infxn (CMV)
Diarrhea - steatorrhea - weight loss - weakness
Peyers patches
Femoral hernia - through femoral canal - lateral to pubic tubercle and women

7. What does the gastrocolic ligament connect - What is contained - and what larger structure is it a part of...
Greater curvature of stomach to transverse colon - gastroepiploic arteries - greater omentum
Striated and smooth
Cushings ulcers - inc vagal stimulation leading to inc vagal stim - inc ACH and inc H+ secretion
Hepatic steatosis

8. What ligament connects the liver to the abdominal wall - What is contained within it and From what structure is it derived
Falciform - ligamentum teres - fetal umbilical vein
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood
Increase tumorigenesis
Lye ingestion and acid reflux

9. What are the branches of the celiac trunk and What do they supply
Common hepatic - splenic - left gastric - main blood supply for stomach
Chief cells of the stomach - protein digestion - inc by vagal stimulation local acid
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
Brush border of intestine - produce monosaccharides from oligo and di

10. How is salivary secretion stimulated
Gamma glutamyl transferase GGT
Sympathetic (T1- T3 superior cervical ganglion) and parasympathetic (facial and glossopharyngeal nerve)
Penicillinamine - AR inheritance
Below

11. in jaundice of obstructive etiolgy is the hyperbilirubinemia conj or unconj - what happens to urine bili - and what happens to urine urobilinogen
Hernia
SGLT1 (Na dependent) glucose - galactose - GLUT 5 fructose (facilitated diffusion)
Superior rectal
Conj - inc - dec

12. What is the most common indication of emergent abdominal surgery in children
Left and right gastroepiploics - left and right gastrics
Appendicitis
Intussusception
Jaundice - fever - RUQ

13. What portion of the bowel does sprue effect
Greater curvature of stomach to transverse colon - gastroepiploic arteries - greater omentum
The proximal small bowel
Peutz jeghers
MSI (15%) and APC/beta catenin chromosomal instability (85%)

14. What is biliary colic
Where hindgut meets ectoderm
Crohns = maybe - UC= always
Duodenal atresia - Downs
Pain associated with cholecystitis and galls stones - diabetics may not present with pain

15. What enzyme is necessary to create conjugated bilirubin
Hyperpigmented mouth - lips - hands - genitalia
Uridine glucuronyl transferase
Decrease - weight gain
Jaundice - tender hepatomegaly - ascites - polycythemia - hypoglycemia

16. What is the path of an indirect inguinal hernia
Krukenbergs tumor
Diarrhea - steatorrhea - weight loss - weakness
Goes through deep inguinal ring - external inguinal ring and into the scrotum
Copious diarrhea - non alpha - non beta cell pancreatic tumor

17. What can fistula between the gallbladder and small intestine create and how can you tell
Air into the biliary tree - if gallstone obstructs ileocecal valve - air can be seen in biliary tree on imaging
Striated and smooth
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome
ASA preparations (sulfasalazine) 6- mercaptopurine - infliximab - colectomy

18. What cells make gastric acid - What does it do to stomach pH and what substances regulate it
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin
Liver metabolizes 5HT
Can lead to hematemesis - found in EtOHics and bulimics
Source - K cells (duod - jej) - action - exocrine - dec gastric H+ secretion - endocrine - inc insulin release - regulation - inc by fatty acids - amino acids - oral glucose

19. What are the effects of atropine on parietal cells and G cells
Zollinger ellison - brunners glands
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
HSV-1 - CMV - Candida
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome

20. What is the most common cause of gallstones
Cholesterol - 10-20% opaque due to calcifications
Cholecystitis - also ascending cholangitis - acute pancreatitis and bililary infx
>3mm nodules - significant liver injury leading to hepatic necrosis - postinfectious - drug induced hepatitis with inc risk of HCC
Epigastric abdominal pain radiating to back - anorexia - nausea

21. To what substance is bilirubin conjugated and why
Glucouronate - water soluble (direct)
Warthins' tumor
Left and right gastroepiploics - left and right gastrics
Striated

22. Bilirubin is the product of what?
Chronic hemolysis - alcoholic cirrhosis - advanced age and biliary infxn
Heme metabolism
Mucosa - submucosa - muscularis externa - serosa/adventitia
Jaundice - fever - RUQ

23. What are the signs of peutz jehgers
H+
Alfatoxin in peanuts
3rd most common cancer - 3rd deadliest in US - pts > 50 - 1/4 have fam hx
Hyperpigmented mouth - lips - hands - genitalia

24. Malabsorption syndromes have what common clinical presentation
Diarrhea - steatorrhea - weight loss - weakness
Causes of gall stones
Crohns - CF - advanced age - clofibrate - estrogens - multiparity - rapid weight loss - Native American origin
Upregulated intracellular signal transduction

25. What are the histological findings in the duodenum

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26. What arteries exit just below the SMA
Necrotizing enterocolitis
Inferior epigastric artery - lateral border of rectus abdominis - inguinal ligament
Centrilobular congestion and necrosis - cardiac cirrhosis
L/R renal artery around L1

27. Which patients have pigment stones
Dilated esophagus with an area of distal stenosis - birds beak
Chronic hemolysis - alcoholic cirrhosis - advanced age and biliary infxn
Acute pancreatitis
Distal duodenum to proximal 2/3 of transverse colon - SMA - vagus

28. reduction in intestinal blood flow causes ischemia - pain after eating - weight loss - occurs at splenic flexure and distal colon - elderly
Urobilin
Ischemic colitis
Chronic hemolysis - alcoholic cirrhosis - advanced age and biliary infxn
Necrotizing enterocolitis

29. Is there any structural abnl with IBS - What is the course of disease and presentation
Bleeding - penetration into pancreas - perforation - obstruction
Closer to isotonic because of less time to reabsorb NaCl
Superior rectal from IMA - superior rectal vein to inf mesenteric to portal system
No - chronic - can present with diarrhea or constipation or alternation - treat sx

30. What do mucins do?
T12
Lubricate food (glycoprotiens)
Dissaccharidase def - most commonly lactase
Lesser curvature - gastric arteries - cut in surgery to access lesser sac

31. What reaction does salivary amylase catalyze
Hyrdolyzes alpha 1-4 linkages to yield disaccharides
Jaundice - tender hepatomegaly - ascites - polycythemia - hypoglycemia
90%
Fasting and stress

32. What cells secrete bicarb - What does it do - and what regulates it
The proximal small bowel
Mucosal cells in the stomach - duod - salivary glands - pancreas - brunners glands in the duod - neutralizes acid - inc by pancreatic and biliary secretion with secretin
Pancreatic insuff - steatorrhea - fat soluble vitamin def - DM
L3

33. What are motilin receptor agonists used for clinically
Failure of neural crest migration
Heme metabolism
Acute pancreatitis
Stimulate intestinal persistalsis

34. signet ring cells - acanthosis nigracans - dz - character/association - spread
Hyperplastic
Distal colon - obstruction - colicky pain - hematochezia - proximal colon - dull pain - iron deficiency anemia - fatigue
Hemosiderosis - hemochromatosis
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood

35. What kind of salivary gland tumor is benign - heterotopic salivary gland tissue - trapped in lymph node and surrounded by lymphatic tissue

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36. What parts of the small bowel can tropical sprue effect
Inc risk of CRC and other visceral malignancies
90%
The entire
Meconium ileus

37. What kind of pathways do CCK act on to cause pancreatic secretion
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
Neural muscarinic pathways
Gastrin secreting tumor that causes continuous high levels of acid secretion and ulcers
Chief cells of the stomach - protein digestion - inc by vagal stimulation local acid

38. What kind of cancer to celiac sprue put you as inc risk for
T cell lymphoma
Source - SI - action - produces migrating motor complexes - regulation - inc in fasting state
Begins starch digestion - inactivated by low pH upon reaching the stomach
AST >ALT - ration is usually 1.5

39. What is the term for deposition of hemosiderin and What is the name of the disease caused by that deposition
True and most common congenital anomoly of GI tract
Cholecystitis - usually from gallstones rarely ischemia or infxn (CMV)
Hemosiderosis - hemochromatosis
Falciform - ligamentum teres - fetal umbilical vein

40. most common malignant salivary gland tumor
Protrudes through the Hesselbach's triangle - bulges directly through abdominal wall medial to inferior epigastric vessels
Pruritis - jaundice - dark urine - light stools - hepatosplenomegaly
Serum mitochondrial antibodies including IgM - associated with CREST - RA and celiac dz
Mucoepidermoid carcinoma

41. B cells stimuated in the germinal centers of peyers patches differentiate into what?
All 3
Alcohol/Achalasia - Barretts - Cigarettes - Diverticuli (Zenkers) Esophageal web/Esophagitis - Familial
IgA secreting plasma cells - ultimately reside in the lamina proporia
Alternating strictures and dilation with beading of intra and extrahepatic bile ducts on ERCP

42. motilin - source - action - regulation
Neutralizes gastric acid allowing pancreatic enzymes to fxn
Source - SI - action - produces migrating motor complexes - regulation - inc in fasting state
Cholesterol
Coma - scleral icterus - fetor hepaticus - spider nevi - gynecomastia - jaundice - testicular atrophy - hand tremor - bleeding - anemia - ankle edema

43. What kind of lesions are characteristic of duodenal PUD vs cancer
In the ileum with bile acids - requires IF
Enterokinase/enteropeptidase from the duodenal mucosa
Punched out - clean margins - carcinoma =raised irregular margins
Serous on the sides parotids - mucinous in the middle sublingual

44. Where is IgA shuttled
IgA receives protective secretory component and is then transported across the epithelium to gut lumen
Smooth
Repeated phlebotomy - deferoxamine - HLA- A3
Redundant mesentary

45. How does CRC present in the distal and proximal colon
Terminal ileum and colon
Tropical sprue
Colovesical leading to pneumaturia
Distal colon - obstruction - colicky pain - hematochezia - proximal colon - dull pain - iron deficiency anemia - fatigue

46. What does TOASTED with alcoholic hepatitis stand for
Cimetidine
Squamous - upper 1/3 - adeno - lower 1/3
AST >ALT - ration is usually 1.5
CCK8 receptor - Gq inc IP3/Ca

47. What histological findings are present in the esophagus
In the mucus that covers the gastric epithelium
Achalasia due to loss of myenteric plexus (auberach)
Urobilin
Nonkeritinized stratified sqamous epithelium

48. What is indirect bilirubin
Unconjugated - water insoluble
Achalasia due to loss of myenteric plexus (auberach)
AR
Upregulated intracellular signal transduction

49. How do you DX and TX gallstones
US and cholecystectomy
Chronic constipation early in life with dilated portion of the colon proximal to the aganglionic segment resulting in a transition zone - involves rectum - usually a failure to pass meconium
DIC - ARDS - diffuse fat necrosis - hypcalcemia - pseudocyst formation - hemorrhage - infxn - multiorgan failure
Femoral hernia - through femoral canal - lateral to pubic tubercle and women

50. Pain improves with defaction - changes in stool frequency and changes in stool appearance are associated with
Right and left hepatic duct
Coma - scleral icterus - fetor hepaticus - spider nevi - gynecomastia - jaundice - testicular atrophy - hand tremor - bleeding - anemia - ankle edema
IBS at least 2 with recurrent abdominal pain
Paraumbilical and superficial and inferior epigastric - umbilicus