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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. What is the arterial supply and venous drainage below pectinate line
Ampulla of vater
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
Decreased intercellular adhesion and increased proliferation
Inferior rectal artery - inferior rectal vein to pudendal vein to internal iliac vein to IVC

2. What drug blocks the H2R
Air into the biliary tree - if gallstone obstructs ileocecal valve - air can be seen in biliary tree on imaging
Cimetidine
Pleuroperitoneal
Diverticulitis in elderly - ectopic pregs use hCG to rule out

3. What percentage of gall stones are cholesterol stones and What are the associations
Cigarettes and chronic pancreatitis - not EtOH
Crohns - CF - advanced age - clofibrate - estrogens - multiparity - rapid weight loss - Native American origin
The femoral nerve - only the vein artyer and canal (with deep inguinal lymph nodes)
Acute pancreatitis

4. What is contained within the muscularis externa
Myenteric nerve plexus - aurbach
Juvenille polyps - no risk if single
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
Uridine glucuronyl transferase

5. Who gets gastric ulcers
Older patients
Inguninal ligament - sartorius muscle - adductor longus
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood
Lamina propora and submucosa

6. strictures - fistulas - perianal disease - malabsorption - nutritional depletion - colorectal cancer
High LES opening pressure and uncoordinated peristalsis - both solids and liquids
Gallstones - EtOH - trauma - steroids - mumps - autoimmune - scorpion sting - hypercalcemia/hyperlipidemia - ERCP - Drugs (sulfa)
Complications of crohns
Source - S cells (duod) - action - inc pancreatic bicarb secretion - dec gastric acid secretin - inc bile secretion - regulation - inc by acid - fatty acids in lumen of duod

7. What conditions are associated with budd chiari
Stimulate the H/K ATPase
Antrum - H.pylori - inc risk of MALT lymphoma
Hypercoaguability - polycythemia vera - pregnancy - HCC
Via the superior pancreaticduodenal

8. malnutrition - toxic megacolon - colorectal carcinoma
Northern european - Abs to gliadin and tissue transglutaminase - blunted villi - lymphcytes in the lamina proporia
Esophageal carcinoma
Complications of UC
Virchow's node

9. What is the cause of physiologic neonatal jaundice
Juvenile polyposis syndrome - inc risk of adenocarcinoma
Liver - brain - cornea - kidneys - joints - Asterixis - Basal ganglia degeneration - dec Ceruloplasmin - Cirrhosis - Corneal deposits - Copper accumulation - Carcinoma (HCC) - Choreiform movements - Dementia
Diarrhea - steatorrhea - weight loss - weakness
Immature UDP- glucuronyl transferase to unconjugated hyperbilirubinemia - jaundice kernicuterus

10. Scleroderma is associated with what kind of esophageal dysmotility
Obstruction of the common bile duct
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin
Low pressure proximal to LES
Hiatal hernia - sliding - hourglass shape - and paraesophageal hernia where stomach chomes up through the hiatus

11. What are the borders of the femoral triangle
Colonic polyps
Warthins' tumor
Inguninal ligament - sartorius muscle - adductor longus
Portal triad: hepatic artery - protal vein - common bile duct - greater and lesser sac - to control bleeding

12. What is the risk with peutz jehgers
Chagas disease
Diverticulum
The gastroduodenal
Inc risk of CRC and other visceral malignancies

13. What kind of hernia protrudes below the inguinal ligament - Where does travel relative to pubic tubercle and who gets them
External (superficial) ring only
IBS at least 2 with recurrent abdominal pain
L2
Femoral hernia - through femoral canal - lateral to pubic tubercle and women

14. alcoholic liver disease that requires sustained - long term consumption - with swollen and necrotic hepatocytes with neutrophilic infiltration
Inc risk of CRC and other visceral malignancies
Alcoholic hepatitis
Autoimmune= ulcerative colitis - disordered response to bactere = crohns
Menetriers disease

15. What is contained with in the hepatoduodenal ligament - What two spaces does it connect - and when would you need to compress it
L2
Hiatal hernia - sliding - hourglass shape - and paraesophageal hernia where stomach chomes up through the hiatus
Pyoderma gangrenosum - primary sclerosing cholangitis
Portal triad: hepatic artery - protal vein - common bile duct - greater and lesser sac - to control bleeding

16. What does GET SMASHED stand for in acute pancreatitis
Cirrhosis - DM - skin pigmentation - 'bronze diabetes'
T cell lymphoma
Gallstones - EtOH - trauma - steroids - mumps - autoimmune - scorpion sting - hypercalcemia/hyperlipidemia - ERCP - Drugs (sulfa)
Peyers patches

17. Where is bicarb trapped
Early childhood - neuro sx and malabsorption
Autoimmune rxn leading to lymphcytic infiltrate + granulomas
Phototherapy
In the mucus that covers the gastric epithelium

18. Which IBD may or may not have blood diarrhea - and which will always have bloody diarrhea
Liver metabolizes 5HT
Crohns = maybe - UC= always
Gilbert's
Paraumbilical and superficial and inferior epigastric - umbilicus

19. Achalasia increases the risk For what complication
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
Gallstone - biliary stricture - chronic pancreatitis - carcinoma of the pancreatic head
Esophageal carcinoma
EtOH

20. What is the epi for CRC
Alternating strictures and dilation with beading of intra and extrahepatic bile ducts on ERCP
Abdominal pain radiating to back - weight loss due to malabsorption - migratory thrombophlebitis - obstructice jaundice with palpable gallbladder
3rd most common cancer - 3rd deadliest in US - pts > 50 - 1/4 have fam hx
DIC - ARDS - diffuse fat necrosis - hypcalcemia - pseudocyst formation - hemorrhage - infxn - multiorgan failure

21. Which is used more quickly - an oral glucose load - or that by IV
EtOH
Turcot
Conj/unconj - inc - nl to dec
Oral glucose

22. How are all 3 monosaccharides transported to the blood
Distal colon - obstruction - colicky pain - hematochezia - proximal colon - dull pain - iron deficiency anemia - fatigue
Decrease - weight gain
L4
GLUT 2

23. What structures feed into the common bile duct
Hirschsprungs
Peptic ulcer disease
Cystic duct and common hepatic duct
Gallstone - biliary stricture - chronic pancreatitis - carcinoma of the pancreatic head

24. How does gastrin increase acid secretion?
Centrilobular congestion and necrosis - cardiac cirrhosis
Primarly through ECL leading to histamine release
Dermatitis herpetiformis
Tropheryma whippelii - gram positive and PAS- positive MACS in intestinal lamina proporia and mesenteric nodes

25. What are additional risk factors for CRC
Meconium ileus
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome
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
Lack or have an attenuated muscularis externa - often in the sigmoid colon

26. What serum marker increases with primary biliary cirrhosis and what other autoimmune conditions are it associated with
Hematogenous - alpha fetoprotein - budd chiari (hepatic vein blockage)
Serum mitochondrial antibodies including IgM - associated with CREST - RA and celiac dz
Migratory polyarthritis - erythema nodusum - anklyosing spondylitis - uveitis - immunologic disorders
Bile salts (bile conjugated to glycine or taurine) phospholipids - cholesterol - bilirubin - water and ions

27. What skin condition is associated with celiac sprue
Autoimmune= ulcerative colitis - disordered response to bactere = crohns
Dermatitis herpetiformis
Uridine glucuronyl transferase
Epithelium

28. masses protruding into gut lumen leading to a sawtooth appearance - often rectosigmoid
Primary sclerosing cholangitis
Protrudes through the Hesselbach's triangle - bulges directly through abdominal wall medial to inferior epigastric vessels
Colonic polyps
Normal

29. What is the characteristic histo finding in alcoholic hepatitis
2ndary biliary cirrhosis
Parietal cells in the stomach - B12 binding protein
Mallory bodies
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

30. What do you use to diagnose meckels
Redness and tenderness on palpation of extremities
Osmotic
Squamous - upper 1/3 - adeno - lower 1/3
Pertechnetate - study for uptake

31. How does brain injury lead to acute gastritis and What is it called
Causes of gall stones
Cushings ulcers - inc vagal stimulation leading to inc vagal stim - inc ACH and inc H+ secretion
US and cholecystectomy
Old men - arthralgias - cardiac and neuro sx

32. What are the main components of bile
Bile salts (bile conjugated to glycine or taurine) phospholipids - cholesterol - bilirubin - water and ions
Alpha amylase
Volvulus
Older patients

33. What serum enzyme is elevated in acute pancreatitis and mumps
Terminal ileum and colon
Amylase
Crypts but not villi
ALT>AST

34. multiple juvenil polyps in GI tract - risk
Jaundice - fever - RUQ
Neutralizes gastric acid allowing pancreatic enzymes to fxn
Juvenile polyposis syndrome - inc risk of adenocarcinoma
Cystic duct and common hepatic duct

35. what percentage of colonic polyps are non - neoplastic
90%
H pylori (almost 100%)
L2
Zenkers - halitosis - dysphagia and obstruction

36. Gastrin - source - action - regulation
Source - G cells in the antrum - action - inc gastric H+ secretion - inc growth of gastric mucosa - and inc gastric motility - regulation - inc by stomach distention/alkalinaztion - amino acids - peptides - vagal stimulation - dec by stomach pH < 1.5
Penicillinamine - AR inheritance
Krukenbergs tumor
Curling's ulcer - dec plasma volume and sloughing of gastric mucosa

37. At what level do the testicular/ovarian arteries exit the aorta
Zenkers - halitosis - dysphagia and obstruction
Oral glucose
With albumin
L2

38. Transmural esophageal rupture due to violent retching

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39. With esophageal varices - between What two vessels is the portosystemic anastomoses and Where is it
Source - S cells (duod) - action - inc pancreatic bicarb secretion - dec gastric acid secretin - inc bile secretion - regulation - inc by acid - fatty acids in lumen of duod
Duodenal lumen - hydrolyzes starch to oligosaccharides and disaccharides
Left gastric vein and esophogeal vein - esophagus
Esophageal varices

40. How does hirschsprung present and appear on imaging
Bleeding - intussusception - volvulus - obstruction near terminal ileum
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
Dilated esophagus with an area of distal stenosis - birds beak
Dec PGE2 leading to dec gastric mucosa protection

41. What are the complications of acute pancreatitis
Chief cells of the stomach - protein digestion - inc by vagal stimulation local acid
Cystic dilation of the viteline duct
Spleen to posterior abdominal wall - splenic artery and vein
DIC - ARDS - diffuse fat necrosis - hypcalcemia - pseudocyst formation - hemorrhage - infxn - multiorgan failure

42. Where are carcinoid tumors most commonly malignant
Small intestine
Mitochondrial abnl - fatty liver - hypoglycemia - coma
Antrum - H.pylori - inc risk of MALT lymphoma
GERD - may also present with nocturnal cough and dyspnea

43. In PUD - with gastric ulcers - does pain inc or dec with meals?
LLQ - fever - leukocytosis - can perforate leading to peritonitis - abscess formation - bowel stenosis - give antiobiotics
Viral - adenovirus in kids - rare in adults but associated with intraluminal mass or tumor
Inc - weight loss
Zollinger ellison - brunners glands

44. What is Trousseau's sign
Pancreatic and bile
Barrett's esophagus
Parietal cells in the stomach - B12 binding protein
Redness and tenderness on palpation of extremities

45. B cells stimuated in the germinal centers of peyers patches differentiate into what?
3rd most common cancer - 3rd deadliest in US - pts > 50 - 1/4 have fam hx
Ischemic colitis
Hyperplastic
IgA secreting plasma cells - ultimately reside in the lamina proporia

46. What cells secrete bicarb - What does it do - and what regulates it
Upregulated intracellular signal transduction
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn
Brunners
Mucosal cells in the stomach - duod - salivary glands - pancreas - brunners glands in the duod - neutralizes acid - inc by pancreatic and biliary secretion with secretin

47. Which patients have pigment stones
Inferior epigastric artery - lateral border of rectus abdominis - inguinal ligament
Many diverticula - associated with low fiber diets - caused by inc intraluminal pressure and focal weakness in colonic wall
Low pressure proximal to LES
Chronic hemolysis - alcoholic cirrhosis - advanced age and biliary infxn

48. A protrusion of peritoneum through an opening - usually a site of weakness
Hernia
Cimetidine
Autoimmune= ulcerative colitis - disordered response to bactere = crohns
Chronic calcifying pancreatitis - inc risk of panreatic cancer

49. What does the gastrocolic ligament connect - What is contained - and what larger structure is it a part of...
FAP
Duodenal lumen - hydrolyzes starch to oligosaccharides and disaccharides
Greater curvature of stomach to transverse colon - gastroepiploic arteries - greater omentum
Gamma glutamyl transferase GGT

50. What are the extraintestinal manifestations of crohns
Turcot
Migratory polyarthritis - erythema nodusum - anklyosing spondylitis - uveitis - immunologic disorders
External spermatic fascia only
Protrudes through the Hesselbach's triangle - bulges directly through abdominal wall medial to inferior epigastric vessels