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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 lumen of the pancreatic duct
Distal colon - obstruction - colicky pain - hematochezia - proximal colon - dull pain - iron deficiency anemia - fatigue
Liver metabolizes 5HT
Ampulla of vater
Inc conj bilirubin - inc cholesterol - inc alk phos

2. What is the prognosis of adenocarcinoma
Left gastric vein and esophogeal vein - esophagus
Centrilobular leading to congestive liver disease
Averages 6 months - very aggressive - usually already metastasized at presentation
Colovesical leading to pneumaturia

3. What is the classic triad of hemochromatosis

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4. What is contained within the muscularis externa
Redness and tenderness on palpation of extremities
Myenteric nerve plexus - aurbach
Obstruction of the common bile duct
Sympathetic (T1- T3 superior cervical ganglion) and parasympathetic (facial and glossopharyngeal nerve)

5. Painless bleedgin of submucosal veins in lower 1/3 of esophagus
Begins starch digestion - inactivated by low pH upon reaching the stomach
Protrudes through the Hesselbach's triangle - bulges directly through abdominal wall medial to inferior epigastric vessels
Early childhood - neuro sx and malabsorption
Esophageal varices

6. Transmural esophageal rupture due to violent retching

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7. Where are carcinoid tumors most commonly malignant
The entire
AST >ALT - ration is usually 1.5
Juvenile polyposis syndrome - inc risk of adenocarcinoma
Small intestine

8. What are the ABCDEF of esophageal cancer
Alcohol/Achalasia - Barretts - Cigarettes - Diverticuli (Zenkers) Esophageal web/Esophagitis - Familial
Bleeding - penetration into pancreas - perforation - obstruction
Backup of blood into the liver - RHF - budd chiari
Unconj - absent (acholuria) - inc

9. Where does inflammation in diverticula likely cause pain - what other signs/symptoms are present and What are the complications
LLQ - fever - leukocytosis - can perforate leading to peritonitis - abscess formation - bowel stenosis - give antiobiotics
Serous on the sides parotids - mucinous in the middle sublingual
Worldwide - SC - US - adeno
Dec PGE2 leading to dec gastric mucosa protection

10. What structures feed into the common hepatic duct
Right and left hepatic duct
Striated and smooth
Pancreatic insuff - steatorrhea - fat soluble vitamin def - DM
Above

11. Where is B12 absorbed
Inc size - villous histology - inc epithelial dysplasia - precursor to CRC
In the ileum with bile acids - requires IF
Averages 6 months - very aggressive - usually already metastasized at presentation
Oral glucose

12. What are the layers of the gut wall from inside out
3 waves/min
Jaundice - fever - RUQ
90%
Mucosa - submucosa - muscularis externa - serosa/adventitia

13. What kind of insults results in macronodular cirrhosis
Primarly through ECL leading to histamine release
>3mm nodules - significant liver injury leading to hepatic necrosis - postinfectious - drug induced hepatitis with inc risk of HCC
Striated
Mitochondrial abnl - fatty liver - hypoglycemia - coma

14. What ligament connects the liver to the abdominal wall - What is contained within it and From what structure is it derived
Internal thoracic to superior epigastric to inferior epigastric
ALT>AST
Falciform - ligamentum teres - fetal umbilical vein
Positive urease test

15. What is the most common esophageal cancer worldwide and in the US
Corticosteroids - infliximab
Tropical sprue
The proximal small bowel
Worldwide - SC - US - adeno

16. What is the cause of Barrett's and the assocaited complications
Mucosa - submucosa - muscularis externa - serosa/adventitia
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid
GERD - esophagitis - esophageal ulcers - inc risk of esophageal cancer
Normal

17. Which area of the hindgut is a watershed area
Inc - weight loss
Splenic flexure
Peyers patches
Dec PGE2 leading to dec gastric mucosa protection

18. What are the two molecular pathways that lead to CRC
Primarly through ECL leading to histamine release
Glucose dependent insulinotropic peptide
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Splenic flexure

19. Where does copper accumulate in Wilsons and What are ABCD
Virchow's node
Liver - brain - cornea - kidneys - joints - Asterixis - Basal ganglia degeneration - dec Ceruloplasmin - Cirrhosis - Corneal deposits - Copper accumulation - Carcinoma (HCC) - Choreiform movements - Dementia
Colonic polyps
Osmotic

20. What can hemochromatosis be secondary to...
Around the central vein (zone III)
Volvulus
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid

21. What cells make pepsin - What does it do - and what regulates it
Below
L1
Chief cells of the stomach - protein digestion - inc by vagal stimulation local acid
Peptic ulcer disease

22. What is the most important mechanism in gastric acid secretion
Acute pancreatitis
AST
AR
Gastrin stimulating ECL cells to release histamine - histamine stimulation on parietal cells

23. What factors increase risk of malignancy of adenomatous polyps
Osmotic
Inc size - villous histology - inc epithelial dysplasia - precursor to CRC
Dilated esophagus with an area of distal stenosis - birds beak
Inferior rectal artery - inferior rectal vein to pudendal vein to internal iliac vein to IVC

24. What is Trousseau's sign
Bile salts (bile conjugated to glycine or taurine) phospholipids - cholesterol - bilirubin - water and ions
Hyrdolyzes alpha 1-4 linkages to yield disaccharides
Redness and tenderness on palpation of extremities
The jejunum

25. What serum markers increase in cholecystitis with bile duct involvement
Alk phos
Elevated amylase - and lipase
AST >ALT - ration is usually 1.5
True and most common congenital anomoly of GI tract

26. What congenital birth defect is associated with Hirschsprung
Downs
HPNCC
Pleuroperitoneal
Oral glucose

27. What are the foregut structures and what supplies their blood and PANS innvervation
Causes of gall stones
Stomach to proximal duodenum - liver - gall bladder - pancreas and spleen - celiac - vagus
Elevated amylase - and lipase
Complications of UC

28. What does K- ras mutation cause
Myenteric nerve plexus - aurbach
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith
Reye's syndrome
Upregulated intracellular signal transduction

29. What are the extraintestinal manifestations of crohns
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid
Intussusception
Chief cells of the stomach - protein digestion - inc by vagal stimulation local acid
Migratory polyarthritis - erythema nodusum - anklyosing spondylitis - uveitis - immunologic disorders

30. What is the leading cause of bowel incarceration
Increase tumorigenesis
Abdominal pain radiating to back - weight loss due to malabsorption - migratory thrombophlebitis - obstructice jaundice with palpable gallbladder
Femoral hernia
HBV - HCV - wilsons dz - hemochromatosis - alpha1- antitrypsin def - alcoholic cirrhosis

31. mildly dec UDPGT or dec bilirubin uptake - asymptomatic - elevated uncong bili without over hemolysis

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32. At what level do the testicular/ovarian arteries exit the aorta
L2
Volvulus
Duodenum - 2nd - 3rd and 4th parts
5HT - wheezing - right sided heart murmurs - diarrhea - flushing -

33. If the abdominal aorta is blocked - How does blood get to the left colic artery
Old men - arthralgias - cardiac and neuro sx
Alfatoxin in peanuts
Via the middle colic
Colovesical leading to pneumaturia

34. trypsinogen is converted to trypsin via what enzyme
Poor anastamoses
Cholesterol - 10-20% opaque due to calcifications
Enterokinase/enteropeptidase from the duodenal mucosa
Epigastric abdominal pain radiating to back - anorexia - nausea

35. Scleroderma is associated with what kind of esophageal dysmotility
Begins starch digestion - inactivated by low pH upon reaching the stomach
Low pressure proximal to LES
Pleuroperitoneal
So hypertrophied they look like brain gyri

36. What is the triad of Plummer - Vinson syndrome
Dysphagia (due to esophageal web) - glossitis - iron def anemia
Mitochondrial abnl - fatty liver - hypoglycemia - coma
Enterokinase/enteropeptidase from the duodenal mucosa
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith

37. Where does type B chronic gastritis occur and What causes it
Zollinger ellison - brunners glands
Antrum - H.pylori - inc risk of MALT lymphoma
Female - fat - fertile - forty
CEA - CA-19-9

38. what kind of muscle is in the upper 1/3 of esophagus
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
Worldwide - SC - US - adeno
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith
Striated

39. What is one potential precipitating factor for intussusception
Viral - adenovirus in kids - rare in adults but associated with intraluminal mass or tumor
Dissaccharidase def - most commonly lactase
Chagas disease
Gallstone - biliary stricture - chronic pancreatitis - carcinoma of the pancreatic head

40. What does histo show for alpha1 antitrypsin def
Centrilobular leading to congestive liver disease
PAS- positive globules in liver -
Left gastric vein and esophogeal vein - esophagus
Superior rectal

41. How do you DX and TX gallstones
US and cholecystectomy
AST >ALT - ration is usually 1.5
Positive urease test
Hepatomegaly - ascitis - abdominal pain - varices - visible abdominal and back veins - absence of JVD

42. How are all 3 monosaccharides transported to the blood
H pylori (almost 100%)
GLUT 2
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn
Esophageal varices

43. How does HCC spread - What is a common tumor marker and what syndrome can it lead to...
Primary sclerosing cholangitis
Backup of blood into the liver - RHF - budd chiari
ASA preparations (sulfasalazine) 6- mercaptopurine - infliximab - colectomy
Hematogenous - alpha fetoprotein - budd chiari (hepatic vein blockage)

44. Which IBD has skip lesions and can hit any portion of the GI tract but sprares the rectum - and Which is mainly has continuous lesions in the colon and always has rectal involvement
Repeated phlebotomy - deferoxamine - HLA- A3
ASA preparations (sulfasalazine) 6- mercaptopurine - infliximab - colectomy
Skip lesions =crohns - colon = UC
Portal triad: hepatic artery - protal vein - common bile duct - greater and lesser sac - to control bleeding

45. rare - often fatal childhood hepatoencephalopathy

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46. What does the splenorenal ligament connect - and What does it contain
Spleen to posterior abdominal wall - splenic artery and vein
Inc smooth muscle relaxation - including lower esophageal sphincter
Crigler - najjar type 1
90%

47. Through which aspect of the inguinal canal does a direct inguinal go
Urobilin
Acute pancreatitis
External (superficial) ring only
Alcoholic hepatitis

48. In alchoholic hepatitis which liver enzyme is higher
Goes through deep inguinal ring - external inguinal ring and into the scrotum
The entire
AST>ALT
Lactase is located at the tips of intestinal villi

49. What converts inactive pepsinogen to pepsin
Cirrhosis - DM - skin pigmentation - 'bronze diabetes'
Uremia
H+
Bile salts (bile conjugated to glycine or taurine) phospholipids - cholesterol - bilirubin - water and ions

50. Where is the deep inguinal ring relative to the inferior epigastric vessels
Virchow's node
Alcoholic hepatitis
Lateral
IBS at least 2 with recurrent abdominal pain