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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 are the midgut structures and what supplies their blood and PANS innervation
Triglycerides and micelle formation - required for absorption of of non polar nutrients in small intestine
FAP
Corticosteroids - infliximab
Distal duodenum to proximal 2/3 of transverse colon - SMA - vagus

2. bilateral mets to ovaries with abundant mucus - signet ring cells
Alk phos
Gamma glutamyl transferase GGT
Krukenbergs tumor
GERD - may also present with nocturnal cough and dyspnea

3. What skin condition is associated with celiac sprue
Dermatitis herpetiformis
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
Complications of UC
Portal HTN

4. What serum enzyme is elevated inacute pancreatitis
Lipase
Hypotonic because of more time to reabsorb NaCl
Acute pancreatitis
Hypercoaguability - polycythemia vera - pregnancy - HCC

5. What are the labs for primary/secondary biliary cirrhosis and primary sclerosing cholangitis
Hypotonic because of more time to reabsorb NaCl
Repeated phlebotomy - deferoxamine - HLA- A3
Volvulus
Inc conj bilirubin - inc cholesterol - inc alk phos

6. internal hemorrhoids and adenocarcinoma occur above or below pectinate line?
Phenobarbital - inc liver enzyme synthesis
Above
Positive
In the mucus that covers the gastric epithelium

7. What are the barium swallow findings of achalasia
Dilated esophagus with an area of distal stenosis - birds beak
Myenteric nerve plexus - aurbach
Inguninal ligament - sartorius muscle - adductor longus
Gut bacteria

8. strictures - fistulas - perianal disease - malabsorption - nutritional depletion - colorectal cancer
Budd chiari syndrome
Complications of crohns
Lamina propria
Gallstone - biliary stricture - chronic pancreatitis - carcinoma of the pancreatic head

9. What is diverticulosis
Liver - brain - cornea - kidneys - joints - Asterixis - Basal ganglia degeneration - dec Ceruloplasmin - Cirrhosis - Corneal deposits - Copper accumulation - Carcinoma (HCC) - Choreiform movements - Dementia
Cirrhosis - DM - skin pigmentation - 'bronze diabetes'
Portal HTN
Many diverticula - associated with low fiber diets - caused by inc intraluminal pressure and focal weakness in colonic wall

10. What are the treatmet options for crohns
The entire
Hyperpigmented mouth - lips - hands - genitalia
Corticosteroids - infliximab
Portal HTN

11. What kind of muscle is in the lower 1/3 of the esophagus
Crigler - najjar type 1
Conj - inc - dec
Smooth
Early childhood - neuro sx and malabsorption

12. Why does indirect inguinal hernia happen in infacnts
Dilated esophagus with an area of distal stenosis - birds beak
Turcot
Migratory polyarthritis - erythema nodusum - anklyosing spondylitis - uveitis - immunologic disorders
Failure of the processus vagainlis to close

13. What are the ABCDEF of esophageal cancer
Immature UDP- glucuronyl transferase to unconjugated hyperbilirubinemia - jaundice kernicuterus
Lateral to the inferior epigastric artery
Alcohol/Achalasia - Barretts - Cigarettes - Diverticuli (Zenkers) Esophageal web/Esophagitis - Familial
Hepatomegaly - ascitis - abdominal pain - varices - visible abdominal and back veins - absence of JVD

14. What does the splenorenal ligament connect - and What does it contain
Hyperpigmented mouth - lips - hands - genitalia
2ndary biliary cirrhosis
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
Spleen to posterior abdominal wall - splenic artery and vein

15. What can fistula between the gallbladder and small intestine create and how can you tell
Increase tumorigenesis
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome
Air into the biliary tree - if gallstone obstructs ileocecal valve - air can be seen in biliary tree on imaging
Small intestine

16. How does gastrin increase acid secretion?
Lipase - phospholipase A - colipase
Obstruction of the common bile duct
CHF and inc risk of HCC
Primarly through ECL leading to histamine release

17. What enzyme is necessary to create conjugated bilirubin
Uridine glucuronyl transferase
<3mm nodules - metabolic - etoh - hemochromatosis - wilsons
Downs
Mucoepidermoid carcinoma

18. If the abdomincal aorta is obstructed - What is the path of blood to the inferior epigastric
Hemolytic anemia
Liver metabolizes 5HT
Many diverticula - associated with low fiber diets - caused by inc intraluminal pressure and focal weakness in colonic wall
Internal thoracic to superior epigastric to inferior epigastric

19. What carcinogens are associated with HCC
Duodenum - 2nd - 3rd and 4th parts
Ischemic colitis
AST >ALT - ration is usually 1.5
Alfatoxin in peanuts

20. why infxn is implicated in duodenal PUD
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
External (superficial) ring only
Northern european - Abs to gliadin and tissue transglutaminase - blunted villi - lymphcytes in the lamina proporia
H pylori (almost 100%)

21. AD - mutation of APC gene on chromosome 5q - two hit hypothesis - 100% progress to CRC - 1000s of polyps - pancolonic - rectal involvement
Common hepatic - splenic - left gastric - main blood supply for stomach
FAP
Superior rectal and middle and inferior rectal - rectum
Zenkers - halitosis - dysphagia and obstruction

22. B cells stimuated in the germinal centers of peyers patches differentiate into what?
In the mucus that covers the gastric epithelium
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
PAS- positive globules in liver -
IgA secreting plasma cells - ultimately reside in the lamina proporia

23. In what clinical scenarior do you see portosystemic anastomoses
Mucoepidermoid carcinoma
Many diverticula - associated with low fiber diets - caused by inc intraluminal pressure and focal weakness in colonic wall
Gallbladder
Portal HTN

24. What are additional risk factors for CRC
Barrett's esophagus
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome
Viral - adenovirus in kids - rare in adults but associated with intraluminal mass or tumor
2ndary biliary cirrhosis

25. What do mucins do?
Erosive - disruption of mucosal barrier leading to inflammation
AST>ALT
Triglycerides and micelle formation - required for absorption of of non polar nutrients in small intestine
Lubricate food (glycoprotiens)

26. What are the structures of the femoral triangle and how are they organized
Inc - weight loss
NAV = nerve artery vein - venous near the penis (NAVEL)
Fundus/body - autoimmune - autoantibodies to parietal cells - perncious anemia - and achlorhydria
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation

27. What kind of pathways do CCK act on to cause pancreatic secretion
Neural muscarinic pathways
No - chronic - can present with diarrhea or constipation or alternation - treat sx
Pleomorphic adenoma
Hydrocele

28. Where is IgA shuttled
IgA receives protective secretory component and is then transported across the epithelium to gut lumen
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
IBS at least 2 with recurrent abdominal pain
Inguninal ligament - sartorius muscle - adductor longus

29. subQ peribumbilical metastasis
Sister mary joseph nodule
2ndary biliary cirrhosis
Phototherapy
Serous on the sides parotids - mucinous in the middle sublingual

30. When and why is stomach cancer termed linitis plastica
Initial diffuse periumbilical pain localizing to mcburney's point with nausea - fever - possible perforation leading to peritonitis
When diffusely infiltrative - thickened rigid appearance like a leather bottle
Alcoholic cirrhosis
Alcohol/Achalasia - Barretts - Cigarettes - Diverticuli (Zenkers) Esophageal web/Esophagitis - Familial

31. FAP + malignant CNS tumor
Dec synthesis of apo B - inability to generate chylomicrons - dec secretion of cholesterol - VLDL into the bloodstream - fat accumulation in enterocytes
Bleeding - penetration into pancreas - perforation - obstruction
Duodenum - 2nd - 3rd and 4th parts
Turcot

32. What layer in the mucosa is responsible for absorption
Epithelium
Krukenbergs tumor
Antrum - H.pylori - inc risk of MALT lymphoma
Dec PGE2 leading to dec gastric mucosa protection

33. in CF - meconium plug obstructs intestine - preventing stool passage at birth
Pleomorphic adenoma
Meconium ileus
Urobilin
Budd chiari syndrome

34. How do NSAIDs cause acute gastritis
Dec PGE2 leading to dec gastric mucosa protection
Splenic flexure
Normal
Chronic calcifying pancreatitis - inc risk of panreatic cancer

35. What is the most common esophageal cancer worldwide and in the US
The entire
When diffusely infiltrative - thickened rigid appearance like a leather bottle
Femoral hernia - through femoral canal - lateral to pubic tubercle and women
Worldwide - SC - US - adeno

36. How do villi appear in disaccharidease def
Normal
Hydrocele
...
Complications of crohns

37. What kind of insults results in macronodular cirrhosis
>3mm nodules - significant liver injury leading to hepatic necrosis - postinfectious - drug induced hepatitis with inc risk of HCC
So hypertrophied they look like brain gyri
In the ileum with bile acids - requires IF
Crypts but not villi

38. What are the two molecular pathways that lead to CRC
Autoimmune= ulcerative colitis - disordered response to bactere = crohns
DNA mistmatch repair gene mutations lead to sporadic and HNPCC syndrome - mutations accumulate but not define morphologic correlates
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Complications of crohns

39. What arteries exit just below the SMA
Turcot
EtOH
Inc pressure in the intrahepatic ducts leading to injury/fibrosis and bile stasis
L/R renal artery around L1

40. What layer of fascia covers a direct inguinal hernia
Alpha amylase
Lamina propora and submucosa
External spermatic fascia only
Paraumbilical and superficial and inferior epigastric - umbilicus

41. What serum enzyme is decreased in wilsons disease
Ceruplasmin
Neural muscarinic pathways
Diverticulum
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation

42. What infection causes Whipple disease and What can you see on LM
AST>ALT
Epigastric abdominal pain radiating to back - anorexia - nausea
Tropheryma whippelii - gram positive and PAS- positive MACS in intestinal lamina proporia and mesenteric nodes
Dermatitis herpetiformis

43. What layer in the mucosa is responsible for support
Lamina propria
Cystic duct and common hepatic duct
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn
Skip lesions =crohns - colon = UC

44. What is biliary colic
Coma - scleral icterus - fetor hepaticus - spider nevi - gynecomastia - jaundice - testicular atrophy - hand tremor - bleeding - anemia - ankle edema
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
Protrudes through the Hesselbach's triangle - bulges directly through abdominal wall medial to inferior epigastric vessels
Inc smooth muscle relaxation - including lower esophageal sphincter

45. Where is folate absorbed
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid
Dense core bodies
The jejunum
5HT - wheezing - right sided heart murmurs - diarrhea - flushing -

46. What makes a true diverticula
Lamina propria
HBV - HCV - wilsons dz - hemochromatosis - alpha1- antitrypsin def - alcoholic cirrhosis
All 3 gut layers outpouch as in Meckels
Zollinger ellison - brunners glands

47. final and irreversible alcoholic liver disease with micronodular irregularly shrunken liver with hobnail appearance
L1
Alcoholic cirrhosis
Hyrdolyzes alpha 1-4 linkages to yield disaccharides
Inspiratory arrest on deep palpation due to pain

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

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49. What histological findings are present in the esophagus
Nonkeritinized stratified sqamous epithelium
Viral - adenovirus in kids - rare in adults but associated with intraluminal mass or tumor
HBV - HCV - wilsons dz - hemochromatosis - alpha1- antitrypsin def - alcoholic cirrhosis
Omeprazole

50. Where and How is iron absorbed
PAS- positive globules in liver -
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
Barrett's esophagus
Fe2+ in the duod