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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. If the abdomincal aorta is obstructed - What is the path of blood to the inferior epigastric
Zollinger Ellison - phenylalanine and tryptophan
Duodenal atresia - Downs
Failure of the processus vagainlis to close
Internal thoracic to superior epigastric to inferior epigastric

2. somatostatin - source - action - regulation
Duodenal lumen - hydrolyzes starch to oligosaccharides and disaccharides
Parietal cells in the stomach - B12 binding protein
Stimulate the H/K ATPase
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

3. a false diverticulum - herniation of mucosal tissue at junction of pharynx and esophagus - How does this present
Zenkers - halitosis - dysphagia and obstruction
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood
Pancreatic and bile
Mucosa - submucosa - muscularis externa - serosa/adventitia

4. What kind of digestion is bile needed for
Gamma glutamyl transferase GGT
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
Triglycerides and micelle formation - required for absorption of of non polar nutrients in small intestine
Stercobilin

5. gastric hypertrophy with protein loss - parietal cell atrophy and inc mucous cells
External spermatic fascia only
L2
Gallstone - biliary stricture - chronic pancreatitis - carcinoma of the pancreatic head
Menetriers disease

6. Which area of the hindgut is a watershed area
Colovesical leading to pneumaturia
Splenic flexure
Sister mary joseph nodule
Autoimmune rxn leading to lymphcytic infiltrate + granulomas

7. multiple juvenil polyps in GI tract - risk
Juvenile polyposis syndrome - inc risk of adenocarcinoma
Liver metabolizes 5HT
Below
Pancreatic and bile

8. What separates the right greater and lesser sacs
Source - parasympathetic ganglion in sphincters - gallbladder - small intestine - action - inc intestinal water and electrolyte secretion - inc relaxation of intestinal smooth muscle and sphincters - regulation - inc by distention and vagal stimulati
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Gastrohepatic ligament
VZV and influenza B treated with salicylates

9. What cells make gastric acid - What does it do to stomach pH and what substances regulate it
Alk phos
Pleomorphic adenoma
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin
Mucosa - submucosa - muscularis externa - serosa/adventitia

10. At what level do the testicular/ovarian arteries exit the aorta
5HT - wheezing - right sided heart murmurs - diarrhea - flushing -
Positive urease test
L2
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

11. What nerve innervates the external hemorrhoids
External - receive somatic innervation - internal receive visceral innervation - not painful but sign of portal HTN
Femoral hernia
Inferior rectal nerve
AR

12. What are the layers of the gut wall from inside out
Gallbladder
Cholesterol
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome
Mucosa - submucosa - muscularis externa - serosa/adventitia

13. People of what decent are associated with celiac sprue and what findings/antibodies are present
External spermatic fascia only
Northern european - Abs to gliadin and tissue transglutaminase - blunted villi - lymphcytes in the lamina proporia
Decreased intercellular adhesion and increased proliferation
The submucosal nerve plexus - meissner's

14. What conditions are associated with budd chiari
Juvenile polyposis syndrome - inc risk of adenocarcinoma
Gastrohepatic ligament
Hydrocele
Hypercoaguability - polycythemia vera - pregnancy - HCC

15. How is bilirubin carried in the blood
With albumin
Old men - arthralgias - cardiac and neuro sx
Immature UDP- glucuronyl transferase to unconjugated hyperbilirubinemia - jaundice kernicuterus
Juvenile polyposis syndrome - inc risk of adenocarcinoma

16. What congenital birth defect is associated with Hirschsprung
Downs
Mallory bodies
Intussusception
Lipase - phospholipase A - colipase

17. What is the most important mechanism in gastric acid secretion
Gastrin stimulating ECL cells to release histamine - histamine stimulation on parietal cells
Decrease - weight gain
Peutz jeghers
Muscularis mucosae

18. Transmural esophageal rupture due to violent retching

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19. When do you see hypertrophy of brunners glands
Peptic ulcer disease
Turcot
Hepatomegaly - ascitis - abdominal pain - varices - visible abdominal and back veins - absence of JVD
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith

20. what kind of fistula is associated with diverticulitis
Colovesical leading to pneumaturia
Complications of UC
L2
Hyperpigmented mouth - lips - hands - genitalia

21. What kind of insults results in macronodular cirrhosis
Cystic dilation of the viteline duct
Source - SI - action - produces migrating motor complexes - regulation - inc in fasting state
US and cholecystectomy
>3mm nodules - significant liver injury leading to hepatic necrosis - postinfectious - drug induced hepatitis with inc risk of HCC

22. What is the path of an indirect inguinal hernia
Villi and microvilli inc absorptive surface - brunner's glands and crypts of lieberkuhn
Ceruplasmin
Copious diarrhea - non alpha - non beta cell pancreatic tumor
Goes through deep inguinal ring - external inguinal ring and into the scrotum

23. What causes primary biliary cirrhosis
L1
Autoimmune rxn leading to lymphcytic infiltrate + granulomas
Dec synthesis of apo B - inability to generate chylomicrons - dec secretion of cholesterol - VLDL into the bloodstream - fat accumulation in enterocytes
Backup of blood into the liver - RHF - budd chiari

24. How does abetalipoproteinemia lead to malabsorption
Striated and smooth
Inguninal ligament - sartorius muscle - adductor longus
Meconium ileus
Dec synthesis of apo B - inability to generate chylomicrons - dec secretion of cholesterol - VLDL into the bloodstream - fat accumulation in enterocytes

25. What color is the liver in dubin johnson - and what similar syndrome doesn't have gross color changes in the liver
Skip lesions =crohns - colon = UC
Dense core bodies
Black - rotors syndrome
Adhesion

26. If trypsin activates more trypsinogen - what kind of feedback loop is established
Cirrhosis
Paraumbilical and superficial and inferior epigastric - umbilicus
Positive
Alcohol/Achalasia - Barretts - Cigarettes - Diverticuli (Zenkers) Esophageal web/Esophagitis - Familial

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

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28. What are the tumor markers for pancreatic adenocarcinoma
CF - obstructing cancer - chronic pancreatitis - causes malabsorption of fat and fat soluble vitamins (ADEK)
Epigastric abdominal pain radiating to back - anorexia - nausea
CEA - CA-19-9
Gastric glands

29. occlusion of IVC or hepatic veins
Gastrohepatic ligament
Budd chiari syndrome
Brunners
Internal thoracic to superior epigastric to inferior epigastric

30. What are the histological findings in the jejunum
DIC - ARDS - diffuse fat necrosis - hypcalcemia - pseudocyst formation - hemorrhage - infxn - multiorgan failure
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn
Necrotizing enterocolitis
Superior rectal

31. What causes pancreatic insuff and What does it cause
Spleen to posterior abdominal wall - splenic artery and vein
3rd most common cancer - 3rd deadliest in US - pts > 50 - 1/4 have fam hx
Alk phos
CF - obstructing cancer - chronic pancreatitis - causes malabsorption of fat and fat soluble vitamins (ADEK)

32. What is the triad of Plummer - Vinson syndrome
Dysphagia (due to esophageal web) - glossitis - iron def anemia
Hypercoaguability - polycythemia vera - pregnancy - HCC
Meconium ileus
Coma - scleral icterus - fetor hepaticus - spider nevi - gynecomastia - jaundice - testicular atrophy - hand tremor - bleeding - anemia - ankle edema

33. What are the signs and symptoms of budd chiari
Hepatomegaly - ascitis - abdominal pain - varices - visible abdominal and back veins - absence of JVD
Around the central vein (zone III)
Mucosal cells in the stomach - duod - salivary glands - pancreas - brunners glands in the duod - neutralizes acid - inc by pancreatic and biliary secretion with secretin
Lipase - phospholipase A - colipase

34. What layer in the mucosa is repsonsible for motility
Lipase
Muscularis mucosae
L1
CCK8 receptor - Gq inc IP3/Ca

35. most common non - neoplastic polyp in colon
Inc lower esphogeal tone leading to achalasia
Falciform - ligamentum teres - fetal umbilical vein
Hyperplastic
90%

36. Where is the arterial supply from above the pectinate line - and What is the venous drainage
Carcinoid syndrome
Superior rectal from IMA - superior rectal vein to inf mesenteric to portal system
Protrudes through the Hesselbach's triangle - bulges directly through abdominal wall medial to inferior epigastric vessels
Muscularis mucosae

37. Where is the pectinate line
Where hindgut meets ectoderm
Unconjugated - water insoluble
Crohns = noncaseating granulomas - UC = crypt abscesses
Zollinger Ellison - phenylalanine and tryptophan

38. Who gets gastric ulcers
Older patients
Omeprazole
Alk pho
Lactase is located at the tips of intestinal villi

39. 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
Greater curvature of stomach to transverse colon - gastroepiploic arteries - greater omentum
Oral glucose
All 3
Skip lesions =crohns - colon = UC

40. What is the cause of Barrett's and the assocaited complications
Lye ingestion and acid reflux
Alternating strictures and dilation with beading of intra and extrahepatic bile ducts on ERCP
Elevated amylase - and lipase
GERD - esophagitis - esophageal ulcers - inc risk of esophageal cancer

41. What drug blocks the H2R
Cimetidine
Hepatic steatosis
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn
Meckels

42. in carcinoid tumors - What is seen on EM
Menetriers disease
Begins starch digestion - inactivated by low pH upon reaching the stomach
Dense core bodies
Crohns = maybe - UC= always

43. Why are most diverticula considered false
Migratory polyarthritis - erythema nodusum - anklyosing spondylitis - uveitis - immunologic disorders
Lack or have an attenuated muscularis externa - often in the sigmoid colon
Cholesterol - 10-20% opaque due to calcifications
Celiac sprue

44. trypsinogen is converted to trypsin via what enzyme
T cell lymphoma
Inspiratory arrest on deep palpation due to pain
Striated and smooth
Enterokinase/enteropeptidase from the duodenal mucosa

45. Progressive dyshphage beginning with solids and moving to liquids and weight loss
Esophageal cancer
Primary sclerosing cholangitis
Cushings ulcers - inc vagal stimulation leading to inc vagal stim - inc ACH and inc H+ secretion
Brunners

46. What causes nutmeg liver
Diverticulum
NAV = nerve artery vein - venous near the penis (NAVEL)
Backup of blood into the liver - RHF - budd chiari
GERD - may also present with nocturnal cough and dyspnea

47. What is biliary colic
Cholesterol - 10-20% opaque due to calcifications
Pancreatic insuff - steatorrhea - fat soluble vitamin def - DM
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
Abdominal pain radiating to back - weight loss due to malabsorption - migratory thrombophlebitis - obstructice jaundice with palpable gallbladder

48. necrosis of intestinal mucosa and possible perforation - usual colon involvement - more common in preemies
Necrotizing enterocolitis
Glucose dependent insulinotropic peptide
3rd most common cancer - 3rd deadliest in US - pts > 50 - 1/4 have fam hx
No - chronic - can present with diarrhea or constipation or alternation - treat sx

49. What kind of muscle is in the middle 1/3 of esophagus
Inferior rectal artery - inferior rectal vein to pudendal vein to internal iliac vein to IVC
8-9 waves/min
Striated and smooth
Meconium ileus

50. inflammatino of gallbadder
Striated and smooth
Glucose dependent insulinotropic peptide
Superior rectal from IMA - superior rectal vein to inf mesenteric to portal system
Cholecystitis - usually from gallstones rarely ischemia or infxn (CMV)