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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. What serum enzyme is decreased in wilsons disease
Lactase is located at the tips of intestinal villi
Dense core bodies
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
Ceruplasmin

2. What findings are associated with reyes
Reye's syndrome
Mitochondrial abnl - fatty liver - hypoglycemia - coma
Erosive - disruption of mucosal barrier leading to inflammation
Hepatic steatosis

3. What does primary sclerosing cholangitis lead to...
Alternating strictures and dilation with beading of intra and extrahepatic bile ducts on ERCP
Source - SI - action - produces migrating motor complexes - regulation - inc in fasting state
GERD - may also present with nocturnal cough and dyspnea
H pylori (almost 100%)

4. malnutrition - toxic megacolon - colorectal carcinoma
Smooth
Complications of UC
Gallstones - EtOH - trauma - steroids - mumps - autoimmune - scorpion sting - hypercalcemia/hyperlipidemia - ERCP - Drugs (sulfa)
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin

5. What are the extraintestinal manifestations of crohns
<3mm nodules - metabolic - etoh - hemochromatosis - wilsons
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation
Esophageal varices
Migratory polyarthritis - erythema nodusum - anklyosing spondylitis - uveitis - immunologic disorders

6. What are the results of hemochromatosis
Mitochondrial abnl - fatty liver - hypoglycemia - coma
CHF and inc risk of HCC
Common hepatic - splenic - left gastric - main blood supply for stomach
Epithelium

7. external hemorrhoids and squamous cell carcinoma occur above or below the pectinate line
3 waves/min
Redness and tenderness on palpation of extremities
Below
External - receive somatic innervation - internal receive visceral innervation - not painful but sign of portal HTN

8. What type of insults result in micronodular cirrhosis
<3mm nodules - metabolic - etoh - hemochromatosis - wilsons
Tropheryma whippelii - gram positive and PAS- positive MACS in intestinal lamina proporia and mesenteric nodes
Portal HTN
Diverticulum

9. What are the signs and symptoms of budd chiari
Averages 6 months - very aggressive - usually already metastasized at presentation
No
Hepatomegaly - ascitis - abdominal pain - varices - visible abdominal and back veins - absence of JVD
Menetriers disease

10. What histological findings are present in the esophagus
Nonkeritinized stratified sqamous epithelium
Terminal ileum and colon
Redness and tenderness on palpation of extremities
Inc pressure in the intrahepatic ducts leading to injury/fibrosis and bile stasis

11. HCC is associated with what other conditions
HBV - HCV - wilsons dz - hemochromatosis - alpha1- antitrypsin def - alcoholic cirrhosis
Carcinoid syndrome
Inc pressure in the intrahepatic ducts leading to injury/fibrosis and bile stasis
Esophageal carcinoma

12. What does histo show for alpha1 antitrypsin def
Immature UDP- glucuronyl transferase to unconjugated hyperbilirubinemia - jaundice kernicuterus
DIC - ARDS - diffuse fat necrosis - hypcalcemia - pseudocyst formation - hemorrhage - infxn - multiorgan failure
Jaundice - fever - RUQ
PAS- positive globules in liver -

13. How does CRC present in the distal and proximal colon
Alpha amylase
Lateral to the inferior epigastric artery
Fundus/body - autoimmune - autoantibodies to parietal cells - perncious anemia - and achlorhydria
Distal colon - obstruction - colicky pain - hematochezia - proximal colon - dull pain - iron deficiency anemia - fatigue

14. Achalasia can be secondary to what infectious disease common in South America
Chagas disease
2ndary biliary cirrhosis
Primarly through ECL leading to histamine release
All 3 gut layers outpouch as in Meckels

15. absent UDPGT - presents early in life - early mortality
Older patients
Internal thoracic to superior epigastric to inferior epigastric
Viral - adenovirus in kids - rare in adults but associated with intraluminal mass or tumor
Crigler - najjar type 1

16. What is contained in the gastrosplenic and What areas does it separate
Short gastrics - left greater and lesser
Low pressure proximal to LES
Hernia
Goes through deep inguinal ring - external inguinal ring and into the scrotum

17. What is the most common cause of gallstones
Cholecystitis - also ascending cholangitis - acute pancreatitis and bililary infx
Failure of the processus vagainlis to close
Inferior rectal artery - inferior rectal vein to pudendal vein to internal iliac vein to IVC
Sister mary joseph nodule

18. Which area of the hindgut is a watershed area
ASA preparations (sulfasalazine) 6- mercaptopurine - infliximab - colectomy
Liver - brain - cornea - kidneys - joints - Asterixis - Basal ganglia degeneration - dec Ceruloplasmin - Cirrhosis - Corneal deposits - Copper accumulation - Carcinoma (HCC) - Choreiform movements - Dementia
Peyers patches
Splenic flexure

19. What is the omphalomesenteric cyst
Cystic dilation of the viteline duct
Barrett's esophagus
Lateral
Zollinger ellison - brunners glands

20. subQ peribumbilical metastasis
Gut bacteria
Sister mary joseph nodule
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith
Duodenal lumen - hydrolyzes starch to oligosaccharides and disaccharides

21. What are the histological findings in the ileum

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22. Malabsorption syndromes have what common clinical presentation
The gastroduodenal
Diarrhea - steatorrhea - weight loss - weakness
90%
Poor anastamoses

23. What drug inhibits the H/K ATPase
Omeprazole
Hypercoaguability - polycythemia vera - pregnancy - HCC
Inc lower esphogeal tone leading to achalasia
Gilbert's

24. What serum marker increases with primary biliary cirrhosis and what other autoimmune conditions are it associated with
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Unconj - absent (acholuria) - inc
Serum mitochondrial antibodies including IgM - associated with CREST - RA and celiac dz
Inc pressure in the intrahepatic ducts leading to injury/fibrosis and bile stasis

25. What does loss of p53 cause
Dermatitis herpetiformis
In the ileum with bile acids - requires IF
Superior rectal
Increase tumorigenesis

26. conjugated hyperbilirubinemia due to defective liver excretion
90%
Dubin johnson
M3 - Gq - inc IP3/Ca
HSV-1 - CMV - Candida

27. How do villi appear in disaccharidease def
Normal
Diverticulitis in elderly - ectopic pregs use hCG to rule out
Hyrdolyzes alpha 1-4 linkages to yield disaccharides
Copious diarrhea - non alpha - non beta cell pancreatic tumor

28. congenital megacolon characterized by lack of ganglion/enteric nervous plexuses in segment on intestinal biopsy
Dilated esophagus with an area of distal stenosis - birds beak
Black - rotors syndrome
Peutz jeghers
Hirschsprungs

29. GIP - source - action regulation
Source - K cells (duod - jej) - action - exocrine - dec gastric H+ secretion - endocrine - inc insulin release - regulation - inc by fatty acids - amino acids - oral glucose
Meconium ileus
Juvenille polyps - no risk if single
Liver - brain - cornea - kidneys - joints - Asterixis - Basal ganglia degeneration - dec Ceruloplasmin - Cirrhosis - Corneal deposits - Copper accumulation - Carcinoma (HCC) - Choreiform movements - Dementia

30. What are the borders of the femoral triangle
Initial diffuse periumbilical pain localizing to mcburney's point with nausea - fever - possible perforation leading to peritonitis
Inguninal ligament - sartorius muscle - adductor longus
Paraumbilical and superficial and inferior epigastric - umbilicus
Bile salts (bile conjugated to glycine or taurine) phospholipids - cholesterol - bilirubin - water and ions

31. Where is the pectinate line
CCK8 receptor - Gq inc IP3/Ca
Amylase
Where hindgut meets ectoderm
External (superficial) ring only

32. What is the most important mechanism in gastric acid secretion
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith
Source - K cells (duod - jej) - action - exocrine - dec gastric H+ secretion - endocrine - inc insulin release - regulation - inc by fatty acids - amino acids - oral glucose
Gastrin stimulating ECL cells to release histamine - histamine stimulation on parietal cells
Dilated esophagus with an area of distal stenosis - birds beak

33. How many layers outpouch in a false diverticula and they occur At what point of weakness and what?
Transjugular intrahepatic portosystemic shunt between portal and hepatic vein percutaneously by shunting blood to the systemic circulation
Lamina propora and submucosa
Cholecystitis - also ascending cholangitis - acute pancreatitis and bililary infx
Only mucosa or submucosa - occur where vasa recta perforate muscularis externa

34. Scleroderma is associated with what kind of esophageal dysmotility
Low pressure proximal to LES
With albumin
Begins starch digestion - inactivated by low pH upon reaching the stomach
FAP

35. What can hemochromatosis be secondary to...
Muscularis mucosae
External spermatic fascia only
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation
Hirschsprungs

36. If the abdominal aorta is blocked - How does blood get to the middle rectal artery
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
Superior rectal
Chronic gastritis and pernicious anemia
Uridine glucuronyl transferase

37. How does abetalipoproteinemia lead to malabsorption
Jewish and African American men
Centrilobular congestion and necrosis - cardiac cirrhosis
Dec synthesis of apo B - inability to generate chylomicrons - dec secretion of cholesterol - VLDL into the bloodstream - fat accumulation in enterocytes
EtOH

38. Which glands secrete alkaline mucus to neutralize acid contents entering the duodenum from the stomach and are located in the duodenal submucosa
Brush border of intestine - produce monosaccharides from oligo and di
Liver - brain - cornea - kidneys - joints - Asterixis - Basal ganglia degeneration - dec Ceruloplasmin - Cirrhosis - Corneal deposits - Copper accumulation - Carcinoma (HCC) - Choreiform movements - Dementia
Lateral
Brunners

39. What artery passes around the duodenum
Dubin johnson
Cholecystitis - also ascending cholangitis - acute pancreatitis and bililary infx
Black - rotors syndrome
The gastroduodenal

40. What is the path of an indirect inguinal hernia
Goes through deep inguinal ring - external inguinal ring and into the scrotum
Internal thoracic to superior epigastric to inferior epigastric
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin
Gastrin secreting tumor that causes continuous high levels of acid secretion and ulcers

41. In what scenarios do pts with gilberts have inc bili
Ceruplasmin
Inc pressure in the intrahepatic ducts leading to injury/fibrosis and bile stasis
Cholecystitis - also ascending cholangitis - acute pancreatitis and bililary infx
Fasting and stress

42. What does a gastrinoma cause
Gastrin secreting tumor that causes continuous high levels of acid secretion and ulcers
No - chronic - can present with diarrhea or constipation or alternation - treat sx
Lateral to the inferior epigastric artery
IBS at least 2 with recurrent abdominal pain

43. which pancreatic enzyme - secreted in its active form - is responsible for starch digestion
Worldwide - SC - US - adeno
Trypsin - chymotrypsin - elastase - carboxypeptidases
Above
Alpha amylase

44. What receptors does ACH bind on the parietal cells and What does it activate
Causes of gall stones
External spermatic fascia only
M3 - Gq - inc IP3/Ca
Pleuroperitoneal

45. What causes carcinoid syndrome amd What are the symptoms
Diarrhea - steatorrhea - weight loss - weakness
Lactase is located at the tips of intestinal villi
Muscularis mucosae
5HT - wheezing - right sided heart murmurs - diarrhea - flushing -

46. What is the mechanism for reyes syndrome
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin
Acute pancreatitis
Aspirin metabolites dec beta oxidation by reversible inhibition of mitocondrial enzyme - ASPIRIN Not RECOMMENDED FOR CHILDREN
Diarrhea - steatorrhea - weight loss - weakness

47. AD mutation in DNA mismatch repair genes - 80% progress to CRC - proximal colon always involved
Urobilin
AST >ALT - ration is usually 1.5
HPNCC
Reye's syndrome

48. Who gets gastric ulcers
Older patients
L2
Dense core bodies
Many diverticula - associated with low fiber diets - caused by inc intraluminal pressure and focal weakness in colonic wall

49. trypsinogen is converted to trypsin via what enzyme
Short gastrics - left greater and lesser
Enterokinase/enteropeptidase from the duodenal mucosa
Via the superior pancreaticduodenal
12 waves/min

50. Which IBD has noncaseating granulomas and lymphoid aggregates - and which has crypt abscesses and ulcers with bleeding
Pyoderma gangrenosum - primary sclerosing cholangitis
Small intestine
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
Crohns = noncaseating granulomas - UC = crypt abscesses