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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 enzyme is necessary to create conjugated bilirubin
Appendicitis
Protrudes through the Hesselbach's triangle - bulges directly through abdominal wall medial to inferior epigastric vessels
Tropical sprue
Uridine glucuronyl transferase

2. Which serum enzyme increases with heavy EtOH consumption
Virchow's node
Gamma glutamyl transferase GGT
Gardner's syndrome
Hypercoaguability - polycythemia vera - pregnancy - HCC

3. Who gets Whipple disease and How do they present
Old men - arthralgias - cardiac and neuro sx
Decreased intercellular adhesion and increased proliferation
Source - SI - action - produces migrating motor complexes - regulation - inc in fasting state
Only mucosa or submucosa - occur where vasa recta perforate muscularis externa

4. What is the omphalomesenteric cyst
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Cystic dilation of the viteline duct
Inspiratory arrest on deep palpation due to pain
Via the middle colic

5. What is the lumen of the pancreatic duct
Bleeding - intussusception - volvulus - obstruction near terminal ileum
Pertechnetate - study for uptake
Ampulla of vater
Early childhood - neuro sx and malabsorption

6. What drug inhibits the H/K ATPase
H2 receptor - inc cAMP
Omeprazole
Lack or have an attenuated muscularis externa - often in the sigmoid colon
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

7. What are additional risk factors for CRC
Inc conj bilirubin - inc cholesterol - inc alk phos
Inguninal ligament - sartorius muscle - adductor longus
MSI (15%) and APC/beta catenin chromosomal instability (85%)
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome

8. What are the four Fs of gallstones
Alk phos
Ceruplasmin
Female - fat - fertile - forty
Peptic ulcer disease

9. In what syndrome is gastric very elevatad - and amino acids are potent gastrin stimulators
FAP
Right and left hepatic duct
Zollinger Ellison - phenylalanine and tryptophan
Diarrhea - steatorrhea - weight loss - weakness

10. How do burns cause acute gastritis and What is it called

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11. What causes primary biliary cirrhosis
H pylori (almost 100%)
Virchow's node
Autoimmune rxn leading to lymphcytic infiltrate + granulomas
Increase tumorigenesis

12. What are the treatment options for uclerative colitis
Autoimmune rxn leading to lymphcytic infiltrate + granulomas
Femoral hernia
ASA preparations (sulfasalazine) 6- mercaptopurine - infliximab - colectomy
Distal 1/3 of transverse colon to supper portion of rectum - IMA - and PANS

13. Why would a self - limited lactase def occur following an injury (viral diarrhea)
Lactase is located at the tips of intestinal villi
Inc lower esphogeal tone leading to achalasia
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
Via the middle colic

14. What structures feed into the common bile duct
Myenteric nerve plexus - aurbach
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
Cystic duct and common hepatic duct
FAP

15. What percentage of gall stones are cholesterol stones and What are the associations
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
Crohns - CF - advanced age - clofibrate - estrogens - multiparity - rapid weight loss - Native American origin
Zollinger Ellison - phenylalanine and tryptophan
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

16. What is the most common diaphragmatic hernia and What are the two types
Hiatal hernia - sliding - hourglass shape - and paraesophageal hernia where stomach chomes up through the hiatus
Reye's syndrome
L/R renal artery around L1
Jaundice - fever - RUQ

17. strictures - fistulas - perianal disease - malabsorption - nutritional depletion - colorectal cancer
Gallstones - EtOH - trauma - steroids - mumps - autoimmune - scorpion sting - hypercalcemia/hyperlipidemia - ERCP - Drugs (sulfa)
Complications of crohns
Dubin johnson
Hepatic steatosis

18. What infection causes Whipple disease and What can you see on LM
Copious diarrhea - non alpha - non beta cell pancreatic tumor
Tropheryma whippelii - gram positive and PAS- positive MACS in intestinal lamina proporia and mesenteric nodes
HSV-1 - CMV - Candida
Inc smooth muscle relaxation - including lower esophageal sphincter

19. What are causes of extrahepatic biliary obstruction
Gallstone - biliary stricture - chronic pancreatitis - carcinoma of the pancreatic head
AST>ALT
Crohns = noncaseating granulomas - UC = crypt abscesses
Duodenal atresia - Downs

20. alcoholic liver disease with short term change and moderate EtOH intake - macrovesicular fatty change that may be reversible
<3mm nodules - metabolic - etoh - hemochromatosis - wilsons
No - chronic - can present with diarrhea or constipation or alternation - treat sx
Hepatic steatosis
Above

21. Why does indirect inguinal hernia happen in infacnts
Aspirin metabolites dec beta oxidation by reversible inhibition of mitocondrial enzyme - ASPIRIN Not RECOMMENDED FOR CHILDREN
Failure of the processus vagainlis to close
Turcot
Older patients

22. What is contained in the gastrosplenic and What areas does it separate
Intussusception
Short gastrics - left greater and lesser
Antrum - H.pylori - inc risk of MALT lymphoma
High LES opening pressure and uncoordinated peristalsis - both solids and liquids

23. What kind of pathways do CCK act on to cause pancreatic secretion
Corticosteroids - infliximab
Increase tumorigenesis
Femoral hernia
Neural muscarinic pathways

24. How does HCC spread - What is a common tumor marker and what syndrome can it lead to...
Hematogenous - alpha fetoprotein - budd chiari (hepatic vein blockage)
Portal triad: hepatic artery - protal vein - common bile duct - greater and lesser sac - to control bleeding
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
Crigler - najjar type 1

25. How does abetalipoproteinemia lead to malabsorption
Unconj - absent (acholuria) - inc
Dec synthesis of apo B - inability to generate chylomicrons - dec secretion of cholesterol - VLDL into the bloodstream - fat accumulation in enterocytes
ALT>AST
Left gastric vein and esophogeal vein - esophagus

26. What structures feed into the cystic duct
Brunners
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
Gallbladder
Hyperpigmented mouth - lips - hands - genitalia

27. Which monosaccharides are absorbed by the enterocytes and which transporters carry each
SGLT1 (Na dependent) glucose - galactose - GLUT 5 fructose (facilitated diffusion)
GERD - esophagitis - esophageal ulcers - inc risk of esophageal cancer
Transjugular intrahepatic portosystemic shunt between portal and hepatic vein percutaneously by shunting blood to the systemic circulation
IgA secreting plasma cells - ultimately reside in the lamina proporia

28. What is the leading cause of bowel incarceration
Hematogenous - alpha fetoprotein - budd chiari (hepatic vein blockage)
Femoral hernia
Cirrhosis
Dermatitis herpetiformis

29. What serum markers increase in cholecystitis with bile duct involvement
Dilated esophagus with an area of distal stenosis - birds beak
Increase tumorigenesis
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
Alk phos

30. What is indirect bilirubin
Tropical sprue
Unconjugated - water insoluble
Autoimmune rxn leading to lymphcytic infiltrate + granulomas
Peptic ulcer disease

31. Achalasia increases the risk For what complication
Dysphagia (due to esophageal web) - glossitis - iron def anemia
Alternating strictures and dilation with beading of intra and extrahepatic bile ducts on ERCP
Complications of crohns
Esophageal carcinoma

32. What are the complications of chronic pancreatitis
Pancreatic insuff - steatorrhea - fat soluble vitamin def - DM
H+
Crypts but not villi
Inc size - villous histology - inc epithelial dysplasia - precursor to CRC

33. Tortuous dilation of vessels and bleeding - most often in cecum - terminal ileum and ascending colon - common in older patients - confirmed by angiography
Angiodysplasia
Adhesion
Trypsin - chymotrypsin - elastase - carboxypeptidases
Lack or have an attenuated muscularis externa - often in the sigmoid colon

34. Bile is critical for exrection of what substance
IgA receives protective secretory component and is then transported across the epithelium to gut lumen
Cholesterol
Hypotonic because of more time to reabsorb NaCl
Bleeding - intussusception - volvulus - obstruction near terminal ileum

35. Why does volvulus occur more at cecum and sigmoid colon
Acute pancreatitis
Redundant mesentary
Inc pressure in the intrahepatic ducts leading to injury/fibrosis and bile stasis
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood

36. Where on the stomach does the gastrohepatic ligament attach to - What does it contain - and How is used in surgery
Lesser curvature - gastric arteries - cut in surgery to access lesser sac
Hepatic steatosis
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin
Increase tumorigenesis

37. What are the histological findings of the colon
Neutralizes oral bacertial acids and maintains dental health
Crypts but not villi
Gastric glands
Cushings ulcers - inc vagal stimulation leading to inc vagal stim - inc ACH and inc H+ secretion

38. What causes pancreatic insuff and What does it cause
CF - obstructing cancer - chronic pancreatitis - causes malabsorption of fat and fat soluble vitamins (ADEK)
Small intestine
Acute pancreatitis
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid

39. Which IBD has noncaseating granulomas and lymphoid aggregates - and which has crypt abscesses and ulcers with bleeding
Alcoholic hepatitis
Crohns = noncaseating granulomas - UC = crypt abscesses
Intussusception
Common hepatic - splenic - left gastric - main blood supply for stomach

40. twisting of portion of bowel around its mesentery leading to obstruction and infarction - usually in elderly
Cirrhosis
GERD - esophagitis - esophageal ulcers - inc risk of esophageal cancer
SGLT1 (Na dependent) glucose - galactose - GLUT 5 fructose (facilitated diffusion)
Volvulus

41. Which viral infxns/treatments are associated with reyes syndrome
Redundant mesentary
Northern european - Abs to gliadin and tissue transglutaminase - blunted villi - lymphcytes in the lamina proporia
VZV and influenza B treated with salicylates
Can lead to hematemesis - found in EtOHics and bulimics

42. What kind of cancer to celiac sprue put you as inc risk for
T cell lymphoma
Warthins' tumor
Sphincter of oddi
In the mucus that covers the gastric epithelium

43. What structures feed into the common hepatic duct
Alpha amylase
Oligosaccharide digestion
Right and left hepatic duct
Cholesterol

44. In PUD - with gastric ulcers - does pain inc or dec with meals?
Cholecystitis - usually from gallstones rarely ischemia or infxn (CMV)
Inc - weight loss
Pruritis - jaundice - dark urine - light stools - hepatosplenomegaly
Neural muscarinic pathways

45. subQ peribumbilical metastasis
Inferior rectal artery - inferior rectal vein to pudendal vein to internal iliac vein to IVC
Sister mary joseph nodule
Nonkeritinized stratified sqamous epithelium
Muscularis mucosae

46. congenital megacolon characterized by lack of ganglion/enteric nervous plexuses in segment on intestinal biopsy
Right and left hepatic duct
Hirschsprungs
M3 - Gq - inc IP3/Ca
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

47. Bilirubin is the product of what?
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood
Heme metabolism
Fundus/body - autoimmune - autoantibodies to parietal cells - perncious anemia - and achlorhydria
3rd most common cancer - 3rd deadliest in US - pts > 50 - 1/4 have fam hx

48. What is the HLA association and treatment for hemochromatosis
Repeated phlebotomy - deferoxamine - HLA- A3
Dysphagia (due to esophageal web) - glossitis - iron def anemia
Gardner's syndrome
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation

49. What can hemochromatosis be secondary to...
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation
Dec PGE2 leading to dec gastric mucosa protection
HSV-1 - CMV - Candida
Complications of crohns

50. involvement of left supraclavicular node by mets from stomach

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