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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. Where does an indirect inguinal hernia enter the deep inguinal ring
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
VZV and influenza B treated with salicylates
Lateral to the inferior epigastric artery

2. Dysphagia in achalasia results from
3rd most common cancer - 3rd deadliest in US - pts > 50 - 1/4 have fam hx
Around the central vein (zone III)
High LES opening pressure and uncoordinated peristalsis - both solids and liquids
Only mucosa or submucosa - occur where vasa recta perforate muscularis externa

3. What is the path of a direct inguinal hernia and Where does it travel relative to the inferior epigastric artery

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4. What kind of cancer to celiac sprue put you as inc risk for
Mitochondrial abnl - fatty liver - hypoglycemia - coma
Peyer's patches - plicae circulares in the proximal ileum and crypts of lieberkuhn
Positive
T cell lymphoma

5. Gallstones that reach the common channel at ampulla can block which two ducts
Gastrin secreting tumor that causes continuous high levels of acid secretion and ulcers
Pancreatic and bile
Dec synthesis of apo B - inability to generate chylomicrons - dec secretion of cholesterol - VLDL into the bloodstream - fat accumulation in enterocytes
Stercobilin

6. What are the complications of duodenal PUD
Northern european - Abs to gliadin and tissue transglutaminase - blunted villi - lymphcytes in the lamina proporia
Lactase is located at the tips of intestinal villi
Bleeding - penetration into pancreas - perforation - obstruction
Hernia

7. When do you see hypertrophy of brunners glands
Primary sclerosing cholangitis
Peptic ulcer disease
Goes through deep inguinal ring - external inguinal ring and into the scrotum
Lipase

8. What retroperitoneal structure flanks both sides of the pancreas on CT
Duodenum - 2nd - 3rd and 4th parts
Poor anastamoses
Hemolytic anemia
FAP

9. What converts inactive pepsinogen to pepsin
H+
AST
>3mm nodules - significant liver injury leading to hepatic necrosis - postinfectious - drug induced hepatitis with inc risk of HCC
Sphincter of oddi

10. AD mutation in DNA mismatch repair genes - 80% progress to CRC - proximal colon always involved
Redundant mesentary
External spermatic fascia only
8-9 waves/min
HPNCC

11. What is contained with in the hepatoduodenal ligament - What two spaces does it connect - and when would you need to compress it
Krukenbergs tumor
Portal triad: hepatic artery - protal vein - common bile duct - greater and lesser sac - to control bleeding
Epigastric abdominal pain radiating to back - anorexia - nausea
Squamous - upper 1/3 - adeno - lower 1/3

12. What portion of the bowel does sprue effect
Gilbert's
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid
Pertechnetate - study for uptake
The proximal small bowel

13. occlusion of IVC or hepatic veins
Distal 1/3 of transverse colon to supper portion of rectum - IMA - and PANS
Via the superior pancreaticduodenal
All 3 gut layers outpouch as in Meckels
Budd chiari syndrome

14. strictures - fistulas - perianal disease - malabsorption - nutritional depletion - colorectal cancer
Complications of crohns
Bleeding - intussusception - volvulus - obstruction near terminal ileum
Dense core bodies
PAS- positive globules in liver -

15. What source of salivary secretion is the most serous and What is the most mucinous
Femoral hernia
Serous on the sides parotids - mucinous in the middle sublingual
Via the middle colic
Urobilin

16. What does a low flow rate mean for saliva
Neutralizes gastric acid allowing pancreatic enzymes to fxn
2ndary biliary cirrhosis
Hypotonic because of more time to reabsorb NaCl
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome

17. Where is the arterial supply from above the pectinate line - and What is the venous drainage
Superior rectal from IMA - superior rectal vein to inf mesenteric to portal system
Tropheryma whippelii - gram positive and PAS- positive MACS in intestinal lamina proporia and mesenteric nodes
Female - fat - fertile - forty
Cimetidine

18. Where is folate absorbed
High LES opening pressure and uncoordinated peristalsis - both solids and liquids
Crohns = maybe - UC= always
The jejunum
FAP

19. conjugated hyperbilirubinemia due to defective liver excretion
Dubin johnson
Chief cells of the stomach - protein digestion - inc by vagal stimulation local acid
L/R renal artery around L1
Phototherapy

20. Bile is critical for exrection of what substance
Distal duodenum to proximal 2/3 of transverse colon - SMA - vagus
12 waves/min
Upregulated intracellular signal transduction
Cholesterol

21. What is the cause of Barrett's and the assocaited complications
Femoral hernia - through femoral canal - lateral to pubic tubercle and women
GERD - esophagitis - esophageal ulcers - inc risk of esophageal cancer
Menetriers disease
Can lead to hematemesis - found in EtOHics and bulimics

22. Which glands secrete alkaline mucus to neutralize acid contents entering the duodenum from the stomach and are located in the duodenal submucosa
Brunners
Pancreatic and bile
Chronic calcifying pancreatitis - inc risk of panreatic cancer
CCK8 receptor - Gq inc IP3/Ca

23. At what spinal level does the SMA exit
Skip lesions =crohns - colon = UC
Terminal ileum and colon
L1
Meckels

24. What is biliary colic
Gastrohepatic ligament
Protrudes through the Hesselbach's triangle - bulges directly through abdominal wall medial to inferior epigastric vessels
Positive urease test
Pain associated with cholecystitis and galls stones - diabetics may not present with pain

25. in carcinoid tumors - What is seen on EM
Dense core bodies
>3mm nodules - significant liver injury leading to hepatic necrosis - postinfectious - drug induced hepatitis with inc risk of HCC
Redundant mesentary
Inferior rectal artery - inferior rectal vein to pudendal vein to internal iliac vein to IVC

26. What gives stool its characteristic color
2ndary biliary cirrhosis
Lateral to the inferior epigastric artery
Stercobilin
Bleeding - penetration into pancreas - perforation - obstruction

27. What is the most common esophageal cancer worldwide and in the US
Diarrhea - steatorrhea - weight loss - weakness
Worldwide - SC - US - adeno
Gallbladder
Cimetidine

28. What are the extraintestinal manifestations of ulcerative colitis
Jaundice - tender hepatomegaly - ascites - polycythemia - hypoglycemia
Pyoderma gangrenosum - primary sclerosing cholangitis
Around the central vein (zone III)
Cholecystitis - usually from gallstones rarely ischemia or infxn (CMV)

29. malnutrition - toxic megacolon - colorectal carcinoma
Angiodysplasia
Peutz jeghers
Complications of UC
Redundant mesentary

30. congenital megacolon characterized by lack of ganglion/enteric nervous plexuses in segment on intestinal biopsy
Cirrhosis
Hirschsprungs
Pancreatic and bile
Superior rectal and middle and inferior rectal - rectum

31. To what substance is bilirubin conjugated and why
Cirrhosis
Cystic dilation of the viteline duct
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Glucouronate - water soluble (direct)

32. How is bilirubin carried in the blood
Positive urease test
Lateral
Air into the biliary tree - if gallstone obstructs ileocecal valve - air can be seen in biliary tree on imaging
With albumin

33. What kind of gall stones are mostly radiolucent and what percentage is opaque and due to what?
3 waves/min
Liver - brain - cornea - kidneys - joints - Asterixis - Basal ganglia degeneration - dec Ceruloplasmin - Cirrhosis - Corneal deposits - Copper accumulation - Carcinoma (HCC) - Choreiform movements - Dementia
Cholesterol - 10-20% opaque due to calcifications
Urobilin

34. What causes carcinoid syndrome amd What are the symptoms
5HT - wheezing - right sided heart murmurs - diarrhea - flushing -
Sister mary joseph nodule
Short gastrics - left greater and lesser
Mucoepidermoid carcinoma

35. What is the characteristic histo finding in alcoholic hepatitis
Mallory bodies
Left gastric vein and esophogeal vein - esophagus
Aspirin metabolites dec beta oxidation by reversible inhibition of mitocondrial enzyme - ASPIRIN Not RECOMMENDED FOR CHILDREN
Upregulated intracellular signal transduction

36. What histological findings are present in the esophagus
Lactase is located at the tips of intestinal villi
Chronic calcifying pancreatitis - inc risk of panreatic cancer
Nonkeritinized stratified sqamous epithelium
Dense core bodies

37. Through which aspect of the inguinal canal does a direct inguinal go
Obstruction of the common bile duct
Serous on the sides parotids - mucinous in the middle sublingual
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
External (superficial) ring only

38. What gives urine its characteristic color
Urobilin
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
Punched out - clean margins - carcinoma =raised irregular margins
Alk pho

39. Autoantibodies to gluten (gliadin) in wheat and other grains
Celiac sprue
Phenobarbital - inc liver enzyme synthesis
Distal 1/3 of transverse colon to supper portion of rectum - IMA - and PANS
Volvulus

40. What are the histological findings in the jejunum
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn
Adhesion
Peutz jeghers
Achalasia due to loss of myenteric plexus (auberach)

41. What are the signs of peutz jehgers
Triglycerides and micelle formation - required for absorption of of non polar nutrients in small intestine
Autoimmune rxn leading to lymphcytic infiltrate + granulomas
Celiac sprue
Hyperpigmented mouth - lips - hands - genitalia

42. signet ring cells - acanthosis nigracans - dz - character/association - spread
Corticosteroids - infliximab
AR
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood
Liver - brain - cornea - kidneys - joints - Asterixis - Basal ganglia degeneration - dec Ceruloplasmin - Cirrhosis - Corneal deposits - Copper accumulation - Carcinoma (HCC) - Choreiform movements - Dementia

43. FAP + malignant CNS tumor
Turcot
AST >ALT - ration is usually 1.5
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
Fe2+ in the duod

44. Why does indirect inguinal hernia happen in infacnts
When diffusely infiltrative - thickened rigid appearance like a leather bottle
Failure of the processus vagainlis to close
Corticosteroids - infliximab
Mitochondrial abnl - fatty liver - hypoglycemia - coma

45. In what clinical scenarior do you see portosystemic anastomoses
Centrilobular congestion and necrosis - cardiac cirrhosis
12 waves/min
Portal HTN
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid

46. inc cholesterol and/or bilirubin - dec bile salts and gallbladder stasis
Dense core bodies
Gallbladder
Hepatomegaly - ascitis - abdominal pain - varices - visible abdominal and back veins - absence of JVD
Causes of gall stones

47. inadequate hepatic liver copper excretion and failure of copper to enter circulation as ceruloplasmin
Hirschsprungs
...
True and most common congenital anomoly of GI tract
Diverticulitis in elderly - ectopic pregs use hCG to rule out

48. What commonly leads to appendicity in kids vs adults
Fasting and stress
Liver metabolizes 5HT
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith
Inc - weight loss

49. What percentage of gall stones are cholesterol stones and What are the associations
The gastroduodenal
Crohns - CF - advanced age - clofibrate - estrogens - multiparity - rapid weight loss - Native American origin
AR
Obstruction of the common bile duct

50. What are the borders of Hesselbach's triangle
Terminal ileum and colon
Elevated amylase - and lipase
Redness and tenderness on palpation of extremities
Inferior epigastric artery - lateral border of rectus abdominis - inguinal ligament