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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. How do secondary biliary cirrhosis - primary biliary cirrhosis and primary sclerosing cholangitis present
Hemolytic anemia
All 3 gut layers outpouch as in Meckels
Volvulus
Pruritis - jaundice - dark urine - light stools - hepatosplenomegaly

2. congenital megacolon characterized by lack of ganglion/enteric nervous plexuses in segment on intestinal biopsy
Inguninal ligament - sartorius muscle - adductor longus
Hirschsprungs
HPNCC
No

3. Where is IgA shuttled
GERD - esophagitis - esophageal ulcers - inc risk of esophageal cancer
Gastric glands
IgA receives protective secretory component and is then transported across the epithelium to gut lumen
Urobilin

4. subQ peribumbilical metastasis
Sister mary joseph nodule
EtOH
Stomach to proximal duodenum - liver - gall bladder - pancreas and spleen - celiac - vagus
Serous on the sides parotids - mucinous in the middle sublingual

5. trypsinogen is converted to trypsin via what enzyme
Achalasia due to loss of myenteric plexus (auberach)
Enterokinase/enteropeptidase from the duodenal mucosa
Dissaccharidase def - most commonly lactase
Jaundice - tender hepatomegaly - ascites - polycythemia - hypoglycemia

6. 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)
Crypts but not villi
Zollinger ellison - brunners glands
Left gastric vein and esophogeal vein - esophagus

7. Esophagitis can result From which 3 infectious agents - or chemical ingestion
HSV-1 - CMV - Candida
Phenobarbital - inc liver enzyme synthesis
Bleeding - intussusception - volvulus - obstruction near terminal ileum
Erosive - disruption of mucosal barrier leading to inflammation

8. What are the signs of peutz jehgers
Diverticulitis in elderly - ectopic pregs use hCG to rule out
Hyperpigmented mouth - lips - hands - genitalia
Dilated esophagus with an area of distal stenosis - birds beak
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

9. What serum enzyme is elevated in acute pancreatitis and mumps
Cirrhosis
Amylase
Antrum - H.pylori - inc risk of MALT lymphoma
Lack or have an attenuated muscularis externa - often in the sigmoid colon

10. When and why is stomach cancer termed linitis plastica
Gardner's syndrome
When diffusely infiltrative - thickened rigid appearance like a leather bottle
Meckels
Northern european - Abs to gliadin and tissue transglutaminase - blunted villi - lymphcytes in the lamina proporia

11. What is the most important mechanism in gastric acid secretion
Gastrin stimulating ECL cells to release histamine - histamine stimulation on parietal cells
2ndary biliary cirrhosis
Alfatoxin in peanuts
Splenic flexure

12. What are the common causes of gastric ulcers - What causes gastric ulcer
H+
Juvenille polyps - no risk if single
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid
Barrett's esophagus

13. Where does an indirect inguinal hernia enter the deep inguinal ring
Jewish and African American men
Hematogenous - alpha fetoprotein - budd chiari (hepatic vein blockage)
Lateral to the inferior epigastric artery
Autoimmune rxn leading to lymphcytic infiltrate + granulomas

14. What are causes of extrahepatic biliary obstruction
Reye's syndrome
AST >ALT - ration is usually 1.5
Gallstone - biliary stricture - chronic pancreatitis - carcinoma of the pancreatic head
Curling's ulcer - dec plasma volume and sloughing of gastric mucosa

15. What is the cause of Barrett's and the assocaited complications
Neutralizes gastric acid allowing pancreatic enzymes to fxn
5HT - wheezing - right sided heart murmurs - diarrhea - flushing -
GERD - esophagitis - esophageal ulcers - inc risk of esophageal cancer
Dec PGE2 leading to dec gastric mucosa protection

16. What is the presenting course for appendicity

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17. Which viral infxns/treatments are associated with reyes syndrome
Primary sclerosing cholangitis
Achalasia due to loss of myenteric plexus (auberach)
DIC - ARDS - diffuse fat necrosis - hypcalcemia - pseudocyst formation - hemorrhage - infxn - multiorgan failure
VZV and influenza B treated with salicylates

18. What are the treatmet options for crohns
ASA preparations (sulfasalazine) 6- mercaptopurine - infliximab - colectomy
Corticosteroids - infliximab
Epithelium
HSV-1 - CMV - Candida

19. What does loss of APC cause
Decreased intercellular adhesion and increased proliferation
Upregulated intracellular signal transduction
Begins starch digestion - inactivated by low pH upon reaching the stomach
Unconjugated - water insoluble

20. What is the main symptom if a VIPoma
Oral glucose
Copious diarrhea - non alpha - non beta cell pancreatic tumor
Inc lower esphogeal tone leading to achalasia
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

21. Achalasia increases the risk For what complication
Cirrhosis
Portal HTN
The gastroduodenal
Esophageal carcinoma

22. To what substance is bilirubin conjugated and why
Alk pho
Ampulla of vater
Chagas disease
Glucouronate - water soluble (direct)

23. Bile is critical for exrection of what substance
Left and right gastroepiploics - left and right gastrics
Cholesterol
GERD - esophagitis - esophageal ulcers - inc risk of esophageal cancer
Peyer's patches - plicae circulares in the proximal ileum and crypts of lieberkuhn

24. What are the complications of chronic pancreatitis
Brunners
Fundus/body - autoimmune - autoantibodies to parietal cells - perncious anemia - and achlorhydria
Alcoholic hepatitis
Pancreatic insuff - steatorrhea - fat soluble vitamin def - DM

25. which pancreatic enzyme - secreted in its active form - is responsible for starch digestion
Alpha amylase
Urobilin
In the ileum with bile acids - requires IF
Failure of neural crest migration

26. Pain improves with defaction - changes in stool frequency and changes in stool appearance are associated with
AST
L3
Inc smooth muscle relaxation - including lower esophageal sphincter
IBS at least 2 with recurrent abdominal pain

27. What is the presentation of pancreatic adenocarcinoma
Coma - scleral icterus - fetor hepaticus - spider nevi - gynecomastia - jaundice - testicular atrophy - hand tremor - bleeding - anemia - ankle edema
Diverticulitis in elderly - ectopic pregs use hCG to rule out
Abdominal pain radiating to back - weight loss due to malabsorption - migratory thrombophlebitis - obstructice jaundice with palpable gallbladder
All 3 gut layers outpouch as in Meckels

28. In jaundice of hemolytic etiology - is the hyperbilirubinemia conj or unconj - what happens to urine bili - and urine urobilinogen
Unconj - absent (acholuria) - inc
Enterokinase/enteropeptidase from the duodenal mucosa
Zollinger Ellison - phenylalanine and tryptophan
FAP

29. What do you use to diagnose meckels
Conj - inc - dec
Pertechnetate - study for uptake
Skip lesions =crohns - colon = UC
In the ileum with bile acids - requires IF

30. What kind of salivary gland tumor is painless - moveable mass - bening with high rate of recurrence - most common salivary gland tumor
Inferior rectal artery - inferior rectal vein to pudendal vein to internal iliac vein to IVC
Complications of UC
Jewish and African American men
Pleomorphic adenoma

31. What are the layers of the gut wall from inside out
Mucosa - submucosa - muscularis externa - serosa/adventitia
Cushings ulcers - inc vagal stimulation leading to inc vagal stim - inc ACH and inc H+ secretion
Enterokinase/enteropeptidase from the duodenal mucosa
Urobilin

32. What commonly leads to appendicity in kids vs adults
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith
FAP
Redness and tenderness on palpation of extremities
Hypotonic because of more time to reabsorb NaCl

33. What are additional risk factors for CRC
Uremia
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome
Krukenbergs tumor
Mucosa - submucosa - muscularis externa - serosa/adventitia

34. What cell produces IF and What does it do
Parietal cells in the stomach - B12 binding protein
Redundant mesentary
Female - fat - fertile - forty
L/R renal artery around L1

35. What are the extraintestinal manifestations of crohns
Early childhood - neuro sx and malabsorption
When diffusely infiltrative - thickened rigid appearance like a leather bottle
Migratory polyarthritis - erythema nodusum - anklyosing spondylitis - uveitis - immunologic disorders
Appendicitis

36. What histological findings are present in the esophagus
Nonkeritinized stratified sqamous epithelium
Sympathetic (T1- T3 superior cervical ganglion) and parasympathetic (facial and glossopharyngeal nerve)
Volvulus
Primarly through ECL leading to histamine release

37. Which monosaccharides are absorbed by the enterocytes and which transporters carry each
Early childhood - neuro sx and malabsorption
Reye's syndrome
SGLT1 (Na dependent) glucose - galactose - GLUT 5 fructose (facilitated diffusion)
Autoimmune rxn leading to lymphcytic infiltrate + granulomas

38. What are the ABCDEF of esophageal cancer
Smooth
Alcohol/Achalasia - Barretts - Cigarettes - Diverticuli (Zenkers) Esophageal web/Esophagitis - Familial
Distal duodenum to proximal 2/3 of transverse colon - SMA - vagus
Crohns = noncaseating granulomas - UC = crypt abscesses

39. final and irreversible alcoholic liver disease with micronodular irregularly shrunken liver with hobnail appearance
Alcoholic cirrhosis
Air into the biliary tree - if gallstone obstructs ileocecal valve - air can be seen in biliary tree on imaging
The gastroduodenal
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

40. Gastrin - source - action - regulation
Black - rotors syndrome
GERD - may also present with nocturnal cough and dyspnea
Source - G cells in the antrum - action - inc gastric H+ secretion - inc growth of gastric mucosa - and inc gastric motility - regulation - inc by stomach distention/alkalinaztion - amino acids - peptides - vagal stimulation - dec by stomach pH < 1.5
Chronic gastritis and pernicious anemia

41. At what spinal level does the SMA exit
All 3 gut layers outpouch as in Meckels
L1
Amylase
Gamma glutamyl transferase GGT

42. In what scenarios do pts with gilberts have inc bili
Fasting and stress
Chief cells of the stomach - protein digestion - inc by vagal stimulation local acid
Increase tumorigenesis
HPNCC

43. Autoantibodies to gluten (gliadin) in wheat and other grains
Celiac sprue
Abdominal pain radiating to back - weight loss due to malabsorption - migratory thrombophlebitis - obstructice jaundice with palpable gallbladder
Begins starch digestion - inactivated by low pH upon reaching the stomach
T12

44. What can fistula between the gallbladder and small intestine create and how can you tell
Necrotizing enterocolitis
Turcot
Alk phos
Air into the biliary tree - if gallstone obstructs ileocecal valve - air can be seen in biliary tree on imaging

45. Which glands secrete alkaline mucus to neutralize acid contents entering the duodenum from the stomach and are located in the duodenal submucosa
Triglycerides and micelle formation - required for absorption of of non polar nutrients in small intestine
Neutralizes oral bacertial acids and maintains dental health
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith
Brunners

46. What enzyme is necessary to create conjugated bilirubin
Paraumbilical and superficial and inferior epigastric - umbilicus
Antrum - H.pylori - inc risk of MALT lymphoma
H pylori (almost 100%)
Uridine glucuronyl transferase

47. What drug inhibits the H/K ATPase
Omeprazole
Inc conj bilirubin - inc cholesterol - inc alk phos
Angiodysplasia
Hirschsprungs

48. vasoactive intestinal polypeptide (VIP) - source - action - regulation
Warthins' tumor
Hepatic steatosis
Lipase
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

49. What is the characteristic histo finding in alcoholic hepatitis
Budd chiari syndrome
Serum mitochondrial antibodies including IgM - associated with CREST - RA and celiac dz
GERD - may also present with nocturnal cough and dyspnea
Mallory bodies

50. What kind of pancreatitis is associated with EtOH and smoking
US and cholecystectomy
Brunners
Chronic calcifying pancreatitis - inc risk of panreatic cancer
Abdominal pain radiating to back - weight loss due to malabsorption - migratory thrombophlebitis - obstructice jaundice with palpable gallbladder