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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. List the clinical findings of HCC
Jaundice - tender hepatomegaly - ascites - polycythemia - hypoglycemia
So hypertrophied they look like brain gyri
Serous on the sides parotids - mucinous in the middle sublingual
Krukenbergs tumor

2. secretin - source - action - regulation
HBV - HCV - wilsons dz - hemochromatosis - alpha1- antitrypsin def - alcoholic cirrhosis
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn
Alcoholic hepatitis
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

3. What are the two molecular pathways that lead to CRC
Tropheryma whippelii - gram positive and PAS- positive MACS in intestinal lamina proporia and mesenteric nodes
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Crohns = noncaseating granulomas - UC = crypt abscesses
Lipase

4. signet ring cells - acanthosis nigracans - dz - character/association - spread
Stomach cancer (usually adenocarcinoma) - early aggressive spread - node/liver mets - associated with nitrosamines (smoked foods) - achlorhydria - chronic gastritis - type A blood
Brush border of intestine - produce monosaccharides from oligo and di
L2
Duodenum - 2nd - 3rd and 4th parts

5. What is contained with in the hepatoduodenal ligament - What two spaces does it connect - and when would you need to compress it
GERD - esophagitis - esophageal ulcers - inc risk of esophageal cancer
Portal triad: hepatic artery - protal vein - common bile duct - greater and lesser sac - to control bleeding
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
CHF and inc risk of HCC

6. mostly sporadic lesions in children < 5 - 80% in rectum - When is there no risk of malignant potential
Cystic duct and common hepatic duct
Juvenille polyps - no risk if single
Goes through deep inguinal ring - external inguinal ring and into the scrotum
Decrease - weight gain

7. What does bicab do in the mouth
Neutralizes oral bacertial acids and maintains dental health
Inc lower esphogeal tone leading to achalasia
Old men - arthralgias - cardiac and neuro sx
Brush border of intestine - produce monosaccharides from oligo and di

8. What causes nutmeg liver
Worldwide - SC - US - adeno
Backup of blood into the liver - RHF - budd chiari
Neutralizes oral bacertial acids and maintains dental health
H2 receptor - inc cAMP

9. In alchoholic hepatitis which liver enzyme is higher
DNA mistmatch repair gene mutations lead to sporadic and HNPCC syndrome - mutations accumulate but not define morphologic correlates
Left and right gastroepiploics - left and right gastrics
Uremia
AST>ALT

10. What conditions are associated with budd chiari
H2 receptor - inc cAMP
Volvulus
Hypercoaguability - polycythemia vera - pregnancy - HCC
The submucosal nerve plexus - meissner's

11. What percentage of gall stones are cholesterol stones and What are the associations
Can lead to hematemesis - found in EtOHics and bulimics
Cystic dilation of the viteline duct
Cigarettes and chronic pancreatitis - not EtOH
Crohns - CF - advanced age - clofibrate - estrogens - multiparity - rapid weight loss - Native American origin

12. milk intolerance
Ischemic colitis
Many diverticula - associated with low fiber diets - caused by inc intraluminal pressure and focal weakness in colonic wall
Lesser curvature - gastric arteries - cut in surgery to access lesser sac
Dissaccharidase def - most commonly lactase

13. What is the rule of 2s for meckels
Conj - inc - dec
Tropheryma whippelii - gram positive and PAS- positive MACS in intestinal lamina proporia and mesenteric nodes
2 inches long - 2 feet from ileocecal valve - 2% of pop - first 2 years of life - 2 types of epithelia
Old men - arthralgias - cardiac and neuro sx

14. How is the diagonsis of CRC made
3 waves/min
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
Coma - scleral icterus - fetor hepaticus - spider nevi - gynecomastia - jaundice - testicular atrophy - hand tremor - bleeding - anemia - ankle edema
L3

15. Where does crohns usually affect the GI tract
Terminal ileum and colon
Zollinger ellison - brunners glands
Esophageal varices
The proximal small bowel

16. Gastrin - source - action - regulation
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
Left gastric vein and esophogeal vein - esophagus
No - chronic - can present with diarrhea or constipation or alternation - treat sx
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

17. What serum marker increases with primary biliary cirrhosis and what other autoimmune conditions are it associated with
H+
Inc lower esphogeal tone leading to achalasia
Pleuroperitoneal
Serum mitochondrial antibodies including IgM - associated with CREST - RA and celiac dz

18. Where is there sclerosis in alcoholic cirrohosis
GLUT 2
Around the central vein (zone III)
Lamina propria
Pertechnetate - study for uptake

19. What is charcot triad of cholangitis
HBV - HCV - wilsons dz - hemochromatosis - alpha1- antitrypsin def - alcoholic cirrhosis
Left and right gastroepiploics - left and right gastrics
Jaundice - fever - RUQ
CF - obstructing cancer - chronic pancreatitis - causes malabsorption of fat and fat soluble vitamins (ADEK)

20. FAP + osseous and soft tissue tumors - retinal hyperplasia

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21. What cells make gastric acid - What does it do to stomach pH and what substances regulate it
Gallstone - biliary stricture - chronic pancreatitis - carcinoma of the pancreatic head
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin
Unconj - absent (acholuria) - inc
Initial diffuse periumbilical pain localizing to mcburney's point with nausea - fever - possible perforation leading to peritonitis

22. What layer of fascia covers a direct inguinal hernia
Failure of the processus vagainlis to close
Duodenum - 2nd - 3rd and 4th parts
Mitochondrial abnl - fatty liver - hypoglycemia - coma
External spermatic fascia only

23. necrosis of intestinal mucosa and possible perforation - usual colon involvement - more common in preemies
Conj - inc - dec
CF - obstructing cancer - chronic pancreatitis - causes malabsorption of fat and fat soluble vitamins (ADEK)
Krukenbergs tumor
Necrotizing enterocolitis

24. Liver cell failure can lead to multisystem signs including
Epigastric abdominal pain radiating to back - anorexia - nausea
Alternating strictures and dilation with beading of intra and extrahepatic bile ducts on ERCP
Lateral
Coma - scleral icterus - fetor hepaticus - spider nevi - gynecomastia - jaundice - testicular atrophy - hand tremor - bleeding - anemia - ankle edema

25. What arteries exit just below the SMA
Dubin johnson
Fasting and stress
Source - SI - action - produces migrating motor complexes - regulation - inc in fasting state
L/R renal artery around L1

26. At what level do the testicular/ovarian arteries exit the aorta
Gastrohepatic ligament
Serous on the sides parotids - mucinous in the middle sublingual
L2
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn

27. How does CRC present in the distal and proximal colon
Distal colon - obstruction - colicky pain - hematochezia - proximal colon - dull pain - iron deficiency anemia - fatigue
External - receive somatic innervation - internal receive visceral innervation - not painful but sign of portal HTN
IgA secreting plasma cells - ultimately reside in the lamina proporia
Decrease - weight gain

28. What does histo show for alpha1 antitrypsin def
The submucosal nerve plexus - meissner's
PAS- positive globules in liver -
Pancreatic and bile
Alcoholic cirrhosis

29. What is indirect bilirubin
Unconjugated - water insoluble
Internal thoracic to superior epigastric to inferior epigastric
Decreased intercellular adhesion and increased proliferation
Distal 1/3 of transverse colon to supper portion of rectum - IMA - and PANS

30. What separates the right greater and lesser sacs
Gastrohepatic ligament
Failure of neural crest migration
...
Mucoepidermoid carcinoma

31. With esophageal varices - between What two vessels is the portosystemic anastomoses and Where is it
Low pressure proximal to LES
Primarly through ECL leading to histamine release
Left gastric vein and esophogeal vein - esophagus
Penicillinamine - AR inheritance

32. What do you use to diagnose meckels
Pertechnetate - study for uptake
8-9 waves/min
Low pressure proximal to LES
Left gastric vein and esophogeal vein - esophagus

33. What nerve innervates the external hemorrhoids
Phenobarbital - inc liver enzyme synthesis
Inferior rectal nerve
Elevated amylase - and lipase
Cholecystitis - usually from gallstones rarely ischemia or infxn (CMV)

34. What are the histological findings in the jejunum
Gallbladder
Juvenile polyposis syndrome - inc risk of adenocarcinoma
Largest nimber of goblet cells in the small intestine - plicae circulares and crypts of lieberkuhn
Older patients

35. Which IBD usually has transmural inflammation and which has mucosal and submucosal inflammation and What are the characteristic signs of each
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
Ischemic colitis
Complications of crohns
Centrilobular congestion and necrosis - cardiac cirrhosis

36. acute bowel obstruction - commonly from a recent surgery - can have well demarcated necrotic zones
Female - fat - fertile - forty
Adhesion
AST >ALT - ration is usually 1.5
Hypotonic because of more time to reabsorb NaCl

37. What do you treat Wilsons disease with and What is the inheritance
Penicillinamine - AR inheritance
Boerhaave's Syndrome - Been heaving syndrome
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
AST

38. why infxn is implicated in duodenal PUD
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
H pylori (almost 100%)
Jewish and African American men
Centrilobular leading to congestive liver disease

39. What kind of anemia is in Wilsons
Via the middle colic
Abdominal pain radiating to back - weight loss due to malabsorption - migratory thrombophlebitis - obstructice jaundice with palpable gallbladder
Hemolytic anemia
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin

40. What is Trousseau's sign
Goes through deep inguinal ring - external inguinal ring and into the scrotum
H pylori (almost 100%)
Esophageal cancer
Redness and tenderness on palpation of extremities

41. What serum enzyme is elevated inacute pancreatitis
Complications of crohns
Decreased intercellular adhesion and increased proliferation
Lipase
Jaundice - tender hepatomegaly - ascites - polycythemia - hypoglycemia

42. Is there any structural abnl with IBS - What is the course of disease and presentation
No - chronic - can present with diarrhea or constipation or alternation - treat sx
Inferior rectal nerve
M3 - Gq - inc IP3/Ca
Ischemic colitis

43. strictures - fistulas - perianal disease - malabsorption - nutritional depletion - colorectal cancer
Primarly through ECL leading to histamine release
Sister mary joseph nodule
Portal HTN
Complications of crohns

44. What does loss of p53 cause
Increase tumorigenesis
<3mm nodules - metabolic - etoh - hemochromatosis - wilsons
Inc smooth muscle relaxation - including lower esophageal sphincter
Gastric glands

45. Bilirubin is the product of what?
Distal 1/3 of transverse colon to supper portion of rectum - IMA - and PANS
Heme metabolism
Begins starch digestion - inactivated by low pH upon reaching the stomach
Oligosaccharide digestion

46. Cholecytsokinin - source - action - regulation
Colonic polyps
Complications of crohns
Inc lower esphogeal tone leading to achalasia
Source - I cells (duod - jej - action - inc pancreative secretion - inc gallbladder contraction - dec gastric emptying - sphincter of Oddi relaxation - regulation - inc by fatty acids and amino acids

47. What are additional risk factors for CRC
Esophageal carcinoma
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome
Neutralizes gastric acid allowing pancreatic enzymes to fxn
Oral glucose

48. What are the tumor markers for pancreatic adenocarcinoma
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
CEA - CA-19-9
Downs
Old men - arthralgias - cardiac and neuro sx

49. What serum markers increase in cholecystitis with bile duct involvement
Above
Conj - inc - dec
Alk phos
Downs

50. What transforms conjugated bilirubin to urobilinogen
Gut bacteria
Ischemic colitis
External - receive somatic innervation - internal receive visceral innervation - not painful but sign of portal HTN
EtOH