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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 are additional risk factors for CRC
Crigler - najjar type 1
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation
Distal duodenum to proximal 2/3 of transverse colon - SMA - vagus
IBD - Strep bovis bacteremia - tobacco - large villous adenomas - juvenille polyposis syndrome - peutz jehgers syndrome

2. internal hemorrhoids and adenocarcinoma occur above or below pectinate line?
Inferior rectal artery - inferior rectal vein to pudendal vein to internal iliac vein to IVC
Coma - scleral icterus - fetor hepaticus - spider nevi - gynecomastia - jaundice - testicular atrophy - hand tremor - bleeding - anemia - ankle edema
Goes through deep inguinal ring - external inguinal ring and into the scrotum
Above

3. What serum enzyme is elevated in obstructive liver disease - bone disease and bile duct disease
Budd chiari syndrome
Source - K cells (duod - jej) - action - exocrine - dec gastric H+ secretion - endocrine - inc insulin release - regulation - inc by fatty acids - amino acids - oral glucose
Alk pho
Northern european - Abs to gliadin and tissue transglutaminase - blunted villi - lymphcytes in the lamina proporia

4. What does K- ras mutation cause
Upregulated intracellular signal transduction
Diverticulum
SGLT1 (Na dependent) glucose - galactose - GLUT 5 fructose (facilitated diffusion)
Jaundice - tender hepatomegaly - ascites - polycythemia - hypoglycemia

5. If the abdominal aorta is blocked - How does blood get to the middle rectal artery
Fasting and stress
H pylori (almost 100%)
Pyoderma gangrenosum - primary sclerosing cholangitis
Superior rectal

6. How many layers of spermatic fascia are covers an indirect inguinal hernia
All 3
Mucoepidermoid carcinoma
Inc conj bilirubin - inc cholesterol - inc alk phos
Averages 6 months - very aggressive - usually already metastasized at presentation

7. Which patients have pigment stones
Inc - weight loss
Chronic hemolysis - alcoholic cirrhosis - advanced age and biliary infxn
Complications of UC
All 3 gut layers outpouch as in Meckels

8. What infection causes Whipple disease and What can you see on LM
Tropheryma whippelii - gram positive and PAS- positive MACS in intestinal lamina proporia and mesenteric nodes
Crohns = maybe - UC= always
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
Cimetidine

9. What are the borders of Hesselbach's triangle
Inferior epigastric artery - lateral border of rectus abdominis - inguinal ligament
Warthins' tumor
Lateral to the inferior epigastric artery
In the mucus that covers the gastric epithelium

10. what kind of muscle is in the upper 1/3 of esophagus
Dubin johnson
Striated
Hernia
Via the middle colic

11. How does loss of NO secretion affect the esophagus and what results
AST>ALT
Pleomorphic adenoma
>3mm nodules - significant liver injury leading to hepatic necrosis - postinfectious - drug induced hepatitis with inc risk of HCC
Inc lower esphogeal tone leading to achalasia

12. Malabsorption syndromes have what common clinical presentation
Hyperplastic
Diarrhea - steatorrhea - weight loss - weakness
Neutralizes gastric acid allowing pancreatic enzymes to fxn
CCK8 receptor - Gq inc IP3/Ca

13. What are the tumor markers for pancreatic adenocarcinoma
CEA - CA-19-9
Esophageal cancer
Liver - brain - cornea - kidneys - joints - Asterixis - Basal ganglia degeneration - dec Ceruloplasmin - Cirrhosis - Corneal deposits - Copper accumulation - Carcinoma (HCC) - Choreiform movements - Dementia
Inguninal ligament - sartorius muscle - adductor longus

14. What do the rugae of stomach look like in menetriers disease
Cirrhosis
Chronic transfusion therapy in beta thal major - inc ferritin - inc iron - dec TIBC - inc transferrin saturation
Abdominal pain radiating to back - weight loss due to malabsorption - migratory thrombophlebitis - obstructice jaundice with palpable gallbladder
So hypertrophied they look like brain gyri

15. At what spinal level does the is the bifurcation of aorta
H pylori (almost 100%)
Peutz jeghers
Crohns - CF - advanced age - clofibrate - estrogens - multiparity - rapid weight loss - Native American origin
L4

16. Where does type A chronic gastritis occur and What causes it
Upregulated intracellular signal transduction
Fasting and stress
Hiatal hernia - sliding - hourglass shape - and paraesophageal hernia where stomach chomes up through the hiatus
Fundus/body - autoimmune - autoantibodies to parietal cells - perncious anemia - and achlorhydria

17. To what substance is bilirubin conjugated and why
Averages 6 months - very aggressive - usually already metastasized at presentation
Glucouronate - water soluble (direct)
Alcohol/Achalasia - Barretts - Cigarettes - Diverticuli (Zenkers) Esophageal web/Esophagitis - Familial
Hyperpigmented mouth - lips - hands - genitalia

18. What are motilin receptor agonists used for clinically
Brunners
Gilbert's
Hypotonic because of more time to reabsorb NaCl
Stimulate intestinal persistalsis

19. What is one potential precipitating factor for intussusception
Inc lower esphogeal tone leading to achalasia
Distal colon - obstruction - colicky pain - hematochezia - proximal colon - dull pain - iron deficiency anemia - fatigue
Causes of gall stones
Viral - adenovirus in kids - rare in adults but associated with intraluminal mass or tumor

20. What is the epi for CRC
Menetriers disease
3rd most common cancer - 3rd deadliest in US - pts > 50 - 1/4 have fam hx
Pleomorphic adenoma
Nonkeritinized stratified sqamous epithelium

21. Painless bleedgin of submucosal veins in lower 1/3 of esophagus
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
Erosive - disruption of mucosal barrier leading to inflammation
8-9 waves/min
Esophageal varices

22. Who is at risk for pancreatic adenocarcinoma
Uridine glucuronyl transferase
Internal thoracic to superior epigastric to inferior epigastric
Pancreatic insuff - steatorrhea - fat soluble vitamin def - DM
Jewish and African American men

23. What are the histological findings in the duodenum

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24. What are the main components of bile
Gamma glutamyl transferase GGT
Bile salts (bile conjugated to glycine or taurine) phospholipids - cholesterol - bilirubin - water and ions
Phenobarbital - inc liver enzyme synthesis
Jewish and African American men

25. What converts inactive pepsinogen to pepsin
H+
Liver metabolizes 5HT
Inc lower esphogeal tone leading to achalasia
Juvenile polyposis syndrome - inc risk of adenocarcinoma

26. What are the common causes of gastric ulcers - What causes gastric ulcer
HSV-1 - CMV - Candida
External - receive somatic innervation - internal receive visceral innervation - not painful but sign of portal HTN
H pylori (70%) - NSAIDS - dec mucosal protection against gastric acid
CCK8 receptor - Gq inc IP3/Ca

27. alcoholic liver disease that requires sustained - long term consumption - with swollen and necrotic hepatocytes with neutrophilic infiltration
Alcoholic hepatitis
Pancreatic head causing obstructive jaundice
Dec synthesis of apo B - inability to generate chylomicrons - dec secretion of cholesterol - VLDL into the bloodstream - fat accumulation in enterocytes
Low pressure proximal to LES

28. bilateral mets to ovaries with abundant mucus - signet ring cells
The entire
...
Krukenbergs tumor
Carcinoid syndrome

29. HCC is associated with what other conditions
HBV - HCV - wilsons dz - hemochromatosis - alpha1- antitrypsin def - alcoholic cirrhosis
Decreased intercellular adhesion and increased proliferation
12 waves/min
Serous on the sides parotids - mucinous in the middle sublingual

30. What cells make gastric acid - What does it do to stomach pH and what substances regulate it
Portal triad: hepatic artery - protal vein - common bile duct - greater and lesser sac - to control bleeding
Parietal cells in the stomach - decrease pH - inc by histamine - ACH - gastrin - dec by somatostatin - GIP - prostaglandin - secretin
All 3 gut layers outpouch as in Meckels
So hypertrophied they look like brain gyri

31. What is the cause of physiologic neonatal jaundice
Lactase is located at the tips of intestinal villi
Hepatomegaly - ascitis - abdominal pain - varices - visible abdominal and back veins - absence of JVD
Immature UDP- glucuronyl transferase to unconjugated hyperbilirubinemia - jaundice kernicuterus
Trypsin - chymotrypsin - elastase - carboxypeptidases

32. At what level do the testicular/ovarian arteries exit the aorta
Gut bacteria
L2
Jewish and African American men
In the ileum with bile acids - requires IF

33. A protrusion of peritoneum through an opening - usually a site of weakness
Hernia
Conj - inc - dec
Amylase
12 waves/min

34. Where are tumors commonly in pancreatic adenocarcinoma
Portal triad: hepatic artery - protal vein - common bile duct - greater and lesser sac - to control bleeding
Right and left hepatic duct
Autoimmune rxn leading to lymphcytic infiltrate + granulomas
Pancreatic head causing obstructive jaundice

35. Why does carcinoid syndrome not occur if tumor is confined to GI system
Inc - weight loss
External spermatic fascia only
Positive urease test
Liver metabolizes 5HT

36. Pain improves with defaction - changes in stool frequency and changes in stool appearance are associated with
Sympathetic (T1- T3 superior cervical ganglion) and parasympathetic (facial and glossopharyngeal nerve)
Below
IBS at least 2 with recurrent abdominal pain
Pleuroperitoneal

37. In what scenarios do pts with gilberts have inc bili
Fasting and stress
Mitochondrial abnl - fatty liver - hypoglycemia - coma
Via the middle colic
CEA - CA-19-9

38. When do you see hypertrophy of brunners glands
Via the superior pancreaticduodenal
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Femoral hernia
Peptic ulcer disease

39. What is the TX of physiologic neonatal jaundice
H pylori (almost 100%)
Cigarettes and chronic pancreatitis - not EtOH
Phototherapy
EtOH

40. What are the histological findings of the colon
Phototherapy
...
Worldwide - SC - US - adeno
Crypts but not villi

41. reduction in intestinal blood flow causes ischemia - pain after eating - weight loss - occurs at splenic flexure and distal colon - elderly
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
Crohns = maybe - UC= always
Ischemic colitis
Oligosaccharide digestion

42. trypsinogen is converted to trypsin via what enzyme
Gamma glutamyl transferase GGT
Amylase
Enterokinase/enteropeptidase from the duodenal mucosa
Lateral to the inferior epigastric artery

43. What kind of pathways do CCK act on to cause pancreatic secretion
Lye ingestion and acid reflux
Neural muscarinic pathways
Only mucosa or submucosa - occur where vasa recta perforate muscularis externa
Virchow's node

44. What are the complications of duodenal PUD
Zollinger ellison - brunners glands
Bleeding - penetration into pancreas - perforation - obstruction
L2
2ndary biliary cirrhosis

45. What does loss of APC cause
Gilbert's
Decreased intercellular adhesion and increased proliferation
L/R renal artery around L1
Gardner's syndrome

46. What causes hirschsprungs
Female - fat - fertile - forty
Failure of neural crest migration
Peyers patches
L1

47. What layer of fascia covers a direct inguinal hernia
Pancreatic insuff - steatorrhea - fat soluble vitamin def - DM
Upregulated intracellular signal transduction
External spermatic fascia only
Small intestine

48. Between what structures do strong anastamoses exist
Dubin johnson
AST
Zenkers - halitosis - dysphagia and obstruction
Left and right gastroepiploics - left and right gastrics

49. Which kind of hemorrhoids are painful and why
Increase tumorigenesis
Juvenile polyposis syndrome - inc risk of adenocarcinoma
External - receive somatic innervation - internal receive visceral innervation - not painful but sign of portal HTN
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

50. Who gets Whipple disease and How do they present
Crohns - CF - advanced age - clofibrate - estrogens - multiparity - rapid weight loss - Native American origin
Turcot
Old men - arthralgias - cardiac and neuro sx
Lamina propora and submucosa