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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. malnutrition - toxic megacolon - colorectal carcinoma
Jaundice - tender hepatomegaly - ascites - polycythemia - hypoglycemia
Decrease - weight gain
Alk phos
Complications of UC

2. What is the epi for CRC
Bleeding - intussusception - volvulus - obstruction near terminal ileum
3rd most common cancer - 3rd deadliest in US - pts > 50 - 1/4 have fam hx
Distal duodenum to proximal 2/3 of transverse colon - SMA - vagus
Portal triad: hepatic artery - protal vein - common bile duct - greater and lesser sac - to control bleeding

3. What is biliary colic
Inc conj bilirubin - inc cholesterol - inc alk phos
H2 receptor - inc cAMP
Pain associated with cholecystitis and galls stones - diabetics may not present with pain
Bleeding - penetration into pancreas - perforation - obstruction

4. How many layers of spermatic fascia are covers an indirect inguinal hernia
All 3
Carcinoid syndrome
Lesser curvature - gastric arteries - cut in surgery to access lesser sac
Femoral hernia

5. At what spinal level does the SMA exit
Sympathetic (T1- T3 superior cervical ganglion) and parasympathetic (facial and glossopharyngeal nerve)
Chief cells of the stomach - protein digestion - inc by vagal stimulation local acid
Menetriers disease
L1

6. What are the histological findings in the duodenum

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7. alcoholic liver disease that requires sustained - long term consumption - with swollen and necrotic hepatocytes with neutrophilic infiltration
Alcoholic cirrhosis
Alcoholic hepatitis
Bile salts (bile conjugated to glycine or taurine) phospholipids - cholesterol - bilirubin - water and ions
Hyperpigmented mouth - lips - hands - genitalia

8. final and irreversible alcoholic liver disease with micronodular irregularly shrunken liver with hobnail appearance
Muscularis mucosae
Juvenile polyposis syndrome - inc risk of adenocarcinoma
Alcoholic cirrhosis
Cirrhosis - DM - skin pigmentation - 'bronze diabetes'

9. misfolded gene product protein accumulates in hepatocellular ER - dec in elastic tissu in lungs leading panacinar emphysema
Many diverticula - associated with low fiber diets - caused by inc intraluminal pressure and focal weakness in colonic wall
Alpha1 antitrypsin def - codominant trait
Hyperplastic
Internal thoracic to superior epigastric to inferior epigastric

10. Mucosal lacerations at the gastroesophageal junction due to severe vomiting - presentation - and risk groups
External - receive somatic innervation - internal receive visceral innervation - not painful but sign of portal HTN
Positive urease test
Can lead to hematemesis - found in EtOHics and bulimics
Early childhood - neuro sx and malabsorption

11. What is indirect bilirubin
Meckels
Heme metabolism
Serum mitochondrial antibodies including IgM - associated with CREST - RA and celiac dz
Unconjugated - water insoluble

12. what percentage of colonic polyps are non - neoplastic
Achalasia due to loss of myenteric plexus (auberach)
L2
Dec PGE2 leading to dec gastric mucosa protection
90%

13. In MSI - What is the mechanism for CRC and what syndrome is associated with this defect
DNA mistmatch repair gene mutations lead to sporadic and HNPCC syndrome - mutations accumulate but not define morphologic correlates
Old men - arthralgias - cardiac and neuro sx
90%
Positive

14. What are the labs in acute pancreatitis
Alk phos
Femoral hernia
Elevated amylase - and lipase
GLUT 2

15. What are the borders of the femoral triangle
Inguninal ligament - sartorius muscle - adductor longus
Alpha1 antitrypsin def - codominant trait
L/R renal artery around L1
Only mucosa or submucosa - occur where vasa recta perforate muscularis externa

16. What is the presentation of pancreatic adenocarcinoma
Aspirin metabolites dec beta oxidation by reversible inhibition of mitocondrial enzyme - ASPIRIN Not RECOMMENDED FOR CHILDREN
T12
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
Abdominal pain radiating to back - weight loss due to malabsorption - migratory thrombophlebitis - obstructice jaundice with palpable gallbladder

17. Gastrin - source - action - regulation
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
<3mm nodules - metabolic - etoh - hemochromatosis - wilsons
Lamina propria
Autoimmune= ulcerative colitis - disordered response to bactere = crohns

18. What causes hirschsprungs
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
Krukenbergs tumor
Failure of neural crest migration
Sympathetic (T1- T3 superior cervical ganglion) and parasympathetic (facial and glossopharyngeal nerve)

19. Malabsorption syndromes have what common clinical presentation
Diarrhea - steatorrhea - weight loss - weakness
DIC - ARDS - diffuse fat necrosis - hypcalcemia - pseudocyst formation - hemorrhage - infxn - multiorgan failure
Hypercoaguability - polycythemia vera - pregnancy - HCC
Juvenille polyps - no risk if single

20. Between what structures do strong anastamoses exist
Left and right gastroepiploics - left and right gastrics
Inferior rectal artery - inferior rectal vein to pudendal vein to internal iliac vein to IVC
Colonic polyps
LLQ - fever - leukocytosis - can perforate leading to peritonitis - abscess formation - bowel stenosis - give antiobiotics

21. in CF - meconium plug obstructs intestine - preventing stool passage at birth
Cholecystitis - also ascending cholangitis - acute pancreatitis and bililary infx
8-9 waves/min
Meconium ileus
Gallbladder

22. What are the results of hemochromatosis
CHF and inc risk of HCC
Fundus/body - autoimmune - autoantibodies to parietal cells - perncious anemia - and achlorhydria
Femoral hernia
Begins starch digestion - inactivated by low pH upon reaching the stomach

23. Achalasia increases the risk For what complication
Esophageal carcinoma
Dec PGE2 leading to dec gastric mucosa protection
Chronic calcifying pancreatitis - inc risk of panreatic cancer
Lubricate food (glycoprotiens)

24. involvement of left supraclavicular node by mets from stomach

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25. Abuse of what substance leads to acute gastritis
So hypertrophied they look like brain gyri
EtOH
AST >ALT - ration is usually 1.5
5HT - wheezing - right sided heart murmurs - diarrhea - flushing -

26. At what spinal level does the is the bifurcation of aorta
Alpha1 antitrypsin def - codominant trait
Meconium ileus
Failure of neural crest migration
L4

27. Failure of relaxation of lower esophageal sphincter - Name and etiology
FAP
Achalasia due to loss of myenteric plexus (auberach)
Esophageal carcinoma
Reye's syndrome

28. Where does type A chronic gastritis occur and What causes it
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
Juvenille polyps - no risk if single
Fundus/body - autoimmune - autoantibodies to parietal cells - perncious anemia - and achlorhydria
Lipase

29. Which IBD has skip lesions and can hit any portion of the GI tract but sprares the rectum - and Which is mainly has continuous lesions in the colon and always has rectal involvement
EtOH
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
Skip lesions =crohns - colon = UC
HPNCC

30. Unencapsulated lymphoid tissue found in lamina proporia and submucosa of small intestine containing specialized M cells that take up antigen
Peyer's patches - plicae circulares in the proximal ileum and crypts of lieberkuhn
Peyers patches
Glucose dependent insulinotropic peptide
AST>ALT

31. How does hirschsprung present and appear on imaging
Hematogenous - alpha fetoprotein - budd chiari (hepatic vein blockage)
Inhibits parietal cells because of ACH is NT - while GRP works at the G cells
Positive
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

32. In what scenarios do pts with gilberts have inc bili
Portal HTN
Fasting and stress
Pancreatic head causing obstructive jaundice
Gardner's syndrome

33. Who gets gastric ulcers
Diarrhea - steatorrhea - weight loss - weakness
Older patients
Barrett's esophagus
Peyers patches

34. What is the most important mechanism in gastric acid secretion
Distal duodenum to proximal 2/3 of transverse colon - SMA - vagus
Decreased intercellular adhesion and increased proliferation
Gastrin stimulating ECL cells to release histamine - histamine stimulation on parietal cells
The jejunum

35. How do you DX and TX gallstones
Epigastric abdominal pain radiating to back - anorexia - nausea
HPNCC
Averages 6 months - very aggressive - usually already metastasized at presentation
US and cholecystectomy

36. Through which aspect of the inguinal canal does a direct inguinal go
External (superficial) ring only
Striated
Goes through deep inguinal ring - external inguinal ring and into the scrotum
Serous on the sides parotids - mucinous in the middle sublingual

37. What reaction does salivary amylase catalyze
Closer to isotonic because of less time to reabsorb NaCl
Begins starch digestion - inactivated by low pH upon reaching the stomach
Kids - lymphoid hyperplasia afer viral infxn - adults - obstruction - fecalith
Hyrdolyzes alpha 1-4 linkages to yield disaccharides

38. What serum enzyme is elevated inacute pancreatitis
Barrett's esophagus
Hydrocele
Meckels
Lipase

39. twisting of portion of bowel around its mesentery leading to obstruction and infarction - usually in elderly
Splenic flexure
Portal HTN
Volvulus
Glucose dependent insulinotropic peptide

40. What artery passes around the duodenum
90%
Terminal ileum and colon
The gastroduodenal
Phototherapy

41. How many layers outpouch in a false diverticula and they occur At what point of weakness and what?
Only mucosa or submucosa - occur where vasa recta perforate muscularis externa
Inguninal ligament - sartorius muscle - adductor longus
Tropical sprue
Autoimmune= ulcerative colitis - disordered response to bactere = crohns

42. What are the extraintestinal manifestations of ulcerative colitis
Pyoderma gangrenosum - primary sclerosing cholangitis
All 3 gut layers outpouch as in Meckels
Conj - inc - dec
Early childhood - neuro sx and malabsorption

43. Scleroderma is associated with what kind of esophageal dysmotility
Greater curvature of stomach to transverse colon - gastroepiploic arteries - greater omentum
Older patients
Low pressure proximal to LES
Positive urease test

44. What kind of gall stones are mostly radiolucent and what percentage is opaque and due to what?
Hemolytic anemia
Mitochondrial abnl - fatty liver - hypoglycemia - coma
Cholesterol - 10-20% opaque due to calcifications
Reye's syndrome

45. Where is the deep inguinal ring relative to the inferior epigastric vessels
Sister mary joseph nodule
Internal thoracic to superior epigastric to inferior epigastric
Unconjugated - water insoluble
Lateral

46. What are the treatment options for uclerative colitis
ASA preparations (sulfasalazine) 6- mercaptopurine - infliximab - colectomy
Sympathetic (T1- T3 superior cervical ganglion) and parasympathetic (facial and glossopharyngeal nerve)
High LES opening pressure and uncoordinated peristalsis - both solids and liquids
Chagas disease

47. What is the most common indication of emergent abdominal surgery in children
Female - fat - fertile - forty
...
Appendicitis
Jaundice - fever - RUQ

48. What causes nutmeg liver
MSI (15%) and APC/beta catenin chromosomal instability (85%)
Backup of blood into the liver - RHF - budd chiari
Esophageal carcinoma
GERD - may also present with nocturnal cough and dyspnea

49. Who gets Whipple disease and How do they present
Increase tumorigenesis
Old men - arthralgias - cardiac and neuro sx
Juvenille polyps - no risk if single
Gallstones - EtOH - trauma - steroids - mumps - autoimmune - scorpion sting - hypercalcemia/hyperlipidemia - ERCP - Drugs (sulfa)

50. What kind of anemia is in Wilsons
Smooth
Liver metabolizes 5HT
Hemolytic anemia
Common hepatic - splenic - left gastric - main blood supply for stomach