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Gastrointestinal
Questions ANATOMY
1. Which GI ligament is sometimes cut during surgery, and why? (p. 309) ______________________ ______________________________________________________________________________ 2. What are the four layers of the GI tract, from inside to out? (p. 310) ________________________ ______________________________________________________________________________ 3. At what spinal cord level does the celiac trunk branch off the aorta? Where does the aorta bifurcate? Where do the renal arteries branch off? (p. 311) ________________________________ What are the three branches of the celiac trunk? (p. 312) _________________________________ Portal hypertension is characterizes by varices of which three structures? (p. 313) _____________ ______________________________________________________________________________ 6. 7. Which type of hemorrhoid is painful? Why? (p. 313) _____________________________________ In the image below, identify the structures within the femoral region. (p. 314)

4. 5.

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8.

Direct hernias protrude through the _______________ (abdominal wall/internal inguinal ring), while indirect hernias protrude through the _______________ (abdominal wall/internal inguinal ring). (p. 315) In the image below, identify Hesselbachs triangle. Identify the three structures that define this triangle. For each of the red Xs, identify the type of hernia that can occur. (p. 316)

9.

10.

How does the course of a direct inguinal hernia differ from that of an indirect inguinal hernia? (p. 316) __________________________________________________________________________ ______________________________________________________________________________

PHYSIOLOGY
11. 12. What are the three major salivary glands? (p. 318) ______________________________________ What are the major functions of saliva? (p. 318) ________________________________________ ______________________________________________________________________________ What cells are responsible for producing gastric acid? What hormones act on them to cause secretion? (p. 319) _______________________________________________________________ Describe the three major steps in carbohydrate digestion. (p. 320) __________________________ ______________________________________________________________________________ 15. Where in the GI tract is iron absorbed? Vitamin B12? Folate? Do they require cofactors to facilitate absorption? (p. 320) ______________________________________________________________ ______________________________________________________________________________ 16. Why are Peyers patches important in the immune response? (p. 320) ______________________ ______________________________________________________________________________ Copyright 2011 by MedIQ Learning, LLC All rights reserved

13.

14.

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17. 18.

What is the composition of bile? (p. 320) ______________________________________________ Direct bilirubin is _______________ (conjugated/unconjugated) with glucuronic acid and is _______________ (soluble/ insoluble) in water. Indirect bilirubin is _______________ (conjugated/ unconjugated) with glucuronic acid and is _______________ (soluble/ insoluble) in water. (p. 321) How is urobilinogen removed from the body? (p. 321) ____________________________________ ______________________________________________________________________________

19.

PATHOLOGY
20. How do the symptoms of achalasia differ from those of esophageal obstruction? (p. 322) ________ ______________________________________________________________________________ 21. 22. What is the characteristic imaging finding in a patient with achalasia? (p. 322) _________________ What is the most common type of esophageal cancer in the United States? Worldwide? Why? (pp. 322-323) _______________________________________________________________________ What are the symptoms of Plummer-Vinson syndrome? (p. 322) ___________________________ ______________________________________________________________________________ 24. Name four symptoms common to all malabsorption syndromes. (p. 323) _____________________ ______________________________________________________________________________ 25. What are three causes of pancreatic insufficiency? What is a major consequence? (p. 323) ______ ______________________________________________________________________________ 26. Celiac sprue is characterized by antibodies to __________ and __________ __________, and is associated with a skin condition called _______________ _______________. (p. 324) What is a risk factor for acute gastritis? For chronic gastritis? (p. 324) _______________________ ______________________________________________________________________________ 28. What are the four major risk factors for stomach cancer? (p. 324) __________________________ ______________________________________________________________________________ 29. What are three common stomach cancer metastases? (p. 324) ____________________________ ______________________________________________________________________________ 30. The pain of gastric ulcers is __________ (increased/decreased) with meals, whereas the pain of duodenal ulcers is __________ (increased/decreased) with meals. (p. 325)

23.

27.

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31.

Compare and contrast the characteristics of Crohns disease vs. ulcerative colitis. (p. 326) Characteristic Associated with colorectal cancer? Characteristic lesion Extent of inflammation Crohns Disease Ulcerative Colitis

Extraintestinal manifestations

Granulomas? Location of ulcers Rectal involvement? 32. How is McBurneys point used to diagnose appendicitis? (p. 327) __________________________ ______________________________________________________________________________ 33. An older man presents with subacute onset of left lower quadrant pain. He has a fever. He reports a typical American diet without much fiber. What is the most likely diagnosis? (p. 327) __________ What is the difference between a false diverticulum and a true diverticulum? (p. 327) ___________ ______________________________________________________________________________ 35. _______________ (Intussussception/Volvulus) occurs when a portion of the bowel twists around its mesentery; _______________ (intussusceptions/volvulus) occurs when a part of the one bowel telescopes into a more distal segment. (p. 328) Which intestinal disorders are associated with Down syndrome? Cystic fibrosis? Premature neonates? (p. 328) _______________________________________________________________ What surgical complication can lead to acute bowel obstruction? (p. 328) ____________________ What three features of a colonic polyp are associated with increased risk of malignancy? (p. 329) ______________________________________________________________________________ 39. A 55-year-old woman presents with colicky pain. Results of a fecal occult blood test are positive. Colonoscopy reveals literally thousands of polyps in the colon and rectum. What is the most likely diagnosis? What if the patient also has osteosarcoma? What if, instead, she has a glioma? (p. 329) ______________________________________________________________________________ 40. Why do some patients with a carcinoid tumor develop carcinoid syndrome and others dont? (p. 330) __________________________________________________________________________

34.

36.

37. 38.

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41.

What are the signs and symptoms of liver disease? (p. 330) _______________________________ ______________________________________________________________________________

42.

In alcoholic hepatitis, the AST level is __________ (greater than/less than) the ALT level; in viral hepatitis, the AST level is __________ (greater than/less than) the ALT level. (p. 331) Match the type of liver disease with its notable characteristic(s) (pp. 331-332) _____ A. 1-Antitripsin deficiency _____ B. Alcoholic cirrhosis _____ C. Alcoholic hepatitis _____ D. Budd-Chiari syndrome _____ E. Hepatic steatosis _____ F. Hepatocellular carcinoma _____ G. Nutmeg liver 1. 2. 3. 4. 5. 6. 7. Causes panacinar emphysema Common cause is right-sided heart failure Due to occlusion of IVC or hepatic veins Fatty changes in macrovesicles; reversible Mallory bodies Primary malignant liver tumor in adults Shrunken liver with irregular surface

43.

44.

Compare and contrast the characteristics of the hereditary hyperbilirubinemias. (p. 333) Characteristic Impairment Prognosis Symptoms Crigler-Najjar Syndrome Dubin-Johnson Syndrome Gilberts Syndrome

45.

What molecule accumulates to cause Wilsons disease? What molecule is not made (tests show low levels) because of this accumulation? (p. 333) ______________________________________ What is the cause of bronze diabetes? (p. 334) _______________________________________ List four extrahepatic causes of biliary obstruction. (pp. 334-335) ___________________________ ______________________________________________________________________________

46. 47.

48. 49.

List two intrahepatic causes of biliary obstruction. (pp. 334-335) ____________________________ Match the term with its definition. (p. 335) _____ A. Cholangitis _____ B. Cholecystitis _____ C. Choledocholithiasis _____ D. Cholelithiasis 1. 2. 3. 4. Gallstones Gallstones in the common bile duct Infection of the biliary tree Inflammation of the gallbladder

50. 51.

What enzymes are elevated in acute pancreatitis? (pp. 331, 335) __________________________ Acute pancreatitis and pancreatic adenocarcinoma share two symptoms: _______________ and _________________________. What two maneuvers can differentiate between these two diseases? (pp. 335-336) ___________________________________________________________ ______________________________________________________________________________

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PHARMACOLOGY
52. List the most common histamine blockers for the GI tract. Which histamine receptor do they affect? (p. 337) _______________________________________________________________________ What are the proton pump inhibitors? Why are they such effective drugs? (p. 337) _____________ ______________________________________________________________________________ 54. What drug combination is most often used as triple therapy for H. pylori infection? (p. 338) _______ ______________________________________________________________________________ 55. 56. 57. How is misoprostol most commonly used as a GI agent? (p. 338) __________________________ What is the most dangerous adverse effect of all antacids? (p. 338) _________________________ Infliximab is a monoclonal antibody that targets which molecule? What is a major concern relating to its use? (p. 338) _______________________________________________________________ What powerful medicine is used to control vomiting and nausea after surgery? What receptor does it target? (p. 339) ________________________________________________________________ What drug can be used to treat gastroparesis? What is a worrisome adverse effect? (p. 339) _____ ______________________________________________________________________________

53.

58.

59.

Answers ANATOMY
1. 2. 3. 4. 5. 6. The gastrohepatic ligament may be cut during surgery to provide access to the lesser sac. Mucosa, submucosa, muscularis externa, and serosa/adventitia. T12; L4; L1. Left gastric artery, splenic artery, and common hepatic artery. Esophagus, umbilicus, and rectum. External hemorrhoids are painful because they receive somatic innervation.

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7.

8. 9.

Abdominal wall; internal inguinal ring.

10.

A direct hernia goes through Hesselbachs triangle (medial to inferior epigastrics), whereas an indirect hernia passes into the spermatic cord (lateral to inferior epigastrics).

PHYSIOLOGY
11. Parotid, submandibular, and sublingual.

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12.

Saliva begins starch digestion (amylase/ptyalin), nurtures the teeth and oropharynx, lubricates food (mucins), and carries antibacterial secretory products and growth factors that promote epithelial renewal. Parietal cells. Acetylcholine and gastrin contribute, but the most important stimulator of acid secretion is histamine (whose production is stimulated by circulating gastrin). Carbohydrate (salivary amylase) disaccharides. Carbohydrate (pancreatic amylase) oligosaccharides, disaccharides. Oligo- and disaccharides (brush border hydrolases) monosaccharides. Iron is absorbed in the duodenum, vitamin B12 is absorbed in the ileum; and folate is absorbed in the jejunum. Vitamin B12 absorption requires a cofactor (intrinsic factor), whereas iron and folate absorption does not require a cofactor. Peyers patches produce IgA-secreting plasma cells that combat intraluminal antigens. Bile salts, phospholipids, cholesterol, bilirubin, water, and ions. Conjugated; soluble; unconjugated; insoluble. About 80% is excreted as stercobilin in the feces; of the other 20%, about 10% is excreted in the urine as urobilin and about 90% returns to the liver via enterohepatic circulation.

13.

14.

15.

16. 17. 18. 19.

PATHOLOGY
20. Esophageal obstruction causes dysphagia with solids, whereas achalasia causes dysphagia with both solids and liquids. A birds beak, or narrowing of the LES at the gastroesophageal junctio n. Adenocarcinoma; squamous cell carcinoma. GERD is common in the U.S. and GERD can lead to Barretts esophagus, which in turn can lead to adenocarcinoma. Dysphagia, glossitis and iron deficiency anemia. Diarrhea, steatorrhea, weight loss, and weakness. Cystic fibrosis, obstructing cancer, and chronic pancreatitis. A major consequence is deficiency of the fat-soluble vitamins (A, D, E, and K). Gliadin; tissue transglutaminase; dermatitis herpetiformis. Daily NSAID use; Helicobacter pylori infection. Diet high in smoked foods (nitrosamines), achlorhydria, chronic gastritis, and type A blood. Virchows node (involvement of left supraclavicular node), Krukenbergs tumor (metastasis to ovaries), and Sister Mary Josephs nodule (subcutaneous periumbilical metastases). Increased; decreased.

21. 22.

23. 24. 25.

26. 27. 28. 29. 30.

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31. Characteristic Associated with colorectal cancer? Characteristic lesion Extent of inflammation Crohns Disease Yes Skip lesions on cobblestone mucosa Transmural Ankylosing spondylitis Arthritis Erythema nodosum Immunologic disorders Uveitis Yes Any part of GI tract No Ulcerative Colitis Yes Continuous lesion on friable mucosa Submucosa Pyoderma gangrenosum Primary sclerosing cholangitis No Colon Yes

Extraintestinal manifestations

Granulomas? Location of ulcers Rectal involvement? 32.

McBurneys point is one-third the distance from the iliac crest to the umbilicus on the right side; pain at this point is pathognomonic for appendicitis. This is a typical presentation of diverticulitis, which is also associated with fever and leukocytosis. In a false diverticulum, only the mucosa and submucosa form the pouch; in a true diverticulum, all three gut wall layers form the pouch. Volvulus; intussusception. Hirschsprungs disease and duodenal atresia are associated with Down syndrome. Cystic fibrosis is associated with meconium ileus. Necrotizing enterocolitis is more common in premature neonates. Adhesions. Larger size, villous histology, and epithelial dysplasia. Familial adenomatous polyposis; Gardners syndrome; Turcots syndrome. Carcinoid tumors often produce 5-HT, which causes carcinoid syndrome (wheezing, diarrhea, flushing, right-sided heart murmur). If the tumor is confined to the GI tract, the liver metabolizes the 5-HT and the syndrome doesnt develop. Portal hypertension can cause hematemesis (esophageal varices), melena (peptic ulcer), splenomegaly, caput medusa, ascites, gastropathy, and hemorrhoids. Liver cell failure can cause coma, scleral icterus, fetor hepaticus, spider nevi, gynecomastia, jaundice, testicular atrophy, asterixis, bleeding tendency, anemia, and ankle edema. Greater than; less than. A-1, B-7, C-5, D-3, E-4, F-6, G-2.

33. 34.

35. 36.

37. 38. 39. 40.

41.

42. 43.

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44. Characteristic Impairment Prognosis Symptoms Crigler-Najjar Syndrome Bilirubin conjugation Fatal within a few years of diagnosis Jaundice Kernicterus Dubin-Johnson Syndrome Conjugated bilirubin excretion Benign disease Jaundice Gilberts Syndrome Bilirubin uptake Benign disease Jaundice

45. 46. 47. 48. 49. 50. 51.

Copper; ceruloplasmin; basal ganglia. Deposition of hemosiderosin in the skin. Gallstones, biliary strictures, chronic pancreatitis, and carcinoma of the pancreatic head. Primary biliary cirrhosis and primary sclerosing cholangitis. A-3, B-4, C-2, D-1. Amylase and lipase. Anorexia and abdominal pain radiating to back. Pancreatic adenocarcinoma is also associated with migratory thrombophlebitis and a positive Courvoisiers sign (obstructive jaundice with a palpable, nontender gallbladder).

PHARMACOLOGY
52. 53. Cimetidine, ranitidine, famotidine, nizatidine. These are H2 receptor blockers. Omeprazole, lansoprazole. PPIs are very effective because they act directly on the H /K ATPase, instead of blocking just one of several stimulatory receptors. Metronidazole, an antibiotic (amoxicillin or tetracycline), and bismuth; or metronidazole, amoxicillin/tetracycline, and a PPI. Preventing NSAID-induced peptic ulcers. Hypokalemia. TNF; reactivation of latent tuberculosis. Ondansetron; 5-HT3. Metoclopramide; parkinsonian effects (because it is a D 2 antagonist).
+ +

54.

55. 56. 57. 58. 59.

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