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M2 Questions Webmaster: 2Lt David Lynch |
Helpful links: http://www.indiana.edu/~anat550/gianim/index.html - This site has two videos, each 2 minutes long, about GI embryology. It's easy to understand, and it's good review of Nichol's lectures. There's no sound, however.
Questions by Lecture: Anatomy Review-Question 1, 40 L01-Nichols-Question 2 L02-Nichols-Questions 6, 7 L03-06-Reidelberger-Questions 3-5, 9-11, 41, 42 L07-Hunter-Questions 16, 17 L08-Nichols-Questions 13-15 Histology lab-Nichols-Question 18, 19 L09-Reidelberger-Questions 12, 20 L10-11-Gatalica-Questions-21-23 L12-Dunlay-Questions 24, 25 L13-Hunter-Questions 27-29, 44 L14-Hunter-Questions 30-31 L15-Hunter-Questions 32-33 L16-Nichols-Question 8 L17-18-Reidelberger 34, 35 L19-Hunter-Questions 36, 37 L20-Hunter-Questions 38, 39 L21-Lanspa-Question 45 L22-Lanspa-Question 46 L23-Richards-47 Histology Lab II-Nichols-48 Histopathology lab-Hunter-49 L24-Dunlay-50-51 L25-Reidelberger-52, 53, 85 L26-Zach-54, 74 L27-28-Bockman-58 L29-30-Gatalica-55 L32-33-Zetterman-56 L34-Dunlay-59 L35-Thorson-60 L36-Thorson-57, 61 L37-Silberstein-65,66 L38-Lynch-62 L39-Lanspa-67,68 L40-Forse-69 L41-Madision-70 L42-43-Reidelberger-78-80 L44-Hunter-71-73
-Gastrointestinal Questions- Want these questions as a word document? click here ...click 'cancel' if a password box opens! Questions 1-5 1. Which of the following correctly describes the layers of the abdominal wall from outside to inside? A. Fatty fascia, membranous fascia, external oblique m., internal oblique m., transverse abdominal m. B. Fatty fascia, membranous fascia, external oblique m., transverse abdominal m., internal oblique m. C. Membranous fascia, fatty fascia, external oblique m., internal oblique m., transverse abdominal m. D. Membranous fascia, fatty fascia, external oblique m., transverse abdominal m., internal oblique m.
2. The net gut rotation (from the perspective of looking at the ventral aspect of the embryo) that results in the duodenum being anterior to the transverse colon is: A. 90 degrees counterclockwise (CCW) B. 90 degrees clockwise (CW) C. 0 degrees D. 270 degrees counterclockwise E. 270 degrees clockwise
3. The hormone that has overlapping function with gastrin is A. GIP B. somatostatin C. secretin D. CCK E. GRP
4. Which of the following promotes H+ secretion by gastric parietal cells? A. 2.0 stomach pH B. GIP C. atropine D. secretin E. histamine
5. The components of saliva do not include: A. lingual lipase B. amylase C. IgA D. lysozyme E. mucin F. all of the above are found in saliva
Answers 1-5 1. Answer A Just beneath the skin is the fatty (Camper's) fascia followed by the membranous (Scarpa's) fascia.
2. Answer B This is reverse rotation, and results from 90 degrees CCW rotation followed by 180 degrees CW rotation. Normally, there is a net 270 degrees of CCW rotation (answer D). If there is only 90 degrees CCW rotation, then it is a left sided colon, or non-rotation.
3. Answer D Cholecystokinin is homologous to gastrin. CCK differs from gastrin in that its secretion is stimulated by fatty acids, and it is secreted in the proximal small bowel (not the stomach). CCKs major actions include contraction of the gallbladder and inhibited gastric emptying.
4. Answer E Gastric H+ is stimulated by gastrin, parasympathetics, and histamine. Histamine acts on H2 receptors on parietal cells. Atropine blocks the direct action of the vagus on parietal cells via ACh. Any pH below 3 will inhibit H+ secretion.
5. F
Questions 6-10 6. Which of the following is not a characteristic of a parietal cell? A. intracellular canaliculus B. abundant mitochondria C. low carbonic anhydrase activity D. mostly found in the upper part of stomach glands E. produces HCL
7. Which part of the gastric gland is most likely to contain undifferentiated stem cells? A. isthmus B. neck C. base
8. Below is an image from the ileum. Which of the following is a major product of the cell indicated by the arrow?
A. mucin B. lysozyme C. secretin D. CCK E. motilin
9. Which type of receptor is found throughout the gut from the esophagus to the rectum? A. thermoreceptors B. pH chemoreceptors C. osmotic chemoreceptors D. tension mechanoreceptors E. all of the above
10. Which of the following substances is not correctly matched with the cells that secretes it? A. secretin - S cells of the duodenum B. CCK - I cells of duodenum and jejunum C. gastrin - G cells of stomach D. VIP - mucosal neurons of GI tract E. HCL - parietal cells in fundus of stomach F. pepsinogen - chief cells in fundus of stomach G histamine - ECL cells H. all are correctly paired
Answers 6-10 6. Answer C Parietal cells get their supply of H+ ions from carbonic acid, and therefore need large amounts of carbonic anhydrase.
7. Answer A Dr. Nichols' last slide points this out. There are some stem cells found in the neck, but mostly they are in the isthmus. This differs from the small intestine where stem cells are found deep within glands.
8. Answer B This is Panneth's cell, which produces lysozyme, an antibacterial enzyme.
9. Answer D Both touch and tension mechanoreceptors are found throughout the gut.
10. Answer H
Questions 11-15 11. Which of the following best describes the way atropine blocks H+ secretion by parietal cells? A. It blocks the H+/K+ ATPase B. It blocks the action of the vagus on G cells C. It blocks the action of the vagus on H2 receptors D. It blocks the action of the vagus nerve on M3 receptors E. It has little to no effect of H+ secretion
12. Pancreatic secretions are not regulated by: A. secretin B. gastrin C. parasympathetics D. GIP E. CCK
13. In the liver lobule, the flow of bile A. flows towards the center, the same as the flow of blood. B. flows both toward the periphery and the center C. flows towards the periphery, which is opposite to the flow of blood. D. hasn't started yet. Bile forms outside the lobule.
14. In the liver, fatty-acid synthesizing enzymes would most likely be seen in A. the first cells to contact incoming blood, perilobular cells B. the last cells to contact incoming blood, perilobular cells C. the first cells to contact incoming blood, centrolobular cells D. the last cells to contact incoming blood, centrolobular cells E. intermediate cells
15. Bilirubin is conjugated to ________ in the ________ of hepatocytes to form a water-soluble product that is moved out by the ________. A. glucuronic acid, smooth ER, bile canaliculi B. glucuronic acid, cytoplasm, central vein C. glucuronic acid, cytoplasm, bile canaliculi D. glycogen, smooth ER, bile canaliculi E. glycogen, cytoplasm, central vein F. glycogen, cytoplasm, bile canaliculi
Answers 11-15 11. Answer D Atropine is a cholinergic muscarinic antagonist, which means that it blocks ACh from the vagus from affecting M3 receptors. The vagus also stimulated G cells through GRP (answer B), but atropine has no affect on this. Answer A describes the action of omeprazole. Answer C is partially correct since histamine (and also gastrin) is potentiated by ACh from the vagus. Histamine from enterochromaffin-like cells is the primary stimulator of H2 receptors.
12. Answer B Gastrin stimulates H+ secretion. The major players in pancreatic secretions are secretin, CCK, and vagal stimulation via ACh, GRP, and VIP. GIP affects insulin release from the pancreas in the presence of glucose. It is the reason that oral glucose results in higher insulin release than IV glucose.
13. Answer C Bile move opposite to blood. Bile moves from the inside out. It is collected in bile ducts surrounding the lobule, which are located next to portal veins and hepatic arteries.
14. Answer D Blood moves past perilobular cells first and then to centrilobular cells. It is collected in the central vein. Fatty-acid synthesizing and glycolysis enzymes are more likely to be found in centroacinar cells. Conversely, glucose-liberating enzymes and fatty acid oxidation enzymes are more likely found in perilobular cells.
15. Answer A Bilirubin in conjugated to glucuronic acid by glucuronyltransferase in the smooth endoplasmic reticulum. This produces bilirubin glucuronide which can be excreted. It is moved out by bile canaliculi.
Questions 16-20 16. Which of the following is least likely to recur? A. ameloblastoma B. aphthous ulcers C. odontogenic keratocyst D. idiopathic leukoplakia E. odontoma
17. Which of the following is most likely to be squamous cell carcinoma? A. blue-red mass on gingiva B. leukoplakia C. erythroplakia D. red smooth tongue E. unilocular radiolucency
18. Below is a section taken from the fundus of a stomach. Match each cell indicated by an arrow to its primary secretion.
A. pepsinogen B. mucin C. HCL D. CCK E. 5-HT
19. Which gland(s) produce(s) entirely serous secretions? A. submandibular B. parotid C. sublingual D. minor salivary glands E. all of the above
20. Which of the following is not a mechanism used by the pancreas to protect itself from its own enzymes? A. secreting HCO3- B. secreting inactive forms of proteases C. secreting protease inhibitors D. secreting inactive forms of lipolytic enzymes E. confining the enzymes in granules before they are released
Answers 16-20 16. Answer E Many of the pathologies that Dr. Hunter talked about have high recurrence rates:
17. Answer C Dr. Hunter said that 90% of erythroplakia has either severe dysplasia or squamous cell carcinoma.
18. Answers: The red arrow indicates a chief cell, which makes pepsinogen. The black arrow is an enteroendocrine (EC) cell, which makes serotonin. The green arrow shows a parietal cell, which makes HCl. Finally, the blue arrow points to a mucus neck cell, which makes mucin.
19. Answer B The parotid gland is the only gland which produces entirely serous secretions. Mucus producing glands appear clear when stained, whereas the parotid gland appears dark. There may be a few small exceptions to the minor salivary glands, but they are generally mucus producing.
20. Answer D All enzymes from the pancreas that are used to digest fats are secreted in their active form. The pancreas secretes trypsin inhibitors to block protease activity (answer C). The proteases it secretes are pro-peptides, or inactive forms (for example: procarboxypeptidase A/B). The large amounts of bicarbonate that it secretes helps to neutralize stomach acid.
Questions 21-25 21. Barrett's esophagus is glandular metaplasia that resembles intestine in that it contains goblet cells. It is considered to be A. a complication of persistent inflammation occuring in most patients with reflux B. a condition that is associated with increased risk for adenocarcinoma C. a condition that is associated with H pylori CagA+ infection D. all of the above
22. A patient with the sudden growth of what appears to be multiple seborrheic keratoses on his body should be: A. screened for gastric adenocarcinoma B. screened for lymphoma C. tested for H pylori infection D. screened for esphageal leioma
23. Which of the following is most likely to be found in a patient with a gastrointestinal stromal tumor? A. underlying H pylori infection B. left supraclavicular lymph node involvement C. periumbilical metastasis D. CD117 overexpression E. paraneoplastic skin lesions
24. Which of the following is not associated with H pylori infection? A. lymphoma B. adenocarcinoma C. gastrinoma D. dyspepsia without an ulcer
25. In the diagnosis of an H pylori infection, which of the following is not an appropriate diagnostic tool? A. serum antibodies B. Carbon-14-urea breath test C. stool antigen testing D. histology on a tissue biopsy E. all of the above are acceptable
Answers 21-25 21. Answer B Barrett's only occurs in about 10% of people with reflux, so answer A is wrong. Answer C is wrong because H pylori is allociated with peptic ulcer disease (often in the duodenum) and gastric malignancy. The CagA+ variety is more likely to produce inflammation than CagA-.
22. Answer A There sudden appearance of many seborrheic keratoses is known as the Leser-Trelat sign. It is often a paraneoplasic condition caused by gastric adenocarcioma.
23. Answer D CD117 or c-kit overexpression is a feature of GIST, or gastrointestinal stromal tumors. These tumors can be treated with imatinib (Gleevac), the same drug used to treat CML. All of the other answers are likely found in gastric adenocarcinoma.
24. Answer C Gastrinomas, or cancers which secrete gastrin, usually originate in the duodenum or pancreas. This is known as Zollinger-Eliison syndrome. Both gastrinomas and H pylori can cause of peptic ulcer disease, but the two are unrelated.
25. Answer E Of course, culture would work as well.
Questions 26-30 26. In the metabolism of bilirubin, where is the first place that conjugated bilirubin is produced? Where is urobilinogen first produced? A. macrophage after phagocytosing a RBC B. hepatocyte C. bile ducts D. gallbladder E. small bowel F. large bowel
27. What is the main role of the Ito cell in cirrhosis of the liver? A. production of cytokines such as TNF B. production of intra-hepatocyte fatty deposits C. deposition of collagen within the space of Disse D. deposition of collagen within the bile ductules
28. Portal hypertension and hepatic failure are both characterized by A. macrocytic anemia B. poor clotting function C. hemorrhoids D. ascites E. black stools
29. The virus which causes hepatitis and incorporates into host DNA A. is the leading cause of cirrhosis of the liver B. is a flavivirus C. transmitted by the fecal oral route D. produces healthy carriers 10% of the time E. requires to delta factor to replicate
30. In alcohol-induced liver cell necrosis, which is true about the liver enzymes found in the serum? A. mitochondrial enzymes are preferentially elevated B. cytosolic enzymes are preferentially elevated C. both mitochondrial and cytosolic enzymes are equally elevated D. no enzymes are released into the serum
Answers 26-30 26. Answers B, E After bilirubin becomes conjugated in hepatocytes it becomes water soluable. After moving throught the gallbladder it enters the duodenum. Bacteria in the intestines convert conjugated bilirubin to urobilinogen.
27. Answer C The stellate, or Ito, cell responds to cytokines from other cells in the liver. It disrupts the extracellular matrix and deposits collagen within the space of Disse.
28. Answer D Portal hypertension and hepatic failure are two complications of cirrhosis. Here's a description of each. Portal hyptertion is an increase in hydrostatic pressure in the portal system, which pushes fluid into the abdominal cavity (ascites). Portal hypertension also causes dilation of veins, mainly in the esophagus, umbilicus, and rectum. This results in symptoms like hemorrhoids, vomiting blood (hematemesis), and black stools (melena). Since the portal vein is mainly supplied by the superior mesenteric and splenic veins, the spleen becomes congested (splenomegaly). Secondary hyperaldosteronism results from decreased renal perfusion. Hepatic failure results in decreased products of the liver, such as albumin and clotting factors (II, V, IX, X). Reduced albumin causes decreased oncotic pressure and results in ascites and edema. In addition the liver can not perform its normal metabolic functions. Therefore estrogens and bilirubin are not eliminated. The excess estrogen causes testicular atrophy and gynecomastia, while the excess bilirubin results in jaundice. Normally the liver maintains a 6 year supply of vitamin B12. In hepatic failure, the body loses this store and macrocytic anemia results. Less obvious features of hepatic failure include spider nevi and bad breath (fetor hepaticus).
29. Answer D This is the hepatitis B virus. The leading cause of cirrhosis is alcoholism. The hepatitis C virus is a flavivirus. Hepatitis A and E are transmitted by the fecal-oral route (vowels come from the bowels). Answer E in incorrect because hepatitis D requires acute hepatitis B infection to reproduce.
30. Answer A The major mitochondial enzyme released is AST, and the major cytosolic enzyme released is ALT. Alcohol is toxic to mitochondria, so AST is more elevated.
Questions 31-35 31. A 58 year old woman presents with jaundice and joint pain. On physical examination, you notice mild ascites, edema, and splenomegaly. She appears hyperpigmented. A fasting blood sugar is 150. mg/dL. Which of the following explains the fundamental cause of this heritable condition? A. the lack of transferrin within the hepatocyte B. damage to mitochondria within the hepatocyte C. Kupffer cell dysfunction D. inadequate binding of transferrin to its receptor on intestinal cells E. overproduction of ferritin by hepatocytes
32. Primary biliary cirrhosis is A. an autoimmune disorder characterized by granulomas in the portal triad B. an autoimmune disorder characterized by fibrosis of the bile ductules C. a genetic disorder characterized by granulomas in the portal triad D. a genetic disorder characterized by fibrosis of the bile ductules
33. A patient develops tenderness around the area of his liver 10 days after a bone marrow transplant. What is the most likely basis for the liver disease? A. T cell infiltration and destruction of bile ductules between hepatocytes B. mixed inflammatory cells attacking endothelial cells, as well as hepatic and portal veins C. T cell mediated attack on hepatic arteries causing ischemia D. a type III hypersensitivity reaction
34. You are managing a patient who recently had most of his duodenum resected. Which of the following is he most at risk of developing? A. microcytic anemia B. macrocytic anemia C. normocytic anemia D. anemia of chronic disease E. electrolyte imbalance
35. Loss of which of the following is most likely to interrupt fat absorption into the systemic circulation? A. gall bladder B. cisterna chyli C. superior mesenteric vein D. gastric lipase
Answers 31-35 31. Answer D Primary hemochromatosis is caused by a defect in HFE (or hereditary hemochromatosis gene) which helps plasma transferrin to bind with its receptor on intestinal cells, where it is endocytosed. Defective HFE results in a buildup of iron in the liver, as well as other sites such as the pituitary, joints, heart, and skin. In women, symptoms may not present until after they stop losing iron through menstuation.
32. Answer A Primary biliary cirrhosis is most often found in middle aged women. It is likely to be an autoimmune disorder since almost all patients have antimitochondrial antibodies. The inflammation occurs around the portal triad, not in the lobule.
33. Answer B Since the graft-versus-host disease is occuring within a few weeks, it is an acute rejection (the most common type). It is both a type IV and type II hypersensitivity reaction that involves many inflammatory cells. Both answers A and C describe chronic rejection by T cells. Answer D is not characteristic of organ rejection.
34. Answer A The duodenum is the site for iron absorption. If he is constantly losing iron in the stool, he could develop a microcytic anemia. If the ileum were removed, he would be at greater risk for a macrocytic anemia, since that is the site for B12 absoption. Electrolytes are mostly absorbed in the colon.
35. Answer B Chylomicrons are absorped through the lymphatics of the small intestine, pass through the cisterna chyli, thoracic duct, and are released into systemic circulation through the left subclavian vein. Loss of all bile salts only reduces fat absorption by about 1/3 (answer A), as shown in slide 25 in Dr. Reidelberger's lecture. Moreover, some bile salts would still be produced in the absence of a gall bladder. The superior mesenteric vein brings many other nutrients through the liver, but fats bypass the liver. Finally, acid lipases such as gastric and lingual lipase are far less important than pancreatic lipases (answer D), as shown in slide 26.
Questions 36-40 36. A 60 year old man presents with bilateral parotid enlargement. He claims they cause minimal discomfort. He has a 40 pack year history of smoking, and he drinks daily. What is the most likely diagnosis? A. branchial cleft cyst B. mumps C. pleomorphic adenoma D. papillary cystadenoma lymphomatosum E. adenoid cystic carcinoma
37. Malignant tumors of the salivary glands are most common in the A. parotid glands B. submandibular gland C. minor salivary glands D. sublingual glands
38. The most likely complication of a patient who produces antigliadin antibodies is (are) A. T cell lymphoma B. malabsorption C. multiple small bowel ulcers D. adhesions
39. A patient develops a polyp inside the ileus. What is the most likely way he will develop an obstruction? A. stricture B. volvulus C. intussusception D. hernia
40. During surgery the gastrosplenic ligament was accidentally cut. What structure was likely damaged? A. short gastric arteries B. left gastroepiploic artery C. hepatic artery D. ligamentum teres E. splenic artery
Answers 36-40 36. Answer D This is Warthin's tumor, the second most common benign parotid tumor. It occurs in older men who smoke, and only occurs in the parotid gland. It can be bilateral in 10% of cases, which is a good tip that it isn't something else. Branchial cleft cysts tend to occur below the parotid gland in young adults. Mumps often is bilateral, but it is unlikely in an elderly man, particularly since it isn't painful. Adenoid cystic carcinoma is a malignant tumor more often found in non-parotid glands. Pleomorphic adenoma is by far the most common tumor in the parotid, but it is unlikely to be bilateral.
37. Answer D About 80% of tumors in the sublingual gland are malignant. Malignant tumors account for only about 20% of parotid tumors.
38. Answer B Celiac sprue disease is the result of gluten intollerance, and is marked by antigliadin or antiendomysial antibodies. Small bowel villi become flattened, leading to malabsorption.
39. Answer C Polyps can lead to intussusceptions, or telescoping of the bowel.
40. Answer A The gastrosplenic ligament connects the greater curvature of the stomach and spleen. It separates the greater and lesser sacs on the left side of the abdomen. It contains the short gastric arteries.
Questions 41-45 41. The GI tract mediates responses via endocrine, neurocrine, and paracrine mechanisms. Which of the following is used in all three mechanisms? A. histamine B. substance P C. VIP D. CCK E. secretin F. nitric oxide
42. Which of the following is a neurocrine mediator of the GI system that causes copious diarrhea if over expressed by a tumor? A. histamine B. substance P C. VIP D. CCK E. secretin
43. Which enzyme involved in carbohydrate digestion results in monosaccharides? A. salivary amylase B. pancreatic amylase C. oligosaccharide hydrolase D. all of the above
44. Which of the following best describes cirrhosis of the liver? A. fibrosis around the central vein and vascular reorganization B. fibrosis from portal vein to the central vein C. swollen hepatocytes with distended bile canaliculi D. focal nodularity without fibrosis
45. The most important factor in the development and progression of inflammatory bowel syndrome is: A. immune function B. psychologic factors C. diet D. bacterial flora
Answers 41-45 41. Answer D Cholecystokinin acts in all three ways.
42. Answer C Of the choices, histamine and secretin are not neurocrine mediators. VIP is released by parasympathetic gangia in the sphincters, gallbladder, and small intestine. It causes relaxation of the sphincters and intestinal smooth muscle. In addition, ions and water are secreted into the intestines, resulting in diarrhea. The tumor which produces excess VIP is from an islet cell tumor in the pancreas.
43. Answer C Oligosaccharide hydrolases are located at the brush border of the intestine. Amylase produces disaccharides and oligosaccharides.
44. Answer B Cirrhosis is caused by stellate cells, or Ito cells, producing large amounts of collagen. This fibrosis extends all the way from the portal vein to the central vein. Answer A is wrong because the fibrosis is not localized, although there is vascular reorganization. Cirrhosis disrupts the entire liver, so answer D is wrong. Answer C describes cholestasis.
45. Answer B IBS is clearly linked to psychologic factors. Up to 60% of IBS patients have psychologic disturbances. Patients' improvement parallels their psychological improvement. The other factors listed may contribute, but to a lesser extent.
Questions 46-50 46. Which of the following conditions would cause a patient to have the highest need for caloric intake? A. cholecystectomy B. sepsis C. fracture D. major burn
47. A patient presents to the emergency room with fever, chills, right upper quadrant pain, and jaundice. Which is most likely? A. pancreatitis caused by gallstone obstruction B. gallstone ileus C. gallstone in the common bile duct D. gallbladder carcinoma
48. The following section was taken from the liver. What is the major function of the cell indicated by the black arrow?
A. phagocytosis within space of Disse B. phagocytosis within sinusoid C. maintenance of sinusoid structure D. production of collagen E. immunoglobulin production
49. What is this section most likely from?
A. serous salivary gland B. mucus salivary gland C. endocrine pancreas D. exocrine pancreas
50. Which of the following is a positive Ranson criterion regarding pancreatitis? A. low LDH on admission B. normal hematocrit after 48 hours C. low PaO2 after 48 hours D. low glucose on admission
Answers 46-50 46. Answer D A major burn causes the body to use 2x as many calories over the baseline.
47. Answer C A gallstone blocking the common bile duct can lead to inflammation of gallbladder and the pancreas. However, the right upper quadrant pain and jaundice imply that the gallbladder is affected in this case. Therefore, C is a better answer than A. Answer B is unlikely since this would occur in the lower right quadrant and would not likely result in jaundice. Carcinoma of the gallbladder is rare. Moreover, it would likely not present acutely.
48. Answer B This is a Kupffer cell, which is a derivative of the macrophage. It is located within the sinusoid.
49. Answer A This is the parotid gland. The darkly stained portion indicates that it is a serous gland. The lighter areas are the ducts
50. Answer C The Ranson Criteria are divided into those upon admission and after 48 hours. The admission criteria look at age, WBC, glucose, LDH and AST. After 48 hours, Hct, BUN, Calcium, O2, Base deficit, and fluid balance are examined. Of the four answers, only C is a problem.
Questions 51-55 51. The most important etiologic factor contributing to all cases of pancreatitis is (are) A. diabetes B. alcohol C. gallstones D. H pylori E. autoimmune F. drugs
52. During segmental contractions of the small intestine, the receiving segment is responding to A. inhibitory motor neurons producing VIP and NO B. excitatory motor neurons producing Substance P and ACh C. inhibitory motor neurons producing Substance P and ACh D. excitatory motor neurons producing VIP and NO
53. Slow waves in the gut are A. action potentials which cause smooth muscle contraction B. action potentials which originate in the interstitial cells of Cajal C. oscillating membrane potentials which cause smooth muscle contraction D. oscillating membrane potentials which originate in the interstitial cells of Cajal
54. Which of the following would you expect to be diagnosed the latest in life? A. pyloric stenosis B. congenital diaphragmatic hernia C. tracheoesophageal fistula, H type D. duodenal atresia E. imperforate anus
55. Which of the following is least likely to be the site of colon cancer? A. ascending B. transverse C. descending D. sigmoid
Answers 51-55 51. Answer B Although gallstones are slightly more important in the etiology of acute pancreatitis, alcohol is a very close second. Alcohol is the cause of the vast majority of chronic pancreatitis.
52. Answer A The receiving segment is relaxed to allow the chyme to move. It is responding to inhibitory motor neurons which prevent its contraction. Tha major inhibitory neurotransmitters are VIP and NO. Substance P and ACh are excitatory neurotransmitters in the gut.
53. Answer D Slow waves are not action potentials, but rather periodically allow action potentials to occur. In this way, they regulate the frequency of contraction in the gut. The origin of slow waves is in the interstitial cells of Cajal.
54. Answer C This type of TEF allows for normal feeding and breathing. However, some food may be pushed into the trachea, causing persistent cough and pneumonia. Pyloric stenosis tends to occur around 1 month with projectile non-bilious vomiting. This is contrasted with malrotation which produces bilious vomit. Malrotation may not be diagnosed until later in life, although most are found within one year. Congenital diaphragmatic hernia will present with early breathing difficulties. Duodenal atresia and imperforate anus are both complete blockages of the GI system, and will be discovered quickly.
55. Answer C The descending colon accounts for only 8% of colon cancers.
Questions 56-60 56. The hepatitis virus that is most likely to produce a carrier state is A. hepadnavirus B. picornavirus C. adenovirus D. flavivirus
57. Which of the following aymptomatic patients is past due for colorectal cancer screening? A. 45 year old man B. 55 year old with a colonoscopy done 7 years ago C. 60 year old with a flexible sigmoidoscopy done 7 years ago D. 65 year old with fecal occult blood test done 7 months ago E. 70 year old with a double contrast barium enema done 7 years ago
58. In the treatment of GERD and gastroparesis, which drug inhibits a receptor found on cholinergic motor neurons? A. bethanechol B. erythromycin C. cisapride D. metoclopramide E. alginate
59. The majority of GI bleeding is A. lower GI, variceal B. lower GI, neoplasia C. lower GI, ulcerations D. upper GI, variceal E. upper GI, neoplasia F. upper GI, ulcerations
60. A thrombosis within an anal hemorrhoid is most consistent with A. intermittent, sharp pain, bleeding, and sudden onset B. continuous, sharp pain, rapid onset C. continuous, dull pain, slow onset D. continuous, dull pain, rapid onset
Answers 56-60 56. Answer D Hepatitis C has a >65% carrier rate, and it is a flavivirus. Hepatitis B has a 10% carrier rate, and it is a hepadnavirus. Hepatitis A has no carrier state, and it is a picornavirs. Adenovirus often causes the common cold.
57. Answer C Current guidelines are that everyone 50 or older be given any of the following: -a fecal occult blood test every year -a flexible sigmoidoscopy every 5 years -a colonoscopy every 10 years -a double contrast barium enema every 5-10 years
58. Answer D Metoclopramide is a D2 antagonist. Dopamine normally acts to inhibit ACh release, so blocking the D2 receptor results in an increase in ACh. Also acting on cholinergic motor neuron receptors, cisapride and erythromycin are agonists of the 5-HT4 and motilin receptors, respectively. Bethanechol acts as an agonist on the M3 receptor on smooth muscle.
59. Answer F 3/4 of GI bleeds are upper GI. Of those, most are ulcerations.
60. Answer D
Questions 61-65 61. A 40 year old man is about to undergo surgery for colorectal cancer. You ask him about previous surgery, and he says that as a child he had surgery for 'extra teeth' and impacted teeth. What hereditary syndrome does he most likely have? A. HNPCC B. Gardner's syndrome C. Turcot syndrome D. Peutz-Jehger's syndrome
62. Which of the following is a feature of HNPCC? A. diagnosis is made by exclusion of other hereditary disorders B. numerous polyps on last 2/3 of colon C. autosomal recessive inheritance D. age of colorectal cancer ~60 years old E. infiltrating lymphocytes within adenomas
63. Which of the following would you most expect to be reduced in an alcoholic who has developed cirrhosis? A. capillary hydrostatic pressure B. interstitial hydrostatic pressure C. capillary osmotic pressure D. interstitial osmotic pressure
64. Patients on long term parenteral feeding may develop atrophy in the GI tract. The lack of which of the following contributes most to this? A. secretin B. CCK C. gastrin D. pepsin
65. Which neoplasm is treated with the same drug used to treat CML? A. hepatocellular cancer B. GIST C. carcinoid D. esophageal adenocarcinoma E. pancreatic cancer
Answers 61-65 61. Answer B Gardner's has the same features of FAP but patients often have dental issues. Peutz-Jeghers Syndrome can present with hyperpigmented macules on buccal mucosa and lips.
62. Answer E HNPCC can be diagnosed by genetic analysis of the MMR gene (answer A). This is hereditary non-polyposis colorectal cancer (answer B). The inheritance is autosomal dominant (answer C). The average age of onset is 20 years below the general population: 45 vs 64 (answer D). By exclusion, E is the correct answer. Infiltrating lymphocytes into that HNPCC cancer is a key histologic feature. 63. Answer C Alcoholics develop cirrhosis, which would result in reduced albumin levels, and therefore decreased capillary osmotic pressure.
64. Answer C Gastrin functions to increase H+ secretion, and to stimulate growth of the mucosa in the stomach, pancreas, and small intestine.
65. Answer B In advanced gastrointestinal stromal tumors (GIST), the treatment is either imatinib or stutent. Imatinib (brand name Gleevec) is used to treat chronic myelogenous leukemia, which is caused by t(9;22) bcr-abl tyrosine kinase activity.
Questions 66-70 66. Which cancer has the best prognosis? A. hepatocellular cancer B. pancreatic cancer C. carcinoid D. esophageal adenocarcinoma
67. Ulcerative colitis may manifest with all the following except: A. bile duct lesions B. pseudopolyps C. toxic dilation with megacolon D. non-caseating granulomas E. crypt abscesses
68. A 28 year old male smoker presents with an obstructed bowel. He says he's had 'overactive' bowels for years, but hasn't sought medical help until now. It is discovered that he has a fistula in his small bowel. What lab values best correlate with this type of inflammatory bowel disease? A. positive ASCA, positive pANCA B. negative ASCA, positive pANCA C. positive ASCA, negative pANCA D. negative ASCA, negative pANCA
69. The most effective way of reducing weight in Class II and III obesity is A. pharmacotherapy B. lifestyle changes C. both A and B D. surgery
70. According to DSM-IV criteria, Binge Eating Disorder must be present for how long to be diagnosed? A. 3 months, occurring 2 times per week B. 6 months, occurring 2 times per week C. 12 months, occurring 2 times per week D. 24 months, occurring 2 times per week
Answers 66-70 66. Answer C Carcinoid is a relatively indolent cancer. It can produce excess serotonin resulting in flushing, diarrhea, sweating, etc.
67. Answer D Granulomas are a key distinguishing factor between ulcerative colitis and Crohn's disease. All the other features are taken straight from Lanspa's lecture.
68. Answer C These serologic findings have a 97% specificity for Crohn's disease. Answer B would indicate chronic ulcerative colitis. The question stem gives many clues that this man has Crohn's. He's male, 20s, smoker, and has a fistula. All of these are more likely found in Crohn's.
69. Answer D This was the conclusion of the WHO. Class II obesity is BMI > 35 and Class III is BMI > 40. Class II patients are candidates for bariatric surgery if they have co-morbidities.
70. Answer B
Questions 71-75 71. Which of the following vitamin B deficiencies will not cause anemia? A. B1 - thiamine B. B6 - pyridoxine C. B9 - folic acid D. B12 - cobalamin
72. A nursing home resident with dementia has developed a red, scaling rash. He has had diarrhea for 2 weeks. What vitamin deficiency does this man most likely have? A. thiamine B. niacin C. riboflavin D. ascorbic acid E. zinc
73. A pregnant woman presents to the ER in a stupor. Her husband says she had deteriorated over the last few days and was complaining of a headache. What vitamin overdose could cause this? A. any fat soluble vitamin B. vitamin A C. vitamin K D. niacin E. vitamin C
74. You are observing a surgery on an infant with volvulus secondary to malrotation. The surgeon asks you where the cecum is located. What do you say? A. LRQ (lower right quadrant) B. URQ C. LLQ D. ULQ
75. The cells that are responsible for the excess collagen production in cirrhosis A. also phagocytose material in the sinusoids B. also create fenestrations in sinusoids C. are endothelial cells D. also store vitamin A in lipid droplets
Answers 71-75 71. Answer A B1 is thiamine, and a deficiency will result in beriberi. B6 is pyridoxine, B9 is folic acid, and B12 is cobalamin. A deficiency of any of these three will result in anemia.
72. Answer B Niacin deficiency results in pellagra: dermatitis, diarrhea, and dementia.
73. Answer B Vitamin A overdose is particularly worrisome in pregnancy since it can cause malformations. It presents with headache, vomiting, stupor, and papilladema.
74. Answer B In malrotation, the gut only rotates 90 degrees counterclockwise (instead of 270 degrees). The cecum starts low in the abdomen at the midline. The 90 degree rotation during physiologic herniation puts it on the right side of the abdomen. As the gut tube moves back in, the cecum is pushed up. This places the cecum in the upper right quadrant. See slides 26-39 of Zach's lecture.
75. Answer D Ito cells, or stellate cells are located in the space of Disse. They store vitamin A and are a critical player in cirrhosis.
Questions 76-80 76. Pancreatic secretions are induced by A. CCK B. ACh and other neurotrasmitters C. secretin D. all of the above E. only A F. only A and B G. only A and C
77. You are treating a patient who has high cholesterol with ezetimibe. You explain to your patient that this drug prevents reabsorption of bile acids in the distal small bowel. What else would you expect this drug to do? A. up-regulate LDL receptors in the liver B. up-regulate HDL receptors in the liver C. down-regulate LDL receptors in the liver D. down-regulate HDL receptors in the liver
78. Which of the following will likely result in consuming less calories? A. eating with many other people B. eating energy dense food C. living in a warm environment D. running every day E. eating at Lo Sole Mio
79. The peripheral signal that causes increased food intake is A. PYY B. CCK C. amylin D. leptin E. ghrelin F. GLP-1
80. In the majority of cases of human obesity, plasma leptin levels are A. elevated B. decreased C. absent D. normal
Answers 76-80 76. Answer D Secretin, released by duodenal S cells, is the main cause of bicarbonate secretion in the pancreas. Synergy occurs in the presence of CKK and neural reflexes (ACh, GRP, VIP).
77. Answer A This question is more cardio than GI. Remember that most of the cholesterol that goes into bile acids comes from LDL. Therefore, if the hepatocyte is not getting recycled bile acids, it needs to take more LDL out of systemic circulation. Around 95% of bile acids are normally recycled. This question is adapted from Dr. Goljan's GI lecture 1.
78. Answer C The ambient temperature is inversely proportional to the amount of food we consume. Answer E could also be right, since after eating massive amounts of Italian food at Lo Sole Mio, you may go into a coma, which will result in a long-term decrease in caloric intake.
79. Answer E
80. Answer A Adipocytes produce leptin. Therefore, obese individuals will have higher plasma leptin levels. Defects in the leptin gene and leptin receptor gene are rare.
Questions 81-85 81. The most likely location for squamous cell carcinoma of the esophagus is in the portion where A. there is only striated muscle B. there is both striated and smooth muscle C. there is only smooth muscle D. there is no muscle
82. An internal hemorrhoid is A. innervated by the inferior rectal nerve B. painful C. supplied by the superior rectal artery D. inferior to the pectinate line
83. Where are submucosal glands not a sign of adenocarcinoma? A. antrum of stomach B. duodenum C. jejunum D. ileum E. colon
84. Which enzyme is essential for proper functioning of pancreatic proteases? A. enterokinase B. trypsinogen C. chymotrypsinogen D. amylase
85. The nerve plexus responsible for motility in the GI tract is found between the A. lamina propria and muscularis mucosa B. muscularis mucosa and the circular muscle C. circular muscle and longitudinal muscle D. longitudinal mucle and serosa
Answers 81-85 81. Answer B The top third of the esophagus has only striated muscle, the middle third has both striated and smooth muscle, and the bottom third has only smooth muscle. Since squamous cell carcinoma is most likely to occur in the middle third of the esophagus, answer B is correct. Adenocarcinoma would most likely occur in the bottom third, where there is only smooth muscle.
82. Answer C All the other choices are characteristics of external hemorrhoids. Internal hemorrhoids have visceral, not somatic innervation, so they are painless. They are supplied by the superior rectal artery which eventually drains into the portal system.
83. Answer B These are Brunner's glands, and they secrete bicarbonate.
84. Answer A Found on the brush border in the duodenum, enterokinase activates trypsin (from trypsinogen). Trypsin in turn activates many other pancreatic enzymes. Without enterokinase, the pancreatic enzymes would not be converted into their active form. Amylase is secreted by the pancreas and has no role in the function of proteases.
85. Answer C The Myenteric (Auerbach) nerve plexus is responsible for motility, and it is found between the circular and longitudinal layers of muscle. The submucosal (Meissner) nerve plexus regulates secretions, and is found between the muscularis mucosa and the circular muscle (answer B).
Fact Recall: Meckel's diverticulum is found where? distal ileum The greater and lesser omentum communicate by what? epiploic foramen (near the hilum of the liver) The primitive gut loop rotates around what artery? superior mesenteric What is the major carrier of information from the gut to the brain? vagus What is the function of the myenteric plexus? motility of the gut What is the function of the submucosal plexus? secretion and blood flow in the gut The vomiting center is located where? medulla Most common oral cancer? Squamous cell carcinoma (90%) Portal vein mainly arises from which veins? Superior & inferior mesenteric, splenic What are the fat soluble vitamins? ADEK Where is vitamin A stored? Ito cells (aka stellate cells) in the liver The space of Disse is located between what two cells? endothelial cells and hepatocytes Sphincter that regulates bile flow? sphincter of Oddi Major hormone involved in gallbladder contraction? cholecystokinin (CCK) Bacteria that causes dental caries? Streptococcus mutans Most common intraoral site of squamous cell carcinoma? tongue Cell that monitors pH in the duodenum? S cells - produce secretin to keep pH > 4.5 What ion is exchanged during bicarbonate secretion in the pancreas? Cl Bile acids are synthesized from what? cholesterol Most common place for peptic ulcer disease? duodenum Gastrointestinal stromal tumors arise from mutation in what gene? c-kit aka CD117 in Cajal cells Most common primary cancer of the esophagus? distal adenocarcinoma Characteristics of Plummer-Vinson syndrome? dysphagia, glossitis, iron deficiency anemia Where can jaundice first be ostensively observed? sclera Most common malignant tumor in the liver? metastases What is the sugar bond that amylase can attack? alpha-1-4 What is the major brush border peptidase? aminooligopeptidase Most common malignant salivary gland tumor? mucoepidermoid carcinoma In the liver, what zone is closest to the central vein? Zone III (also the most sensitive to ischemia) How does the body excrete cholesterol? Bile Barrett's esophagus produces what change? nonkeratinized squamous → columnar Which cell is the most fundamental to causing cirrhosis? stellate cell (Ito cell) Excitatory neurotransmitters in the gut? Substance P and ACh Inhibitory neurotransmitters in the gut? VIP and NO What stool osmolarity indicates osmotic diarrhea? 60 Most important risk factor for pancreatitis? alcohol Overall mortality of pancreatitis? 10% What is the pacemaker of slow waves in the gut? interstitial cells of Cajal Where is the frequency of slow waves the highest? small intestine (duodenum) What test is used to diagnose hemangioma on the liver? technetium RBC scan Pancreatic insufficiency least affects digestion of what? carbohydrates Most common extra-colonic cancer in HNPCC? endometrial Action of neostigmine? Block ACh esterase What stain definitively diagnoses Barrett's esophagus? Alcian blue H pylori produces what substance to damage gastric mucosa? ammonium (made by urease) Primary biliary cirrhosis is characterized by what autoantibody? antimitochondrial antibodies What is the cellular basis for Reye syndrome? mitochondrial dysfunction Where does Celiac sprue affect the GI tract? proximal small bowel Treatment for ulcerative colitis? 5-aminosalicylate (as sulfasalazine) Xray finding in bowel obstruction? air-fluid level Three major regulators of gastric HCl secretion? ACh(M3 receptor), histamine(H2), gastrin(CCK2) Current percent of Americans that are obese? ~33% (about 67% are overweight)
Find a mistake? Email dlynch@creighton.edu
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