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What are the five (5) phases of digestion? 1. 2. 3. 4. 5. 6.

Cephalic Oral Pharyngeal Esophageal Upper GI Lower GI

What nerve regulates the cephalic phase of digestion? The CEPHALIC PHASE Is regulated entirely by Cranial Nerve X. This includes All senses, touch, sound, smell, feel, and taste all feed into the corticobulbar tract and cranial nerve X.

What effect would a vagotomy have on digestion? A vagatomy (removal of the vagus) would cause loss of all senses to the cephalic phase.

What part of the brain is responsible for all urges? What other system can override it? The Limbic System is Responsible for ALL urges. This is the oldest part of the human brain. The Cerebrum is part of the neocortex. It is able to override the Limbic System.

What two part of the Hypothalamus function in eating? Where in the hypothalamus does each reside? What does each regulate? What results from lesions to each? The hunger & satiety centers The hunger center resides in the Lateral Hypothalamus. Stimulation of it causes the feeling of hunger. Lesion of the hunger center causes death by ANOREXIA because the urge to eat is gone. The Satiety Center resides in the Medial Hypothalamus (Middle gets big). Stimulation causes the feeling of fullness. Lesion causes death by HYPERPHAGIA (Overeating)

How do you calculate the IDEAL BODY EIGHT for Men? Women? How is obesity defined? Men - 106lbs for the first 5' + 5lbs for each inch after 5' + 15lbs for frame (15 for medium frame, 30 for large frame)

Women - 100lbs for the first 5' + 5lbs for each inch after 5' + 15lbs for frame (15 for medium frame, 30 for large frame) Obesity is a person more than 20% over their ideal weight. What is the psychology is behind Anorexia and Bulimia, respectively? Body Dysmorphism. Anorexics think they are overweight despite being normal of below ideal weight. Bulimics are ashamed of their eating habbits.

What is the body type of anorexia and Bulimia? What social factors are typically seen in each? How does each achieve their respective goals? ANOREXics are typically slim, underweight girls trying to please their mothers. They starve themselves. BULEMics are typical chubby girls trying to please their boyfriends. They binge and purge (Eats and then cause themselves to vomit or defecate)

What is the pathology behind PRADER-WILLI? Prader-Willi One of the two gnomic imprinting diseases. It is Inherited paternally and Presents with Obesity, Hypotonia, and Mental retardation. It is essentially a Lesion of the Satiety Center.

What neuro transmitters affect the Satiety and hunger centers? Do these neuro-transmitters sitmulate of inhibit the centers? Both Hunger and Satiety centers are affected by Norepinephrine (NE) and Serotonin (5-HT). 5HT is more specific. These catecholamines are 80% stimulatory to the Satiety center and 20% stimulatory to the Hunger center.

What drug classes are a good choice for use in weight loss? What is the general principle behind using these drug classes? How does each class work specifically? Amphetamines and SSRI's are a good choice for use in weight los. Both set of drugs work by increasing the amount of catecholamines in the system. This has the effect of stimulating the satiety center leading to a feeling of fullness. Amphetamines cause the release of preformed catecholamines.

SSRI's inhibit the re-uptake of 5-HT at the presynaptic terminal.

What is the main stimulant for the hunger and satiety centers? What other substance also stimulates hunger? The main stimulus for the Hunger and the Satiety center is Glucose. Decreased Glucose stimulates the Hunger Center. Increased Glucose and Gastric distention stimulates the Satiety Center. Progesterone also stimulates appetite. This is the reason women are more hungery during menses and why pregnant women want to eat.

Why should you eat small frequent meals? To keep blood glucose levels even. This is because if the levels are low, the hunger center fires and you eat a lot. If the glucose level is high, insulin kicks in and causes the glucose levels to drop and you end up eating.

What are the two phases of the stress response? Phase I - is the Parasympathetic Phase. You get Increased sympathetic outflow causing: Deification, urination, sweating, etc... Phase II - is the Sympathetic phase. You get Increased sympathetic outflow causes: tachycardia, HTN, mydriasis, etc...

What is the pathology of a STRESS ULCER Parasympathetic outflow causes increased motility of GI tract and then sympathetic outflow cause decreased blood flow. This causes the gut to produce more acid, but then blood is shunted away from the gut and the papillae sloughs off.

What is the pathology of IRRITABLE BOWEL SYNDROME? During stress parasympathetic cause diarrhea followed by the sympathetic outflow which causes constipation.

In what patient population do you see CURLING ULCERS?

Stress ulcers caused in burn patients In what patient population do you see CUSHING ULCERS Increased Intra cranial Pressure (ICP)

What is the Cushing Triad? Increased ICP Bardycardia HTN

What gland is responsible for telling time in the body and regulates the Hunger and Satiety center? The PINEAL GLAND affects the hunger and satiety centers.

How does the Pineal gland tell time? How does it perform this function? What will result from lesion of this gland? The Pineal gland senses time of day (Circadian Rhythm) using with Melatonin Increased Melatonin nighttime and the body is shut down Decreased Melatonin daytime and the body is turned on. Lesion of the Pineal Gland causes Precocious Puberty

List all the salivary glands (4)? Parotid Lingual Sublingual Submandibular

Which is the largest salivary gland? The Parotid gland is 90% of all salivary glands by weight.

Which salivary glands are mucinus? Which are are serous? What nerve innervates each? Parotid and lingual are serous (Lingual is most serous). Sublingual and Submandibular are mucinous (Sublingual is the most serous) The Parotid is controlled by CN IX and the Lingual, Sublingual, and Submandible are controlled by CN VII

What is the tonicity of saliva? Saliva is hypotonic because you want the saliva to be able to diffuse into food you eat.

What bacteria and virus causes infection of the salivary glands? Acute infection - Staph. Aureus induced by intubation Mumps virus

What are several complications of mumps infection? Parotitis Pancreatitis Orchitis Oopheritis

What is the most common tumor and cancer of the salivary glands? Most common tumor is a Pleaomrphic ADENOMA Most common Cancer is a Mucoepidermoid ADENOCARCINOMA

How does the parasympathetic system affect the amount and tonicity of saliva? Saliva production is increased by parasympathetic simulation. This causes increase in the amount of saliva produced. However, since there is greater flow, less time is given for reabsorption of solutes (Na and HCO3). This results in the saliva produced having an increased tonicity (NEVER BECOMES HYPERTONIC).

How does the Sympathetic system affect the amount and tonicity of saliva? Sympathetic stimulation causes decreased production of saliva. The amount of saliva produced is lower. Since sympathetic also cause vasoconstriction, there is decreased blood flow near the lumen of the gland resulting in decreased reabsorption of solutes. This gives rise to a saliva that also has increased tonicity (like parasympathetic).

What is the structural defect in cystic fibrosis? What is the inheritance pattern? What gene is defective? Structural defect is of the Na-K ATPase Inherited - Autosomal Recessive Defect on Chr 7 (CFTR gene)

What is the most common cause of malabsorption in children? Cystic Fibrosis

What is the most common presentation of cystic fibrosis in the newborn? To what other complications does it usually prograss? The most common presentation of cystic fibrosis in the newborn is miconium Ileus It the progresses to MALABSORPTION, LUNG PROBLEMS, and finally STERILITY.

What level of sweat sodium is diagnostic for CF? What sweat sodium suggests CF in the heterozygote? What is normal? Normal sweat sodium is less than 20 Greater than 60 is diagnostic for CF Heterozygotes sweat sodium is 30-60

What drug is used for the Cystic Fibrosis sweat test? Pilocarpine

From what structure do the muscles of mastication arise? What nerve innervates them? The muscles of mastication arise from the first Brachial pouch and are innervated by (CN V).

List each of the muscles of mastication and their function? L - Lateral Pterygoid - Lowers Jaw (Opens mouth) T - Temporalis - Moves Jaw Forwards and Backwards M - Medial Pterygoid M Masseter

Give the sequence of events that takes place during swallowing? Tip of tongue rises up and sides come up an medially to form a gutter Tip of tongue rises to hard palate and uses gravity to start food bolus rolling. The bolus rolls until it comes near the glottis and the epiglottis closes to trachea. The bolus rolls over the close epiglottis and touches the pharynx. Once the bolus touches the pharynx, the levator villi palatine raises the soft palate. The posterior pharynx comes down and medially to complete the gutter. Food rolls into the esophagus.

What nerver innervates the upper pharynx? The lower pharynx? Upper Pharynx is innervated by CN IX Lower Pharynx is innervated by CN X

What are the sources of acid in the mouth? Food and Drinks - Main source Fermentation by bacteria - Strep Mutans. Reflux Normal

Why do we salivate?

We salivate to produce Bicarb to neutralize the refluxed acid.

What is GERD? When reflux becomes symptomatic

What is Esophagitis? Inflamed Esophagus on visualization

What is Barrett's Esophagus? Squamous metaplasia (Squamous to columnar) of the lower esophagus

What is a Malloy Weiss Tear? Superficial tear in esophagus due to forcefull vomiting

What is Boorhaave's? Perforation of esophagus

In what populations do you typically see Boorhaave's? What are the common presenting signs and symptoms? Alcoholics and Bullemics Signs and symptoms are Chest pain, Pneumothorax, and Pleural effusion.

What is HAMMAN'S SIGN? Subcutaneous Emphysema can be seen with any pheumothorax. Crunches below skin are called HAMMAN'S SIGN.

Is the Upper esophageal Sphincter voluntary or involuntary? Voluntary

What muscles make up the UES? Upper, Middle, & Lower pharyngeal constrictors, and the Stylopharyngeus.

What innervates the UES? Upper, Middle, and Lower pharyngeal constrictors are innervated by CN X. Stylopharyngeus innervated by CN IX. The ganglia is the nucleus ambiguous.

For what neurological exam finding is the UES responsible? It is Responsible for the GAG reflex.

Into how many parts is the esophagus divided? Esophagus is divided into thirds

Give the histology of each part of the Esophagus. 1st third is made up of Skeletal muscle and squamous cells 2nd third is made up of skeletal and smooth muscle with mixed squamous and columnar cells Final third has smooth muscle and mostly short columnar cells.

What is the most common cancer of the esophagus? Since the esophagus is mostly squamous cells the most common cancer is squamous cell carcinoma.

What is the most common presenting symptom of esophageal cancer? Most common presentation is painful swallowing (Odynophagia)

What sign does the patient use to indicate the problem? Patient will use one finger to point to location of pain (one-finger sign).

When does peristalsis start in the esophagus? Primary Peristalsis Starts with bolus of food entering the esophagus

What nerves are responsible for the constriction phase of peristalsis and the relaxation phase? Where does secondary peristalsis start? What is its function? The Vagus (CN X) causes constriction and The Aurabach plexus via VIP causes relaxation. Secondary Peristalsis begins when food gets stuck in esophagus and it where the food is stuck and carries that piece of food down the esophagus.

What is Achalasia? Achalasia is Lack of Aurabach's plexus in the esophagus. Therefor you cannot relax during peristalsis.

Clues for Achalasia? Narrowed distal esophagus & dilated proximal portion Show 4 months of age because this is when most children are switched to solids. Bird's beak sign, upside down ace of spades are seen on barium swallow

How is Achalasia diagnosed? What is the treatment? Diagnose with Barium swallow and confirm with biopsy Treat with surgery - Partial vagotomy and myotomy

When the Lower Esophageal Sphincter Relaxes to allow bolus of food to drop into the stomach, this is called: This is called Receptive Relaxation

What types of cells are below the LES? Cells below LES are tall columnar.

Given the pathology, name the disease:

1. 2. 3. 4. 5. 6. 7. 8. 9.

Pouch above UES where food gets stuck and can reflux. Pouches below UES and above LES Most Common congenital esophageal GI problem Vomit with first feeding. Large gastric bubble on Xray Blue on feeding and ping on crying Failure of separation of nostril and posterior pharynx Cough and choke while feeding Extra pieces of mucosa that exist in the esophagus

10. Extra pieces of mucosa in the esophagus along with Iron deficiency anemia. it is called Plummer Vinson

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Zenkers Diverticulum Traction diverticulum Esophageal atresia with distal tracheal fistula Esophageal atresia with distal tracheal fistula Esophageal atresia with distal tracheal fistula Cloacal Atresia Cloacal Atresia H-type tracheoesophageal fistula Esophageal webs Plummer Vinson

Clues for Carcinoid Syndrome? Flushing Wheezing Diarrhea

In what layer of the GI tract do sugar enzymes reside? In the mucosa in contact with food.

In what layer of the intestinal tract do AV anastamoses exist? What is their function? They exist in the Lamina Propria. They are normally closes. During stress they shunt blood across the AV anastamoses. This causes the mucosa to slough off. What tissues of the body have the most AV anastamoses? Fingers and toes Toes Lips Ear lobes

What is the name for icles formed in the intestitium when cold? Chilbain

What is primary and secondary peristalsis called in the Esophagus, sm Intestine, and Colon: Esophagus/Stomach: Primary and Secondary peristalsis Small Intestine: Primary - Segmentation, Secondary - MMC Colon: Primary - Haustration, Secondary - Mass Movement

What two places in the GI tract have transverse muscle only on the anterior and posterior surfaces? What does this allow these structures to do? Gallbladder and Stomach. Churning

What are the five layers of the GI tract? 1. 2. Mucosa Lamina Propria

3. 4. 5.

Submucosa Muscularis Mucosa Muscularis Externa

What is located in each of the five layers of the GI tract? Mucosa - Location of enzymes, artery and veins. Lamina Propria - Arterioles, small lymphoid tissue, AV anastamoses Submucosa - Meissner's complex, large lymphoid tissues (MALT, GALT, PEYERS PATCH) Muscularis Mucosa absorption. Causes folds in the mucosa causing an increase of surface area and

Muscularis Externa Made up of two sets of muscles. The inner set is the circular muscle and the outer is the longitudinal muscle. Auerbach's Plexus is located here.

What is the pathology of Achalasia and Hirshprungs? Auerbach's plexus is missing in Achalasia And Hirschsprungs. Which layer of the GI tract contains all the sensory apparatus of the GI tract? What is the complex call in which it is located? The sensory apparatus of the GI tract is located in the Submucosa. It is contained in meissner's complex.

What enzymes are contained in Saliva? What is the function of each enzyme? Lysozymes - Impair the adhesion of bacteria to the teeth. In this way they act as detergents. Salivary Amylase - Chops sugars into sucrose, lactose, maltose, alpha-dextrin. The most common primary deficiency is sugcrase. Lipase - Negligable amount in the mouth. So, these is fat digestion in the mouth, but it is not significant.

Which is the most common secondary deficiency of enzymes? The most common secondary deficiency is lactase.

Which is the first enzyme to disappear during gastroenteritis? In gastroenteritis, the first enzyme to disappear is lactase.

Which Immunoglobulin is contained in Saliva? In what form does it exist? IgA exists in saliva. IgA exists as a dimer in secretions

What are its two functions in the saliva? Protects against encapsulated organisms, except Strep. Pneumo, H. Influenza, and Neisseria. These all have IgA protease. Fixed complement by the alternative pathway.

Where are in the GI are Carbohydrates, Proteins, and Fats digestion 90% of carbohydrates are digested in the mouth and 0% in the small intestine. 90% of proteins are digested in the stomach and 10% in the small intestine. 90% of fats are digested in the small intestine No carbohydrates or fats are digested in the stomach. Salivary amylase and lipase are BOTH inactivated in the stomach by the acidic environment.

What three layers/mechanisms protect the stomach?

Mucus produced by GOBLET CELLS Prostaglandins - cause increased production of mucuc (Inibited by PREDNISONE and NSAID's ALKALINE TIDE - Bicarb produced during the excretion of Hcl from the parietal cell.

What five substances stimulate HCL production? Gastrin

Ach Histamine Cholinergic Agonist Calcium

Describe the process of digestion beginning with food entering the stomach from the esophagus? Food enters the stomach from the esophagus by receptive relaxation It drops in the middle third of the body of the stomach due to gravity. The food absorbs the acid in the stomach increasing the pH. The Increased pH causes G-cells (at the pylorus) to release Gastrin Gastrin flows to the Body of the stomach and stimulates the parietal cells (via its 2nd messenger calcium) to produce HCL. The pH level (1-2) causes chief cells, which are below the parietal cells to release pepsinogen which is cleaved to pepsin and pepsin goes on to digest proteins.

What is the most common type of Heatal Hernia? What is the pathology? What is the typical etiology? What is the most common symptom and treatment? Most common type of hiatal hernia is the Sliding hernia. Due to a defect in the esophageal hiatus The most common cause is obesity Symptoms are those associated with reflux Treat with weight loss, drugs, nissen fundoplication if other therapies do not work. (Problem with fundoplication is that you cannot belch).

What is a rolling hiatal hernia? To what is it due? Rolling is due to a defect in the diaphram. The Fundus is sucked in through the hole.

What are the two main types of Gastritis? Where part of the stomach is involved in each? Type of Gastritis A and B

Type A Usually in the body of the stomach Type B Usually in the antrum of the stomach.

What pathology is responsible for each type A Gastritis? Type B? Type A is due to an autoimmune process (anti-parietal cell antibodies) Type B is Typically due to Irritation, Foods, H.Pylori.

Clue for Type A Gastritis? Pernitious anemia Predisposes to gastric cancer

What is pernicious Anemia? Parietal cells cannot make IF.

What are clues for gastric cancer? Leather waterbottle Signet Ring cells

How do you treat gastritis/ulcers caused by H. Pylori? Bismmuth Metronidazole or tetracycline H+ blocker or pump blocker Amoxicillin

What is the cause of Gastric Ulcers? Duodenal? What percentage of each is caused by H. Pylori?

Gastric ulcers are caused by barrier breakdown in the stomach. Duodenal ulcers are caused by increased acid production. 95% of duodenal ulcers and 70 percent of gastric ulcers are caused by H. Pylori.

With what blood type are gastric ulcers associated? Duodenal? Which is worse after a meal? With a meal? Gastric - Type A blood, worse with meal Duodenal - Type O blood, worse after a meal

What do you call a Mass of inanimate object in GI tract causing obstruction? Bezoar

What do you call a Protein losing gastropathy Menetries

Clues for Menetries Thick rugal folds in GI

Clues for duodenal atresia Bilious Vomiting Double Bubble sign

Clues for pyloric stenosis Non-bilious Projectile vomiting

MCC UGI Bleed in Newborn Swallowed Maternal Blood

MCC UGI Bleed in Children Trauma (usually Nose Picking)

MCC UGI Bleed in Older children > 8yo and Adults Gastritis Peptic ulcer disease

MCC Massive UGI Bleed in Children Mekel's Diverticulum

MCC Massive UGI Bleed in Older children/Adults Peptic Ulcer disease

MCC LGI bleed in Newborn Swallowed Maternal Blood

MCC LGI bleed > 1 yo Rectal Fissure (due to hard stools)

MCC LGI bleed > 1 yo Hyperplastic Polyps

MCC LGI bleed in older children and adults Inflammatory Bowel Disease (e.g. Crohns)

MCC LGI bleed in > 40 years old Angiodysplasia

List (3) types of angiodysplasias that will cause LGI bleed in > 40 years old Vericose Veins Diverticulosis Cancer

MCC of UGI obstruction in newborn Cloanal Atresia C-type Esphageal atresia with tracheoesophageal fistula Duodenal Atresia

MCC of UGI obstruction in 3-4wks Pyloric Stenosis

MCC of UGI obstruction in 4 month old Achalasia

MCC of UGI obstruction 4 mos - 2 yr old Intessuception

MCC of UGI obstruction in > 2 yo Adhesions

MCC of LGI obstruction in 1st yr of life Hirshsprungs

What is the treatment for Intessuception? Adult Barium Enema

Child Surgery

What is the most adhesiogenic material Blood

MCC of LGI obstruction > 1 yo Adhesions Internal Hernias

MCC of LGI obstruction > 40 yo Adhesions Internal Hernias Obstipation Diverticulitis Cancer

Clues for colon cancer Napkin ring appearance Apple core appearance

MCC of diverticulitis Fecolith in a diverticulum causing scarring

What is obstipation? Obstruction from Constipation

How can you differentiate between a diverticulitis and diverticulosis?

Diverticulitis is painful Diverticulosis bleeds

MCC of LGI pain in adult Constipation Diverticulitis

MCC of LGI pain > 40 yr old Cancer

MCC of LGI pain in elderly Adhesions Diverticulitis Opstepation

What causes unexplained massive Upper GI bleed? Peptic Ulcer Disease

Where in the GI do you absorb most substances? In The Jejunum

Where in the GI do you absorb fat soluble vitamins and B12? In The Ileum

Where in the GI do you absorb Iron? MC Hernia in children Umbilical

MCC hiatal hernia Obesity Restrictive Lung Disease

MC hernia overall Indirect

Most frequent hernia in women Femoral

What is the main complication diverticulitis Abscess formation

MCC of enterovesicular fistulas? Diverticulitis Crohns

Clue for Intessuception Currant Jelly Stools Stacked Coin Appearance Sausage Shaped Mass

Clues for Vulvulus Abnormal Stoppage of Gas Bird Beak Sign Upside down ace of spades

What is the MC cause of vulvulus?

Heavy stool makes bowel whip around

What part of the Small Intestine requires the most blood Ileum

Where is the watershed area of the GI At the splenic flexture

What part of the colon is least likely to form an obstruction? Why? The Ceacum is least likely because it is the largest part of the colon

What part of the colon is retroperitoneal Ascending and Descending Colon

What part of the GI has the highest resorptive capacity? Colon

What controls the reabsorption of water in the colon? Aldosterone via Na+/K+ pumps

How does the low volume state lead to constipation? LVS Aldosterone Reabsorb water from colon hard stools

What causes abdominal angina Ischemic Bowel

Clues for Abdominal Angina Severe abdominal pain after meals

What is a sign if infracted Bowel Hemorrhage

What is the treatment for Infarcted bowel? Surgery

What is spastic bowel? How is it diagnosed? It is a diagnosis of exclusion for cronic abdominal pain in older adults. It is diagnosed by endoscopy and injection with glucacon. This caused the bowel to spasm and is seen on endoscopy.

From what embryonic structure is a Mekel s Diverticulum derived? The Vitiline duct

What is the rule of 2 s for Mekel s diverticulum? Peaks @ 2 yo Occurs in 2% of children 2 feet from ileocecal valve 2cm in length involves 2 types of mucosa

What types of mucosa are involved in a Mekel s diverticulum? Which bleeds? Gastric and pancreatic Pancreatic bleeds

Clues for Zanker s Diverticulum Blind pouch above UES Regurgitate undigested food

Clues for Traction Diverticulum Blind pouch below UES and above LES Regurgitate undigested food

MC congenital GI problem Esophageal Atresia with distal Tracheal fistula

Clues for cloanal atresia Baby blue with feeding and pinks when crying

Clues for H-Type TE fistula Cough and choking with feeds

Clues Esophageal webs Remnant mucosa in the esophagus

What is plummer vinson? Esophageal webs Iron deficiency anemia

Give the Associated Disease 1. 2. 3. 4. 5. 6. Low chylomicrons Cerebellar problem in 5-10yo IgA on biopsy of Bowel Wall Meconium Ileus in newborn Blunting of brush border on Biopsy mostly ileum Blunting of brush border on Biopsy mostly jejunum

7. 8. 9. 10. 11. 12. 13. 14. 15.

Hives Linear Burrows in web of finger and waste line Thicken Flat Plaques on skin Middle aged man with arthritis, PAS positive macrophages Current Jelly stool Abrupt stopping of gas on abdominal X-ray Creeping fat Pseudopolyps GI Obstruction with double bubble

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Abetalipoproteinemia Ataxia telangiectasia Heavy chain disease Cystic fibrosis Celiac Sprue Tropical Sprue Urticaria Scabies Lichen planus Whipple Intussusceptions Vulvulus Crohn's Ulcerative colitis Downs

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