First Aid Express 2019 workbook: GASTROINTESTINAL page 1

Gastrointestinal

Questions

EMBRYOLOGY
1. What are the critical weeks of midgut development? (p 352)_______________________________

______________________________________________________________________________

2. Describe the major differences between gastroschisis and omphalocele. (p 352) ______________

______________________________________________________________________________

______________________________________________________________________________

3. A newborn is noted to choke and vomit immediately after first feeding. The mother had

polyhydramnios during pregnancy, and abdominal x-ray shows large amounts of air throughout the

bowel. What is the most likely diagnosis? (p 353) _______________________________________

4. Hypertrophic pyloric stenosis leads to what problem? (p 353) _____________________________

______________________________________________________________________________

5. What is the treatment for hypertrophic pyloric stenosis? (p 353) ___________________________

6. The head of the pancreas is derived from the _______________ (ventral/dorsal) pancreatic bud, the

body is derived from the _______________ (ventral/dorsal) pancreatic bud, and the tail is derived

from the _______________ (ventral/dorsal) pancreatic bud. (p 354)

Copyright © 2019 by ScholarRx All rights reserved v1.0

page 2 First Aid Express 2019 workbook: GASTROINTESTINAL

ANATOMY
7. Which GI ligament can be incised to access the lesser sac and which cannot? Why? (p 355) ____

______________________________________________________________________________

______________________________________________________________________________

8. Name the four histologic layers of the GI tract, from inside to out. (p 356) ____________________

______________________________________________________________________________

9. What histologic feature distinguishes the duodenum from any other part of the GI tract? What is the

purpose of this feature? (p 356, 366) _________________________________________________

______________________________________________________________________________

10. What are the three branches of the celiac trunk? (p 358) _________________________________

______________________________________________________________________________

11. Portal hypertension can lead to varices of which three structures? (p 359) ___________________

______________________________________________________________________________

12. Which type of hemorrhoid is painful? Why? (p 360) _____________________________________

______________________________________________________________________________

13. Which zone of the liver is most sensitive to ischemic injury? (p 362) ________________________

14. What is the order of major structures that pass through the femoral region from lateral to medial.

(p 362) ________________________________________________________________________

15. The gastroesophageal junction is displaced in ______________________ hernias, whereas it is

undisturbed in ______________________ hernias. (p 364)

Copyright © 2019 by ScholarRx All rights reserved v1.0

 First Aid Express 2019 workbook: GASTROINTESTINAL page 3

16. In the image below, identify the inguinal (Hesselbach) triangle and the three structures that define
this triangle. For each of the three regions (in blue), what type of hernia can occur at that location?
(p 364)

17. How does the course of a direct inguinal hernia differ from that of an indirect inguinal hernia?
(p 364) ________________________________________________________________________

______________________________________________________________________________

PHYSIOLOGY
18. Which cells are responsible for secreting cholecystokinin (CCK)? What are the effects of CCK
secretion? (p 365) _______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

19. What cells are responsible for producing gastric acid? What hormones act on them to cause
secretion? (p 366) _______________________________________________________________

______________________________________________________________________________

20. Where in the GI tract is iron absorbed? Vitamin B12? Folate? Which requires cofactors to facilitate
absorption? (p 368) ______________________________________________________________

______________________________________________________________________________

Copyright © 2019 by ScholarRx All rights reserved v1.0

page 4 First Aid Express 2019 workbook: GASTROINTESTINAL

21. Peyer patches contain B cells, which primarily secrete which class of immunoglobulin? (p 368)

______________________________________________________________________________

22. What is the composition of bile? (p 368) ______________________________________________

______________________________________________________________________________

23. Direct bilirubin is _______________ (conjugated/unconjugated) with glucuronic acid and is

_______________ (soluble/insoluble) in water. Indirect bilirubin is _______________ (conjugated/
unconjugated) and is _______________ (soluble/insoluble) in water. (p 369)

24. How is urobilinogen removed from the body? (p 369) ____________________________________

______________________________________________________________________________

PATHOLOGY
25. What are two causes of sialolithiasis? (p 370) __________________________________________

26. How do the symptoms of achalasia differ from those of esophageal obstruction? (p 370) ________

______________________________________________________________________________

______________________________________________________________________________

27. What is the characteristic imaging finding in a patient with achalasia? (p 370) _________________

28. What are the symptoms of Plummer-Vinson syndrome? (p 371) ___________________________

______________________________________________________________________________

29. What is a more common type of esophageal cancer in the United States? Worldwide? Why?

(p 372) ________________________________________________________________________

______________________________________________________________________________

30. What is a risk factor for acute gastritis? For chronic gastritis? (p 373) _______________________

______________________________________________________________________________

Copyright © 2019 by ScholarRx All rights reserved v1.0

 First Aid Express 2019 workbook: GASTROINTESTINAL page 5

31. What are the five major risk factors for stomach cancer? (p 373) ___________________________

______________________________________________________________________________

32. What are four common stomach cancer metastases? (p 373) _____________________________

______________________________________________________________________________

33. The pain of gastric ulcers is _______________ (increased/decreased) with meals, whereas the pain

of duodenal ulcers is ________________ (increased/decreased) with meals. (p 374)

34. Name the five symptoms common to all malabsorption syndromes. (p 375) __________________

______________________________________________________________________________

35. What are three causes of pancreatic insufficiency? What is a major consequence? (p 375) ______

______________________________________________________________________________

______________________________________________________________________________

36. Celiac disease is characterized by antibodies to _____________, ___________________, and

_____________________, and is associated with a skin condition called ____________________.
(p 375)

37. Compare and contrast the characteristics of Crohn disease and ulcerative colitis. (p 376)

Characteristic Crohn Disease Ulcerative Colitis

Associated with colorectal
cancer?

Gross morphology

Depth of inflammation

Distinguishing complications

Granulomas?
Location
Rectal involvement

Copyright © 2019 by ScholarRx All rights reserved v1.0

page 6 First Aid Express 2019 workbook: GASTROINTESTINAL

38. How is the McBurney point used to diagnose appendicitis? (p 377) _________________________

______________________________________________________________________________

39. 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 377) ____________

______________________________________________________________________________

40. What is the difference between a false diverticulum and a true diverticulum? (p 377) ___________

______________________________________________________________________________

______________________________________________________________________________

41. ____________________ (Intussusception/Volvulus) occurs when a portion of the bowel twists

around its mesentery; ___________________ (intussusception/volvulus) occurs when a proximal

bowel segment telescopes into a distal segment. (p 379-380)

42. What surgical complication is this a common cause of small bowel obstruction? (p 380) _________

______________________________________________________________________________

43. A 55-year-old woman presents with colicky pain. Results of a fecal occult blood test are positive.
Colonoscopy reveals 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 CNS glioma?
(p 381) ________________________________________________________________________

______________________________________________________________________________

44. What is the first mutational event typically associated with colorectal cancer? (p 383) ___________

______________________________________________________________________________

45. What are the signs and symptoms of cirrhosis and portal hypertension? (p 383) _______________

______________________________________________________________________________

______________________________________________________________________________

46. 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 384)

Copyright © 2019 by ScholarRx All rights reserved v1.0

 First Aid Express 2019 workbook: GASTROINTESTINAL page 7

47. Match the type of liver disease with its notable characteristic(s) (pp 385-386)

_____ A. α1-Antitrypsin deficiency 1. Causes panacinar emphysema

_____ B. Alcoholic cirrhosis
_____ C. Alcoholic hepatitis
_____ D. Budd-Chiari syndrome
_____ E. Hepatic steatosis
_____ F. Hepatocellular carcinoma
2. Thrombosis or compression of hepatic veins
3. Fatty changes in macrovesicles; reversible
4. Mallory bodies
5. Portal hypertension
6. Primary malignant liver tumor in adults

48. A newborn presents with persistent jaundice after two weeks of life, darkening urine, acholic

stools, and hepatomegaly. The labs indicate high direct bilirubin and GGT. What is the likely

diagnosis? (p 387) _________________________________________________________

49. Compare and contrast the characteristics of the hereditary hyperbilirubinemias. (p 388)

Crigler-Najjar Dubin-Johnson
Characteristic Gilbert Syndrome
Syndrome Syndrome

Impairment

Course of disease

Symptoms

50. What molecule accumulates to cause Wilson disease? What molecule is not made (tests show low
levels) because of this accumulation? What is the treatment? (p 389) _______________________

______________________________________________________________________________

51. What causes the classic triad of: cirrhosis, diabetes mellitus, and “bronze diabetes”? (p 389)
______________________________________________________________________________

______________________________________________________________________________

52. List three extrahepatic causes of biliary obstruction. (p 389) ______________________________

______________________________________________________________________________

53. List two intrahepatic causes of biliary obstruction. (p 389) ________________________________

______________________________________________________________________________

Copyright © 2019 by ScholarRx All rights reserved v1.0

page 8 First Aid Express 2019 workbook: GASTROINTESTINAL

54. Match the term with its definition. (p 390)

_____ A. Ascending cholangitis 1. Gallstones

_____ B. Cholecystitis 2. Infection of biliary tree
_____ C. Cholelithiasis 3. Inflammation of the gallbladder

55. What enzymes are elevated in acute pancreatitis? (p 391) _______________________________

56. Name one common cause of chronic pancreatitis (p 391) ________________________________

PHARMACOLOGY
57. List the most common histamine-2 blockers for the GI tract. Which histamine receptor do they affect?

(p 392) ________________________________________________________________________

58. What are the proton pump inhibitors? Why are they such effective drugs? (p 392) _____________

______________________________________________________________________________

59. How is misoprostol most commonly used as a GI agent? (p 393) __________________________

______________________________________________________________________________

60. What is the most dangerous adverse effect of all antacids? (p 393) _________________________

61. What powerful medicine is used to control vomiting and nausea after surgery? What receptor does

it target? (p 394) _________________________________________________________________

62. What drug can be used to treat gastroparesis? What is a worrisome adverse effect? (p 394) _____

______________________________________________________________________________

63. What is the most common side effect of orlistat? What enzymes does it inhibit? (p 394) _________

______________________________________________________________________________

Copyright © 2019 by ScholarRx All rights reserved v1.0

 First Aid Express 2019 workbook: GASTROINTESTINAL page 9

Answers

EMBRYOLOGY
1. Week 6: midgut herniates through umbilical ring
Week 10: returns to abdominal cavity, rotates around SMA 270 degrees.

2. Gastroschisis: Caused by failure of lateral fold closure, abdominal contents herniate lateral to
umbilicus; abdominal contents NOT covered in peritoneum or amnion; is not associated with
chromosome abnormalities. Omphalocele: Caused by failure of lateral walls to migrate at umbilical
ring, persistent midline herniation of abdominal contents into umbilical cord; abdominal contents ARE
surrounded by peritoneum; associated with congenital anomalies (eg, trisomies 13 and 18, Beckwith-
Wiedemann syndrome) and other structural abnormalities.

3. Esophageal atresia with tracheoesophageal fistula.

4. Gastric outlet obstruction. (A classic sign is nonbilious projectile vomiting.)

5. Surgical incision to relax the pyloric muscle (pyloromyotomy).

6. Ventral AND dorsal (ventral = uncinate process); dorsal; dorsal.

ANATOMY
7. The gastrohepatic ligament may be cut during surgery to access the lesser sac because there is a
thin minimally vascular portion that does not require violating the gastric arteries. The
hepatoduodenal ligament may NOT be incised, as the portal triad runs longitudinally through this
ligament.

8. Mucosa, submucosa, muscularis externa, and serosa (when intraperitoneal), adventitia (when
retroperitoneal). Remember MSMS.

9. Brunner’s glands; these glands secrete bicarbonate solution to neutralize acidic chyme that leaves
the stomach before it can reach the rest of the intestines.

10. Left gastric artery, splenic artery, and common hepatic artery.

11. Esophageal varices, Caput medusae (umbilicus), and anorectal varices.

Copyright © 2019 by ScholarRx All rights reserved v1.0

page 10 First Aid Express 2019 workbook: GASTROINTESTINAL

12. External hemorrhoids are painful because they receive somatic innervation.

13. Zone III (centrilobular zone).

14. Femoral nerve, femoral artery, femoral vein, lymphatics (femoral canal). Remember: You go from
lateral to medial to find your NAVeL.

15. sliding hiatal hernias; paraesophageal hiatal hernias.

16.

17. A direct inguinal hernia protrudes through the inguinal (Hesselbach) triangle (medial to inferior
epigastric vessels), whereas an indirect inguinal hernia goes through the internal inguinal ring,
external inguinal ring, and into the scrotum (lateral to inferior epigastric vessels).

PHYSIOLOGY
18. CCK is released by the I cells in the duodenum and jejunum. It acts on the neural muscarinic
pathways to cause pancreatic secretion and relaxation of the sphincter of Oddi. It also results in
increased gallbladder contraction and decreased gastric emptying.

19. Parietal cells. Histamine, acetylcholine and gastrin contribute to acid secretion.

20. Iron is absorbed in the duodenum, vitamin B12 is absorbed in the ileum; and folate is absorbed in the
small bowel. Vitamin B12 absorption requires a cofactor (intrinsic factor), whereas iron and folate
absorption do not.

21. Peyer patches contain B cells that differentiate into IgA-secreting plasma cells, which combat
intraluminal antigens.

Copyright © 2019 by ScholarRx All rights reserved v1.0

 First Aid Express 2019 workbook: GASTROINTESTINAL page 11

22. Bile salts, phospholipids, cholesterol, bilirubin, water, and ions.

23. Conjugated; soluble; unconjugated; insoluble.

24. 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.

PATHOLOGY
25. Dehydration or trauma.

26. Esophageal obstruction causes dysphagia with solids, whereas achalasia causes dysphagia with
both solids and liquids.

27. A “bird’s beak,” or dilated esophagus with an area of distal stenosis.

28. Dysphagia, iron deficiency anemia, and esophageal webs; may be associated with glossitis.

29. More common in America: adenocarcinoma; worldwide: squamous cell carcinoma. GERD is
common in the U.S. and can result in Barrett esophagus, which in turn can lead to adenocarcinoma.

30. Daily NSAID use; Helicobacter (H) pylori infection.

31. H pylori infection, diet high in smoked foods (nitrosamines), tobacco smoking, achlorhydria, and
chronic gastritis.

32. Virchow node (involvement of left supraclavicular node), Krukenberg tumor (bilateral metastases to
ovaries), Sister Mary Joseph nodule (subcutaneous periumbilical metastasis), and Blumer shelf
(metastasis to pouch of Douglas).

33. Increased; decreased.

34. Diarrhea, steatorrhea, weight loss, weakness, and vitamin and mineral deficiencies.

35. Cystic fibrosis, obstructing cancer, and chronic pancreatitis. A major consequence is deficiency in
the fat-soluble vitamins (A, D, E, and K) as well as B12 due to malabsorption of these vitamins.

36. anti-endomysial, anti-deamidated gliadin peptide antibodies; IgA anti-tissue transglutaminase;

dermatitis herpetiformis.

Copyright © 2019 by ScholarRx All rights reserved v1.0

page 12 First Aid Express 2019 workbook: GASTROINTESTINAL

37.

Characteristic Crohn Disease Ulcerative Colitis

Associated with colorectal
cancer?
Gross morphology
Depth of inflammation
Distinguishing complications
Granulomas?
Location
Rectal involvement
Yes Yes
cobblestone mucosa,
Friable mucosa with superficial
creeping fat, bowel wall
and/or deep ulcerations. Loss
thickening, linear ulcers,
of haustra
fissures
Transmural Mucosal and submucosal only
Fistulas,
phlegmon/abscess, Fulminant colitis, toxic
strictures, perianal megacolon, perforation
disease
Yes No
Any part of GI tract,
typically terminal ileum, Colon
then colon
Usually rectal sparing Always involves rectum

38. McBurney point is one-third the distance from the right anterior superior iliac spine to the umbilicus;
pain localized to McBurney point (RLQ) is pathognomonic for appendicitis.

39. This is a typical presentation of diverticulosis, which can present with painless hematochezia.

40. In a false diverticulum, only the mucosa and submucosa outpouch; in a true diverticulum, all three
gut wall layers outpouch.

41. Volvulus; intussusception.

42. Adhesions; this is the most common cause of small bowel obstruction.

43. Familial adenomatous polyposis; Gardner syndrome; Turcot syndrome.

44. Loss of APC gene, which is associated with decreased intracellular adhesion and greater
proliferation.

45. Portal hypertension can cause hematemesis (esophageal varices), melena (gastric varices), caput
medusa, ascites, and hemorrhoids (anorectal varices). Cirrhosis can cause coma, scleral icterus,
fetor hepaticus, spider nevi, gynecomastia, jaundice, testicular atrophy, asterixis, bleeding tendency,
anemia, and ankle edema.

46. Greater than; less than.

Copyright © 2019 by ScholarRx All rights reserved v1.0

 First Aid Express 2019 workbook: GASTROINTESTINAL page 13

47. A-1, B-5, C-4, D-2, E-3, F-6.

48. Biliary atresia

49.

Crigler-Najjar Dubin-Johnson
Characteristic Gilbert Syndrome
Syndrome, type I Syndrome
↑ unconjugated Conjugated
Impairment Bilirubin uptake
Bilirubin hyperbilirubinemia
Symptomatic; cure is
Course of disease Benign Benign
liver transplant

Jaundice Asymptomatic or
Symptoms Jaundice
Kernicterus mild jaundice

50. Copper; serum ceruloplasmin; chelation with penicillamine or trientine, oral zinc. Liver transplant in
acute liver failure related to Wilson disease.

51. Hemochromatosis. Iron deposits in the liver can cause cirrhosis, iron in the pancreas can lead to
DM, and deposition of hemosiderin in the skin will lead to the hyperpigmentation.

52. Gallstones, biliary strictures, and pancreatic carcinoma.

53. Primary biliary cholangitis and primary sclerosing cholangitis.

54. A-2, B-3, C-1.

55. Serum amylase or lipase.

56. Alcohol abuse.

PHARMACOLOGY
57. Cimetidine, ranitidine, famotidine, nizatidine. These are H2 receptor blockers.

58. Omeprazole, lansoprazole, esomeprazole, pantoprazole, and dexlansoprazole. PPIs are very
effective because they irreversibly inhibit H+/K+ ATPase, instead of blocking just one of several
stimulatory receptors.

59. Preventing NSAID-induced peptic ulcers.

Copyright © 2019 by ScholarRx All rights reserved v1.0

page 14 First Aid Express 2019 workbook: GASTROINTESTINAL

60. Hypokalemia.

61. Ondansetron; 5-HT3 antagonist.

62. Metoclopramide; parkinsonian effects (because it is a D2 receptor antagonist).

63. Orlistat inhibits gastric and pancreatic lipase, which results in decreased absorption of dietary fats.
Common side effects are: abdominal pain, flatulence, steatorrhea, and decreased absorption of fat-
soluble vitamins.

Copyright © 2019 by ScholarRx All rights reserved v1.0