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Gastrointestinal
How to Use the Workbook with the Videos
Using this table as a guide, read the Facts in First Aid for the USMLE Step 1 2014,
watch the corresponding First Aid Express 2014 videos, and then answer the workbook
questions.

Facts in First Aid for Corresponding First Aid Workbook


the USMLE Step 1 2014 Express 2014 video questions
334.1335.1 Embryology (1 video) 15
335.2344.1 Anatomy (3 videos) 616
345.1349.1 Physiology (2 videos) 1723
349.2369.1 Pathology (8 videos) 2454
370.1372.5 Pharmacology (1 video) 5561

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page 2 First Aid Express 2014 workbook: GASTROINTESTINAL

Questions

EMBRYOLOGY
1. What is the term for the persistence of herniated abdominal contents into the umbilical cord? (p.
334) __________________________________________________________________________

2. A newborn is noted to choke and vomit with routine feedings. The mother had polyhydramnios
during pregnancy. What is the most likely diagnosis? (p. 334) _____________________________

3. In congenital pyloric stenosis, hypertrophy of the pylorus leads to what problem? (p. 334) _______
______________________________________________________________________________

4. What is the treatment for congenital pyloric stenosis? (p. 334) _____________________________

5. 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. 335)

ANATOMY
6. Which GI ligament is sometimes cut during surgery, and why? (p. 336) ______________________
______________________________________________________________________________

7. What are the four layers of the GI tract, from inside to out? (p. 337) ________________________
______________________________________________________________________________

8. At what spinal cord level does the celiac trunk branch off the aorta? Where does the aorta
bifurcate? Where do the renal arteries branch off? (p. 338) ________________________________

9. What are the three branches of the celiac trunk? (p. 339) _________________________________

10. Portal hypertension is characterized by varices of which three structures? (p. 340) _____________
______________________________________________________________________________

11. Which type of hemorrhoid is painful? Why? (p. 341) _____________________________________

12. Which zone of the liver is most sensitive to toxic injury? (p. 341) ___________________________

13. Name the major vascular, neurologic, and lymphatic structures that pass through the femoral tri-
angle in order from lateral to medial: (p. 342) __________________________________________

14. Direct hernias protrude through the _______________________ (abdominal wall/internal inguinal
ring), whereas indirect hernias protrude through the ________________________ (abdominal
wall/internal inguinal ring). (p. 344)

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15. In the image below, identify the Hesselbach triangle and the three structures that define this
triangle. For each of the Xs, identify the type of hernia that can occur at that location. (p. 344)

16. How does the course of a direct inguinal hernia differ from that of an indirect inguinal hernia?
(p. 344) ________________________________________________________________________
______________________________________________________________________________

PHYSIOLOGY
17. Which cells are responsible for secreting cholecystokinin (CCK)? What are the effects of CCK
secretion? (p. 345) _______________________________________________________________
______________________________________________________________________________

18. What cells are responsible for producing gastric acid? What hormones act on them to cause
secretion? (p. 346) _______________________________________________________________

19. Where in the GI tract is iron absorbed? Vitamin B12? Folate? Which require cofactors to facilitate
absorption? (p. 348) ______________________________________________________________
______________________________________________________________________________

20. Why are Peyer patches important in the immune response? (p. 348) ______________________
______________________________________________________________________________

21. What is the composition of bile? (p. 348) ______________________________________________

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


_______________ (soluble/ insoluble) in water. Indirect bilirubin is _______________ (conjugated/
unconjugated) with glucuronic acid and is _______________ (soluble/ insoluble) in water. (p. 349)

23. How is urobilinogen removed from the body? (p. 349) ____________________________________
______________________________________________________________________________

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page 4 First Aid Express 2014 workbook: GASTROINTESTINAL

PATHOLOGY
24. How do the symptoms of achalasia differ from those of esophageal obstruction? (p. 349) ________
______________________________________________________________________________

25. What is the characteristic imaging finding in a patient with achalasia? (p. 349) _________________

26. What are the symptoms of Plummer-Vinson syndrome? (p. 350) ___________________________
______________________________________________________________________________

27. What is the most common type of esophageal cancer in the United States? Worldwide? Why?
(pp. 350-351) ___________________________________________________________________
______________________________________________________________________________

28. What is a risk factor for acute gastritis? For chronic gastritis? (p. 351) _______________________
______________________________________________________________________________

29. What are the five major risk factors for stomach cancer? (p. 351) __________________________
______________________________________________________________________________

30. What are three common stomach cancer metastases? (p. 351) ____________________________
______________________________________________________________________________

31. The pain of gastric ulcers is _______________ (increased/decreased) with meals, whereas the
pain of duodenal ulcers is ________________ (increased/decreased) with meals. (p. 352)

32. Name the five symptoms common to all malabsorption syndromes. (p. 353) __________________
______________________________________________________________________________

33. What are three causes of pancreatic insufficiency? What is a major consequence? (p. 353) ______
______________________________________________________________________________

34. Celiac sprue is characterized by antibodies to _____________ and _____________________, and


is associated with a skin condition called _______________________________________. (p. 353)

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35. Compare and contrast the characteristics of Crohn disease and ulcerative colitis. (p. 354)

Characteristic Crohn Disease Ulcerative Colitis


Associated with colorectal
cancer?

Characteristic lesion

Extent of inflammation

Extraintestinal manifestations

Granulomas?
Location of ulcers
Rectal involvement?

36. How is McBurney point used to diagnose appendicitis? (p. 355) __________________________
______________________________________________________________________________

37. 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. 355) __________

38. What is the difference between a false diverticulum and a true diverticulum? (p. 355) ___________
______________________________________________________________________________

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


around its mesentery; ___________________ (intussusception/volvulus) occurs when a part of the
one bowel telescopes into a more distal segment. (p. 356)

40. Which intestinal disorders are associated with Down syndrome? Cystic fibrosis? Premature
neonates? (p. 357) ___________________________________________________________
______________________________________________________________________________

41. What surgical complication can lead to acute bowel obstruction? (p. 357) ____________________

42. What three features of a colonic polyp are associated with increased risk of malignancy? (p. 358)
______________________________________________________________________________

43. A 55-year-old woman presents with colicky pain. Results of a fecal occult blood test are positive.
Colonoscopy reveals literally thousands of polyps in the colon and rectum. What is the most likely
diagnosis? What if the patient also has osteosarcoma? What if, instead, she has a glioma? (p. 359)
______________________________________________________________________________

44. What are the signs and symptoms of liver disease? (p. 360) _______________________________
______________________________________________________________________________

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page 6 First Aid Express 2014 workbook: GASTROINTESTINAL

45. 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. 360)

46. Match the type of liver disease with its notable characteristic(s) (pp. 361-363)
_____ A. 1-Antitripsin deficiency 1. Causes panacinar emphysema
_____ B. Alcoholic cirrhosis 2. Common cause is right-sided heart failure
_____ C. Alcoholic hepatitis 3. Due to occlusion of IVC or hepatic veins
_____ D. Budd-Chiari syndrome 4. Fatty changes in macrovesicles; reversible
_____ E. Hepatic steatosis 5. Mallory bodies
_____ F. Hepatocellular carcinoma 6. Primary malignant liver tumor in adults
_____ G. Nutmeg liver 7. Shrunken liver with irregular surface

47. Compare and contrast the characteristics of the hereditary hyperbilirubinemias. (p. 364)

Crigler-Najjar Dubin-Johnson
Characteristic Gilbert Syndrome
Syndrome Syndrome

Impairment

Prognosis

Symptoms

48. 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. 365) ____________________
______________________________________________________________________________

49. What is the cause of bronze diabetes? (p. 365) _______________________________________

50. List four extrahepatic causes of biliary obstruction. (p. 366) ____________________________
______________________________________________________________________________

51. List two intrahepatic causes of biliary obstruction. (p. 366) ________________________________

52. Match the term with its definition. (p. 367)


_____ A. Cholangitis 1. Gallstones
_____ B. Cholecystitis 2. Infection of the biliary tree
_____ C. Cholelithiasis 3. Inflammation of the gallbladder

53. What enzymes are elevated in acute pancreatitis? (p. 368) ____________________________

54. Acute pancreatitis and pancreatic adenocarcinoma share two symptoms: _______________ and
_________________________. What two maneuvers can differentiate between these two
diseases? (pp. 368-369) ___________________________________________________________
______________________________________________________________________________

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PHARMACOLOGY
55. List the most common histamine blockers for the GI tract. Which histamine receptor do they affect?
(p. 371) ________________________________________________________________________

56. What are the proton pump inhibitors? Why are they such effective drugs? (p. 371) _____________
______________________________________________________________________________

57. How is misoprostol most commonly used as a GI agent? (p. 371) __________________________

58. What is the most dangerous adverse effect of all antacids? (p. 371) _________________________

59. Infliximab is a monoclonal antibody that targets which molecule? What is a major concern relating
to its use? (p. 372) _______________________________________________________________

60. What powerful medicine is used to control vomiting and nausea after surgery? What receptor does
it target? (p. 372) ________________________________________________________________

61. What drug can be used to treat gastroparesis? What is a worrisome adverse effect? (p. 372) _____
______________________________________________________________________________

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page 8 First Aid Express 2014 workbook: GASTROINTESTINAL

Answers

EMBRYOLOGY
1. Omphalocele.

2. Tracheoesophageal fistula.

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

4. Surgical incision to relax the pyloric muscle (pyloromytomy).

5. Ventral; dorsal; dorsal.

ANATOMY
6. The gastrohepatic ligament may be cut during surgery to provide access to the lesser sac.

7. Mucosa, submucosa, muscularis externa, and serosa/adventitia.

8. T12; L4; L1.

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

10. Esophagus, umbilicus, and rectum.

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

12. Zone III (pericentral vein zone)

13. Femoral nerve, femoral artery, femoral vein, lymphatics (femoral canal).

14. Abdominal wall; internal inguinal ring.

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15.

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

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

18. Parietal cells. Acetylcholine and gastrin contribute, but the most important stimulator of acid
secretion is histamine (whose production is stimulated by circulating gastrin).

19. Iron is absorbed in the duodenum, vitamin B12 is absorbed in the ileum; and folate is absorbed in
the jejunum. Vitamin B12 absorption requires a cofactor (intrinsic factor), whereas iron and folate
absorption does not require a cofactor.

20. Peyer patches produce IgA-secreting plasma cells that combat intraluminal antigens.

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

22. Conjugated; soluble; unconjugated; insoluble.

23. 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.

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page 10 First Aid Express 2014 workbook: GASTROINTESTINAL

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

25. A birds beak, or narrowing of the LES at the gastroesophageal junction.

26. Dysphagia, glossitis, and iron deficiency anemia.

27. Adenocarcinoma; squamous cell carcinoma. GERD is common in the U.S. and can result in Barrett
esophagus, which in turn can lead to adenocarcinoma.

28. Daily NSAID use; Helicobacter pylori infection.

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

30. Virchow node (involvement of left supraclavicular node), Krukenberg tumor (metastasis to ovaries),
and Sister Mary Joseph nodule (subcutaneous periumbilical metastases).
31. Increased; decreased.

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

33. Cystic fibrosis, obstructing cancer, and chronic pancreatitis. A major consequence is deficiency in
the fat-soluble vitamins (A, D, E, and K).

34. Gliadin; tissue transglutaminase; dermatitis herpetiformis.

35.

Characteristic Crohn Disease Ulcerative Colitis


Associated with colorectal
Yes Yes
cancer?
Skip lesions on Continuous lesion on friable
Characteristic lesion
cobblestone mucosa mucosa

Extent of inflammation Transmural Submucosa


Arthritis Ankylosing spondylitis
Erythema nodosum Pyoderma gangrenosum
Extraintestinal manifestations
Aphthous ulcers Primary sclerosing cholangitis
Kidney stones Uveitis
Granulomas? Yes No
Location of ulcers Any part of GI tract Colon
Rectal involvement? No Yes

36. McBurney point is one-third the distance from the anterior superior iliac spine to the umbilicus on
the right side; pain at this point is pathognomonic for appendicitis.

37. This is a typical presentation of diverticulitis, which is also associated with fever and leukocytosis.

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38. In a false diverticulum, only the mucosa and submucosa form the pouch; in a true diverticulum, all
three gut wall layers form the pouch.

39. Volvulus; intussusception.

40. Hirschsprung disease and duodenal atresia are associated with Down syndrome. Cystic fibrosis is
associated with meconium ileus. Necrotizing enterocolitis is more common in premature neonates.

41. Adhesions.

42. Larger size, villous histology, and epithelial dysplasia.

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

44. Portal hypertension can cause hematemesis (esophageal varices), melena (peptic ulcer),
splenomegaly, caput medusa, ascites, gastropathy, and hemorrhoids. Liver cell failure can cause
coma, scleral icterus, fetor hepaticus, spider nevi, gynecomastia, jaundice, testicular atrophy,
asterixis, bleeding tendency, anemia, and ankle edema.

45. Greater than; less than.

46. A-1, B-7, C-5, D-3, E-4, F-6, G-2.

47.

Crigler-Najjar Dubin-Johnson
Characteristic Gilbert Syndrome
Syndrome Syndrome
Conjugated bilirubin
Impairment Bilirubin conjugation Bilirubin uptake
excretion
Fatal within a few
Prognosis Benign disease Benign disease
years of diagnosis

Jaundice
Symptoms Jaundice Jaundice
Kernicterus

48. Copper; ceruloplasmin; penicillamine.

49. Deposition of hemosiderosin in the skin.

50. Gallstones, biliary strictures, chronic pancreatitis, and carcinoma of the pancreatic head.

51. Primary biliary cirrhosis and primary sclerosing cholangitis.

52. A-3, B-3, C-1.

53. Amylase and lipase.

54. Anorexia and abdominal pain radiating to back. Pancreatic adenocarcinoma is also associated with
migratory thrombophlebitis and a positive Courvoisiers sign (obstructive jaundice with a palpable,
nontender gallbladder).

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page 12 First Aid Express 2014 workbook: GASTROINTESTINAL

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

56. Omeprazole, lansoprazole, esomeprazole, pantoprazole, and dexlansoprazole. PPIs are very
+ +
effective because they act directly on the H /K ATPase, instead of blocking just one of several
stimulatory receptors.

57. Preventing NSAID-induced peptic ulcers.

58. Hypokalemia.

59. TNF; reactivation of latent tuberculosis.

60. Ondansetron; 5-HT3.

61. Metoclopramide; parkinsonian effects (because it is a D 2 antagonist).

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