This copy belongs to Ochaudhery (Omarchaudhery@yahoo.

com)
First Aid Express 2016 workbook: GASTROINTESTINAL

page 1

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 2016,
watch the corresponding First Aid Express 2016 videos, and then answer the workbook
questions.
Facts in First Aid for
the USMLE Step 1 2016
338.1339.2

Corresponding First Aid

Express 2016 video
Embryology (1 video)

Workbook
questions
15

339.2349.1

Anatomy (3 videos)

616

350.1353.1

Physiology (2 videos)

1723

353.2373.1

Pathology (8 videos)

2454

374.1376.5

Pharmacology (1 video)

5561

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

page 2

First Aid Express 2016 workbook: GASTROINTESTINAL

Questions
EMBRYOLOGY
1.

Describe three major differences between gastroschisis and omphalocele. (p 338)_____________

______________________________________________________________________________
______________________________________________________________________________

2.

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 338) _______________________________________

3.

Hypertrophic pyloric stenosis leads to what problem? (p 339) _____________________________

______________________________________________________________________________

4.

What is the treatment for hypertrophic pyloric stenosis? (p 339) ___________________________

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 339)

ANATOMY
6.

Which GI ligament can be incised to access the lesser sac and which cannot? Why? (p 340) ____
______________________________________________________________________________

7.

Name the four histologic layers of the GI tract, from inside to out. (p 341) ____________________
______________________________________________________________________________

8.

What histologic feature distinguishes the duodenum from any other part of the GI tract? What is the
purpose of this feature? (p 341) ____________________________________________________

9.

What are the three branches of the celiac trunk? (p 343) _________________________________

10.

Portal hypertension can lead to varices of which three structures? (p 344) ___________________
______________________________________________________________________________

11.

Which type of hemorrhoid is painful? Why? (p 345) _____________________________________

12.

Which zone of the liver is most sensitive to ischemic injury? (p 346) ________________________

13.

Name the major structures that pass through the femoral triangle in order from lateral to medial. (p
347) __________________________________________________________________________

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

First Aid Express 2016 workbook: GASTROINTESTINAL

14.

page 3

Direct hernias protrude through the _______________________ (abdominal wall/internal inguinal

ring), whereas indirect hernias protrude through the ________________________ (abdominal
wall/internal inguinal ring). (p 349)

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 349)

16.

How does the course of a direct inguinal hernia differ from that of an indirect inguinal hernia?
(p 349) ________________________________________________________________________
______________________________________________________________________________

PHYSIOLOGY
17.

Which cells are responsible for secreting cholecystokinin (CCK)? What are the effects of CCK
secretion? (p 350) _______________________________________________________________
______________________________________________________________________________

18.

What cells are responsible for producing gastric acid? What hormones act on them to cause
secretion? (p 351) _______________________________________________________________

19.

Where in the GI tract is iron absorbed? Vitamin B12? Folate? Which require cofactors to facilitate
absorption? (p 352) ______________________________________________________________
______________________________________________________________________________

20.

Peyer patches contain B cells, which primarily secrete which class of immunoglobulin? (p 352)
______________________________________________________________________________

21.

What is the composition of bile? (p 352) ______________________________________________

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

page 4

22.

First Aid Express 2016 workbook: GASTROINTESTINAL

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 353)

23.

How is urobilinogen removed from the body? (p 353) ____________________________________

______________________________________________________________________________

PATHOLOGY
24.

How do the symptoms of achalasia differ from those of esophageal obstruction? (p 354) ________
______________________________________________________________________________

25.

What is the characteristic imaging finding in a patient with achalasia? (p 354) _________________

26.

What are the symptoms of Plummer-Vinson syndrome? (p 354) ___________________________

______________________________________________________________________________

27.

What is the most common type of esophageal cancer in the United States? Worldwide? Why?
(p 355) ________________________________________________________________________
______________________________________________________________________________

28.

What is a risk factor for acute gastritis? For chronic gastritis? (p 356) _______________________
______________________________________________________________________________

29.

What are the five major risk factors for stomach cancer? (p 356) __________________________
______________________________________________________________________________

30.

What are three common stomach cancer metastases? (p 356) ____________________________

______________________________________________________________________________

31.

The pain of gastric ulcers is _______________ (increased/decreased) with meals, whereas the pain
of duodenal ulcers is ________________ (increased/decreased) with meals. (p 357)

32.

Name the five symptoms common to all malabsorption syndromes. (p 358) __________________
______________________________________________________________________________

33.

What are three causes of pancreatic insufficiency? What is a major consequence? (p 358) ______
______________________________________________________________________________

34.

Celiac disease is characterized by antibodies to _____________ and _____________________,

and is associated with a skin condition called ___________________________________. (p 358)

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

First Aid Express 2016 workbook: GASTROINTESTINAL

35.

page 5

Compare and contrast the characteristics of Crohn disease and ulcerative colitis. (p 359)
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 the McBurney point used to diagnose appendicitis? (p 360) _________________________

______________________________________________________________________________

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 360) ____________

38.

What is the difference between a false diverticulum and a true diverticulum? (pp 360-361) ______
______________________________________________________________________________

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 362)

41.

What surgical complication can lead to acute bowel obstruction? Is this a common cause of small
bowel obstruction (p 362) __________________________________________________________

42.

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 CNS glioma? (p
363
______________________________________________________________________________

43.

What is the first mutational event typically associated with colorectal cancer? (p 364)___________

44.

What are the signs and symptoms of cirrhosis? (p 365) _______________________________

______________________________________________________________________________

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

page 6

45.

First Aid Express 2016 workbook: GASTROINTESTINAL

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 366)

46.

Match the type of liver disease with its notable characteristic(s) (pp 367-369)
_____ A. 1-Antitripsin deficiency
_____ B. Alcoholic cirrhosis
_____ C. Alcoholic hepatitis
_____ D. Budd-Chiari syndrome
_____ E. Hepatic steatosis
_____ F. Hepatocellular carcinoma

47.

1.
2.
3.
4.
5.
6.

Causes panacinar emphysema

Due to occlusion of IVC or hepatic veins
Fatty changes in macrovesicles; reversible
Mallory bodies
Primary malignant liver tumor in adults
Shrunken liver with irregular surface

Compare and contrast the characteristics of the hereditary hyperbilirubinemias. (p 370)

Characteristic

Crigler-Najjar
Syndrome

Dubin-Johnson
Syndrome

Gilbert 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 371) ______________________
______________________________________________________________________________

49.

What is the cause of bronze diabetes? (p 371) _______________________________________

50.

List three extrahepatic causes of biliary obstruction. (p 371) ______________________________

______________________________________________________________________________

51.

List two intrahepatic causes of biliary obstruction. (p 371) ________________________________

52.

Match the term with its definition. (pp 371-372)

_____ A. Cholangitis
_____ B. Cholecystitis
_____ C. Cholelithiasis

1. Gallstones
2. Infection of the biliary tree
3. Inflammation of the gallbladder

53.

What enzymes are elevated in acute pancreatitis? (p 373) _______________________________

54.

Acute pancreatitis and pancreatic adenocarcinoma share two symptoms: _______________ and
_________________________. What two maneuvers can differentiate between these two
diseases? (pp 373) ______________________________________________________________
______________________________________________________________________________

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

First Aid Express 2016 workbook: GASTROINTESTINAL

page 7

PHARMACOLOGY
55.

List the most common histamine blockers for the GI tract. Which histamine receptor do they affect?
(p 374) ________________________________________________________________________

56.

What are the proton pump inhibitors? Why are they such effective drugs? (p 374) _____________
______________________________________________________________________________

57.

How is misoprostol most commonly used as a GI agent? (p 375) __________________________

58.

What is the most dangerous adverse effect of all antacids? (p 375) _________________________

59.

What powerful medicine is used to control vomiting and nausea after surgery? What receptor does
it target? (p 376) ________________________________________________________________

60.

What drug can be used to treat gastroparesis? What is a worrisome adverse effect? (p 376) ____
______________________________________________________________________________

61. What is the most common side effect of orlistat? What enzymes does it inhibit? (p 376) _________
______________________________________________________________________________

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

page 8

First Aid Express 2016 workbook: GASTROINTESTINAL

Answers
EMBRYOLOGY
1.

Gastroschisis: Caused by failure of lateral fold closure, abdominal contents herniate lateral to
umbilicus, abdominal contents NOT covered in peritoneum. Omphalocele: Caused by failure of
intestines to return to abdomen after physiologic 6-10wk herniation, abdominal contents herniate
through umbilical ring, abdominal contents ARE covered in peritoneum.

2.

Esophageal atresia with tracheoesophageal fistula.

3.

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

4.

Surgical incision to relax the pyloric muscle (pyloromyotomy).

5.

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

ANATOMY
6.

The gastrohepatic ligament may be cut during surgery to provide access to 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.

7.

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

8.

Brunners glands; these are tightly packed glands that secrete copious bicarbonate solution to
neutralize the acidic chyme that leaves the stomach before it can reach the rest of the intestines.

9.

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

10.

Esophageal varices, Caput Medusae (umbilicus), and rectal varices.

11.

External hemorrhoids are painful because they receive somatic innervation.

12.

Zone III (centrilobular zone)

13.

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

14.

Abdominal wall; internal inguinal ring.

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

First Aid Express 2016 workbook: GASTROINTESTINAL

page 9

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 enzyme secretion and relaxation of the sphincter of Oddi. It also results
in increased gallbladder contraction.and decreased gastric emptying.

18.

Parietal cells. Acetylcholine and gastrin contribute to acid secretion, 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 contain IgA-secreting B 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.

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

page 10

First Aid Express 2016 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

cancer?

Yes

Yes

Characteristic lesion

Skip lesions on
cobblestone mucosa

Continuous lesion on friable

mucosa

Extent of inflammation

Transmural

Submucosa

Extraintestinal manifestations

Arthritis
Erythema nodosum
Aphthous ulcers
Kidney stones

Ankylosing spondylitis
Pyoderma gangrenosum
Primary sclerosing cholangitis
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.

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

First Aid Express 2016 workbook: GASTROINTESTINAL

page 11

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.

41.

Adhesions; this is the most common cause of small bowel obstruction in the United States.

42.

Familial adenomatous polyposis; Gardner syndrome; Turcot syndrome.

43.

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

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-2, C-4, D-2, E-3, F-5.

47.
Characteristic

Crigler-Najjar
Syndrome

Dubin-Johnson
Syndrome

Gilbert Syndrome

Impairment

Bilirubin conjugation

Conjugated bilirubin
excretion

Bilirubin uptake

Prognosis

Fatal within a few

years of diagnosis

Benign disease

Benign disease

Symptoms

Jaundice
Kernicterus

Jaundice

Jaundice

48.

Copper; ceruloplasmin; penicillamine.

49.

Deposition of hemosiderin in the skin.

50.

Gallstones, biliary strictures, and pancreatic carcinoma.

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 Courvoisier sign (obstructive jaundice with a palpable,
nontender gallbladder).

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0

This copy belongs to Ochaudhery (Omarchaudhery@yahoo.com)

page 12

First Aid Express 2016 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.

Ondansetron; 5-HT3.

60.

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

61.

Orlistat inhibits gastric and pancreatic lipase, which results in decreased absorption of dietary fats.

Copyright 2016 by MedIQ Learning, LLC

All rights reserved

It was generated on 2016-11-04T17:29:01-07:00

v1.0