Chapter 11 - Pancreas

Chronic cholecystitis - Rokitansky-Aschoff sinus - Porcelain gallbladder

Mallory bodies - Alcoholic hepatitis - damaged cytokeratin filament (AST
> ALT); AST is mitochondrial enzyme
Primary hemochromatosis C282Y (cysteine is replaced by tyrosine) - HFE g
ene. Lipofusion is wear and tear vs. blue of iron Prussian
Primary biliary cirrhosis - intrahepatic bile ducts (anti-mitochondrial
antibody) - obstructive jaundice
Primary sclerosing cholangitis (intrahepatic and extrahepatic bile ducts
) - onion skin, beaded, associated with UC (p-anca) - obstructive jaundice
Tender Loving Care For Nancy (B1, B2, B3, B5, Lipoate)
Enzymes: Branched-chain a-ketoacid dehydrogenase, pyruvate dehydrogenase
, and alpha-ketoglutarate dehydrogenase, transketolase
Think ATP
VACCINE: Polysaccharide conjugated with Diphtheria = H Flu B
Paroxysmal Supraventricular tachycardia (PSVT) - sudden heart palpitations witho
ut history, come and go
Carotid sinus massage - enhances Vagal stimulation - parasympathetic ton
e causing temporary inhibition of SA node activity, prolongation of AV node refr
actory period
HNPCC - does not involve mutations of proto-oncogenes or anti-oncogenes, one cop
y is inherited, the other is sporadic mutation. Not from a typical adenomatous p
olyp (sporadic two-hit)
DNA mismatch repair gene defect (0429)
SLE - Anti-dsDNA
CA 19-9 (Pancreatic cancer)
CEA (Colon)
CA-125 (Ovarian)
Drug-induced SLE - Anti-histone
EDTA (Lead/Mercury)
Defero (iron)
Dimercaprol (arsenic) - Garlic odor on breath
Sjogren - Anti-Ribonucleoprotein
Scleroderma (CREST - localized = Anti-centromere) (Systemic - Anti-DNA Topoisome
rase I)
Mixed CT disease (U1 ribonucleoprotein)
Gross hematuria - can be seen with the naked eyes (in case of sickle cell crisis
) vs. Ischemic necrosis (not gross) can be due to acute tubular necrosis, Fancon
i, Hypersensitiviy
Increased estrogen can lead to an increase in Thyroxine-binding protein (increas
e in Total T4 pool)
B. fragilis G- anaerobic bacillus (intraabdominal infections - polymicrobials) E. coli also
Length constant measures how far an axon can travel - in case of MS, demyelinati
on will decrease it
Pneumonia - SOB, fever, cough PE - hypoxia, SOB
Pericarditis - w
orse supine
All can cause sharp pain with inspiration
TTP-HUS (pentad of fever, neurologic symptoms, renal failure, anemia, and thromb
ocytopenia in setting of GI illness) - Schistocytes, normal PT and aPPT, platele
t-rich arterioles
Crescentic/RPGN (Macroscopic hematuria-NOT GROSS, HTN, renal failure, Anti-GBM w
/ hemoptysis in Goodpasture, immune-complex mediated SLE, pauci-immune Wegener)
Diffuse proliferation and subepithelial deposits - PSGN (type III)
Henoch-Schonlein Purpura palpable purpura, IgA nephropathy (upper respiratory i
nfection, recurrent hematuria)
Acute Tubular necrosis - Granular casts, myoglobinuria

Neuroleptic malignant syndrome (NMS) - lead-pipe, mental changes, diffuse bradyr

eflexia (Pt with manic episodes that receive antipsychotic meds) VS. SerotoninS
(hyperreflexia and clonus)
Malignant hyperthermia (inhaled anesthetic/succ induce fever and severe muscle c
ontractions - Dantrolene ryanodine Ca2+ can also be used for NMS)
HPV 16, 18 - Cervical and Anal squamous cell carcinoma
HSV2 - not usual
ly cause Anogenital cancer
Pentose Phosphate Pathway occurs in the cytoplasms (such as Transketolase and G6
PD)
Reactions of B-oxidation, ketogenesis, CTA, parts of Urea (CPS 1
and Ornithine transcarbamoylase) occurs in the mito
Metastatic gastric cancer - Virchow's node, Sister Mary Joseph nodule-periumbili
cal, or krukenberg of ovary
Pt with seizures to ED with fever and generalized diffuse skin rash, symmetrical
facial swelling (had seizures several weeks ago and was prescribe phenytoin) EOSINOPHILIA/DRESS syndrome (Drug Reaction with Eosinophilia & Systemic Symptoms
)
Central Retinal Artery occlusion - pale due to blood loss, ischemic, painless, s
udden, whole visual field. Cherry Red Macula (Macula has different blood supply
makes it red)
Multiple hypodense nodules in the Liver - metastatic liver disease (most common
breast, lung, colon) in a patient without history of cirrhosis or Hep B/C
Patient with DM II with HTN, don't use HCT (hyper GLUC), use ACE inhibitor inste
ad, microalbuminemia can only be detected by urine dipstick if above 300
Matrix metalloproteinases (MMP) are important in wound healing, encourages both
myofibroblast accumulation and scar tissue remodeling (wound contraction) even t
hough its main function is degrade collagen
Systemic candida has to do with neutrophils as compared with localized topical d
ue to T-cells
Primary biliary cirrhosis (PBC) - chronic autoimmune, dense portal tract infiltr
ate of macrophages, lymphocytes, plasma, eosinophils - granulomatous destruction
of intrahepatic/interlobular bile ducts (fatigue, pruritis, pale stools, xanthe
lasma)
Primary Sclerosing cholangitis - diffuse inflammation/fibrosis of large intra/ex
tra hepatic bil ducts with periductal concenric fibrosis (onion skin patterns),
fatigue and high ALP with history of UC
Encephalitits (headache, fever, mental changes, seizure) with history of HSV1-tr
igeminal, necrosis of Temporal Lobe with personality changes (hypersexuality, ag
gression), aphasia
Toxoplasma - think immunocompromised HIV, ring enhancing lesions instead of hemo
rrhagic like HSV
Imatinib - Philadelphia - Tyrosine kinase receptor inhibitor
Inflixim
ab - TNF-a monoclonal antibody
NIB - kiNase InhiBitor
Chronic kidney disease - low Vit. D, hyperphosphatemia binds free Ca2+ leading t
o secondary hyperPTH
Patient with BPH - avoids TCA (imipramine, doxepin, amitryptyline, clomipramine)
due to H1 antogonism, central/peripheral muscarinic, block cardiac fast sodium
(arrhythmias), norEpi & S reuptake block-tremor, insomnia
IV Drug user, hemorrhagic infarct to the lungs (red), mosly likely due to septic
embolism due to tricuspid valve endocarditis, pt experiences fever
Adrenal Insufficiency - vomitting, ab pain, weight loss, hyperpigmentation due t
o increased ACTH due to low corticosteroids) - when pt becomes hypotensive and t
achycardic, hypoglycemic = adrenal crisis, administered Corticosteroids
Scrotum not descended - high temperature affecting seminiferous tubules - no Inh
ibin (lead to high FSH), normal 2nd due to Leydig-LH working fine in higher temp
releasing testosterone. Pull the testicles down through Exernal oblique aponeur
osis
METABOLIC ACIDOSIS - Winter's formula to estimate PaCO2 = 1.5[HCO3-] + 8 +/- 2
if this is not correct within range then most likely respiratory failure
Polycystic ovary syndrome (hyper insulin/resistance alter feedback, high LH:FSH,
high androgens theca interna, anovulation, subfertility, bilateral cystic ovari

es, amenorrhea, hirsutism, acne, obesity) - Clomiphene (Estrogen RECEPTOR MODULA

TOR-decreases negative FB inhibition by circulating estrogen, increasing GnRH se
cretion)
Oral Contraceptive pills - treat hirtutism, suppress LH from pituitary, decreasi
ng ovarian androgen production, increases sex-hormone globulin synthesis by live
r, decrease free testosterone.
Atypical depression: mood reactivity, legs/arm feel heavy, rejection sensitivity
(slight criticism), and increased sleep and appetite - MAO inhibitors such as p
henelzine as well as treatment-resistant depression
Major depression does not have mood reactivity (positive events will not change
mood) - SSRI
PAPILLARY Thyroid carcinoma - most common, psammosa bodies, large cells with nuc
lei finely dispersed chromatin with Orphan Annie eye, intranuclear inclusion, gr
ooves.
MEDULLARY - stains for Calcitonic para-follicular C cells, Men 2AB
Syphyllis - Palms and soles rash, cardiolipin, lecithin, cholesterol
ABPA - asthma, CF, Bronchiectasis, eosinophil
Beurger Disease - segmental vasculitis extending into contiguous veins and nerve
s - intradermally injected tobacco extract. Vasculitis medium/small, tibial/radi
al arteries (age 35 onset) severe distal pain due to neural involvement.
Blunt abdominal trauma - thinks Spleen gone with internal bleeding, encapsulated
bacteria can cause infection due to low systemic bacterial clearance (Strep pne
umonia, H. influenza, Neisseria)
Thiazide (Chlorthalidone) causes NaCl- loss with water leading to an increase in
aldosterone leading to Hypokalemia (cramping symptoms) and metabolic alkalosis.
Cyanide toxicity - direct binding of cyanide ions (hydroxocobalamin), induction
of methemoglobinemia (sodium nitrite), and detoxifying sulfur donors (sodium thi
osulfate)
Craniopharyngioma - cholesterol crystals with dystrophic calcification, stratifi
ed squamous, Rathke, surface ectoderm, forms the anterior pituitary (adenohypoph
ysis). Posterior pituitary - outpouching of diencephalon neuroectoderm
Glycerol kinase converts Glycerol to G3P into DHAP and generate Gluconeogenesis
(can cause DKA)
Acetyl CoA carboxylase is B7 dependent, Acetyl CoA to ma
lonyl CoA
IgA NEPHROPATHY (Berger disease), glomerulonephritis (most common cause), older
children/young adults, PAINLESS hematuria within 5-7 days of upper RESPIRATORY i
nfection, mesangial hypercellularity, IgA deposit
Extrarenal symptoms such as ab pain, arthralgias, palpable purpu
ra = HENOCH-Schonlein purpura
PSGN - Granular IgG and C3 deposits, strep pharyngitis 2-3 weeks
Pregnancy associated clots DVT can be treated with LMWH due to lower risk of HIP
(thrombocytopenia)
CHOLESTEROL GALLSTONES - High level of bile salts and phosphatidylcholine decrea
se risk of stone formation due to increase of cholesterol solubility. Obstructed
stone will have high cholesterol and low bile salts/phosphatidylcholine
Acute MS - internuclear ophthalmoplegia still work somewhat due to loss of salta
tory conduction, loss of axons would occur with chronic
Reduce craving for alcohol - naltrexone 1st line. Alcohol dehydrogenase can caus
e disulfiram. Acamprosate can be used once abstinence has been achieved (glutama
te NMDA)
Fidaxomicin - can be used to treat clostridium difficile infection (macrocyclic
antibiotics) inhibit RNA polymerase, less effect on normal colonic flora.
Glutamin + Aspartate = Pyrimidines
Glutamine + Aspartae + G
lycine = Purine
Sepsis (fever, low BP) and Aspiration (seizures/impaired consciousness) can caus
e ARDS (cytokines acivate pulmonary epithelium, inflammation, neutrophils, capil
lary damage, leakage of protein and fluid into alveolar space)
Corticosteroids can increase risk of infection, Neutrophilia (neutrophil demargi
nation), increase Surfactant production. Decreased lymphocyte, monocyte, basophi
l, and eosinophil counts.

All 3 prokaryotic DNA polymerases can remove mismatched nucleotides via 3'-5' ex
onuclease ("proofreading") activity. Only DNA Pol I has 5'-3' exonuclease activi
ty, remove RNA primer
DNA Pol I = #1 = can do more (remove RNA primer w/ 5'-3')
Pure Red Cell aplasia - hypoplasia of marrow eryhroid elements in normal platele
/leukocyte counts - associated with thymoma, lymphocytic leukemias, parvovirus B
19. IgG/cytotoxic T-lymphocytes
RCC associated with 2nd EPO, NOT LOW erythrocyte count. Also occurs in m
uch older patient instead of 35 years for pure RBC
Circle of Willis - associates with Coarctation of the aorta adult type (before P
DA) cause upper HTN, increasing risk of rupture.
Primaquine (P vivax and ovale) to eradicate inrahepatic stages (hypnozoites - re
sponsible for relapse).
Patient with exertional dyspnea without past MH, relatives dues of pulmonary HTN
. Low S2 at upper sternal border => vascular smooth muscle proliferation
Polyarteritis Nodosa - associated with Hep B, medium-small, young adults, GI ble
eding, myositis, arthritis, glomerulonephritis, HTN, transmural inflammation, fi
brinoid necrosis (VIRAL-weight loss, IV drug abuse)
Aspirin causes microvesicular steatosis (no necrosis or inflammation, swelling,
decreased mitochondria and glycogen) - hyperammonemia-cerebral edema
CLEAR CELL CARCINOMA - RCC (most common subtype) - fever, anorexia, weightloss,
can secrete EPO, PTHrP. Detected incidental, (lungs most common site) - elevate
d Hematocrit
Large, rounded, polygonal cells with clear cytoplasm (hematuria, flank p
ain, palpable mass in late disease)
Dengue Fever - Retro-orbial pain, myalgias & joint pains (break bone fever), Ras
h, thrombocytopenia <100k, Positive tourniquet test
ssRNA
ACE Inhibitor can cause Hyperkalemia, the addition of K-sparing diuretics can wo
rsen the hyperK+ (amiloride, triamterene, and spironolactone)
Crackles at Lung bases - Left heart failure due to transudate accummulate in the
interstitium of the lung => Decreased lung compliance
In cases where 21-hydroxylase def causing an increase in androgen production, co
rticosteroid can be given to suppress ACTH to reduce production of androgen
Coronary Steal is a phenomenon in which blood flow in ischemic areas is reduced
due to arteriolar vasodilation in nonischemic areas - hypoperfusion and worsenin
g of exising ischemia (Adenosine & Dipyridamole)
cANCA associated with Wegener (RPGN) is also called "pauci immune" due to absenc
e of Ig and C3 deposit in IF. Crescent are found. Renal failue, Upper respirator
y, hemoptysis
Dystrophic calcification occurs in damaged or necrotic tissue in the setting of
normal calcium in case of Aortic valve calcification in old age.
Acyl CoA synthase (Primary carnitine deficiency) - Muscle weakness, cardiomyopat
hy, hypoketotic hypoglycemia, elevated muscle TG
Acyl CoA dehydrogenase (Medium chain acyl CoA dehydrogenase MCAD def) - Hypoglyc
emia, hypoketotic hypoglycemia (low Acetoacetate)
Tumor lysis syndrome causes an increase loss of ions and uric acid, soluble at p
hysiologic pH, precipitate in normally acidic environment of distal tubules/coll
ecting ducts. Urine alkalinization (Sodium bicarb & hydration)
Heroin dependent - long half life of methadone
Cortisol increases the conversion of NorEpi to Epi in the adrenal medulla (pheny
lethanolamine-N-methyltransferase)
COMT (to nor/metanephrine) and M
AO (meta to VMA) breaks down catecholamines
Measles (Rubeola) - Prodrome (conjunctivitis, coryza, cough, Koplik spots), rash
from trunk out, spares palms/soles, Encephalitis (days), Acute disseminated enc
ephalomyelitis (weeks), S Sclerosing paneccephalitis (years)
Live attenuated measles vaccine
ssRNA - membrane bound hemagglut
inin
In Metabolic DKA, urine will become acidic (low pH), an increase in Bicarb absor
ption occurs leading to lower HCO3- in the urine, H2PO4- acts as a buffer and wi
ll increase in the urine for trapping H+ (NH4+)

Courvoisier sign - palpable but nontender gallbladder, weight loss, obstructive

jaundice (pale stools, pruritis, dark urine) most likely due to adenocarcinoma o
f pancreas head compressing common bile duct due to smoking
Vitiligo - loss of epidermal melanocytes vs. Albinism (no melanin production)
Prostate cancer - Flutamide nonsteroid anti-androgen, competitive inhibitor of t
estosterone receptors
Rifamixin - nonabsorbable antibiotic that decreases intraluminal ammonia product
ion - treat HEPATIC ENCEPHALOPATHY, lactulose as well (increases conversion of N
H3+ to NH4)
Cephalosporins and penicillin binds to PBP Transpeptidases (Not cell wall glycop
roteins - vanco)
ACUTE TUBULAR NECROSIS (due to blood loss) - Initiation stage, Maintainance (dec
reased urine output, hyperkalemia,fluid overload), Recovery (hypokalemia, Mg, ph
osphate, Ca, high volume diuresis).
Tubular function has not fully recovered so cannot absorb in the proxima
l tubule
THROMBOTIC Thrombocytopenic Purpura - ADAMTS13 large vWF multimers, platelet ric
h thrombi, normal PT/PTT, high LDH, low haptglobin, schistocytes, Renal failure
(high creatinine), Neurologic (weakness, numbness of extremities),Fever
Abnormal RISTOCETIN test (vWF and GP Ib) - 1st step, addition of plasma will cor
rect vWF (plasma contains vWF) but will not correct GP Ib because vWF is normal
Ristocetin is also normal in GP IIb-IIIa due to normal level of vWF and
GP Ib
Cysteine & Uric stones will precipitate in acidic environment (pH < 7) Cystinur
ia (AR) defective transport of COLA (Cysteine, Ornithine, arginine, lysine) caus
es nephrolithiasis, hexagonal cystine crystals
Right sided colon cancers (exophytic masses, bleeding, iron def anemia) Left-sid
ed colon cancers (infiltrate intestinal wall, encircle lumen, constipation and i
ntestinal obstruction, rectosigmoid)
(Ascending colon - weight loss and progressive fatigue)
DNA pol I = DNA #1 can do more, including 5'-3' (this functions remove RNA Prime
r) and 3'-5' exonuclease acitivity (which can be done by DNA pol III as well)
Whipple disease - ab discomfort, greasy stool, weight loss, joint pain, macropha
ges with PAS+ granules. diastase-resistant granules - lysosomes and partially di
gested bacteria
Filtration fraction = GFR/RPF
GFR = 100mL/min
RPF = RBF(1-hema
tocrit)=1L(1-0.5) = 0.5 Filtration fraction = 0.2
Hematocrit is 0.5 meaning that only 0.5 is plasma (the fluid that gets f
iltered)), so if we filter 100mL out of 500mL, the fraction is therefore 0.2
After about 18 hours, Glycogen is depleted (finished glycogenolysis), Gluconeoge
nesis takes place OXA -> PEP by PEP carboxyKINASe
Rheumatoid arthritis - morning stiffness, fever, weight loss, CERVICAL SPine inv
olvement (subluxation, cord compression), ANTI-CCP antibodies
In PRIMARY osteoporosis (old age), serum calcium, phosphate, PTH are all NORMAL
Beta blocker inhibits the B1 receptor at the JG cells reducing Renin excretion,
ATI, ATII, Aldoserone, Bradykinin stays NORMAL (due to ACE intact)
C Dif infection, use nonsterile gloves and gowns for contact due to body fluid.
Gq - IP3 causes release of Ca2+ which activates Protein Kinase C, which phosphor
ylate Protein, smooth muscle contraction
Eye - a1 receptor - agonist will cause mydriasis. Uterine belongs to B2, stimula
tion leads to uterine relaxaction (tocolysis) such as ritodrine and terbutaline.
Head trauma can cause Hyperosmotic volume contraction (decreases volume of both
Extra & Intra compartment and raises the osmolality), as well as profuse sweatin
g (hypotonic nature of sweat)
KIT+, rash, prupritis = Mastocytosis - Gastric hypersecretion due to high Histam
ine
Sepsis can cause Lactic acidosis due to tissue hypoxia (impaired oxidative phosp
horylation resulting in shunting of pyruvate to lactate) - Low Bicarb & High Lac
tic acid/. Increased Anion Gap=[Na+]-['Cl-][HCO3-]

Impaired ubiquitin-proteasome system can contribute to neurodegenerative disorde

rs, Parkinson & Alzheimers
Acute hepatitis A (fever, malaise, anorexia, nausea/vomitting, right upper quad
pain), followed by signs of cholestasis (jaundice, pruritus, dark urine, clay-co
lored stool)
Rabies - encephalitic (hydrophobia, aerophobia, agitation) & Paralytic (ascendin
g), Bats cave, coma, respiratory failure, death within WEEKS - Inactivateds vacc
ine for treatment
1st gen antipsychotics - Low-potency (non-neurologic fx-sedation, anticholinergi
c, orthostatic hypotension), High-potency (ExtraPyramidal)
Polycystic Ovarian Syndrome (Enlarged bilateral ovaries) - elevated LH due to in
crease LH receptor expression, insulin resistance, obesity, lipid, androgen (acn
e, hirsutism, male PHairloss), anovulation/infertility
Aedes aegypti mosquitoes - dengue fever and chikungunya (brazil travel)
Dengue - febrile acute, headache, retro-orbital pain, joint and muscle p
ain
Chikungunya - febrile, flulike symptoms, prominent polyarthralgias, diff
use macular RASH