CHAPTER 2

Solved UHS SEQs &

MCQs of Second-Year MBBS
with Practice MCQs & Notes
According to UHS Modular Syllabus
ALL 3 Blocks in 1 Book

A Path Towards Excellence

Authors

DR. ABDUL MANAN

DR. AAYBAAD AHMAD
DR. GHULAM DASTGEER
 Copyright 2025
© All rights reserved TO THE PUBLISHERS. This book is protected by Copyright Act. No part of this
publication can be reproduced, stored in retrieval system, or transmitted in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, without prior permission of the copyright
owners.
ISBN 969__

FIRST EDITION 2024

SECOND EDITION 2025

Title:
CHAPTER 2

Authors:

DR. ABDUL MANAN

DR. AAYBAAD AHMAD
DR. GHULAM DASTGEER

Printed at:
Ishtiaq Mushtaq Printers, Lhr.
 ‫ٱلر ْح ه َم ِن ا‬
‫ٱلر ِح ِيم‬ ِ ‫ِب ْس ِم ه ا‬
‫ٱَّلل ا‬
"In the name of Allah the Most Gracious, the Most Merciful"

َ ‫ان ِإ اَّل َما‬

‫سعَى‬ ِ ‫س‬َ ‫ْل ْن‬ َ ‫( َوأ َ ْن لَي‬53:39)
ِ ْ ‫ْس ِل‬
And that man shall have nothing but what he strives for.

Contributed by Ahmad Raza (N68)

 Preface
Assalam-o-Alaikum!
We are glad to present you this book of Second Year MBBS which will be very helpful
in UHS exam. Its major aims are to provide topic-wise past SEQ’s and MCQ’s with authentic
answers according to UHS Modular syllabus. This book also contains Notes of Minor Subjects
& Minor topics of Major subjects, Practice MCQs of all subjects from authentic international
sources.
Ideally one should practice SEQ’s and MCQ’s from this book. Adopting this routine, it will
sharpen the conceptual understanding of the subject, and will prove a beneficial tool for
subsequent examination preparation

We tried our best to make this book helpful. Please let us inform your feedback at:
mananansari3424@[Link]
aaybaadahmad@[Link]
g.dastgeer001@[Link]

Wishing you all the success!

D E D I C A T E D TO
Our Parents & Teachers
and
Our Whole Family N-68
(Please Remember our late fellow Dr. Maryam Khan in your prayers)

For Details, Please Contact at:

Abdul Manan: 0308-8054273
Ghulam Dastgeer: 0308-1364301
Aaybaad Ahmad: 0309 0666200
Authors
Appreciation Letter by
Principal of Nishtar
Medical College
As the Principal of Nishtar Medical College,
“I am pleased to express my sincere appreciation to our Nishter graduates, from N68,
who have taken the initiative to write a past paper book series “Medical Mind Series” for their
fellow peers. This book is a valuable resource that will aid students in their preparation for
upcoming exams and provide them with an opportunity to practice and improve their knowledge
and skills. The dedication and hard work that our students have put into this project is
commendable and reflects their commitment to academic excellence. It is a testament to their
passion for learning and their desire to help their fellow students succeed. I am confident that
this past paper book will prove to be an invaluable tool for our students and will contribute to
their success as they progress through their academic journey. Once again, I would like to extend
my heartfelt appreciation to the students who have worked tirelessly to make this initiative a
reality.

Best Regards,
Dr. Muhammad Rashad Qamar Rao
 DETAILED CONTENTS
BLOCK-4

MODULE-6 (GIT & NUTRITION)

# Subject Page No.
01. GROSS ANATOMY 3
02. EMBRYOLOGY 34
03. HISTOLOGY 39
04. PHYSIOLOGY 45
05. BIOCHEMISTRY 59
06. PATHOLOGY 90
07. PHARMACOLOGY 97
08. BEHAVIORAL SCIENCES 99
09. COMMUNITY MEDICINE 107
10. AGING 117
MODULE-7 (RENAL MODULE)
01. GROSS ANATOMY 119
02. EMBRYOLOGY 122
03. HISTOLOGY 125
04. PHYSIOLOGY 29
05. BIOCHEMISTRY 152
06. PATHOLOGY 67
07. PHARMACOLOGY 76
08. BEHAVIORAL SCIENCES 79
09. COMMUNITY MEDICINE 81
10. AGING 185

BLOCK-5

MODULE-8 (ENDOCRINOLOGY & REPRODUCTION)

# Subject Page No.
01. GROSS ANATOMY 192
02. EMBRYOLOGY 214
03. HISTOLOGY 221
04. PHYSIOLOGY 232
05. BIOCHEMISTRY 271
06. PATHOLOGY 314
07. PHARMACOLOGY 332
08. COMMUNITY MEDICINE 333
09. BEHAVIORAL SCIENCES 338
10. AGING 41
 MODULE-9 (HEAD & NECK, SPECIAL SENSES)
01. GROSS ANATOMY 343
02. EMBRYOLOGY 384
03. HISTOLOGY 391
04. PHYSIOLOGY 395
05. BIOCHEMISTRY 416
06. PATHOLOGY 420
07. COMMUNITY MEDICINE 424
08 BEHAVIORAL SCIENCES 426
09. AGING 428

BLOCK-6

MODULE-10 (NEUROSCIENCES)
# Subject Page No.
01. GROSS ANATOMY 435
02. EMBRYOLOGY 470
03. HISTOLOGY 474
04. PHYSIOLOGY 479
05. BIOCHEMISTRY 516
06. PATHOLOGY 536
07. PHARMACOLOGY 538
08. COMMUNITY MEDICINE 542
09. BEHAVIORAL SCIENCES 543
10. MEDICINE 546
11. SURGERY 549
12. PEDIATRICS 551
13. AGING 552
MODULE-11 (INFLAMMATION)
01. EMBRYOLOGY 554
02. HISTOLOGY 557
03. BIOCHEMISTRY 560
04. PATHOLOGY 562
05. PHARMACOLOGY 579
06. COMMUNITY MEDICINE 584
07. BEHAVIORAL SCIENCES 587
08. AGING 588
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

BLOCK-4
TOS
SUBJECT SEQ MCQ MARKS
ANATOMY 3 23 38
PHYSIOLOGY 2 18 28
BIOCHEMISTRY 3 22 37
PATHOLOGY 1 11 16
PHARMACOLOGY 1 5 10
COMMUNITY MEDICINE 0 6 6
BEHAVIORAL SCIENCES 0 5 5
9x5 = 50 90 140

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[1]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

MODULE-6
GIT & NUTRITION

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[2]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

A001 – A013
GIT GROSS ANATOMY
A-001 ֍ORAL CAVITY & OROPHARYNX֍

01. Tonsil & Waldeyer’s ring

1. A 7 years old boy was brought to paediatrician with complains of sore throat, earache, snoring and mouth breathing. His X rays
confirmed the provisional diagnosis of Adenoid hypertrophy. Define this condition. Also give anatomical reasoning of mouth
breathing. Enlist the components of Waldeyer's ring of lymphoid tissue
Adenoid hypertrophy
 Enlargement of Adenoid that is a mass of lymphoid tissue located in the nasopharynx
Anatomical reasoning
 Enlarged adenoid block the nasal passages, forcing the child to breathe through their mouth
Components of Waldeyer‘s ring
1. Pharyngeal tonsil (adenoids)
2. Tubal tonsils
3. Palatine tonsils
4. Lingual tonsils

2. Give location of palatine tonsil. Enumerate the structures forming tonsillar bed & which nerve lies here?
Location
o Tonsillar bed between palatoglossal arch (anterior pillar) & palatopharyngeal arch (posterior pillar)
Structures forming tonsillar bed
o Superior pharyngeal constrictor
o Styloglossus muscle
o Pharyngobasilar fascia
Nerve
o Glossopharyngeal nerve (IX nerve)

3. Name the arterial supply of tonsils. Name the vessel most commonly responsible for postoperative bleeding after tonsillectomy.
Arterial blood supply
1. Tonsillar branch of facial artery (main supply)
2. Ascending palatine
3. Descending palatine
4. Ascending pharyngeal
5. Lingual
Vessel responsible for Post-operative bleeding
o External palatine vein

02. Parotid Gland

1. What are the various relations of the parotid gland?

o Zygomatic arch superiorly
o External ear and anterior border of the sternocleidomastoid posteriorly
o Ramus of the mandible medially
o Anterior border of the masseter muscle anteriorly
o Angle and inferior border of the mandible inferiorly

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[3]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. Name the structures lying within the parotid gland.

o External carotid artery and peri-arterial plexus
o Retromandibular vein
o Parotid plexus of the facial nerve (CN VII)

3. Give nerve supply of parotid gland. Also give the reason for radiation of pain from jaw to ear and forehead of same side in a patient
with swelling of parotid gland.

Parasympathetic supply Glossopharyngeal nerve  otic ganglion  auriculotemporal nerve  gland

Sympathetic supply Cervical ganglia  external carotid nerve plexus on the external carotid artery  gland
Sensory supply Great auricular and auriculotemporal nerves innerve gland & parotid sheath
Reason of pain radiation  auriculotemporal and great auricular nerves, which supply parotid gland also supplies sensory fibers to
the skin over the temporal fossa and auricle

4. Where does parotid duct open within the buccal cavity?

Opposite the upper second molar tooth in the vestibule of mouth

5. A 60 years old male presented with sweating and flushing in preauricular area in response to mastication. He gives history of facial
mass surgery 8 months ago. What is your probable diagnosis? And what is underlying cause? (4th yeal Past paper)
Diagnosis  Frey's Syndrome
Underlying cause  Parasympathetic fibers that supply parotid glands are misdirected to the sweat glands

03. Submandiblar & Sublingual gland

1. A 55 years old man presents with history of recurrent right submandibular painful swelling. Swelling becomes bigger in size &
painful during eating. On examination, she had lump in submandibular area which is slightly tender and on bimanual examination, a
small hard object is noted in floor of mouth in sublingual area. (Final year past paper)
a) What is the diagnosis?
Salivary gland stone (calculus)
b) Which gland is most commonly affected in this condition?
Submandibular gland
c) Write relation of most commonly affected gland with lingual nerve?
Submandibular duct, approximately 5 cm long, arises from the portion of the gland that lies between the mylohyoid and hyoglossus
muscles. Passing from lateral to medial, the lingual nerve loops under the duct that runs anteriorly, opening by one to three orifices on
a small sublingual papilla beside the base of the lingual frenulum
d) To what group of lymph nodes, the submandibular gland drains?
Lymphatic From Submandibular Gland  Submandibular Lymph nodes  Jugulodigastric & Jugulo–omohyoid Lymph Nodes

04. Palate

1. Name muscles of soft palate with their action and nerve supply.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[4]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

05. Tongue

1. What is nerve supply of tongue?

2. Describe the sensory, motor and taste innervation of tongue
3. Which part of tongue is supplied by Pharyngeal plexus?
4. Draw and label a diagram showing sensory nerve supply of tongue

Sensory Special (Taste) Motor

Anterior 2/3 Lingual nerve branch of Chorda tympani branch of the Hypoglossal nerve supplies all intrinsic
Pre-sulcal part mandibular division of trigeminal facial nerve & extrinsic muscles of tongue except
nerve (CN V3) palatoglossus that is innervated by CN
Posterior 1/3 Glossopharyngeal nerve Glossopharyngeal nerve X via pharyngeal plexus
Post-sulcal part

5. Write the lymphatic drainage of tongue.

o Lymph from the root drains bilaterally into the superior deep cervical lymph nodes.
o Lymph from the medial part of the body drains bilaterally and directly to the inferi or deep cervical lymph nodes.
o Lymph from the right and left lateral parts of body drains to the submandibular lymph nodes on the ipsilateral side.
o The apex and frenulum drain to the submental lymph nodes, the medial portion draining bilaterally.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[5]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

6. What is tongue tie? Which muscle is known as safety muscle of tongue?

o Tie tongue  condition where tongue is attached to the flour of mouth by Frenulum
o Safety muscle  Genioglossus
06. Pharynx

1. Enlist the structures passing in gap between superior and middle pharyngeal constrictors to the internal aspects of the pharyngeal
wall.

Gap Structures Passing

Between superior pharyngeal constrictor & cranium  Levator veli palatini
 Pharyngotympanic tube
 Ascending palatine artery
Between the superior and middle pharyngeal  Stylopharyngeus
constrictors  Glossopharyngeal nerve
 Stylohyoid ligament
Between the middle and inferior pharyngeal constrictors  Internal laryngeal nerve
 Superior laryngeal artery and vein
Inferior to the inferior pharyngeal constrictor  Recurrent laryngeal nerve
 Inferior laryngeal artery
Note: Whole table is made because it is important & usually asked in mcqs

2. Give the formation of pharyngeal plexus. Enlist the structures supplied by it.
Formation
o Motor fibers in this plexus are derived from vagus nerve (X nerve)
o Sensory fibers in this plexus are derived from glossopharyngeal nerve (IX nerve)
o Sympathetic fiberes in this plexus are derived from superior cervical ganglion
Structures supplied
o All muscles of pharynx except staylopharyngeus
o All muscles of soft palate except tensor veli palatini
o Palatoglossus muscle of tongue

A-002 & A003 ֍ANTERIOR ABDOMINAL WALL֍

01. Planes & Quadrants of abdomen

1. Name two horizontal and two vertical imaginary lines responsible for this division. (Final year past paper)
Horizontal Imaginary Lines
1. Transpyloric Line (L1) Structures at level of Transpyloric plane (L1)
2. Trans–tubercular Line  9th costal cartilage
 Gallbladder fundus
Vertical Imaginary Lines  Stomach pylorus
1. Left Midclavicular Line  Kidney hilum
2. Right Midclavicular Line  SMA

02. Nerve Supply & Blood Supply

There is no past seq from this topic. However, remember that following nerves of anterior abdominal wall:
o Lower six thoracic nerves
o L1  iliohypogastric & ilioinguinal nerve

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[6]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

03. Muscle & Rectum Sheath

1. Describe the composition of anterior and posterior wall of rectus sheath.

Site Anterior wall formed by Posterior wall formed by

Above the costal margin Aponeurosis of the external oblique Thoracic wall—that is, the 5th, 6th & 7th
costal cartilages and the intercostal spaces.
Between the costal margin and the level of Aponeurosis of external oblique & Aponeurosis of posterior lamina of internal
the anterior superior iliac spine (midway anterior lamina of internal oblique oblique & transversus abdominis
b/w umbilicus & pubic symphysis)
Between the level of the anterosuperior Aponeuroses of external & internal Posterior wall is absent, and the rectus
iliac spine and the pubic symphysis oblique + Transversus abdominis muscle lies on fascia transversalis

DO YOU KNOW!
Hematoma of the Rectus Sheath  acutely tender mass confined to one rectus
sheath is diagnostic. Source of the bleeding is the inferior epigastric vein or, more
rarely, the inferior epigastric artery

04. Inguinal ligament & Inguinal canal

1. Give the location and extent of inguinal canal. What structures form the anterior wall, posterior, roof and floor of the inguinal
canal?
2. What are superficial and deep inguinal rings?
The inguinal canal is about 4cm that extends from the deep inguinal ring, a hole in the fascia transversalis, downward and medially to
the superficial inguinal ring, a hole in the aponeurosis of the external oblique muscle. It lies parallel to and immediately above the
inguinal ligament.
Boundaries
o Roof: Formed by the conjoint tendon
o Posterior wall: Formed by transversalis fascia laterally & reinforced medialy by Conjoint tendon
o Anterior wall: Formed by the external oblique aponeurosis, reinforced laterally by internal oblique
o Floor: Formed by the free inferior edge of the external oblique aponeurosis, rolled inwards thickened to become the inguinal
(Poupart‘s) ligament, and medially by lacunar ligament also.

3. Enumerate the contents of inguinal canal.

4. Give contents of inguinal inguinal canal in male.

In male In female
o Spermatic cord & its contents; o Round ligament of uterus
 Vas deferens o Ilioinguinal nerve
 Testicular artery o Genitofemoral nerve
 Testicular veins (pampiniform plexus)
 Testicular lymph vessels
 Autonomic nerves
 Genital branch of the genitofemoral nerve
 obliterated remains of the processes vaginalis

5. A middle-aged man presented in a hospital with a swelling in the right groin which extended into the right half of the scrotum. A
diagnosis of indirect inguinal hernia was made. Name the apertures through which the abdominal contents had to pass to reach the
scrotum. Enlist the structures present in the anterior wall and posterior wall of the inguinal canal.
Apertures
1. Deep inguinal ring
2. Superficial inguinal ring
Anterior wall & Posterior wall
See Q1

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[7]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

6. An old patient of 65 year of age developed swelling in inguinal region which was extending into the scrotum when examined, with
your knowledge of anatomy: Name the canal involved, give its extent and structures forming wall.
Inguinal canal (See Q1)

05. Hernias

1. Give four differences between direct and indirect inguinal hernia.

2. Name the hernia entering the inguinal canal at deep inguinal ring. Give its relation to inferior epigastric artery.
Features Direct inguinal hernia Indirect Inguinal hernia
Congenital/Acquired Acquired in old age Congenital
Entry of hernial sac Through Hesselbach triangle Through deep inguinal ring into inguinal canal
Extent Pass through only superfical inguinal Pass through both deep & superficial inguinal
ring ring
Descent into scrotum No Yes
Relation with inferior epigastric artery Medial Lateral
Response on deep ring occlusion test Bulge appears No buldge appears

3. A 40 old male weight lifter gradually develops a reducible lump in his left groin region. The General surgeon on examination found
that on coughing this groin mass become more prominent. However, after reducing and blocking deep inguinal ring, this mass does
not appear on coughing. What the most probable type of inguinal hernia in this scenario?
Indirect inguinal hernia
4. A 28 year old male came to surgical OPD with complaint of swelling at right inguinal region extending towards scrotum. He further
added that this swelling is reducible. Surgeon after examination labelled this is as Hernia.
a) Give the type of hernia.
Inguinal hernia
b) Why it's more common in male and on right side?
 Common in males because of passage of spermatic cord through inguinal canal
 More common on right side due to delay ijn atrophy of processus vaginalis after the normal slower descent of right testis to
the scrotum during fetal development
5. A 60-year-old female presented with swelling and severe pain in the left inguinal region for one hour. On clinical examination, it is
suspected strangulated femoral hernia. (Final year past paper)
a) Name the anatomical boundaries occupied by this hernia.
Femoral Hernia occupies the boundaries of femoral Canal which are as follows:
o Laterally: Formed by Femoral Vein
o Anteriorly: Formed by the Inguinal ligament
o Posteriorly: Formed by the Pelvic bone covered by the Iliopectineal ligament (Astley Cooper‘s)
o Medially: Formed by the Lacunar Ligament (Gimbernat‘s)
b) Which structure impedes the reduction of hernia?
Lacunar Ligament

DO YOU KNOW!
 Inguinal hernia  above & medial to pubic tubercle + reducible
 Femoral hernia  below & lateral to pubic tubercle + irreducible
 Femoral hernia is more common in females because of wider pelvis &
femoral canal
 Although femoral hernia is common in females but most common hernia in
females is inguinal hernia like in males

6. What is incisional hernia?

An incisional hernia is a type of hernia that occurs through a previous surgical incision. It is a protrusion of tissue or intestine through
a weakened area in the abdominal wall, typically at the site of a previous surgical incision.
Risk factors
o Obesity
Inadequate closure of the incision
o Increased pressure within the abdominal cavity

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[8]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

o Chronic coughing or straining

o Wound infection or complications
7. A 79 years obese man presents with pain in the right iliac fossa and a palpable, reducible mass. He had an appendectomy 5 years
ago. What type of hernia is the most likely to have?
Incisional hernia
06. Incisions

1. What are the points a surgeon considers in giving incisions? What is safest site for abdominal incision? Give reasons.
Points to be consider
1. Anatomical location: Avoid damaging underlying structures (nerves, vessels, organs)
2. Cosmetic consideration: Minimize visible scarring
3. Access: Provide adequate exposure for the surgical procedure
4. Incision in the direction of muscle fibers
Safest site for abdominal incision
Midline incision, specifically the linea alba is safest side because
1. Fewer blood vessels in this area
2. No major nerves cross the midline
3. Better exposure to the abdominal cavity

2. Enumerate the various abdominal surgical incisions.

1. Median or midline incision
2. Left paramedian incision
3. Gridiron incision (McBurney incision)
4. Transverse abdominal incision
5. Suprapubic (Pfannenstiel) incision
6. Subcostal incision

07. Spermatic cord

1. How is spermatic cord formed? Describe its contents and its coverings.
Formation
o Spermatid cord is formed by combination of the following structures & coverings which come together to form a bundle of
tissues that support testes
Contents
o See Q3 in Topic 4
Coverings
1. External spermatic fascia
2. Cremasteric fascia
3. Internal spermatic fascia

2. What is hydrocele of spermatid cord?

Accumulation of fluid in tunica vaginalis. This swelling is brilliantly transilluminant on transilluminantt test. It can be
o Congenital hydrocele
o Encysted hydrocele

A-004 ֍PERITONIUM֍

01. Mesentery

1. Describe the mesentery. Enumerate its contents.

Mesenteries are two-layered folds of peritoneum connecting parts of the intestines to the posterior abdominal wall, for example, the
mesentery of the small intestine, the transverse mesocolon, and the sigmoid mesocolon
Contents  Blood, lymph vessels, and nerves

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[9]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

02. Omentum

1. Define omentum. Name and give attachments of various omenta of abdominal cavity.
Omenta are two-layered folds of peritoneum that connect the stomach to another viscus.
Various omenta Attachments
Greater omentum Connects the greater curvature of the stomach to the transverse colon. It hangs down like an apron in
front of the coils of the small intestine and is folded back on itself to be attached to the transverse colon
Lesser omentum Connects the lesser curvature of the stomach & proximal part of duodenum to the liver
Connects stomach to the triad of structures that run between duodenum & liver in the free edge of
lesser omentum

2. Write a note on lesser omentum.

 Connects the lesser curvature of the stomach & proximal part of duodenum to the liver. Also connects stomach to the triad of
structures that run between duodenum & liver in the free edge of lesser omentum
 Hepatogastric & hepatoduodenal ligaments are actually continuous part of lesser omentum
 Provide support to stomach & liver

03. Peritoneal ligaments

1. Name three peritoneal ligaments each which connect liver and stomach to another organ and to an abdominal wall
Liver:
1. Coronary ligament connects the liver to the diaphragm.
2. Falciform ligament connects the liver to the anterior abdominal wall.
3. Hepatogastric ligament connects the liver to the stomach
Stomach:
1. Gastrophrenic ligament connects stomach to the diaphragm
2. Gastrosplenic ligament connects the stomach to the spleen.
3. Gastrocolic ligament connects the stomach to the transverse colon.

04. Peritoneal sac, Recesses, Spaces & Gutters

1. Enumerate structures forming the boundaries of lesser sac (omental bursa)

Anteriorly (from above downward)
 Caudate lobe of liver
 lesser omentum
 stomach‘ back
 greater omentum
Posteriorly (from below upward)
 Greater omentum
 Transverse colon
 pancreas
 left supra-renal gland
 left kidney

4. Give the components of left margin of lesser sac.

Left margin is formed by
 Spleen
 Gastrosplenic omentum
 Linorenal ligament

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 10 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. A 30 year old male patient came to emergency with complaint of epigastric pain which aggravates with food intake. On gastroscopy
an ulcer penetrating the posterior wall of stomach was found which may perforate in the peritoneal sac behind the stomach. Enumerate
this peritoneal sac and give its Boundaries.
Lesser sac & its boundaries (See Q1)

3. Name the communication of the lesser sac. Also mention the boundaries of this communication.
4. What is epiploic foramen? Give its boundaries.
Right margin of lesser sac opens into the greater sac (the main part of the peritoneal cavity) through the opening of the lesser sac, or
epiploic foramen. Epiploic foramen which has the following boundaries;
o Anteriorly: Free border of the lesser omentum, the bile duct, the hepatic artery, and the portal vein
o Posteriorly: Inferior vena cava
o Superiorly: Caudate process of the caudate lobe of the liver
o Inferiorly: First part of the duodenum

5. Name the potential pockets of abdomen and pelvis where the fluid may accumulate in supine Position. How intraperitoneal
infections from abdomen spread to pelvis?
Potential pockets
1. Subphrenic spaces
2. Paracolic gutters
Spread
1. Gravity (inclined position)
2. Paracolic gutters
Note: A question can be asked what is the significance of paracolic gutters? Answer is that they provide pathway for spread of infection from
abdominal cavity to pelvic cavity

05. Nerve supply of peritoneum

1. Give the nerve supply of abdominal peritoneum.

 Parietal peritoneum  lower six thoracic and 1st lumbar nerve
 Visceral peritonium  autonomic afferent nerves

A-005 ֍ESOPHAGUS֍
Theres is no past seq from this topic.
o The esophagus is a muscular tube about 10 in. (25 cm) long, extending from the pharynx to the stomach. It begins at the level
of the cricoid cartilage, opposite the body of the sixth cervical vertebra

A-006 ֍STOMACH֍

1. Write posterior relations of stomach

2. Structures forming the stomach bed

Anterior relations Posterior relations (Stomach bed)

 Anterior abdominal wall  Lesser sac
 Left costal margin  Diaphragm
 Left pleura and lung  Spleen
 Diaphragm  Left suprarenal gland
 Left lobe of the liver  Upper part of the left kidney
 Splenic artery
 Pancreas
 Transverse mesocolon
 Transverse colon

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 11 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. Give the lymphatic drainage of stomach.

The lymph vessels follow the arteries into the left and right gastric nodes, the left and right gastroepiploic nodes, and the short gastric
nodes. All lymph from the stomach eventually passes to the celiac nodes located around the root of the celiac artery on the posterior
abdominal wall

4. Give the venous drainage of STOMACH with its applied anatomy?

o The left and right gastric veins drain directly into the portal vein
o The short gastric veins and the left gastroepiploicveins join the splenic vein
o The right gastroepiploic vein joins the superior mesenteric vein.
5. Give arterial supply of stomach, mentioning their arteries of origin and area of supply?

Supplying Area Arteries Supplying Origin

Lesser Curvature  Left Gastric Artery  Celiac Trunk
 Right Gastric Artery  Common Hepatic Artery
Greater Curvature  Left Gastroepiploic Artery  Splenic Artery
 Right Gastroepiploic Artery  Gastroduodenal Artery
Fundus  Short Gastric Arteries (Vasa Brevia)  Terminal part of Splenic Artery

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 12 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

6. A 45 years old male presented in emergency with severe epigastric pain radiating to back. Examination and investigations
confirmed a perforated posterior wall gastric ulcer. Name the area into which the gastric contents will leak along with the structures
affected. Give the arterial supply of the perforated organ. [Annual 2024 held in 2025]
Area  Lesser sac
Structures affected
Ulcer of posterior wall of 1st part of duodenum
 Erosion of the pancreas produces pain referred to the back  erosion of gastroduodenal artery 
 Erosion of splenic artery may produce fatal hemorrhage hemorrhage
Blood supply  See Q5

DO YOU KNOW!
A penetrating ulcer of the anterior stomach wall may result in the escape of stomach
contents into the greater sac, producing diffuse peritonitis. The anterior stomach wall
may, however, adhere to the liver, and the chronic ulcer may penetrate the liver
substance.

A-007 ֍SMALL & LARGE INTESTINE֍

01. Duodenum

1. Give anatomical relations of 3rd part of duodenum. Also give the arterial supply of duodenum above the entry of bile duct
Anatomical relations
o Anteriorly  Root of mesentery of small intestine, superior mesenteric vessels contained within it, and coils of jejunum
o Posteriorly  The right ureter, the right psoas muscle, the inferior vena cava, and the aorta
o Superiorly  The head of the pancreas
o Inferiorly  Coils of jejunum
Arterial supply
o Superior pancreaticoduodenal artery, a branch of the gastroduodenal artery supplies duodenum above the entry of bile duct
o Inferior pancreaticoduodenal artery, a branch of the superior mesenteric artery supplies below the entry of bile duct

02. Appendix

1. A six year old boy presented in Emergency Department of hospital diffuse abdominal pain, fever and diarrhoea. Six hours after the
onset, pain was localized in right iliac fossa. Clinical examination revealed 102°F fever, tender abdomen with positive rebound
tenderness. The Resident Surgeon labelled the case as acute appendicitis after thorough clinical work-up.
a) Why pain was diffuse initially and localized to right iliac fossa after a few hours?
o Initially the pain was diffused because of inflamed appendix
o Later localized pain to right iliac fossa was referred pain
b) Write the blood supply, lymphatic drainage and nerve supply of Appendix.
 Arterial supply  The appendicular artery is a branch of the ileocolic artery
 Venous drainage  The appendicular vein drains into the posterior cecal vein.
 Lymph Drainage  The lymph vessels drain into one or two nodes lying in the mesoappendix and then eventually into the
superior mesenteric nodes.
2. Give referred pain of appendix?
Visceral pain in the appendix is produced by distention of its lumen or spasm of its muscle. The afferent pain fibers enter the spinal
cord at the level of the 10th thoracic segment, and a vague referred pain is felt in the region of the umbilicus. Later, the pain shifts to
where the inflamed appendix irritates the parietal peritoneum. Here the pain is precise, severe, and localized

3. A 15 year old teenager came to ER with history of severe abdominal pain, vomiting and fever for one day. After investigations,
diagnosis of acute appendicitis was made and Appendectomy was planned.
a) Which incision is given for this procedure? Mention the site of incision.
Gridiron incision (McBurney incision) at McBurney point

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 13 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

b) Describe the blood supply and lymphatic drainage of appendix.

See Q1b

4. What is mesoappendix?
Short mesentery of appendix through which it is connected to the mesentery of the small intestine is mesoappendix. It contains the
appendicular vessels and nerves.

5. Give common positions of appendix? How a surgeon identify base of appendix?

The tip of the appendix is subject to a considerable range of movement and may be found in the following positions:
o hanging down into the pelvis against the right pelvic wall
o retrocecal appendix (behind the cecum)
o projecting upward along the lateral side of the cecum
o in front of or behind the terminal part of the ileum.
The first and second positions are the most common sites.
Base of the appendix is easily found by identifying the teniae coli of the cecum and tracing them to the base of the appendix

DO YOU KNOW!
If appendix is retrocecal  hip extension causes irritation of psoas muscle & pain.
So, patient keep right hip flexed. This is known as Psoas sign

6. Enumerate the factors which predispose appendix to infection and perforation?

Factors contributing to the appendix‘ infection
o It is a long, narrow, blind-ended tube, which encourages stasis of large-bowel contents.
o It has a large amount of lymphoid tissue in its wall.
o The lumen has a tendency to become obstructed by hardened intestinal contents (enteroliths), which leads to further
stagnation of its contents.
Factors contributing to the appendix‘ infection
o The appendix is supplied by a long small artery that does not anastomose with other arteries. The blind end of the appendix is
supplied by the terminal branches of the appendicular artery. Inflammatory edema of the appendicular wall compresses the
blood supply to the appendix and often leads to thrombosis of the appendicular artery. These conditions commonly result in
necrosis or gangrene of the appendicular wall, with perforation

03. Jejunum, Ilium, Ascending colon, Transverse colon & Descending colon

1. How can a surgeon distinguish the large intestines from the small intestines with naked eye?

Large intestine Small intestine

o Omental appendices (small fatty omentum like o No omental appendices
projections) o Thinner
o Thicker diameter o No taeniae coli
o More prominent longitudinal muscle layers o No haustra i.e. there is smooth wall
(taeniae coli)
o Presence of sacculations (haustra)
Note: Mucous membrane of the small intestine has permanent folds, called plicae circulares, absent in large intestine

2. A 10-year-old child presents with abdominal pain around the umbilicus, which shifts with movements and also there is history of
melena. Barium meal shows there is outpouching in lower part of ileum. What is the most probable diagnosis?
Meckel diverticulum

3. A 15-year-old male presented with pain in right iliac fossa for one day associated with nausea and anorexia. He has two episodes of
vomiting. On examination, pulse is 90/min, BP is 120/80 mm Hg, temperature is 99 F and abdomen is tender. A diagnosis of acute
appendicitis is made. During surgery, his vermiform appendix looked normal. What would be the cause of his clinical picture?
Meckel diverticulum

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 14 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Condition Anatomical basis Manifestations

Duodenal ulcers Anterior wall ulcer of the first part of duodenum may perforate Anterior wall ulcer  Peritonitis
into the greater sac Posterior wall ulcer  Hemorrhage
Posterior wall ulcer of first part of duodenum may penetrate the
wall and erodes gastroduodenal artery
Meckel‘s diverticulum Located on the antimesenteric border of the ileum about 2 feet Asymptomatis. Pain mimicking
of the ileum from the ileocecal junction. It may possess a small area of gastric appenditicitis if it gets inflamed
mucosa Bleeding from gastric ulcer
Diverticulosis False diverticula (protrusion of colon mucosa), most common in Pain in left iliac fossa if get
sigmoid colon inflamed
Sigmoid volvulus Because of its extreme mobility, the sigmoid colon sometimes Abdominal pain, Constipation &
rotates around its mesentery abdominal distension
Intussusception Telescoping of a proximal segment of the bowel into the lumen of Abdominal pain
an adjoining distal segment. ileocolic is the most common type Currant jelly stool

04. Blood Supply

1. Briefly describe the course, relations and branches of superior mesenteric artery
Course & Relations
 It arises from abdominal aorta at level of
L1, 1cm inferior to celiac trunk and runs
downward and to the right behind the neck
of the pancreas and in front of the third
part of the duodenum. It continues
downward to the right between the layers
of the mesentery of the small intestine and
ends by anastomosing with the ileal
branch of its own ileocolic branch.
Branches
 Inferior pancreaticoduodenal artery
 Middle colic artery
 Right colic artery
 ileocolic artery that gives rise to
o Superior branch
o Inferior branch  give rise to
anterior & posterior cecal
arteries. Posterior cecal artery
gives appendicular artery
 Jejunal and ileal branches

DO YOU KNOW!
SMA syndrome  occlusion of SMA causes sudden severe abdominal pain & this
condition progress to the gangrene of the supplied segment of git. Typically occurs in
condition associated with diminished mesenteric fat

2. What are arterial arcades?

SMA runs between the layers of the mesentery, sending 15–18 branches to the jejunum and ileum. The arteries unite to form loops or
arches, called arterial arcades, which give rise to straight arteries, called vasa recta
 1-2 arcades in jejunum
 3-5 arcades in ileum

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 15 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

A-008 ֍LIVER֍

1. Write the formation, course & termination of portal vein. List its tributaries.
Formation
o Formed by union of splenic vein & superior
mesenteric vein posterior to the neck of pancreas
Course & Termination
o Portal vein enters the liver  divides into portal
venules  venules empty into hepatic sinusoids
 sinusoids drain into central veins  central
veins drain into hepatic veins  hepatic veins
drain into inferior vena cava
Tributaries
o Splenic vein
o SMV
o Right & Left gastric veins
o Cystic vein
o Inferior mesenteric vein

2. Enumerate structures located in porta hepatis.

1. Hepatic artery
Hepatoduodenal ligament encloses Portal triad
2. Hepatic duct
3. Portal vein
4. Lymphatics & lymph nodes
5. Sympathetic & Parasympathetic nerve fibers

3. Name the ligaments of liver.

1. Falciparum ligament 5. Ligamentum venosum
2. Coronary ligament 6. Hepatogastric ligament
3. Right & left triangular ligament 7. Hepatoduodenal ligament
4. Ligamentum teres 8. Hepatorenal ligament

4. Enumerate the sites of portocaval anastomoses in various parts of GIT, mentioning the name of vessels participating in such
anastomoses at these sites and their respective clinical significance.
5. Write the five sites of portal systemic anastomoses in human body and mention any three clinical conditions occurring at any three
sites in portal hypertension.

Site Tributaries Significance

Esophagus  Portal: Oesophageal branch of left gastric veins Esophageal varices
 Systemic: Azygous vein
Anal canal  Portal: Superior rectal vein Hemorrhoids
 Systemic: Middle/inferior rectal veins
Umbilical area  Portal: Paraumbilical veins Caput medusa (dilated veins
 Systemic: Epigastric veins radiating from umbilicus)
Retroperitoneal  Portal: Colonic veins No significance
 Systemic: Veins of posterior abdominal wall
Bare area of liver  Portal: Hepatic/Portal veins No significance
 Systemic: Inferior phrenic veins

7. A man habitual for alcoholic intake received in emergency with hematemesis. On physical examination there was splenomegaly
along with caput medusae. Keeping in mind above scenario:
a) Findings are suggestive of which disease?
Portal hypertension

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 16 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

b) Give explanation for hematemesis and caput medusa.

o Hematemesis (vomiting blood)  due to ruptured esophageal varices, which are dilated veins in the esophagus that become
fragile and prone to bleeding due to increased pressure in the portal venous system.
o Caput medusae (dilated paraumbilical veins radiating from the umbilicus)  a sign of portal hypertension, where blood is
diverted through smaller vessels, leading to their dilatation.
c) Along with splenomegaly, enlist the other two structures enlarged in this condition.
1. Esophagus
2. Liver
d) How can portal hypertension be reduced?
Portal hypertension can be reduced by diverting blood from the portal to the caval system. This is accomplished by connecting the
splenic vein to the left renal vein or by creating a communication between the portal vein and the IVC

A-009 ֍BILIARY SYSTEM֍

1. Write boundaries of Callot triangle & give its significance.

Boundaries
o Superiorly (Base) by Inferior surface of the Liver (Segment V of Right Hemi–Liver)
o Laterally by Cystic Duct and Medial border of Gall bladder
o Medially by Common Hepatic Duct
Significance
o Before cholecystectomy, surgeon easily identify & ligate blood vessels in this triangle

2. Describe the course of common bile duct with its relations?

3. What is hepatopancreatic ampulla?
Course
o In the first part of its course, it lies in the right free margin of the lesser omentum in front of the opening int the lesser sac.
Here, it lies in front of the right margin of the portal vein and on the right of the hepatic artery
o In the second part of its course, it is situated behind the first part of the duodenum to the right of the gastroduodenal artery
o In the third part of its course, it lies in a groove on the posterior surface of the head of the pancreas. Here, the bile duct comes
into contact with the main pancreatic duct.
o The bile duct ends below by piercing the medial wall of the second part of the duodenum about halfway down its length. It is
usually joined by the main pancreatic duct, and together they open into a small ampulla in the duodenal wall, called the
hepatopancreatic ampulla (ampulla of Vater).
Relations
Location Structures
Anteriorly 1. Liver
2. 1st Part of Duodenum
3. Head of Pancreas
Posteriorly 4. Portal Vein
5. Inferior Vena cava
To the Left 6. Common Hepatic Artery
7. Gastroduodenal Artery

4. Why the gall bladder gangrene is rare and more common of appendix?
Unlike the appendix, which has a single arterial supply, the gallbladder rarely becomes gangrenous. In addition to the cystic artery, the
gallbladder also receives small vessels from the visceral surface of the liver

5. A 42 years old obese woman with 7 seven children is brought to the local hospital by her daughter. Physical examination and her
radiograph reveal the large gallstones have ulcerated through the posterior wall of fundus of gallbladder into the intestine. Which part
of intestines is most likely to contain gallstones and why?
 Duodenum
 Transverse colon

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 17 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Both lie posterior to the gallbladder fundus

Note: Gallstones may ulcerate through the gallbladder wall into the transverse colon or duodenum. In the former case, they are passed naturally per
the rectum but in the latter case, they may be held up at the ileocecal junction producing intestinal obstruction

A-010 ֍PANCREAS֍

1. Name the various parts of Pancreas.

2. Give anterior and posterior relations of the head of pancreas.
3. List the structures related to the neck of pancreas

Part Anteriorly Posteriorly

Head Transverse mesocolon IVC
Stomach R renal & vein
SMA anterior to uncinate process L renal vein
Neck Transverse mesocolon Portal vein formation,
Pylorus of stomach SMA, SMV
Body Omental bursa & stomach Aorta
SMA
L suprarenal gland &
kidney
Tail Linorenal ligament L kidney
Note: SMA lies anterior to uncinate process but posterior to head of pancreas

4. Enumerate the arteries which supply the pancreas. Also give the name of parent vessels from which these arteries are derived.
1. Pancreatic branches of Splenic artery supply pancreas
2. Head is additionally supplied by
o Superior pancreaticoduodenal arteries that arise from Gastroduedenal artery (celiac trunk)
o Inferior pancreaticoduodenal arteries that arise from SMA

5. A 55-year-old male presents with intermittent abdominal pain radiating to his back. Upon examination, tenderness is noted in the
upper abdomen, and the patient exhibits jaundice. Laboratory tests reveal elevated levels of serum amylase and lipase. Imaging studies
show a mass located at the head of the pancreas.
a. What is the most likely diagnosis for this patient?
Pancreatic head tumor
b. Give the anatomical justification of jaundice in this patient.
Head of pancreas is located near the bile duct so a tumor of pancreatic head compresses CBD & block the passage of bile

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 18 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

9. Name two clinical conditions involving the Pancreas which cause obstructive jaundice.
1. Pancreatic head tumor
2. Pancreatitis

A-011 ֍SPLEEN֍

1. What are the visceral relations of spleen?

o Anteriorly: Stomach
o Posteriorly: Lungs, Left part of diaphragm, Pancreatic tail at hilum
o Inferiorly: Left colic flexure
o Medially: Left kidney

2. A middle age woman in a road side accident was brought to the emergency. She complained of extreme pain in left hypochondrium
and had a feeble pulse. Investigations revealed fractured ribs and profuse intraperitoneal hemorrhage due to laceration of spleen. An
emergency splenectomy was performed on this patient.
a) Name ribs that may have fractured in this case leading to such an injury with subsequent consequence in case of their
fracture.
9th – 11th ribs
b) Name the peritoneal ligaments associated with spleen and enlist their respective contents

Peritoneal ligament Contents

Gastrosplenic ligament  Short gastric vessels
 Left gastro-omental (gastroepiploic) arteries
Splenorenal/Linorenal ligament  Splenic artery
 Splenic vein
 Tail of pancreas
Phrenicocolic/Hensing‟s ligament  Left inferior phrenic vessels

3. A 24 years old male is brought in emergency in unconscious state after a road traffic accident. On examination, the doctor noticed
multiple bruises on his abdomen. On ultrasonography, it was confirmed that the hematopoietic organ lying in the left hypochondrium
just beneath the 9th, 10th and 11th rib was injured. Using your anatomical knowledge name the organ involved, briefly describe its
blood supply and also differentiate between red and white pulp
Damaged organ  Spleen
Blood supply  Splenic artery & Splenic vein
Features Red Pulp White Pulp
% of total organ 80% 20%
Constituents  Blood Filled sinusoids  Lymphoid Nodules
 Splenic cords (of Billroth)  Periarteriolar Lymphoid Sheaths (PALS)
Function  Removal of old, damaged, and  Important role in normal immune response
dead RBCs to infection

A-012 ֍SIGMOID COLON & RECTUM & ANAL CANAL֍

01. Rectum
1. Give a brief account of peritoneal reflections on rectum.
2. What are the peritoneal relations of the rectum?
3. Describe pouch of Douglas
o Peritoneum covers the anterior and lateral surfaces of the superior third of the rectum, only the anterior surface of the middle
third, and no surface of the inferior third because it is subperitoneal.
o In males, the peritoneum reflects from the rectum to the posterior wall of the bladder, where it forms the floor of the
rectovesical pouch
o In females, the peritoneum reflects from the rectum to the posterior part of the fornix of the vagina, where it forms the floor
of the recto-uterine pouch (Pouch of Douglas) – a site for Culdocentesis, a site for fluid accumulation, a site for pelvic
masses.
o In both sexes, lateral reflections of peritoneum from the superior third of the rectum form pararectal fossae

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 19 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

4. What are posterior relations of the rectum?

1. Sacrum & coccyx
2. Muscles (Piriformis, Coccygeus & Levator ani)
3. Sacral plexus
4. Sympathetic trunk

5. Give brief account for the venous drainage of the rectum.

o Superior rectal vein drains into inferior mesenteric vein
o Middle rectal veins drains into internal iliac vein
o Inferior rectal vein drains into internal pudendal veins

6. A 42 years old female, 2 months after the delivery of her 5th baby, presented in surgical OPD with history of protrusion of Anus on
defecation. There is no history of Bleeding per rectum. What is your diagnosis? (Final year past paper)
Rectal prolapse as it is common in elder age & woman with vaginal deliveries causing weakening of levator ani muscle. It is less
likely to be hemorrhoids because there is no bleeding.

02. Anal Canal

1. A 30 year old pregnant female came to emergency with history of bleeding from anal canal. The blood is bright red in colour. She
also gave history of chronic constipation. There was no associated pain. After examination doctor viewed varicose veins in 3, 7 and 11
o'clock position and diagnosed it as a case of Haemorrhoids. Give the type of haemorrhoids with its cause. Why there was no
associated pain?
Type of haemorrhoid  Internal Haemorrhoids
Cause  Pregnancy & Chronic constipation
Why painless?  It is painless because of its visceral innervation

2. Give the embryological origin, arterial supply, venous drainage and nerve supply of anal canal above and below the pectinate line.
3. Give the important anatomical differences between the upper and lower half of anal canal demarcated by pectinate line.
4. What is difference between internal and external hemorrhoids?

Features Above pectinate line Below pectinate line

Embryological origin Hindgut Proctodeum
Arterial supply Superior rectal artery & Middle rectal artery Inferior & Middle rectal artery
Veins drainage Superior rectal vein & Middle rectal vein Inferior & Middle rectal vein
Nerve supply Visceral innervation from inferior hypogastric plexus Somatic innervation from inferior rectal nerve,
therefore insensitive to pain branch of pudendal nerve therefore sensitive to
pain
Haemorrhoids Internal haemorrhoids External haemorrhoids
Lymphatics Internal iliac lymph nodes Superficial inguinal lumph nodes

A-013 ֍SURGICAL INTERVENTION֍

Vagotomy
o Because the secretion of acid by parietal cells of the stomach is largely controlled by the vagus nerves, vagotomy (surgical
section of the vagus nerves) is performed in some people with chronic or recurring ulcers to reduce the production of acid.
Vagotomy may also be performed in conjunction with resection of the ulcerated area (antrectomy, or resection of the pyloric
antrum) to reduce acid secretion.
Truncal vagotomy
o It is rarely performed because the innervation of other abdominal structures is also sacrificed.
Selective gastric vagotomy
o Stomach is denervated but the vagal branches to the pylorus, liver and biliary ducts, intestines, and celiac plexus are
preserved

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 20 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Selective proximal vagotomy

o Attempts to denervate even more specifically the area in which the parietal cells are located, hoping to affect the acid-
producing cells while sparing other gastric function (motility) stimulated by the vagus nerve

A-014 ֍POSTERIOR ABDOMINAL WALL֍

Psoas Fascia and Tuberculosis

The psoas fascia covers the anterior surface of the psoas muscle and can influence the direction taken by a tuberculous abscess.
Tuberculous disease of the thoracolumbar region of the vertebral column results in the destruction of the vertebral bodies, with
possible extension of pus laterally under the psoas fascia (Fig. 4.34). From there, the pus tracks downward, following the course of the
psoas muscle, and appears as a swelling in the upper part of the thigh below the inguinal ligament. It may be mistaken for a femoral
hernia.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 21 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Practice MCQs

1. A midline abdominal incision below the umbilicus passes c) Hilum of the kidney
through all the following EXCEPT: d) Origin of the portal vein
a) pyradmidalis 10. All of the following are retroperitoneal structures EXCEPT
b) linea alba a) Ureter
c) extra peritoneal fat b) Sympathetic trunk
d) transversalis fascia c) Duodenum
2. Which is the most common site for the appendix found at d) Pancreas
appendicectomy? 11. The main vessel supplying the body of the pancreas is the
a) retro-ileal a. Superior pancreaticoduodenal artery
b) reto-caecal b. Splenic artery
c) pelvic c. Left gastric artery
d) anterior to terminal ileum d. Inferior pancreaticoduodenal artery
3. With regard to the spleen, which is NOT true? 12. Direct tributaries of the portal vein include all but
a) it is in direct contact with the lesser sac a. Right gastric vein
b) it projects into the greater sac b. Short gastric vein
c) its anterior border is notched c. Splenic vein
d) it receives both sympathetic and parasympathetic supply d. Superior pancreaticoduodenal vein
4. The transversalis fascia contributes to which of the following 13. Which lymph nodes drain the lower anal canal?
structures on the anterior abdominal wall? a. Superficial inguinal
a) superficial inguinal ring b. External iliac
b) deep inguinal ring c. Deep inguinal
c) inguinal ligament d. Para-aortic
d) anterior wall of the inguinal canal 14. Superior pancreaticoduodenal vein drains into
5. The transpyloric plane of the abdomen (passing through the a. Left gastric vein
lower border of L1 vertebra) passes through: b. Portal vein
a) the spleen c. Splenic vein
b) the third part of the duodenum d. Superior mesenteric vein
c) the tail of the pancreas 15. A patient comes to your clinic whom you operated for
d) the origin of the superior mesenteric artery obstructed irreducible indirect Left Inguinal hernia one month
6. Which of the following forms the posterior wall of the ago. He says "It has been over four weeks from the surgery and
inguinal canal? I still have much discomfort. Inside of my thigh is numb, burns
a) conjoint tendon or simply hurts when touched. When I move in certain ways I
b) internal oblique muscle get a stabbing pain in that area accompanied with a sensation of
c) transversus abdominus muscle being bit by a bunch of wasps (Bees)." Which nerve is most
d) lacunar ligament likely damaged?
7. Which structure does not enter the inguinal canal through the (A) Genital branch of Genitofemoral nerve
deep inguinal ring? (B) Illioinguinal Nerve
a) testicular artery (C) Cremasteric Nerve
b) vas deferens (D) Illiohypogastric Nerve
c) ilioinguinal nerve 16. This patient has more chances of developing which type of
d) genital branch of genitofemoral nerve hernia in future
(A) Right Direct Inguinal Hernia
8. Contents of the deep inguinal ring include all but:
(B) Left Direct Inguinal Hernia
a) ilioinguinal nerve
(C) Right Indirect Inguinal Hemia
b) vas deferens
(D) Left Indirect Inguinal Hernia
c) cremasturic artery
d) obliterated remains of the processes vaginalis 17. External Spermatic Fascia arise from External oblique
9. The following structures are related to the transpyloric plane aponerosis, So Internal Spermatic Fascia arise from
EXCEPT (A) Internal Oblique Aponeurosis
a) Coeliac trunk (B) Transversalis fascia
b) Tip of the 9th costal cartilage (C) Conjoint tendon
(D) External oblique aponerosis
DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 22 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

18. Just Below the arcuate line of anterior abdominal wall, what (B) Deep inguinal ring
is in direct contact with rectus abdominus muscle (C) Inguinal ligament
(A) Parietal Peritoneum (D) Sac of a direct inguinal hernia
(B) Visceral Peritoneum 25. A 42-year-old obese woman with seven children is brought
(C) Fascia Transversalis to a local hospital by her daughter. Physical examination and her
(D) Posterior Layer of Rectus Sheath radiograph reveal that large gallstones have ulcerated through
19. A 2-year-old boy presents with pain in his groin that has the posterior wall of the fundus of the gallbladder into the
been increasing in nature over the past few weeks. He is found intestine. Which of the following parts of the intestine is most
to have a degenerative malformation of the transversalis fascia likely to initially contain gallstones?
during development. Which of the following structures on the (A) Cecum
anterior abdominal wall is likely defective? (B) Ascending colon
(A) Superficial inguinal ring (C) Transverse colon
(B) Deep inguinal ring (D) Descending colon
(C) Inguinal ligament 26. A 35-year-old woman comes to a local hospital with
(D) Sac of a direct inguinal hernia abdominal tenderness and acute pain. On examination, her
20. A 9-year-old boy was admitted to the emergency department physician observes that an abdominal infection has spread
complaining of nausea, vomiting, fever, loss of appetite. On retroperitoneally. Which of the following structures is most
examination, he was found to have tenderness and pain on the likely affected?
right lower quadrant. Based on signs and symptoms, the (A) Stomach
diagnosis of acute appendicitis was made. During an (B) Transverse colon
appendectomy performed at McBurney's point, which of the (C) Jejunum
following structures is most likely to be injured? (D) Descending colon
(A) Deep circumflex femoral artery 27. A young boy is brought to the hospital after a bicycle
(B) Inferior epigastric artery accident and possible pelvic fracture. While awaiting a compute
(C) Illiohypogastric nerve tomography (CT) scan of his pelvis, a physician proceeds with a
(D) Genitofemoral nerve focal neurologic examination. In testing the child‘s refl exes,
which of the following nerves would carry afferent impulses of
21. A patient presents to her GP in the second trimester of her
the cremasteric reflex?
fourth pregnancy with a ―weird black line‖ running from her
(A) Subcostal nerve
xiphoid to her pubic symphysis. The doctor reassures the
(B) Lateral femoral cutaneous nerve
patient that this is perfectly normal for pregnancy. What is the
(C) Genitofemoral nerve
term for this appearance?
(D) Iliohypogastric nerve
A. Linea nigra
28. A 21-year-old man receives a penetrating knife wound in the
B. Linea albicans
abdomen and is injured in both the superior mesenteric artery
C. Linea alba
and the vagus nerve. Which portion of the colon would most
D. Linea corpus
likely be impaired by this injury?
22. Which one of the following is the most common site of
(A) Ascending and descending colons
pancreatic cancer?
A. Head (B) Transverse and sigmoid colons
B. Body (C) Descending and sigmoid colons
C. Tail (D) Ascending and transverse colons
D. Uncinate process 29. A 42-year-old man with portal hypertension secondary to
23. A 36-year-old woman with yellow pigmentation of the skin cirrhosis of the liver and subsequent massive ascites presents to
and sclerae presents at the outpatient clinic. Which of the the emergency department. He refuses to have a transjugular
following conditions most likely is the cause of her obstructive intrahepatic portosystemic shunt (TIPS) procedure and prefers
jaundice? surgery. Which of the following surgical connections is
(A) Aneurysm of the splenic artery involved in the most practical method of shunting portal blood
(B) Perforated ulcer of the stomach around the liver?
(C) Obstruction of the main pancreatic duct (A) Superior mesenteric vein to the inferior mesenteric vein
(D) Cancer in the head of the pancreas (B) Portal vein to the superior vena cava
24. A 2-year-old boy presents with pain in his groin that has (C) Portal vein to the left renal vein
been increasing in nature over the past few weeks. He is found (D) Splenic vein to the left renal vein
to have a degenerative malformation of the transversalis fascia 30. A radiograph of a 32-year-old woman reveals a perforation
during development. Which of the following structures on the
in the posterior wall of the stomach in which the gastric contents
anterior abdominal wall is likely defective?
(A) Superficial inguinal ring have spilled into the lesser sac. The general surgeon has opened

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 23 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

the lienogastric (gastrosplenic) ligament to reach the lesser sac (A) Middle colic artery
and notes erosion of the ulcer into an artery. Which of the (B) Right colic artery
following vessels is most likely involved? (C) Ileocolic colic artery
(A) Splenic artery (D) Inferior mesenteric artery
(B) Gastroduodenal artery 37. A 38-year-old woman with peptic ulcer disease of the
(C) Left gastric artery stomach experiences severe abdominal pain. Which of the
(D) Left gastroepiploic artery following nervous structures is most likely involved?
31. A 16-year-old boy with a ruptured spleen comes to the (A) Greater splanchnic nerve
emergency department for splenectomy. Soon after ligation of (B) Ventral roots of the spinal nerve
the splenic artery just distal to its origin, a surgical resident (C) Lower intercostal nerve
observes that the patient is healing normally. Normal blood flow (D) Vagus nerve
would occur in which of the following arteries? 38. A 3-year-old boy is diagnosed as having a persistent
(A) Short gastric arteries processus vaginalis in its middle portion. Which of the
(B) Dorsal pancreatic artery following conditions is most likely to be associated with this
(C) Inferior pancreaticoduodenal artery developmental anomaly?
(D) Left gastroepiploic artery (A) Direct inguinal hernia
32. A 9-year-old boy was admitted to the emergency department (B) Gubernaculum testis
complaining of nausea, vomiting, fever, and loss of appetite. On (C) Hematocele
examination, he was found to have tenderness and pain on the (D) Hydrocele
right lower quadrant. Based on signs and symptoms, the 39. Examination of a 54-year-old man reveals an isolated tumor
diagnosis of acute appendicitis was made. During an located at the porta hepatis. This tumor most likely compresses
appendectomy performed at McBurney‘s point, which of the which of the following structures?
following structures is most likely to be injured? (A) Cystic duct
(A) Deep circumflex femoral artery (B) Hepatic veins
(B) Inferior epigastric artery (C) Common hepatic artery
(C) Iliohypogastric nerve (D) Branches of the portal vein
(D) Genitofemoral nerve 40. Mrs. Jones is undergoing a routine colonoscopy for colon
33. While examining radiographs and angiograms of a 52-year- cancer prevention. The gastroenterologist finds a Meckel‘s
old patient, a physician is trying to distinguish the jejunum from diverticulum. Which of the following statements is true about
the ileum. He has observed that the jejunum has: the diverticulum?
(A) Fewer plicae circulares (A) It is found 2 ft distal to the ileocecal junction
(B) Fewer mesenteric arterial arcades (B) It is located on the mesenteric side of the ileum
(C) Less digestion and absorption of nutrients (C) It occurs in approximately 20% of the population
(D) Shorter vasa recta (D) It is a persistent remnant of the embryonic yolk stalk
34. A 67-year-old woman with a long history of liver cirrhosis 41. A 54-year-old man comes to a hospital with abdominal pain,
was seen in the emergency department. In this patient with jaundice, loss of appetite, and weight loss. On examination of
portal hypertension, which of the following veins is most likely his radiograms and CT scans, a physician finds a slowly
to be dilated? growing tumor in the uncinate process of the pancreas. Which of
(A) Right colic vein the following structures is most likely compressed by this
(B) Inferior epigastric vein tumor?
(C) Inferior phrenic vein (A) Main pancreatic duct
(D) Suprarenal vein (B) Splenic artery
35. A 26-year-old patient is admitted to a local hospital with a (C) Portal vein
retroperitoneal infection. Which of the following arteries is most (D) Superior mesenteric artery
likely to be infected? 42. A 6-year-old boy comes to his pediatrician with a lump in
(A) Left gastric artery the groin near the thigh and pain in the groin. On examination,
(B) Proper hepatic artery the physician makes a diagnosis of a direct inguinal hernia
(C) Middle colic artery because the herniated tissue:
(D) Dorsal pancreatic artery (A) Enters the deep inguinal ring
36. A 19-year-old man with a ruptured appendix is sent to the (B) Lies lateral to the inferior epigastric artery
emergency department for surgery. To cut off the blood supply (C) Is covered by spermatic fasciae
to the appendix (if collateral circulation is discounted), a (D) Develops after birth
surgeon should ligate which of the following arteries?

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 24 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

43. During surgical treatment of portal hypertension in a 59- (A) arcuate line
year-old man with liver cirrhosis, a surgeon inadvertently (B) inguinal ligament
lacerates the dilated paraumbilical veins. The veins must be (C) tendinous intersections
repaired to allow collateral flow. Which of the following (D) deep inguinal ring
ligaments is most likely severed? 51. The lacunar ligament is a reflection or extension from the
(A) Lienorenal ligament deep aspect of which of the following structures?
(B) Lienogastric ligament (A) falciform ligament
(C) Gastrophrenic ligament (B) round ligament
(D) Ligamentum teres hepatis (C) rectus sheath
44. An emergent hernia repair is scheduled. As the attending (D) inguinal ligament
physician is driving to the hospital, the medical student assisting 52. Which of the following structures connects the lesser
on the case quickly reviews his anatomy atlas and is trying to curvature of the stomach and the proximal part of the duodenum
commit to memory that the internal oblique abdominis muscle to the liver?
contributes to the formation of which of the following (A) lesser omentum
structures? (B) peritoneal ligament
(A) Inguinal ligament (C) mesentery
(B) Deep inguinal ring (D) lesser omentum
(C) Falx inguinalis (conjoint tendon) 53. Which of the following structures is often referred to as the
(D) Internal spermatic fascia ―abdominal policeman‖?
45. The midclavicular planes pass through the midpoint of the (A) hepatoduodenal ligament
clavicles to the midpoint of which of the following structures? (B) gastrohepatic ligament
(A) anterior superior iliac spine (C) greater omentum
(B) symphysis pubis (D) gastrocolic ligament
(C) umbilicus 54. Which of the following ligaments conducts the portal triad
(D) inguinal ligament (portal vein, hepatic artery, and bile duct)?
46. The fascial layer that covers the deep surface of the (A) greater omentum
transverse abdominal muscle is known as which of the (B) falciform ligament
following? (C) gastrohepatic ligament
(A) parietal peritoneum (D) hepatoduodenal ligament
(B) deep fascia 55. Which of the following structures contains both smooth and
(C) transversalis fascia skeletal muscles?
(D) Scarpa‘s fascia (A) stomach
47. The aponeuroses of all three flat muscles of the anterolateral (B) jejunum
abdominal wall interlace in which of the following structures? (C) cecum
(A) inguinal ligament (D) esophagus
(B) transversalis fascia 56. Which of the following arteries provides the abdominal parts
(C) linea alba of the esophagus with its arterial supply?
(D) rectus abdominis (A) cystic
48. All of the following structures are located within the rectus (B) gastroduodenal
sheath EXCEPT
(C) left gastric
(A) pyramidalis
(D) hepatic
(B) rectus abdominis
57. The bile and pancreatic ducts enter which of the following
(C) inferior epigastric arteries and veins
structures?
(D) deep inguinal ring
(A) stomach
49. Inferiorly, the inferior margin of the external oblique
aponeurosis thickens and folds back on itself to form which of (B) 2nd portion of the duodenum
the following structures? (C) cecum
(A) rectus sheath (D) liver
(B) inguinal ligament 58. The duodenojejunal junction is supported by the attachment
(C) arcuate line of which of the following structures?
(D) deep inguinal ring (A) suspensory muscle of the duodenum (ligament of Treitz)
50. Which of the following structures defines the point at which (B) falciform ligament
the posterior lamina of the internal oblique and the aponeurosis (C) hepatoduodenal ligament
of the transverse abdominal become part of the anterior rectus (D) greater omentum
sheath?

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 25 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

59. The superior anterior and posterior pancreaticoduodenal 65. The porta hepatis gives passage to all of the following
arteries arise from which of the following arteries? structures EXCEPT
(A) right colic (A) portal vein
(B) ileocolic (B) hepatic artery
(C) gastroduodenal (C) hepatic ducts
(D) hepatic (D) cystic artery
60. The superior mesenteric and splenic veins unite to form the 66. Which of the following ligaments encloses the portal triad?
portal vein posterior to which of the following structures? (A) hepatoduodenal
(A) right kidney (B) hepatogastric
(B) neck of the pancreas (C) gastrocolic
(C) pylorus of stomach (D) hepatorenal
(D) 2nd portion of the duodenum 67. The hepatic veins drain into which of the following
61. Circular folds (plicae circulares) are characteristic of which structures?
of the following structures? (A) liver
(A) transverse colon (B) inferior vena cava
(B) stomach (C) spleen
(C) jejunum (D) portal vein
(D) sigmoid colon 68. Which of the following veins, when dilated, produces caput
62. The rectum is continuous with the sigmoid colon at the level medusae?
of which of the following vertebrae? (A) proper hepatic
(A) L3 (B) splenic
(B) L5 (C) cystic
(C) S3 (D) paraumbilical
(D) S5 69. The renal papillae empty into which of the following
63. The head of the pancreas rests posteriorly on which of the structures?
following structures? (A) renal vein
(A) left renal vein (B) ureter
(B) superior vena cava (C) minor calyces
(C) splenic artery (D) renal pyramid
(D) superior mesenteric artery 70. The anatomical left and right lobes of the liver are separated
64. The round ligament of the liver is the fibrous remnant of on the diaphragmatic surface of the liver by which of the
which of the following structures? following structures?
(A) umbilical vein (A) fissure for the round ligament of the liver
(B) ductus venosus (B) fissure for the ligamentum venosum
(C) ductus arteriosus (C) falciform ligament
(D) umbilical artery (D) porta hepatic

ANSWER KEY
1. A 2. B 3. D 4. B 5. D 6. A 7. C 8. A 9. A 10. C
11. B 12. B 13. A 14. B 15. B 16. B 17. B 18. C 19. B 20. C
21. A 22. A 23. D 24. B 25. C 26. D 27. C 28. D 29. D 30. D
31. C 32. C 33. B 34. A 35. D 36. C 37. A 38. D 39. D 40. D
41. D 42. D 43. D 44. C 45. D 46. C 47. C 48. D 49. B 50. A
51. D 52. D 53. C 54. D 55. D 56. C 57. B 58. A 59. C 60. B
61. C 62. C 63. A 64. A 65. D 66. A 67. B 68. D 69. C 70. C

15. The patient's symptoms, including numbness, burning, and stabbing pain in the thigh, are consistent with damage to the
ilioinguinal nerve, which runs near the inguinal canal and can be injured during hernia surgery.
16. The patient has a higher chance of developing a direct inguinal hernia on the same side (left) due to the weakened abdominal wall
muscles and fascia from the previous surgery.
20. During an appendectomy performed at McBurney's point, the iliohypogastric nerve is most likely to be injured, as it runs near the
surgical site.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 26 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

23. Because the bile duct traverses the head of the pancreas, cancer in the head of the pancreas obstructs the bile duct, resulting in
jaundice. Aneurysm of the splenic artery, obstruction of the main pancreatic duct, a stomach ulcer, and cancer in the body of the
pancreas are not closely associated with the bile duct. The tail of the pancreas is located at the hilus of the spleen, which lies far from
the bile duct.
25. The fundus of the gallbladder is in contact with the transverse colon, and thus, gallstones erode through the posterior wall of the
gallbladder and enter the transverse colon.
26. The descending colon is a retroperitoneal organ. The rest of the organs are surrounded by peritoneum.
27. Stimulation of the cremaster muscle draws the testis up from the scrotum toward the superfi cial inguinal ring. The efferent limb of
the refl ex arc is the genital branch of the genitofemoral nerve, whereas the afferent limb is the femoral branch of the genitofemoral
nerve. The other nerves are not involved in the cremasteric reflex.
28. The ascending and transverse colons receive blood from the superior mesenteric artery and parasympathetic nerve fibers from the
vagus nerve. However, the descending and sigmoid colons receive blood from the inferior mesenteric artery and the parasympathetic
nerve fibers from the pelvic splanchnic nerve arising from sacral spinal nerves (S2–S4).
29. Portal hypertension can be reduced by diverting blood from the portal to the caval system. This is accomplished by connecting the
splenic vein to the left renal vein or by creating a communication between the portal vein and the IVC. A connection between a
hepatic vein and a branch of the portal vein can be accomplished by the transjugular intrahepatic portosystemic shunt (TIPS)
procedure in the treatment of bleeding esophageal varices.
30. The left gastroepiploic artery runs through the lienogastric ligament, and hence, it is the artery most likely injured
31. he inferior pancreaticoduodenal artery is a branch of the superior mesenteric artery. All of other arteries are branches of the splenic
artery.
32. The iliohypogastric nerve runs medially and inferiorly between the internal oblique and transverse abdominal muscles near the
McBurney‘s point, the point at the junction of the lateral one-third of the line between the anterior superior iliac spine and the
umbilicus. Other structures are not found near the McBurney‘s point.
33. The jejunum has fewer mesenteric arterial arcades but longer vasa recta than the ileum. The plicae circulares (circular folds) are
tall and closely packed in the jejunum and are low and sparse in the ileum, and the lower part of the ileum has no plicae circulares.
More digestion and absorption of nutrients occurs in the jejunum than in the ileum, and less fat is found in the mesentery of the
jejunum.
34. The right colic vein belongs to the portal venous system and empties into the superior mesenteric vein, which joins the splenic vein
to form the portal vein. The inferior epigastric, inferior phrenic, suprarenal, and ovarian veins belong to the systemic (or caval) venous
system and drain directly or indirectly into the IVC.
35. The pancreas is a retroperitoneal organ, except for a small portion of its tail. The dorsal pancreatic artery would be the infected
artery because it arises from the splenic artery and runs retroperitoneally along the superior border of the pancreas behind the
peritoneum. The other arteries run within layers of the peritoneum. The left gastric arteries run within the lesser omentum; the proper
hepatic artery runs within the free margin of the lesser omentum; the middle colic artery runs within the transverse mesocolon; the
sigmoid arteries run within the sigmoid mesocolon
36. The appendicular artery is a branch of the ileocolic artery. The other arteries do not supply the appendix.
37. The greater splanchnic nerve carries pain fi bers from the upper GI tract. Neither the ventral roots of the spinal nerves nor the gray
rami communicantes contain sensory nerve fi bers. The vagus nerve contains sensory fibers associated with reflexes, but it does not
contain pain fibers
38. If a middle portion of the processus vaginalis persists, it forms a congenital hydrocele. If the entire processus vaginalis persists, it
develops a congenital indirect inguinal hernia.
39. The porta hepatis is the transverse fissure (doorway) in the liver and contains the hepatic ducts, hepatic arteries, and branches of
the portal vein. The other structures are not found in the porta hepatis.
40. Meckel diverticulum occurs 2 feet proximal to ileocecal junction
43. The paraumbilical veins and the ligamentum teres hepatis are contained in the free margin of the falciform ligament. The
lienorenal ligament contains the splenic vessels and a small portion of the tail of the pancreas. The lienogastric ligament contains the
left gastroepiploic and short gastric vessels. The gastrophrenic ligament contains no named structures. The hepatoduodenal ligament, a
part of the lesser omentum, contains the bile duct, proper hepatic artery, and portal vein in its free margin
44. The falx inguinalis (conjoint tendon) is formed by the aponeuroses of the internal oblique and transverse muscles of the abdomen.
50. The inferior limit of the posterior lamina of the rectus sheath is marked by the arcuate line, which defines the point at which the
posterior lamina of the internal oblique and the aponeurosis of the transverse abdominal become part of the anterior rectus sheat
61. The jejunum contains circular folds along with the duodenum. The circular folds are absent in the ileum and large intestine

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 27 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Past MCQs

1. After surgical repair of hernia the patient experiences numbness of skin on the anterior aspect of scrotum. Which nerve may have
been damaged during herniorraphy?
A. Femoral nerve C. Ilioinguinal nerve
B. Obturator nerve D. Iliohypogastric nerve
2. Which nerve is false regarding the supply to presulcal part of tongue?
A. Facial nerve C. Hypoglossal nerve
B. Trigeminal nerve D. Vagus nerve
3. Protrusion of the tongue is produced by:
A. Genioglossus muscles C. Styloglossus
B. Superior longitudinal D. Palatoglossus
4. Which statement is false regarding the spleen?
A. Is a high vascular organ C. Normally lies in the axis of the left tenth rib
B. Is related to both the greater and lesser sacs of peritoneum D. In the adult is normally palpable below the left rib margin
5. Which statement is false regarding hepatic portal system?
A. It is situated between two sets of capillaries or sinusoids.
B. The portal vein is formed by the union of superior mesenteric and inferior mesenteric vein.
C. The splenic vein traverses the leinorenal ligament
D. Portal obstruction may cause ascites.
6. Cancer of the stomach is a common disease and may spread through the lymphatics. Cancer from the body of the stomach will not
spread to the following primary groups of lymph nodes:
A. Left gastric C. Superior mesenteric
B. Right gastric D. Celiac
7. A sixty five year old man who was suffering from duodenal ulcer was brought to the hospital in a state of shock indicating severe
internal hemorrhage. The blood vessel that may be eroded in such a case will include:
A. Common hepatic artery C. Left gastroepiploic artery
B. Splenic artery D. Gastroduodenal artery.
8. A 75 year old man with chronic cough noticed a bulge developing in his left groin. Examination of the patient showed a swelling
situated medial to the pubic tubercle which increased in size on coughing but never reached the level of the scrotal sac. The swelling
could be decreased on pressure. This could be due to:
A. Direct inguinal hernia C. Femoral hernia
B. Oblique inguinal hernia D. Varicocele
9. Which abdominal viscous does not lie at transpyloric plane?
A. Pelvis of the kidneys C. Origin of SMA
B. Hilum of spleen D. Pylorus of the stomach.
10. Which statement is false regarding the lesser sac of peritoneum (omental bursa)?
A. Is a peritoneal pouch situated posterior to the stomach
B. Its left margin is formed by gastrosplenic omentum and linorenal ligament
C. It projects downwards between the layers of greater omentum
D. It contains the splenic artery.
11. During laparotomy the surgeon passed his index finger from greater sac through the omental foramen into the lesser sac and
pinched the hepatodudenal ligament, the index finger of the surgeon will be related superiorly to:
A. Dudenum C. Portal vein
B. Caudate lobe D. Inferior sena cava
12. A 50 year old man was brought to a hospital with the presenting complaint of hematemesis (vomiting of blood). A diagnosis of
hepatic cirrhosis was made. Gastroscopic examination of the patient revealed esophageal varices (dilated submucosal esophageal
veins) in the lower third of the esophagus. Most likely, these varices were produced where the esophageal tributaries of the left gastric
vein anastomose with the esophageal tributaries of the:
A. Azygous vein C. Inferior phrenic vein
B. Internal thoracic vein D. Subcostal veins
13 The surgical treatment of peptic ulcer that attempts to denervate specific area where parietal cells are located while sparing other
gastric functions is:
A. Vagotomy C. Selective gastric vagotomy
B. Truncal vagotomy D. Selective proximal vagotomy

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 28 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

14. The cystic artery commonly arises from right hepatic artery in the cystohepatic triangle of Calot, bounded by visceral surface of
liver, cystic duct and:
A. Comman hepatic duct C. Bile duct
B. Hepatic artery D. Common hepatic artery
15. A muscle of the tongue that receives innervation from glossopharyngeal nerve, vagus & sympathetic nerve & narrows
oropharyngeal isthmus:
A. Styloglossus C. Genioglossus
B. Hypoglossus D. Palatoglossus
16. Cutaneous veins surrounding umbilicus anastomose with paraumbilical veins, which are tributaries
A. Thoracoepigastric vein C. Superficial epigastric vein
B. Axillary vein D. Hepatic portal vein
17. In females, the pararectal fossae are lateral extensions of:
A. Para vesical fossa C. Recto uterine pouch
B. Rectovesical pouch D. Uterovesical pouch
18. The pharyngeal muscle forming the tonsillar bed is:
A. Inferior pharyngeal constrictor C. Palatopharyngeus
B. Middle pharyngeal constrictor D. Superior pharyngeal constrictor
19. The skin around the umbilicus is innervated by:
A. T10 C. T7
B. T6 D. T9
20. A Surgeon operating on epiploic foramen carefully proceeded to avoid any nick to vascular posterior border of this foramen. The
vessel related to its posterior wall is:
A. Inferior vena cava C. Renal artery
B. Aorta D. Hepatic artery
21. A 60 year old patient was diagnosed to be suffering from malignant tumor in the fundus of stomach. Biopsy of which of the
following nodes will confirm metastasis?
A. Gastric C. Pancreaticoduodenal
B. Gastro omental D. Pancreaticosplenic
22. The vessels that cross the anterior aspect of inferior horizontal part of duodenum are:
A. Gastroduodenal C. Superior mesenteric
B. Superior pancreaticoduodenal D. Supraduodenal
23. The left rib that lies parallel to the long axis of spleen is:
A. 11 C. 12
B. 10 D. 9
24. In adults, the hepatic veins drain their venous blood into:
A. Azygos vein C. Inferior vena cava
B. Portal vein D. Right renal vein
25. A 25 year old young man presented in emergency with blunt trauma abdomen. He is in shock with blood pressure 70/40, pulse
124/min. On examination, abdomen is tense & tender more on left upper abdomen. Which solid organ is most likely to be injured?
A. Liver C. Diaphragm
B. Spleen D. Kidney
26. Spleen is supplied by splenic artery which is a branch of:
A. Aorta C. Celiac trunk
B. Right gastroepiploic artery D. Left gastroepiploic artery

27. Which of the following structures is located anterior to the spleen?

A. Left kidney C. Stomach
B. Pancreas D. Transverse colon
28. Duct of parotid gland opens opposite to the:
A. 1st molar C. 3rd molar
B. 2nd molar D. Incisor tooth
29. Which papillae does not contain taste buds:
A. Filiform C. Circumvallate
B. Fungiform D. Foliate

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 29 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

30. Sensory supply of soft palate:

A. Lesser palatine nerve C. Vagus nerve
B. Greater palatine nerve D. Trigeminal nerve
31. Appendicular artery is a branch of:
A. Ileocolic artery C. Superior mesenteric artery
B. Inferior mesenteric artery D. External iliac artery
32. Indirect inguinal hernia:
A. Medial to inferior epigastric artery C. Below the pubic tubercle
B. Lateral to inferior epigastric artery D. More common in females
33. Which nerve gets damaged during removal of stone from submandibular gland duct:
A. Lingual nerve C. Hypoglossal nerve
B. Facial nerve D. Glossopharyngeal nerve
34. Pain of gallbladder occurs in back region & right shoulder due to its relation with:
A. Intestine C. Stomach
B. Liver D. Diaphragm
35. Laterally, the tongue is drained by:
A. Submandibular lymph nodes C. Superficial cervical lymph nodes
B. Sublingual lymph nodes D. Tonsillar lymph nodes
36. Liver cirrhosis causes
A. Ascites C. Esophageal cancer
B. Hemorrhoides D. Stomach cancer
37. 5th – 7th Costal cartilage provides attachment to
A. Pyramidalis C. External oblique
B. Rectus abdominis D. Internal oblique
38. Epiploic foraman is bounded inferiorly by
A. IVC C. Caudate lobe of liver
B. Portal vein D. Duodenum
39. Anterior 2/3 pf tongue is drained by
A. Submandibular lymph nodes C. Superficial cervical lymph nodes
B. Sublingual lymph nodes D. Tonsillar lymph nodes
40. Portal vein formed behind
A. Pancreas C. Duodenum
B. Liver D. Spleen
41. Left 1/3 of transverse colon is supplied by
A. Inferior mesenteric artery and superior mesenteric artery C. Left colic artery only
B. Middle colic artery only D. Inferior mesenteric artery only
42. Posteriorly, 2nd part of duodenum is related to
A. Right ureter and inferior vena cava C. Right kidney and superior mesenteric artery
B. Left ureter and aorta D. Pancreas and splenic vein
43. The quadrate lobe is located on the:
A. Superior surface of the liver C. Anterior surface of the liver
B. Inferior surface of the liver D. Posterior surface of the liver
44. An ENT surgeon removed the Palatine tonsils of an 11 year old boy who was suffering from repeated attacks of throat infection,
The Palatine tonsils are located belween the anterior and posterior Palatine (Faucial) folds. The muscles forming these folds are
respectively:
A. Levator Veli Palatini and Tensor Vell Palatini C. Palatoglossus and Palatopharyngeus
B. Palatopharyngeus and Salpingopharyngeus D. Stytoglossus and Stylopharyngeus
45. A carcinoma in the middle portion of the lower lip is most likely to first metastasize viat
A. Submandibular nodes C. Superficial Cervical nodes
B. Parotid nodes D. Submental nodes
46. The medial umbilical folds are created by the Peritoneum overlying the:
A. Fatform ligament C. urachus
B. Inferior Epigastric arteries D. Obliterated Umbilical arteries

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 30 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

47. A patient is advised resection of Gastrointestinal Tract for Irritable Bowel Syndrome at the site where Vagal Parasympathetic
innervations ends. What is the most suitable site?
A. Left colic flexure C. ilioecal junction
B. Duodenojejunal junction D. Right colic flexure
48. A 50 year old female is diagnosed with Cirrhosis of the liver along with portal venous obstruction & hypertension. Which of the
following veins would still convey blood to the caval system?
A. Internal hac vein C. Ovarian vein
B. Azygous and Hemlazygos vein D. Testicular vein
49. Tumor of which one of the following parts of Pancreas would cause Obstructive Jaundice by compressing the Bile duct?
A. Neck of Pancreas C. Tall of Pancreas
B. Body of Fancreas D. Head of Pancreas
50. A young boy suffering from inflammation of parotid gland complained of severe pain in the region of the gland, in the auricle and
external acoustic meatus. The accompanied pain in the ear is due to common nerve supply by:
A. Auriculotemporal & greater auricular C. Auriculotemporal & superior alveolar
B. Auriculotemporal & chorda tympani D. Posterior auricular & greater auricular
51. Structure passing between middle & inferior constrictor:
A. Superior laryngeal nerve C. Stylohyoid ligament
B. Eustachian tube D. Glossopharyngeal nerve
52. Vessel most commonly responsible for postoperative bleeding after tonsillectomy?
A. Palatine vein C. Lingual artery
B. Palatine artery D. Ascending palatine artery
53. Killian's dehiscence is the gap between:
A. Cricopharyngeus & Thyropharyngeus C. Posterior & Lateral cricoarytenoid
B. Palatoglossal & palatopharyngeal arches D. Thyropharyngeus & Platopharyngeus
54. The diaphragmatic constriction of esophagus occurs when it passes through esophageal hiatus. The distance of this constriction
from incisor tooth is:
A. 15cm C. 22.5cm
B. 40cm D. 27.5cm
55. During appendicectomy, the surgeon after making grid incision on skin reached a tissue deep to obliquely running ligamentous
structure. This is:
A. Membranous layer of superficial fascia C. Transverse abdominis muscle
B. Internal oblique muscle D. Rectus abdominis muscle
56. The femoral ring is bounded medially by:
A. Inguinal ligament C. Pectineal line
B. Pectin pubis D. Lacunar ligament
57. During gastric surgery, the surgeon must appreciate that right gastroepiploic artery runs along:
A. Lesser omentum C. Greater curvature of stomach
B. Greater omentum D. Lesser curvature of stomach
58. A 60 years old male present with dysphagia. Flexible endoscopy shows a growth at cardia. What is the distance of this growth
from incisor teeth?
A. 25 cm C. 35 cm
B. 30 cm D. 40 cm
59. A 2-year-old female is brought to the emergency department because of several episodes of rectal bleeding. A technetium-99m
perfusion scan reveals a 3-cm ileal outpouching located 50 cm from the ileocecalvalve. Which of the following types of ectopic tissue
does this structure most likely contain?
A. Duodenal C. Gastric
B. Esophageal D. Jejunal
60. The posteromedial surface of the parotid gland is related to:
A. Masseter C. Temporomandibular joint
B. Ramus of mandible D. Styloid process
61. The postganglionic secretomotor fibres reach the parotid gland through the:
A. Glossopharyngeal nerve C. Great auricular nerve
B. Greater petrosal nerve D. Auriculotemporal nerve

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 31 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

62. The lymphatics of the palantine tonsil drain into:

A. Postauricular lymph nodes C. Reteropharyngeal lymph nodes
B. Occipital lymph nodes D. Jugulodigastric lymph nodes
63. The lymphatics from the tip of the tongue drain into:
A. Submandibular lymph nodes C. Parotid lymph nodes
B. Submental lymph nodes D. Jugulodigastric lymph nodes.
64. In splenomegaly, the spleen shifts to the left side because of:
A. Splenorenal ligament C. Phrenocolic ligament
B. Gastrocolic ligament D. Gastrosplenic ligament
65. The superior relation of the first part of the duodenum is:
A) Epiploic foramen C) Quadrate lobe of liver
B) Head of pancreas D) Adrenal gland
66. Which of the following is a retroperitoneal organ?
A) Pancreas C) Small intestine
B) Stomach D) Liver
67. The fundus of the stomach is supplied by:
A. SMA C. Right gastroepiploic artery
B. Left gastroepiploic artery D. Short gastric arteries
68. Portosystemic shunts include:
A. Left renal vein and splenic vein C. Portal vein and hepatic artery
B. Hepatic vein and inferior vena cava D. Splenic vein and superior mesenteric vein
69. The cantlie line, which divides the liver into functional left and right lobes, passes from:
A) Gallbladder fundus to IVC C) Inferior vena cava to ligamentum teres
B) Hilum of liver to IVC D) Falciform ligament to IVC
70. The nerve at greater risk of damage during parotidectomy is:
A) Hypoglossal nerve C) Auriculotemporal nerve
B) Facial nerve D) Glossopharyngeal nerve
71. Crocodile tear syndrome is due to damage to:
A) Facial nerve C) Vagus nerve
B) Trigeminal nerve D) Hypoglossal nerve
72. The parotid sheath is innervated by:
A) Lingual nerve C) Auriculotemporal nerve
B) Lesser occipital nerve D) Facial nerve
73. In Meckel's diverticulitis, the surgeon should check the:
A) Ileum C) Mesoappendix
B) Colon D) Appendix
74. The lower end of the esophagus is supplied by:
A) Left gastric artery C) Short gastric arteries
B) Right gastric artery D) Inferior phrenic artery
75. The cystic artery lies in:
A) Linorenal ligament C) Hepatoduodenal ligament
B) Gastrosplenic ligament D) Gastrocolic ligament
76. Calot's triangle is bounded laterally by:
A) Cystic duct C) Hepatic artery
B) Common hepatic duct D) Duodenum
77. Safety muscle of tongue:
A. Genioglossus C. Styloglossus
B. Hyoglossus D. Palatoglossus
78. A diagnosed patient of angina had severe chest pain on exertion. He immediately took sublingual nitroglycerine and felt relief in
less than a minute. Which one of the following vein is responsible for its quick absorption?
A. Dorsal lingual vein C. Lingual vein
B. Facial vein D. Deep lingual vein

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 32 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

79. A young patient came in emergency with crushing injury of left side of rib cage. He was in shock. On ultrasound, severe injury to
spleen was diagnosed. Surgeon planned to remove the organ. Which anatomical relation of spleen he has to keep in mind while
removing the organ?
A. Long axis along 12th rib C. Left kidney posteriorly
B. Tail of pancreas at the hilum D. Left pleura anteriorly

ANSWER KEY
1. C 2. D 3. A 4. D 5. B 6. C 7. D 8. A 9. B 10. D
11. C 12. A 13. D 14. A 15. D 16. D 17. C 18. D 19. A 20. A
21. D 22. C 23. B 24. C 25. B 26. C 27. C 28. A 29. A 30. A
31. A 32. B 33. A 34. D 35. A 36. A 37. B 38. D 39. A 40. A
41. C 42. A 43. B 44. C 45. A 46. D 47. A 48. B 49. D 50. A
51. A 52. A 53. A 54. B 55. C 56. D 57. C 58. D 59. C 60. D
61. D 62. D 63. B 64. D 65. A 66. A 67. D 68. A 69. A 70. B
71. A 72. C 73. A 74. A 75. C 76. A 77. A 78. D 79. B

1. Ilioinguinal nerve supplies the anterior aspect of scrotum & upper medial thigh
11. When the surgeon passes their index finger through the omental foramen (also known as the epiploic foramen) from the greater sac
into the lesser sac, they will encounter the hepatoduodenal ligament, which is a fibrous connective tissue structure that surrounds the
portal vein, hepatic artery, and bile duct as they enter the liver. Superior to the hepatoduodenal ligament is the portal vein, which is a
vital structure that carries blood from the digestive organs to the liver. IVC is located posteriorly
12. See Q4 in topic A008
13. Selective proximal vagotomy is a surgical procedure that aims to denervate the parietal cells in the proximal stomach, which are
responsible for acid secretion, while sparing other gastric functions. This procedure targets the nerve fibers that innervate the parietal
cells, reducing acid production and treating peptic ulcers.
34. The gallbladder is located in the right upper quadrant of the abdomen, and its inflammatory or spasmodic conditions (such as
cholecystitis or biliary colic) can cause referred pain in the back and right shoulder regions due to its relationship with the diaphragm.
The phrenic nerve (C3-C5) innervates the diaphragm and also receives sensory fibers from the gallbladder, which is why pain from
the gallbladder can be referred to the shoulder and back regions. This is known as "referred pain".
36. Liver cirrhosis can cause ascites, which is the accumulation of fluid in the peritoneal cavity. This is a common complication of
cirrhosis. Hemorrhoids (B) are not directly caused by liver cirrhosis, although portal hypertension can lead to hemorrhoids
47. Left colic flexure also known as Splenic flexure
59. Meckel diverticulum contains gastric mucosa
64. In splenomegaly, the enlarged spleen shifts downward and medially (toward the midline) due to the gastrosplenic ligament, which
attaches the spleen to the stomach. This ligament allows the spleen to move downward and compress the stomach and surrounding
structures. Phrenocolic ligament prevents downward movement of spleen in splenomegaly
66. An organ is said to be intraperitoneal when it is almost totally covered with visceral peritoneum. The stomach, jejunum, ileum, and
spleen are good examples of intraperitoneal organs. Retroperitoneal organs lie behind the peritoneum and are only partially covered
with visceral peritoneum. The pancreas and the ascending and descending parts of the colon are examples of retroperitoneal organs
68. Portal hypertension can be reduced by diverting blood from the portal to the caval system. This is accomplished by connecting the
splenic vein to the left renal vein or by creating a communication between the portal vein and the IVC
74. Upper end supplied by inferior thyroid artery, Middle portion by descending thoracic aorta & lower end by left gastric artery
75. The lienorenal ligament contains the splenic vessels and a small portion of the tail of the pancreas. The lienogastric ligament
contains the left gastroepiploic and short gastric vessels. The gastrophrenic ligament contains no named structures. The
hepatoduodenal ligament, a part of the lesser omentum, contains the bile duct, proper hepatic artery, and portal vein in its free margin
78. Book line (KLM)

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 33 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

A015 – A018
GIT EMBRYOLOGY
A-015 ֍ORAL CAVITY֍

01. Tongue

1. Describe the development of tongue with special reference to its nerve supply.

Part Dveleopement Nerve Supply

Oral part Develops from three mesodermal swellings Lingual nerve & Chorda
(Anterior 2/3)  1 median tongue bud (tuberculum impar) + 2 distal tongue buds (lateral tympani nerve
lingual swelling)
 These buds develop from proliferation of mesenchyme in the first pair
of pharyngeal arch. The distal tongue buds over grow the median tongue
bud and fuse in midline forming median sulcus superficially & fibrous
lingual septum internally
Pharyngeal part Develops from two mesodermal swellings Glossophrayngral nerve
(Posterior 1/3)  Copula – forms by the fusion of ventromedial part of second pair of
pharyngeal arches
 Hypobrancial eminence – develops caudal from mesenchyme in the
ventromedial part of third and fourth pairs of pharyngeal arches.
These swellings develop from the proliferation of mesenchyme in the second
third and fourth pairs of pharyngeal arches. The hypobranchial eminence over
grows the copula thereby eliminating the contribution of 2nd pharyngeal arch in
the formation of adult tongue.
Fusion b/w two A V shaped groove terminal sulcus indicates the line of fusion of the anterior & posterior parts of the tongue
parts
Taste buds Taste buds develop during 11th-13th week by inductive interaction between epithelial cells of the tongue and
invading gustatory nerve cells from chorda tympani, glossopharyngeal and vagus nerve
Tongue muscles The intrinsic muscles of the tongue are derived from occipital somities. Hypoglossal nerve &
Vagus nerve

02. Palate & Facial Clefts

Prominence Structure formed

Frontonasal Bridge of nose, medial and lateral nasal processes
Maxillary Lateral portion of upper lip, Palate
Medial nasal Philtrum of upper lip, Tip of nose
Lateral nasal Alae of nose
Mandibular Lower lip
Note: You should know normal embryological development to understand defects

A-016 ֍FOREGUT֍

01. Gut tube, Mesenstery & Esophagus

No past seq from this topic

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 34 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

02. Stomach

1. Give the development of stomach.

2. Give the extent and axis of rotation of stomach.
3. Give the effect of this rotation on development and nerve supply of stomach.
At 4th week
o Stomach appears as a fusiform dilation of the foregut. At this time the stomach has a ventral and dorsal mesentery called
ventral and dorsal mesogastrium.
After 4th week (Rotation)
o Later on during its development, stomach rotates 90° clockwise, around its longitudinal ais along with its blood and nerve
supply. Thus, its left side now faces anteriorly while the right side face posteriorly, innervated by the left and right vagus
nerve respectively.
o This rotation also results in the downward bulging of the dorsal mesogastrium, which continues over the transverse colon and
the loops of small intestine to form a double-layered sac called greater omentum (greater sac of peritoneum). The ventral
mesogastrium forms the lesser omentum (lesser sac) and the falciform ligament of liver
o In addition, the anterior border becomes concave and forms the lesser curvature, while posterior border becomes convex to
forms the greater curvature of the stomach. The fundus appears as the dilation of the upper end of the stomach

4. What is congenital hypertrophic pyloric stenosis?

It is a narrowing of the pyloric sphincter at gastric outlet that leads to projectile non-bilious vomiting

5. A four-week baby presented with non-bilious vomiting after takin meal & there is distension of abdomen. What is the diagnosis?
Hypertrophic pyloric stenosis

03. Duodenum, Liver & Gallbladder

1. Write histogenesis of liver

o The liver bud (hepatic diverticulum) appears in the middle of the 3rd week as an outgrowth of the endodermal epithelium at
the apex of the loop of the developing duodenum. Liver buds consist of rapidly proliferating cells (hepatic cells) that
penetrate the septum transversum (a mass of splanchnic mesoderm between developing heart & midgut).
o The columns of endodermal cells form the liver cords, which then differentiate into parenchyma and also form the lining of
the biliary duct.
o Hematpoietic cells, kupffer cells and connective tissue cells are derived from mesoderm of septum transversum.
o Hepatic bud enlarges rapidly and divides into two parts:
 The large cranial part, which a primordium of the paranchyma of the liver
 The small caudal part, gives rise to the galladder and cystic duct.
o The paired vitelline veins and umbilical veins are broken up by the invading columns liver cells to form liver sinusoids.

DO YOU KNOW!
 Hematopoiesis in liver starts during 6th week
 Bile production starts at 12th week
 Meconium formation begins after 13th week

04. Pancreas

1. Discuss the embryological basis of annular pancreas.

It occurs when ventral and dorsal pancreatic buds form a ring around the duodenum, thereby causing causing obstruction of duodenum

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 35 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

A-017 ֍MIDGUT֍

1. Give the axis and extent of changes of midgut loop within the umbilical cord.
Physiological herniation
 At the beginning of 6th week. mid gut forms a U-shaped loop (mid gut loop) that herniates through the primitive umbilical
ring into the extraembryonic coelom this is know as physiological umbilical herniation. The midgut loop has a cephalic & a
caudal limb
o Cephalic limb that gives rise to the distal part of the duodenum, the jejunum and upper part of ileum.
o Caudal limb becomes the lower portion of the illeum, the ascending colon and the proximal two third of the
transverse colon. A cecal diverticulum arises from the caudal limb, which forms the cecum and vermifrom appendix
Rotation of midgut
 In the extraembryonic coelom, the midgut rotates approximately by 90° around the axis formed by superior mesenteric artery
and the vitelline duct. This rotation brings the cranial limb of the midgut loop to the right & caudal limb to the left.
Return of herniated loops
 During 10th week of development, the herniated intestine loops return to the abdominal cavity.
 During this process of return, the midgut loop rotates counter clockwise by an additional 180°, thus making the rotation of the
loop through a total of 270° counter clock wise.

2. Define physiological umbilical herniation of midgut and state causing factors.

Physiological herniation
 At the beginning of 6th week. mid gut forms a U-shaped loop (mid gut loop) that herniates through the primitive umbilical
ring into the extraembryonic coelom this is know as persiological umbilical herniation. It resolves by 10 th week
Causative factors
1. The midgut grows rapidly and temporarily herniates through the umbilical ring.
2. The umbilical ring is naturally wider during fetal development, allowing the midgut to protrude.
3. Increased intra-abdominal pressure pushing the midgut through the umbilical ring.

3. Describe Ileal/Meckel‘s diverticulum.

The vestigial remnant of the omphalomesenteric (vitelline) duct known as Meckel's diverticulum, is the most frequent malformation of
the gastrointestinal tract and is present in 2% of the population. The majority remains asymptomatic, and they are found twice as
frequently in men as in women. Meckel's diverticulum is located in the distal ileum, usually 2feet from ileocecal valve.

4. During an appendicectomy, an inflamed finger like structure arising from ileum was observed. Name structure, its location and
embryological source.
Structure  Mecklel‘s diverticulum
Location  Distal ileum usually 2feet from ileocecal valve
Embryological source  Vestigial remnant of omphalomesenteric duct (vitellointestinal duct)

A-018 ֍HINDGUT֍
Only anal canal is important & that is already covered in gross anatomy regarding embryological source, nerve supply, blood supply
& lymphatics for above & below the pectinate line

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 36 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Practice & Past MCQs

1. Pancreatic islets consist of alpha, beta, and delta cells, which secrete glucagon, insulin, and somatostatin, respectively. These cells
are derived from
(A) mesoderm (C) ectoderm
(B) endoderm (D) neuroectoderm
2. In the developing embryo, the midgut rotates 270 degrees around which of the following structures?
(A) superior mesenteric artery (C) splenic artery
(B) celiac trunk (D) left renal artery
3. A 28-day-old baby is brought to the physician because of projectile vomiting after feeding. Until this time, the baby has had no
problems in feeding. On examination, a small knot is palpated at the right costal margin. Which of the following disorders might be
suspected?
(A) Esophageal stenosis (C) Hypertrophic pyloric stenosis
(B) Annular pancreas (D) Extrahepatic biliary atresia
4. Which of the following arteries supplies foregut derivatives of the digestive system?
(A) Celiac trunk (C) Inferior mesenteric artery
(B) Superior mesenteric artery (D) Right umbilical artery
5. The most common type of anorectal malformation is
(A) imperforate anus (C) anorectal agenesis
(B) anal agenesis (D) rectal atresia
6. Taste sensation from the oral part (anterior two-thirds) of the tongue is predominantly car ried by
(A) trigeminal nerve (CN V) (C) glossopharyngeal nerve (CN IX)
(B) chorda tympani branch of the facial nerve (CN VII) (D) superior laryngeal branch of the vagus nerve (CN X)
7. A 4-day-old baby boy has not defecated since coming home from the hospital even though feeding has been normal without any
excessive vomiting. Rectal examination reveals a normal anus, anal canal, and rectum. However, a large fecal mass is found in the
colon, and a large release of flatus and feces follows the rectal examination. Which of the following conditions would be suspected?
(A) Imperforate anus (C) Anorectal agenesis
(B) Anal agenesis (D) Colonic aganglionosis
8. Which one of the following structures is derived from the midgut?
(A) Appendix (C) Liver
(B) Stomach (D) Pancreas
9. A 3-month-old baby girl presents with a swollen umbilicus that has failed to heal normally. The umbilicus drains secretions, and
there is passage of fecal material through the umbilicus at times. What is the most likely diagnosis?
(A) Omphalocele (C) Anal agenesis
(B) Gastroschisis (D) Ileal diverticulum
10. The midgut loop normally herniates through the primitive umbilical ring into the extraembryonic coelom during week 6 of
development. Failure of the intestinal loops to return to the abdominal cavity by week 11 results in the formation of
(A) omphalocele (C) anal agenesis
(B) gastroschisis (D) ileal diverticulum
11. Kupffer cells present in the adult liver are derived from
(A) mesoderm (C) ectoderm
(B) endoderm (D) neuroectoderm
12. Which one of the following structures is a derivative of foregut?
(A) Jejunum (C) Gallbladder
(B) Meckel's diverticulum (D) Cecum
13. A baby born to a young woman whose pregnancy was complicated by polyhydramnios was placed in the intensive care unit
because of repeated vomiting containing bile. The stomach was markedly distended, and only small amounts of meconium had passed
through the anus. What is the most likely diagnosis?
(A) Esophageal stenosis (C) Hypertrophic pyloric stenosis
(B) Annular pancreas (D) Duodenal atresia
14. Cleft lip occurs due to non fusion of maxillary palatal process with:
A. Medial nasal prominence C. Mandibular process
B. Lateral nasal prominence D. Medial nasal eminence

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 37 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

15. Oblique facial cleft is due to failure of fusion between:

(A) The two medial nasal processes (C) The two mandibular processes
(B) The two lateral nasal processes (D) The maxillary process and lateral nasal process
16. Which structure is derived from the cloacal membrane?
(A) Anal membrane (C) Hymen
(B) Central fibrous trigone (D) Urorectal septum
17. Main pancreatic duct developes from
(A) Ventral bud (C) Ventral & dorsal bud
(B) Dorsal bud (D) None
18. Muscles of tongue develop from:
(A) Occipital somities (C) Thoracic somities
(B) Cervical somities (D) Lateral plate mesoderm
19. The congenital defect that occurs lateral to the umbilicus is
A. Gastroschisis C. Rectus abdominis hernia
B. Omphalocele D. Diastasis recti
20. Duodenum developes from
A. Hindgut C. Foregut
B. Midgut D. Foregut & Midgut
21. Midgut rotation in opposite direction is opposed by
A. Superior mesenteric artery C. Transverse colon
B. Inferior mesenteric artery D. Hepatosplenic ligament
22. Derivative of ventral mesentery
A. Greater omentum C. Fundus of stomach
B. Falciform ligament D. Head of pancreas
23. A child presents with complaint of projectile vomiting containing bile. Double bubble sign appears on x-ray. What is the
diagnosis?
A. Anorectal atresia C. Duodenal atresia
B. Esophageal atresia D. Pyloric stenosis

ANSWER KEY
1. B 2. A 3. C 4. A 5. C 6. B 7. D 8. A 9. D 10. A
11. A 12. A 13. D 14. A 15. D 16. A 17. C 18. A 19. A 20. D
21. A 22. B 23. C

7. This baby boy suffers from colonic aganglionosis, or Hirschsprung disease, which results in the retention of fecal material, causing
the normal colon to enlarge. The retention of fecal material results from a lack of peristalsis in the narrow segment of colon distal to
the enlarged colon.
9. This baby girl has an ileal diverticulum (Meckel diverticulum), which occurs when a remnant of the vitelline duct persists. In this
case, a fistula is present by which contents of the ileum can be discharged onto the surface of the skin.
10. An omphalocele results when intestinal loops fail to return to the abdominal cavity. Instead, the intestinal loops remain in the
umbilical cord covered by amnion
13. This baby is suffering from duodenal atresia at a level distal to the opening of the common bile duct. This causes a reflux of bile
and its presence in the vomitus. The pregnancy was complicated by polyhydramnios because the duodenal atresia prevented passage
of amniotic fluid into the intestines for absorption.
19. Gastroschisis is a congenital defect where the intestines protrude through a hole in the abdominal wall, usually to the right side of
the umbilicus (belly button), lateral to the umbilicus. Omphalocele is a congenital defect where the intestines or other organs protrude
through a hole in the abdominal wall, but it occurs at the umbilicus (belly button), not lateral to it i.e. midline
23. Double bubble sign is diagnostic for Duodenal Atresia

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 38 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

HISTOLOGY
A019 – A022
GIT

A-019 ֍ORAL CAVITY & ESOPHAGUS֍

01. Lip, Gums, Palate & Tongue

No past seq from this section
Structure Epithelium
Lip Cutaneous surface  Stratified squamous keratinized epi
Red vermilion surface  Stratified squamous non-keratinized epi
Oral surface  Stratified squamous non-keratinized epi
Gums Stratified squamous keratinized epi
Hard palate Stratified squamous keratinized epi
Soft palate Superior/Pharyngeal surface  Pseudostratified columnar epi
Inferior/Oral surface  Stratified squamous non-keratinized epi
Tongue Upper/Dorsal surface  Stratified squamous partially keratinized epi
Lower/Ventral  Stratified squamous non-keratinized epi

02. Salivary Gland

1. Draw and label light microscopic picture of submandibular salivary gland.

Prepare it from your histology notebook

03. Esophagus

1. Enumerate four microscopic structural differences between beginning and end of esophagus in a tabular form.

Differences Upper end Lower end

Epithelium Stratified squamous Simple columnar
Submucosa Less prominent More prominent
Muscularis externa Skeletal muscle Smooth muscle
Adventitia/Serosa Adventitia Serosa

8. Explain the structural features of esophagus regarding reflux esophagitis.

o Esophageal mucosa get inflamed
o Esophageal stricture
o Barrett's esophagus  A condition in which the normal squamous epithelium of the esophagus is replaced by columnar
epithelium, which can increase the risk of esophageal adenocarcinoma

A-020 ֍STOMACH֍
1. Name the cells in gastric glands mentioning their functions.
2. Name the cells found in the mucosal glands of stomach.

Cells Function/Secretion
Gastric/Fundic gland Parietal/Oxyntic cells Secrete HCl & Intrinsic factor
80% Chief/Peptic/Zymogen cells Secrete pepsinogen & gastric lipase
Enteroendocrine cells Secrete GIP & Histamine
Pyloric gland G cells Secrete gastrin
D cells Secrete Somatostatin

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 39 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. Give main structural features of parietal (oxyntic) cells.

o Round or Pyramidal shape
o Centrospherical nucelus
o Large no. of mitochondria, golgi vesicles & mircotubules
o Have intracellular canaliculi

4. What are gastric pits?

o Gastric pits are shallow in fundus & body & occupy 1/3 of mucosal thickness
o Gastric pits are deep in pyloric & cardiac regions & occupy 2/3 of mucosal thickness.

5. Draw and label histological structure of fundus of stomach.

Prepare from your histology practical notebook

A-021 ֍SMALL INTESTINE֍

01. Duodenum, Jejunum & Ilium

1. Name different types of cells found in epithelium of small intestinal mucosa and briefly describe the absorptive cells.
2. Enumerate the cells present in the intestinal epithelium along with their functions. [Annual 2024 held in 2025]

Cells Description
Absorptive  Tall columnar cells with baso-oval nucleus
cells/Enterocytes  Microvilli on apical surface
 Glycocalyx coat on tip of microvilli
 Bind to each other with junctional complex
Goblet cells  Secrete mucus
Enteroendocrine cells  Secrete gastrin, secretin, motilin, GIO, CCK
Paneth cells  Acidophilic granules that contain lysozyme & defensives that kill bracteria
M cells  Antigen presenting cells

2. What structural arrangements are present in the mucosa of small intestine to increase the surface area?
1. Plica circularis/Valves/Folds of kerckering
2. Villi
3. Microvilli
4. Crypts of leiberkuhn

Regional Differences
Feature Duodenum Jejunum Ileum
Villi shape Leaf & Finger shaped Finger shaped Finger shaped & Club shaped
Peyer‘ patches X x Yes
Glands Brunner‘s gland x x
As we move from duodenum towards colon, number of goblet cells increase but number of villi decreases & finally villi disappear in colon

02. Celiac disease & Crohn disease

Celiac disease  Decreased height of villi (villous atrophy) in small intestine + Crypt hyperplasia
 Involve mucus layer
Celiac disease, also called gluten-sensitive enteropathy or sprue, is a disorder of the small intestine in which
one of the first pathologic changes is loss of the microvilli brush border of the absorptive cells. This is
caused by an immune reaction against the wheat protein gluten during its digestion, which produces diffuse
enteritis (intestinal inflammation), changes to the epithelial cells leading to malabsorption, and eventually to
pathologic changes in the intestinal wall
.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 40 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Crohn disease  Cryptitis + Epithelial metaplasia & Paneth cell metaplasia

 Involve all layers
Crohn disease is a chronic inflammatory bowel disease that occurs most commonly in the ileum or colon,
resulting from a poorly understood combination of immune, environmental, and genetic factors. Excessive
lymphocytic activity and inflammation occur in any or all layers of the tract wall, producing pain, localized
bleeding, malabsorption, and diarrhea

A-022 ֍LARGE INTESTINE֍

3. Mention changes in the epithelium of digestive tract as it is traced from stomach to anal canal.

Part of digestive tract Epithelium

Stomach Simple columnar epi
Duodenum Simple columnar epi
Jejunum Simple columnar epi
Ilium Simple columnar epi
Appendix Simple columnar epi
Colon Simple columnar epi
Rectum Simple columnar epi
Anal canal Stratified squamous epi

A-028 ֍LIVER, GALLBLADDER & PANCREAS֍

01. Liver

1. What is the structure of a hepatic lobule? What type of cell lines the hepatic sinusoids?
Hepatic Lobule
1. Hepatocytes form hundreds of irregular plates arranged radially around a small central vein
2. Triangular portal areas at angle of hexagonal hepatic lobules that contain venule, arteriole & bile ductules
3. Bile flows in narrow channels called biliary canaliculi  Bile ductule (canal of hering)
4. Hepatic lobule drains blood from portal vein & hepatic artery to the hepatic or central vein
Types of cells
1. Endothelial cells
2. Kupffer cells (stellate macrophages)

2. Draw and label a diagram showing the difference between hepatic and portal lobules. [Annual 2024 held in 2025]
Prepare from your histology practical notebook.

02. Gallbladder

3. Draw and label histological structure of gall bladder

Prepare from your histology practical notebook.

03. Pancreas

1. Briefly describe the microscopic structure of pancreas and mention the function of different structural component of this organ.
2. Enumerate the secretory cells of islets of langerhans, mentioning the products secreted by them.
3. Enumerate cells forming the Islets of Langerhans along with their specific functions.

Endocrine part Islets of Langerhans in reticular CT with pale staining polyhedral cells arranged
as short cords seperated by capillaries
1. Alpha cells secrete glucagon
2. Beta cells secrete insulin & amyloin

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 41 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. Delta cells secrete somatostatin

4. PP cells secrete Pancreatic polypeptidase
Exocrine part Serous cells in acini
Duct system  intercalcated ducts, Interlobular & intralobular ducts, main duct

4. A young man was presented in OPD with complaints of pain in upper abdomen that radiated to back, gets worse after eating. Patient
also experienced diarrhoea and weight loss. Pancreatic biopsis revealed excessive fibrosis. What do you think patient is suffering
from?
Chronic pancreatitis. It cannot be acute pancreatitis because biopsy is showing fibrosis that is a feature of chronic disease

5. Draw and label microscopic picture of Pancreas

Prepare from your histology practical notebook.

A-029 ֍LYMPHATIC TISSUE ASSOCIATED WITH GIT֍

MALT is one of the largest lymphoid organs, containing up to 70% of all the body‘s immune cells. MALT is found in the mucosa of
most tracts but is concentrated in the
 Tonsils
 Peyer patches in the ileum
 Appendix
APPENDIX
Mucosa Epithelium Simple columnar
Lamina propria Infiltrated with lymphocytes & contains numerous LN extending into submucosa
Muscularis mucosa Longitudinal smooth muscle
Submucosa Adipocytes
Muscularis Externa 2 layers of smooth muscles (inner circular & outer longitudinal)
Adventitia Serosa

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 42 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Practice & Past MCQs

1. Biopsy specimen of mucosa of small intestine of a person suffering from malabsorption as a result of an immune response against
gluten or other proteins in wheat will show:
A. Damaged and destroyed villi C. Change of epithelium from simple to stratified
B. Abnormal accumulation of smooth muscles D. Formation of ulcers and bleed
2. An example of the stratified squamous non-keratinized epithelium is constituted by the lining epithelium of:
A. Trachea C. Oesophagus.
B. Urinary bladder. D. Stomach.
3. The intercalated ducts of the salivary glands are lined by:
A. Tall columnar epithelium. C. Simple squamous epithelium.
B. Low cuboidal epithelium. D. Stratified squamous epithelium
4. Von-Ebner‘s glands are found:
A. On the soft palate. C. On the cheeks.
B. On the lips. D. On the tongue.
5. The oesophagus is lined by:
A. Simple columnar epithelium. C. Stratified squamous keratinized epithelium.
B. Simple cuboidal epithelium. D. Stratified squamous non-keratinized epithelium.
6. In a liver biopsy from a long-time drug user which of the following hepatocyte organelles would be expected to be more extensive
than normal?
a. Rough endoplasmic reticulum c. Lysosomes
b. Golgi apparatus d. Smooth endoplasmic reticulum
7. Which description is true of pancreatic zymogens?
a. Are packaged for secretion in the SER c. Are inactive until they reach the duodenal lumen
b. Are synthesized on free ribosomes d. Are produced by cuboidal cells lining the pancreatic duct
8. Which process increases in response to parasympathetic stimulation of the salivary glands?
a. Volume of secretion c. Mucus content of saliva
b. Cell division in secretory acini d. Inorganic salts content of saliva
9. Which feature is unique to the exocrine pancreas?
a. Insulin-secreting β cells c. Striated interlobular ducts
b. Centroacinar cells d. Striated intralobular ducts
10. Which description is true of the bile canaliculi?
a. Are bordered directly by endothelial cells c. Are surrounded by the hepatic sinusoids
b. Are part of the portal triad d. Lumens are entirely sealed by junctional complexes
11. Which description is true of the gallbladder?
a. Dilutes bile c. Secretes mucus
b. Absorbs bile d. is covered entirely by serosa
12. Which description is true for the hepatic space of Disse?
a. Is surrounded by the hepatic sinusoid d. Contents empty into canals of Hering lined by
b. Contents flow toward the central vein cholangiocytes
c. Is directly contacted by hepatocytes
13. A 50-year-old woman presents to the family medicine clinic. She admits to drinking a six-pack of beer each day with a little more
intake on weekends. Laboratory tests show elevated alanine aminotransferase/serum glutamic oxaloacetic transaminase (AST/SGOT).
Her sclerae appear jaundiced and her serum bilirubin is 2.5 mg/dL (normal 0.3-1.9 mg/dL). A biopsy shows hepatic fibrosis with
significant loss of normal lobular structure. Jaundice is most likely to result when the proper location or orientation of what hepatic
structures is disrupted?
a. Central veins c. Kupffer cells
b. Spaces of Disse d. Hepatocytes
14. A young child presents with hepatomegaly and renomegaly, failure to thrive, stunted growth, and hypoglycemia. A deficiency in
glucose-6-phosphatase is identified and the diagnosis of von Gierke disease is made. What cellular structures would be expected to
accumulate in hepatocytes during progression of this disorder?
a. Chylomicrons c. Mitochondria
b. Glycogen granules d. Zymogen granules
15. Crypts of Lieberkuhn are found in:-
a. Gall bladder c. Tonsil.
C. Stomach d. Intestine

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 43 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

16. The most striking feature that distinguishes the duodenum from the rest of the small intestine histologically is:
a. Presence of smaller villi c. Presence of inner circular and outer longitudinal muscle
b. Presence of Brunner's glands d. Its posterior part lacks serosa
17. Histologically you can differentiate the duodenum from the rest of the small intestine by the presence of:
a. Villi c. Brunner's glands
b. Crypts of Leiberkuhn d. Valves of Kerckring
18. Von-Ebner glands are found in:
a. Duodenum b. Fungiform papillae
b. Filiform papillae d. Circumvellate papillae
19. Which statement is false as regards pancreas?
a. alpha cells of the islet tissue produce glucagon c. Secretions of the islet tissue are drained by ducts
b. Beta cells are more in number than alpha cells in the islet d. The exocrine pancreas is a compound acinar gland
20. Histological slide of both Pancreas and Parotid gland show Compound Acinar glands. The distinguishing feature of Pancreas is
presence of:
a. Serous Demilunes c. Striated ducts
b. Mucus Acini d. Centroacinar cells
21. Epithelial lining of gallbladder
a. Simple columnar with microvilli c. Simple columnar with goblet cells
b. Simple cuboidal with sterocilia d. Simple squamous
22. A 36-year-old man complains of difficulty in swallowing. Esophagoscopy reveals a polypoid mass that is subsequently biopsed. In
addition to tumor cells, the esophageal blopsy show normal smooth muscle and striated muscle in the same section. Which portion of
the esophagus was the source of this biopsy?
a. Middle third of the esophagus c. Lower third of the esophagus
b. Lower esophageal sphincter d. Upper third of esophagus
23. Intracellular canaliculus is found in
a. Chief cells c. Parietal cells
b. Mucous cells d. Goblet cells
24. Goblet cells are found abundantly in
a. Esophagus c. Stomach
b. Small intestine d. Large intestine

ANSWER KEY
1. A 2. C 3. B 4. D 5. D 6. D 7. C 8. A 9. C 10. D
11. C 12. C 13. B 14. B 15. D 16. B 17. B 18. D 19. C 20. C & D
21. A 22. A 23. C 24. B

6. Long-term drug use can lead to increased smooth ER in hepatocytes, which is responsible for detoxification and metabolism of
drugs.
7. Pancreatic zymogens are inactive enzymes that are synthesized in the pancreas and stored in zymogen granules. They are activated
in the small intestine (duodenal lumen) to digest food.
9. The exocrine pancreas has striated ducts, which are unique among exocrine glands. These ducts are surrounded by striated muscle,
which helps to propel pancreatic secretions into the small intestine.
10. Bile canaliculi are sealed by tight junctions to prevent bile from leaking into the surrounding tissue and to maintain the integrity of
the bile transport system.
13. Jaundice occurs when the normal flow of bile through the spaces of Disse is disrupted, leading to a buildup of bilirubin in the
blood.
14. Von Gierke disease is a glycogen storage disorder, leading to excess glycogen accumulation in hepatocytes, which can cause
hepatomegaly, hypoglycemia, and other symptoms.
20. Striated ducts are present in in parotid but absent in pancreas. Centro-acinar cells are present in pancreas but absent in parotid

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 44 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

PHYSIOLOGY
P001 – P010
GIT

P-001 ֍GENERAL PRINCIPLES OF GIT FUNCTION֍

01. Enteric Nervous System

What is enteric nervous system? Give its functions.
The gastrointestinal tract has a nervous system all its own called the enteric
nervous system (intrinsic nervous system). It lies entirely in the wall of the
gut, beginning in the esophagus and extending all the way to the anus.
Although it is connected to the extrinsic nervous system however it can
work independently.
Functions
1. Myenteric plexus (Auerbach plexus) primarily controls the
motility of the GI smooth muscle.
2. Submucosal plexus (Meissner plexus) primarily controls secretion
and blood flow.

2. Enumerate 8 neurotransmitters secreted by the enteric nervous system.

1. Acetylcholine 7. Substance P
2. Norepinephrine 8. Vasoactive intestinal polypeptide
3. Adenosine triphosphate 9. Somatostatin
4. Serotonin 10. leu-enkephalin
5. Dopamine 11. Met-enkephalin
6. Cholecystokinin 12. Bombesin

02. Membrane Potential

Slow waves
Slow waves are not actually the action potential. Instead, they are slow,
undulating changes in the resting membrane potential. Their intensity usually
varies between 5 and 15 millivolts, and their frequency ranges in different
parts of the human gastrointestinal tract from 3 to 12 per minute—about 3 in
the body of the stomach, as much as 12 in the duodenum, and about 8 or 9 in
the terminal ileum. Slow waves are produced by Interstitial cells of Cajal
which act as electrical pacemakers for smooth muscle cells
Spike waves
The spike potentials are true action potentials. Generated by calcium-sodium
channel

03. ANS

1. Compare the effects of sympathetic and parasympathetic system on GIT.

Sympathetic system Parasympthetic system

Enteric nervous system Decreases activity of Increases activity of the Enteric
the Enteric Nervous System Nervous System
Walls Relaxes Contracts
Sphincters Contracts Relaxes
Secretions Decreases Increases
Motility Decreases Increases
Note: Antimuscurinic drug (ATROPINE) blocks myenteric plexus, reduces motility thus used for treating diarrhea

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 45 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

04. GIT Reflexes

No past seq

05. GIT Hormones

1. Enlist the functions of cholecystokinin and secretin.

Note: Whole table is very important so cram this table

06. GIT movements

No past seq. Just give it a read. Cam be asked in mcqs

07. GIT Blood Flow

Possible causes of the increased blood flow during gastrointestinal activity
1. Several vasodilator substances (CCK, Intestinal peptide, Gastrin & Secretin) are released from mucosa of the intestinal tract
during the digestive process.
2. Some of the gastrointestinal glands release two kinins, kallidin and bradykinin, into the lumen. These kinins are powerful
vasodilators
3. Decreased oxygen concentration in the gut wall can increase intestinal blood flow at least 50 to 100 percent; therefore, the
increased mucosal and gut wall metabolic rate during gut activity probably lowers the oxygen concentration enough to cause
much of the vasodilation. The decrease in oxygen can also lead increase of adenosine, a well-known vasodilator that could be
responsible for much of the increased flow.

P-002 ֍ORAL CAVITY & ESOPHAGUS֍

01. Mastication (chewing)

No past seq

02. Swallowing

1. Name the different stages of swallowing.

2. Give the series of events which take place during the pharyngeal stage of swallowing.
3. Name the stages of deglutition. Give the events occurring during second stage of swallowing.
4. What events occur during pharyngeal stage of swallowing. Give their nervous control.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 46 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Stage Steps
Oral stage 1. Bolus is placed over postero-dorsal surface of the tongue
(Voluntary stage) 2. Anterior part of tongue is retracted and depressed
3. Posterior part of tongue is elevated and retracted against the hard palate. This pushes the
bolus backwards into the pharynx
4. Forceful contraction of tongue against the palate produces a positive pressure in the posterior
part of oral cavity. This also pushes the food into pharynx
Pharyngeal stage 1. Soft palate is pulled upward to close the posterior nares to prevent reflux of food into the
(Involuntary stage) nasal cavities
2. Palatopharyngeal folds on each side of the pharynx are pulled medially to approximate each
other
3. Vocal cords of the larynx are strongly approximated, and the larynx is pulled upward and
anteriorly by the neck muscles. Thus, prevent passage of food into the nose and trachea. Also
enlarges the opening to the esophagus
4. Upper esophageal sphincter relax & pharyngeal muscle contracts thus food pass into
esophagus
Esophageal stage 1. When bolus reaches the upper part of esophagus, the peristalsis starts. This is known as
Primary peristalsis. After origin, the peristaltic contractions pass down through the rest of the
esophagus, propelling the bolus towards stomach.
2. If the primary peristaltic contractions are unable to propel the bolus into the stomach, the
Secondary peristaltic contractions appear and push the bolus into stomach. Secondary
peristaltic contractions are induced by the distention of upper esophagus by the bolus
3. When bolus enters this part of the esophagus, this sphincter relaxes so that the contents enter
the stomach. After the entry of bolus into the stomach, the sphincter constricts and closes the
lower end of esophagus.

Nervous control of 2nd stage

 When the bolus enters the oropharyngeal region, the receptors present in this region are stimulated.
 Afferent impulses from the oropharyngeal receptors pass via glossopharyngeal nerve fibers to the deglutition center in the
floor of the fourth ventricle in medulla oblongata of brain.
 Impulses from deglutition center travel through glossopharyngeal and vagus nerves (parasympathetic motor fibers) and reach
soft palate, pharynx and esophagus. The glossopharyngeal nerve is concerned with pharyngeal stage of swallowing. The
vagus nerve is concerned with esophageal stage.
 The reflex causes upward movement of soft palate, to close nasopharynx and upward movement of larynx, to close
respiratory passage so that bolus enters the esophagus. Now the peristalsis occurs in esophagus, pushing the bolus into
stomach

04. Dysphagia

1. What are the causes of dysphagia?

1. Oropharyngeal Dysphagia
o Motility disorders Myasthenia gravis, Bulbar & Pseudobulbar Palsy
o Structural disorders  Malignancy, Zenker‘s diverticulum
1. Esophageal Dysphagia:
o Achalasia & Reflux-related dysmotility
o Benign Conditions  Peptic strictures
o Malignant Conditions  Carcinoma esophagus
2. A two years old child is evaluated for difficulty in swallowing. She regurgitates solid food and vomits frequently. X- ray following
Barium meal shows dilated lower part of the oesophagus. Manometric studies show absence of peristalsis in lower part of oesophagus.
a) What is the most likely diagnosis?
Achalasia
b) Explain the pathophysiology of the diagnosed condition.
No myenteric plexus in lower 2/3 of esophagus  no peristalsis & lower esophageal sphincter fails to relax  food swallowed into
the esophagus fails to pass from the esophagus into the stomach  esophagus dilates

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 47 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. Give pathophysiology, features and treatment of achalasia.

Pathophysiology No myenteric lexus in lower 2/3 of esophagus  no peristalsis & lower esophageal sphincter fails to relax 
food swallowed into the esophagus fails to pass from the esophagus into the stomach  esophagus dilates
Features Dysphagia, Regurgitation, Putrid breath
Treatment Antispasmodic drugs (i.e., drugs that relax smooth muscle) such as nitrates & Ballon esophageal dilatation

4. A two year old child is evaluated for difficulty in swallowing. She regurgitates solid food and vomits. X-ray study shows dilated
lower part of esophagus. What is the most likely diagnosis? Explain the physiology of this condition.
Same as Q2

P-003 ֍STOMACH֍

01. Stomach Functions

1. List motor functions of the stomach.

1. Storage of large quantities of food until the food can be processed in the stomach, duodenum, and lower intes tinal tract
2. Mixing of this food with gastric secretions until it forms a semifluid mixture called chyme
3. Slow emptying of the chyme from the stomach into the small intestine at a rate suitable for proper digestion and absorption
by the small intestine

02. Hunger Contractions

1. What are hunger contractions?

Besides the peristaltic contractions that occur when food is present in the stomach, another type of intense contractions, called hunger
contractions, often occurs when the stomach has been empty for several hours or more. When hunger contractions occur in the
stomach, the person sometimes experiences mild pain in the pit of the stomach, called hunger pangs.
03. Stomach Control & Enterogastric inhibitory reflux
1. Enumerate the factors that regulate gastric emptying.

Factor Description
Gastric Food Volume Increased food volume in the stomach promotes increased emptying from the stomach.
Enterogastric Nervous Reflexes Strongly inhibit the ―pyloric pump‖ propulsive contractions, and second, they increase the tone
from the duodenum of the pyloric sphincter.
Hormonal factors Hormones inhibiting gastric emptying
o Cholecystokinin
o Secretin
o Somatostatin
o Vasoactive intestinal peptide
o Gastric inhibitory peptide (GIP)
o Peptide YY
Hormone that promotes gastric emptying
o Gastrin

2. Enumerate the factors that control enterogastric reflex from duodenum.

3. Enumerate the factors that initiate enterogastric reflexes from duodenum.
1. Distention of the duodenum
2. The presence of any irritation of the duodenal mucosa
3. Acidity of the duodenal chyme
4. Osmolality of the chyme
Factors Stimulating the Secretion of Hydrochloric Acid
1. Gastrin
2. Histamine
3. Vagal stimulation

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 48 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Factors Inhibiting the Secretion of Hydrochloric Acid

1. Secretin
2. Gastric inhibitory polypeptide
3. Somatostatin

02. Gastritis & Gastric Atrophy

1. Name the two deficiencies resulting from chronic atrophic gastritis.

1. Intrinsic factor deficiency
2. Achlorhydria

03. Peptic ulcer

1. A 45-year-old man presents to the emergency with complain of severe epigastric pain and two episodes of vomiting with fresh
blood. There is history of ingestion of aspirin off and on for the last one year for shoulder pain. [Annual 2024 held in 2025]
a) What can be the most likely diagnosis in view of the history?
Peptic ulcer
b) Enumerate the causes and describe the pathophysiology of the disease.
Cause Pathophysiology
NSAID (Aspirin) decrease prostaglandin synthesis  impairs mucosal blood flow and healing  peptic ulcer
Zollinger-Ellison syndrome uncontrolled release of gastrin  massive acid production  peptic ulcer
H-pylori H-pylori infection causes pangastritis or predominantly antral gastritis by Cag-A toxin 
increased gastrin production from G cells due to destruction of somatostatin producing cell 
increased acid production from parietal cells (parietal cell hyperplasia)  increased acid load
causes ulcer in duodenum. H-pylori protect itself from acidic environment of stomach by urease
enzyme
Smoking Increased nervous stimulation of the stomach secretory glands
Alcohol Break down the mucosal barrier

2. What is pathophysiology of gastric/peptic ulcer?

See Q1b

P-004 ֍SMALL INTESTINE֍

01. Hormones & Movements

1. What is the control of peristalsis in small intestine?

1. Enteric Nervous System regulates peristalsis through a series of reflexes, allowing for automatic and coordinated muscle
contractions.
2. Vagus Nerve provides parasympathetic input, stimulating the ENS and enhancing peristalsis.
3. Hormones like gastrin, CCK, insulin, motilin, and serotonin enhance intestinal motility. Conversely, secretin and glucagon
inhibit small intestinal motility
4. Local factors, such as the presence of food, distension, and irritation, can also influence peristalsis through enterogastric
reflex

2. What are the movements of small intestine?

1. Mixing movements
i. Segmentation movements
ii. Pendular movements.
2. Propulsive movements
i. Peristaltic movements
ii. Peristaltic rush
3. Peristalsis in fasting – migrating motor complex
4. Movements of villi

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 49 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. How does the intestine normally handle the excessive acidity in chyme?
1. When excess acid enters the duodenum, it inhibits gastric secretion and peristalsis in the stomach, both by nervous reflexes
and by hormonal feedback from the duodenum, thereby decreasing the rate of gastric
2. The presence of acid in the small intestine liberates secretin from the intestinal mucosa, which then passes by way of the
blood to the pancreas to promote rapid secretion of pancreatic juice. This juice also contains a high concentration of sodium
bicarbonate, thus making still more sodium bicarbonate available for neutralization of the acid.
Reference: Chapter 67 Guyton Physiology

02. Intestinal Spru

1. A 42 year old female presents in OPD with chronic diarrhea, bloating, and increasing fatigue. Histological biopsy from proximal
jejunum reveals that she has gluten sensitive enteropathy. What is the diagnosis?
Celiac disease

2. A 14-year-old girl presented with failure to gain weight, off and on diarrhea and abdominal distension. The proximal small intestine
showed rather flat mucosa with blunting of villi & crypt hyperplasia. What is the most likely diagnosis & What is the pathology?
Diagnosis  Celiac disease
Pathology  Gluten sensitive enteropathy

DO YOU KNOW!
If someone presents with Hx of chronic diarrhea & biopsy shows blunting/reduced
height of villi  Celiac disease

P-005 ֍LARGE INTESTINE֍

01. Functions & Movements of Colon

1. What are the functions of colon?

The principal functions of the colon are
1. Absorption of water and electrolytes from the chyme to form solid feces and
2. Storage of fecal matter until it can be expelled

02. Defecation Reflex

1. Distension of rectum due to the entry of feces by mass movement  Stimulation of sensory nerve endings  Impulses from
the nerve endings are transmitted via afferent fibers of pelvic nerve to the defecation center, situated in sacral segments
(center) of spinal cord  The center in turn, sends motor impulses to the descending colon, sigmoid colon and rectum via
efferent nerve fibers of pelvic nerve  Motor impulses cause strong contraction of descending colon, sigmoid colon and
rectum and relaxation of internal sphincter.
2. Voluntary relaxation of external sphincter occurs due to the inhibition of pudendal nerve, by impulses arising from cerebral
cortex

03. Autonomic reflexes & Constipation

No past seq

04. Hirschsprung’s disease/Megacolon

1. A 2-day-old newborn baby, born at term, is brought to the pediatrician with symptoms of abdominal distension, vomiting, and
failure to pass meconium. The baby's abdomen is swollen, and there is no evidence of bowel movements. The pediatrician orders a
rectal biopsy, which shows an absence of ganglion cells in the rectal wall. What is the most likely diagnosis?
Hirschsprung‘ disease
Note: Ganglion cells in the myenteric plexus are absent

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 50 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

P-006 ֍LIVER֍

1. In the concentrating process in the gallbladder, water and large portions of

the electrolytes (except calcium ions) are reabsorbed by the gallbladder
mucosa; essentially all other constituents, especially the bile salts and the
lipid substance s cholesterol and lecithin, are not reabsorbed and, therefore,
become highly concentrated in the gallbladder bile.
2. Cholecystokinin Stimulates Gallbladder Emptying

P-007 ֍PANCREAS֍

1. A 45-year-old man, who has a history of heavy alcohol consumption, is admitted to the emergency department with severe
epigastric pain radiating to his back, nausea, vomiting, and fever. His blood work shows elevated serum amylase and lipase levels.
Abdominal CT scan shows gallstones.
a) What is the most likely diagnosis?
Acute pancreatitis
b) Write two most important causes of this condition.
1. Excessive alcohol intake
2. Gallstones
c) Write its pathophysiology.
When a gallstone blocks the papilla of Vater, the main secretory duct from the pancreas and the common bile duct are blocked. The
pancreatic enzymes are then dammed up in the ducts and acini of the pancreas. Eventually, so much trypsinogen accumulates that it
overcomes the trypsin inhibitor in the secretions and a small quantity of trypsinogen becomes activated to form trypsin. Once this
happens, the trypsin activates still more trypsinogen, as well as chymotrypsinogen and carboxypolypeptidase, resulting in a vicious
circle until most of the proteolytic enzymes in the pancreatic ducts and acini become activated. These enzymes rapidly digest large
portions of the pancreas, sometimes completely and permanently destroying the ability of the pancreas to secrete digestive enzymes.

P-008 ֍VOMITING REFLEX֍

1. Give a brief outline of sequence of events occurring during vomiting reflex.

1. Beginning of antiperistalsis, which runs from ileum towards the mouth through the intestine, pushing the intestinal contents
into the stomach within few minutes. Velocity of the antiperistalsis is about 2 to 3 cm/second
2. Deep inspiration followed by temporary cessation of breathing
3. Closure of glottis
4. Upward and forward movement of larynx and hyoid bone
5. Elevation of soft palate
6. Contraction of diaphragm and abdominal muscles with a characteristic jerk, resulting in elevation of intra-abdominal pressure
7. Compression of the stomach between diaphragm and abdominal wall leading to rise in intragastric pressure
8. Simultaneous relaxation of lower esophageal sphinc ter, esophagus and upper esophageal sphincter
9. Forceful expulsion of gastric contents (vomitus) through esophagus, pharynx and mouth.

2. What do you know about chemoreceptor-trigger zone?

Chemoreceptor trigger zone for vomiting is located in the area postrema on the lateral walls of the fourth ventricle. Electrical
stimulation of this area can initiate vomiting, but more importantly, administration of certain drugs, including apomorphine, morphine,
and some digitalis derivatives, can directly stimulate this chemoreceptor trigger zone and initiate vomiting. Destruction of this area
blocks this type of vomiting but does not block vomiting resulting from irritative stimuli in the gastrointestinal tract itself

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 51 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

P-009 & P-010 ֍MALNUTRITION & DIARRHEA֍

1. About 1.7 to 5 billion cases of diarrhea occur per year. It is most common in developing countries where young children get
diarrhea on average three times a year. Frequent episodes of diarrhea are also a common cause of malnutrition. Other long-term
problems that can result include stunted growth and poor intellectual development. [Annual 2017 Community Medicine]
a) What is the definition of diarrhea according to WHO/UNICEF? (1)
Answer: Passage of 3 or more loose stools per day
b) What are the various host factors underlying diarrhea? (2)
1. Age 2. Malnutrition
3. Poverty 4. Reduced gastric acidity
5. Prematurity 6. Deficient functioning of immune system
7. Lack of hygiene 8. Incorrect breastfeeding
c) What are the short term and long-term intervention measures to control diarrhea? (2)
Short term management
 ORS
 IV rehydration: Ringer lactate or normal saline
 Maintenance therapy: fluids and electrolytes
 Appropriate Breast feeding
 Zinc supplementation
Long term management
1. MCH care practices
o Maternal nutrition during prenatal period
o Child nutrition
o breastfeeding
o weaning
o vit A supplements
2. Preventive strategies
o Sanitation
 Provision of sanitatory latrines
 Provision of piped water supply
o Food hygiene
o Health education
o Immunization
 measles
 Rota virus vaccine

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 52 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

֍Practice MCQs֍

1. Which of the following substances is released from neurons in (D) Pancreatic enzyme secretion is increased by cholecystokinin
the GI tract and produces smooth muscle relaxation? (CCK)
(A) Secretin 10. Slow waves in small intestinal smooth muscle cells are
(B) Gastrin (A) action potentials
(C) Cholecystokinin (CCK) (B) phasic contractions
(D) Vasoactive intestinal peptide (VIP) (C) tonic contractions
2. Which of the following is the site of secretion of intrinsic (D) oscillating resting membrane potentials
factor? 11. A 24-year-old male graduate student participates in a clinical
(A) Gastric antrum research study on intestinal motility. Peristalsis of the small
(B) Gastric fundus intestine
(C) Duodenum (A) mixes the food bolus
(D) Ileum (B) is coordinated by CNS
3. Vibrio cholerae causes diarrhea because it (C) involves contraction of circular smooth muscle behind and in
(A) increases HCO3- secretory channels in intestinal epithelial front of the food bolus
cells (D) involves contraction of circular smooth muscle behind the
(B) increases Cl- secretory channels in crypt cells food bolus and relaxation of circular smooth muscle in front of
(C) prevents the absorption of glucose and causes water to be the bolus
retained in the intestinal lumen isosmotically 12. A 38-year-old male patient with a duodenal ulcer is treated
(D) inhibits cAMP production in intestinal epithelial cells successfully with the drug cimetidine. The basis for cimetidine‘s
4. Cholecystokinin (CCK) has some gastrin-like properties inhibition of gastric H+ secretion is that it
because both CCK and gastrin (A) blocks M receptors on parietal cells
(A) are released from G cells in the stomach (B) blocks H2 receptors on parietal cells
(B) are released from I cells in the duodenum (C) increases intracellular cAMP levels
(C) are members of the secretin homologous family (D) enhances the action of ACh on parietal cells
(D) have five identical C-terminal amino acids 13. Which of the following substances inhibits gastric emptying?
5. Cholecystokinin (CCK) inhibits (A) Secretin
(A) gastric emptying (B) Gastrc inhibitory peptide (GIP)
(B) pancreatic HCO3− secretion (C) Cholecystokinin (CCK)
(C) pancreatic enzyme secretion (D) All of these
(D) contraction of the gallbladder 14. A 44-year-old woman is diagnosed with Zollinger–Ellison
6. Secretion of which of the following substances is inhibited by syndrome. Which of the following findings is consistent with the
low pH? diagnosis?
(A) Decreased serum gastrin levels
(A) Secretin
(B) Increased serum insulin levels
(B) Gastrin
(C) Increased absorption of dietary lipids
(C) Cholecystokinin (CCK)
(D) Peptic ulcer disease
(D) Vasoactive intestinal peptide (VIP)
15. A 43-year-old man eats a meal consisting of 40% protein,
7. Which of the following is the site of secretion of gastrin?
10% fat, and 50% carbohydrate. Thirty minutes later the man
(A) Gastric antrum feels the urge to defecate. Which reflex results in the urge to
(B) Gastric fundus defecate when the duodenum is stretched?
(C) Duodenum A) Duodenocolic
(D) Ileum B) Enterogastric
8. Which of the following changes occurs during defecation? C) Intestino-intestinal
(A) Internal anal sphincter is relaxed D) Rectosphincteric
(B) External anal sphincter is contracted 16. The ileum and distal jejunum of a 34-year-old man are
(C) Rectal smooth muscle is relaxed ruptured in an automobile accident. The entire ileum and a
(D) Segmentation contractions predominates portion of the jejunum are resected. What is most likely to occur
9. Which of the following is true about the secretion from the in this man?
exocrine pancreas? A) Atrophic gastritis
(A) It has a higher Cl- concentration than does plasma B) Constipation
(B) It is stimulated by the presence of HCO3- in the duodenum C) Gastric ulcer
(C) Pancreatic HCO3- secretion is increased by gastrin D) Vitamin B12 deficiency

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 53 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

17. A 10-year-old boy consumes a cheeseburger, fries, and 24. Mass movements are often stimulated after a meal by
chocolate shake. The meal stimulates the release of several distention of the stomach (gastrocolic reflex) and distention of
gastrointestinal hormones. The presence of fat, carbohydrate, or the duodenum (duodenocolic reflex). Mass movements often
protein in the duodenum stimulates the release of which
lead to which of the following?
hormone from the duodenal mucosa?
A) Cholecystokinin (CCK) A) Bowel movements
B) Glucose-dependent insulinotropic peptide (GLIP) B) Gastric movements
C) Gastrin C) Haustrations
D) Secretin D) Esophageal contractions
18. Which hormone is released by the presence of fat and protein 25. An 89-year-old man has a cerebrovascular accident (stroke)
in the small intestine and has a major effect in decreasing gastric in the medulla and pons that completely eliminates all vagal
emptying? output to the gastrointestinal tract. Which function is most likely
A) CCK to be totally eliminated in this man?
B) GLIP A) Gastric acid secretion
C) Gastrin B) Gastrin release
D) Secretin C) Primary esophageal peristalsis
19. Migrating motility complexes (MMCs) occur about every 90 D) Secondary esophageal peristalsis
minutes between meals and are thought to be stimulated by the 26. A newborn boy does not pass meconium within 48 hours of
gastrointestinal hormone motilin. An absence of MMCs causes delivery. His abdomen is distended, and he begins vomiting. A
an increase in which of the following? suction biopsy of a distally narrowed segment of the colon
A) Duodenal motility shows a lack of ganglionic nerve cells. This newborn is at risk
B) Gastric emptying for developing which condition?
C) Intestinal bacteria A) Achalasia
D) Mass movements B) Enterocolitis
20. Swallowing is a complex process that involves signaling C) Pancreatitis
between the pharynx and swallowing center in the brain stem. D) Peptic ulcer
Which structure is critical for determining whether a bolus of 27. Damage to the gastric mucosal barrier is a forerunner of a
gastric ulcer. Which substance can both damage the gastric
food is small enough to be swallowed?
mucosal barrier and stimulate gastric acid secretion?
A) Epiglottis A) Bile salts
B) Larynx B) Epidermal growth factor
C) Palatopharyngeal folds C) Gastrin
D) Soft palate D) H. pylori
21. H. pylori damages the gastric mucosa primarily by 28. CF is the most common cause of pancreatitis in children.
increasing mucosal levels of which of the following? Which option best explains the mechanism of CF induced
A) Ammonium pancreatitis?
B) Bile salts A) Activation of enterokinase
C) Gastrin B) Activation of trypsin inhibitor
D) NSAIDs C) Autodigestion of pancreas
22. A 65-year-old man eats a healthy meal. Approximately 40 D) Gallstone obstruction
minutes later the ileocecal sphincter relaxes and chyme moves 29. Which of the following has little effect on pancreatic
into the cecum. Gastric distention leads to relaxation of the secretion or it's components?
A. Acetylcholine.
ileocecal sphincter by way of which reflex?
B. Sympathetic stimulation.
A) Enterogastric
C. Secretin
B) Gastroileal
D. Cholecystokinin
C) Gastrocolic
30. Of the approximately 9 liters of water that go through the GI
D) Rectosphincteric
tract daily, how much makes it out in the feces?
23. A 10-year-old boy consumes a glass of milk and two A. 100 ml
cookies. His LES and fundus relax while the food is still in the B. 1000 ml
esophagus. Which substance is most likely to cause relaxation of C. 2000 ml
the LES and fundus in this boy? D. 500 ml
A. Gastrin 31. The progressive wave of muscle contractions that proceeds
B. Histamine along the esophagus, compressing the lumen and forcing food
C. Motilin ahead of it is called:
D. Nitric oxide A. primary peristalsis

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 54 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

B. segmentation 40. Which of the following gastrointestinal hormones DOES

C. the migrating myoelectric complex NOT stimulate gastric acid secretion?
D. mass movement A. VIP
32. What prevents food from entering the nasal passages during B. Gastrin
swallowing? C. Acetylcholine
A) elevation of uvula D. Histamine
B) contraction of pharyngeal muscles 41. Which hormone stimulates an increase in the volume of
C) apposition of vocal folds pancreatic juice but not the enzyme content?
D) elevation of epiglottis A. Vagus nerve
33. The hormone that inhibit gastric secretion and motility is... B. Secretin
A) Gastrin C. ACH
B) histamine D. CCK
C) secretin 42. Gastrin secretion is not increased by
D) Pepsin A. Protein
34. Which of the following would most likely decrease the B. Stomach distension
number of spike potentials generated in the GI smooth muscle? C. Stomach alkalinization
A] Sympathetic Stimulation D. Alcohol consumption
B) Acetylcholine 43. Which hormone is responsible for delayed gastric emptying
C) Stretching of the muscle after fatty meal?
D) Parasympathetic stimulation A. CCK
35. A patient with trigeminal neurapraxia (temporary segmental B. Secretin
demyelination of the trigeminal nerve leading to conduction C. Motilin
difficulties) would have the greatest difficulty with which of the D. Gastrin
following activities? 44. Which hormone is responsible for delayed gastric emptying
A) Secondary peristalsis in the esophagus & bloating?
B) Swallowing A. CCK
C) Secondary peristalsis in the esophagus B. Secretin
D) Chewing C. Motilin
D. Gastrin
36. The movements of the small intestine are 45. Opening of lower esophageal sphincter is mediated by
A) Mixing and propulsive contractions A. Nitric oxide
B) Propulsive contractions B. Motilin
C) Antiperistaltic contraction C. Somatostatin
D) Receptive relaxation D. CCK
37. In duodenum in response to acidic chyme is released 46. Main action of gut somatostatin is to inhibit
A) Cholecystokinin A. Secretin
B) Gastrin B. CCK
C) Secretin C. VIP
D) Amylase D. Ghrelin
38. Cause of Spike Potential in intestine 47. Secretions from which of the following will contain highest
A) Na influx only levels of potassium?
B) Ca influx only A. Rectum
C) Na & Ca influx B. Stomach
D) Ca outflux C. Gallbladder
39. Regarding bile composition, which of the following D. Pancreas
substances makes up the largest proportion? 48. Which of the following is not secreted by parietal cells?
A. Bile pigments A. HCl
B. Bile salts B. Intrinsic factor
C. Lecithin C. Mucus
D. Cholesterol D. Mg

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 55 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

ANSWER KEY
1. D 2. B 3. B 4. D 5. A 6. B 7. A 8. A 9. D 10. D
11. D 12. B 13. D 14. D 15. A 16. D 17. B 18. A 19. C 20. C
21. A 22. B 23. D 24. A 25. C 26. B 27. C 28. C 29. B 30. A
31. A 32. A 33. C 34. A 35. D 36. A 37. C 38. C 39. B 40. A
41. B 42. D 43. A 44. A 45. A 46. B 47. A 48. C 49. 50.

2. Intrinsic factor is secreted by the parietal cells of the gastric fundus (as is HCl). It is absorbed, with vitamin B12, in the ileum
3. Cholera toxin activates adenylate cyclase and increases cAMP in the intestinal crypt cells. In the crypt cells, cAMP activates the Cl-
secretory channels and produces a primary secretion of Cl− with Na+ and H2O following.
6. Gastrin‘s principal physiologic action is to increase H+ secretion. H+ secretion decreases the pH of the stomach contents. The
decreased pH, in turn, inhibits further secretion of gastrin—a classic example of negative feedback.
9. The major anion in pancreatic secretions is HCO3− (which is found in higher concentration than in plasma), and the Cl−
concentration is lower than in plasma. Pancreatic secretion is stimulated by the presence of fatty acids in the duodenum. Secretin (not
gastrin) stimulates pancreatic HCO3− secretion, and cholecystokinin (CCK) stimulates pancreatic enzyme secretion
14. Zollinger–Ellison syndrome (gastrinoma) is a tumor of the non–β-cell pancreas. The tumor secretes gastrin, which then circulates
to the gastric parietal cells to produce increased H+ secretion & leads to peptic ulcer
15. The appearance of mass movements after meals is facilitated by gastrocolic and duodenocolic reflexes. These reflexes result from
distention of the stomach and duodenum.
17. GLIP is the only gastrointestinal hormone released by all three major foodstuffs (fats, proteins, and carbohydrates).
18. CCK is the only gastrointestinal hormone that inhibits gastric emptying under physiological conditions.
19. MMCs (sometimes called interdigestive myoelectric complexes) are peristaltic waves of contraction that begin in the stomach and
slowly migrate in an aboral direction along the entire small intestine to the colon. By sweeping undigested food residue from the
stomach, through the small intestine, and into the colon, MMCs function to maintain low bacterial counts in the upper intestine. It
should be clear that an absence of MMCs would decrease duodenal motility and gastric emptying. MMCs do not have a direct effect
on mass movements
20. The palatopharyngeal folds located on each side of the pharynx are pulled medially, forming a sagittal slit through which the bolus
of food must pass. This slit performs a selective function, allowing food that has been masticated sufficiently to pass by but impeding
the passage of larger objects
21. H. pylori is characterized by high urease activity, which metabolizes urea to NH3 (ammonia). Ammonia reacts with H+ to become
ammonium (NH4+). This reaction allows the bacterium to withstand the acid environment of the stomach. The ammonium production
is believed to be the major cause of cytotoxicity because the ammonium directly damages epithelial cells, increasing the permeability
of the gastric mucosal barrier
22. Gastroileal reflex is named with the origin of the reflex first (gastro) and the target of the reflex named second (ileal)
23. The fundus of the stomach and lower esophageal sphincter both relax during a swallow while the bolus of food is still higher in the
esophagus. This phenomenon is called receptive relaxation. Receptive relaxation is mediated by afferent and efferent pathways in the
vagus nerves. Nitric oxide is the neurotransmitter thought to mediate receptive relaxation at the smooth muscle cell
24. Mass movements force feces into the rectum. When the walls of the rectum are stretched by the feces, the defecation reflex is
initiated and a bowel movement follows when this is convenient. Mass movements do not affect gastric motility. Haustrations are
bulges in the large intestine caused by contraction of adjacent circular and longitudinal smooth muscle. It should be clear that mass
movements in the colon do not affect esophageal contractions or pharyngeal peristalsis.
25. Primary peristalsis of the esophagus is a continuation of pharyngeal peristalsis; central control originates in the swallowing center
located in the medulla and pons. Visceral somatic fibers in the vagus nerves directly innervate smooth muscle fibers of the pharynx
and upper esophagus, which coordinate pharyngeal peristalsis and primary peristalsis of the esophagus. Esophageal contractions can
occur independently of vagal stimulation by a local stretch reflex initiated by the food bolus itself; this phenomenon is called
secondary peristalsis. Although the vagus nerves can stimulate gastric acid secretion, gastrin release, but these processes can be
activated by other mechanisms. Thus, elimination of vagal stimulation does not completely eliminate them.
26. This infant has Hirschsprung‘s disease, which is characterized by a congenital absence of ganglion cells in the distal colon
resulting in a functional obstruction. Prolonged fecal stasis can lead to enterocolitis (i.e., inflammation of the colon)
41. Secretin acts on the pancreatic ducts to cause copious secretion of a very alkaline pancreatic juice and volume but poor in
enzymes.
CCK acts on the acinar cells to cause the release of zymogen granules and production of pancreatic juice rich in enzymes but poor in
volume. ACh and Vagus N stimulation stimulate pancreatic juice rich in enzymes but poor in volume in the same way as CCK

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 56 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

֍Past MCQs֍
1. Which hormone causes stomach emptying? B. Steatorrhea
A. CCK C. Pernicious anemia
B. Gastrin D. Hyperchlorhydria
C. Somatostatin 12. Correct statement about enterogastric reflex?
D. Secretin A. It is initiated by distention of duodenum
2. Hormone causing gallbladder contraction B. It stimulates stomach emptying
A. CCK C. It stimulates stomach secretion
B. Secretin D. It is initiated by distention of stomach
C. Gasterin 13. Intestinal motility is increased by
D. Somatostatin A. CCK
3. Segmentation is the predominant movement of B. VIP
A. Small intestine C. Secretin
B. Large intestine D. Gastrin
C. Stomach 14. The myenteric plexus:
D. Esophagus A. Controls motility of the intestines.
4. Gastrin is secreted mainly by B. Controls secretion of the intestines.
A. Pylorus of duodenum C. Consists of sympathetic nerve fibers.
B. Cardiac glands of stomach D. Consists of parasympathetic nerve
C. Fundus of stomach 15. The event not likely to occur during the pharyngeal stage of
D. Pyloric gland of stomach swallowing is:
5. Parietal cells serete A. Deglutition apnea.
A. HCl & intrinsic factor B. Closure of the the posterior nares.
B. Mucin C. Narrowing the palatopharyngeal folds
C. Gastrin D. Opening of the glottis.
D. Secretin 16. If ileum and jejunum are resected, ___ absorption will be
6. Defecation is accomplished mainly by disturbed.
A. Parasympathetic reflex A. Vitamin B12
B. Sympathetic reflex B. Vitamin D
C. Mass reflex C. Iron
D. Gastrocolic reflex D. Calcium
7. Parasympathetic system in GIT 17. HCl secretion is decreased by
A. increases wall contraction A) Gastrin
B. increases sphincter tone B) Somatostatin
C. decreases secretions C) Histamine
D. increases motility D) Vagal stimulation
8. GIT speciality is 18. Mass movement in the large intestine is triggered by the ___
A. Slow & spike waves
reflex.
B. totally independence of ANS
A) Gastrocolic
C. independence of hormones
B) Enterogastric
D. no congenital abnormality
C) Intestino-intestinal
9. In Achalasia, there is
D) Recto-sigmoid
A. Shortening of esophagus
19. The gallbladder bile has a significantly lower concentration
B. Neurological disorder of esophagus
of ___ compared to liver bile.
C. Stenosis of lower part of esophagus
A) Sodium ions
D. Sensory disorder of esophagus
B) Fatty acid
10. Stimulant for electrolyte rich pancreatic juice
A. Somatostatin C) Water
B. Secretin D) Chloride
C. VIP 20. The highest frequency of slow waves in the small intestine is
D. CCK found in the ___.
11. Chronic gastritis can cause A) Duodenum
A. Megaloblastic anemia B) Jejunum

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 57 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

C) Ileum 25. Which hormone is responsible for delayed gastric emptying

D) Pylorus after fatty meal?
21. Food entering the nose during swallowing is prevented by A. CCK
the ___ nerve. B. Secretin
A) Vagus C. Motilin
B) Glossopharyngeal D. Gastrin
C) Trigeminal 26. Which hormone is responsible for delayed gastric emptying
D) Hypoglossal & bloating?
22. The main function of the colon is ___. A. CCK
A) Absorption of water and electrolytes B. Secretin
B) Secretion of digestive enzymes C. Motilin
C) Storage of food D. Gastrin
D) Production of hormones 27. Opening of lower esophageal sphincter is mediated by
23. Contraction of GIT smooth muscles is regulated by the _ A. Nitric oxide
A) Myenteric plexus B. Motilin
B) Submucosal plexus C. Somatostatin
C) Hormones D. CCK
D) Meissner's plexus 28. Main action of gut somatostatin is to inhibit
24. Gastrin secretion is not increased by A. Secretin
A. Protein B. CCK
B. Stomach distension C. VIP
C. Stomach alkalinization D. Ghrelin
D. Alcohol consumption

ANSWER KEY
1. B 2. A 3. A 4. D 5. A 6. A 7. D 8. A 9. C 10. B
11. C 12. A 13. D 14. A 15. D 16. A 17. B 18. A 19. D 20. A
21. A 22. A 23. A 24. D 25. A 26. A 27. A 28. B

18. The gastrocolic reflex, also known as the gastrocolic response, is a physiological response that occurs when food enters the
stomach, triggering a wave of contractions in the large intestine (colon) to move feces towards the rectum and prepare for defecation.
This reflex is triggered by the presence of food in the stomach and is mediated by the vagus nerve
19. Bile, which is produced by the liver and stored in the gallbladder, has a high concentration of chloride ions (Cl-). However, the
gallbladder itself has a lower concentration of chloride ions compared to bile. This is because the gallbladder absorbs chloride ions
from the bile, concentrating it and making it more potent.
21. Soft palate & Uvula prevent entry of food into nasal cavity & they are supplied by vagus nerve

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 58 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

BIOCHEMISTRY
B001 – B024
GIT

B-001 ֍BIOCHEMISTRY OF GIT֍

01. Saliva

1. What are the sources and functions of saliva?

Sources Functions
o Parotid gland (serous secretion) o Oral hygiene
o Sublingual gland (secrous secretion & mucus) o Digestion
o Submandibular gland (serous secretion & o Lubrication & Protection by lysozyme
mucus) o pH regulation
o Minor salivary glands

DO YOU KNOW!
Salivary glands are the only glands in GIT whose secretions are increased by both
sympathetic & parasympathetic nervous system.

02. Gastric Juice

1. Give chemical composition of gastric juice.

Oxyntic/Gastric glands secrete hydrochloric acid, pepsinogen, intrinsic factor, and mucus While Pyloric glands secrete mucus & gastrin

2. Name the organic constituents of gastric juice and give their functions.

Organic constituent Function

Pepsin breaks down proteins into smaller peptides and amino acids
Renin helps to coagulate/curdle milk in the stomach, creating a solid clot that can be more easily digested
Gastric lipase breaks down fats into fatty acids and glycerol
Gelatinase Breaks down gelatin into peptides
Urease Convert urea into ammonia
Mucus Protection of mucosa
Intrinsic factor binds to vitamin B12, facilitating its absorption in the small intestine

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 59 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. Write any three functions of HCl.

1. Activates pepsinogen into pepsin
2. Kills some of the bacteria entering the stomach along with food substances. This action is called bacteriolytic action
3. Provides acid medium, which is necessary for the action of hormones.

3. What is achlorhydria?
Achlorhydria is a condition in which the production of hydrochloric acid in gastric secretions of the stomach and other digestive
organs is absent. It is commonly associated with gastritis

03. Pancreatic Juice

1. Give composition of pancreatic juice.

2. Enumerate proteases of pancreatic juice, give specificity of each.

3. Name various lipolytic enzymes present in pancreatic juice and elaborate their digestive mechanism on dietary lipomes (lipids).
4. Name various proteolytic enzymes present in pancreatic juice with their specific actions in protein digestion.

5. Enumerate the endopeptidases of pancreatic juice and give the specific role of each.
1. Trypsin

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 60 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. Chymotrypsin
3. Elastase
Their functions are written in above table
6. What are functions of pancreatic phopholipase A2 and alpha amylase?
o Phospholipase breaks down phospholipids into lysophospholipids
o Alpha amylase breaks down alpha 1,4 glycosidic linkages of glucose polymers

7. How secretion of bicarbonate component of pancreatic juice is regulated?

Duodenum detects the low pH of the food entering from the stomach  duodenum releases secretin hormone  Secretin stimulates
the pancreatic duct cells to release bicarbonate-rich fluid  bicarbonate in the pancreatic juice neutralizes the acidic chyme i.e. raises
the pH

8. After taking meal, plasma bicarbonate of a man increased from 22mEq to 27mEq. What is the reason?
Alkaline tide (Secretion of bicarbonate-rich pancreatic juice into the small intestine in response to acidic chyme)

9. Give the effect of Cholecystokinin and secretin on secretions of pancreatic juice.

o CCK  secretion of pancreatic juice rich in enzyme
o Secretin  secretion of pancreatic juice rich in bicarbonate

DO YOU KNOW!
Daily saliva secretion  1000 ml Daily gastric secretion  1500 ml
Daily pancreatic secretion  1000 ml Total daily git secretion  6700 ml

04. Clinical disorders

Pancreatitis
You will do this topic in physiology portion so I‘m not adding detail here
Cystic Fibrosis
This autosomal recessive disorder is caused by mutations to the gene for the CF transmembrane conductance regulator (CFTR) protein
that functions as a chloride channel on epithelium. Defective CFTR results in decreased secretion of chloride and increased
reabsorption of sodium and water. In the pancreas, the decreased hydration results in thickened secretions such that pancreatic
enzymes are not able to reach the intestine, leading to pancreatic insufficiency.
Cholelithiasis
It is defined as the presence of gallstones in the gallbladder. Gallstones are hardened deposits of bile components, such as cholesterol
or bilirubin, which can cause inflammation, obstruction, and infection

05. Digestion & Absorption of Carbohydrates

1. Give the digestion of dietary carbohydrates.

2. Enlist all the enzymes along with their site of production and secretion that are involved in digestion of carbohydrates throughout
the GIT.

Site Enzyme/Secretion Role

Mouth Alpha amylase/Ptyalin acts briefly on dietary starch and glycogen, hydrolyzing random alpha (14) bonds
Stomach No digestion occurs in stomach
Pancreas Alpha amylase Pancreatic alpha amylase continues the process of starch digestion.
Intestine Isomaltase Isomaltase cleaves the alpha (16) bond in isomaltose producing glucose
Maltase Maltase cleaves maltose and maltotriose producing glucose
Sucrase Sucrase cleaves sucrose producing glucose and fructose
Lactase lactase (alpha-galactosidase) cleaves lactose producing galactose and glucose.
Trehalase Trehalose, alpha (11) disaccharide of glucose found in mushrooms and other
fungi, is cleaved by trehalase.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 61 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. How dietary hexoses are actively absorbed from intestinal lumen?

4. How are glucose and galactose absorbed in the GIT?
The duodenum and upper jejunum absorb the bulk of the dietary sugars. However, different sugars have different mechanisms of
absorption
o Galactose and glucose are transported into the mucosal cells (enterocytes) by an active, energy-requiring process i.e. sodium-
dependent glucose cotransporter 1 (SGLT-1)
o Fructose uptake requires a sodium-independent monosaccharide transporter (GLUT-5) for its absorption.
o All three monosaccharides are transported from the intestinal mucosal cell (enterocytes) into the portal circulation by
GLUT-2

5. How milk sugar ―lactose‖ is digested and absorbed in milk feed of new born. What is effect of lactase deficiency?
6. A new born baby developed diarrhea, abdominal distension and foul smell in breath after breast feeding. Stools contains reducing
substances and hydrogen breath test is positive. Which enzyme is deficient in this patient?
o Lactose digestion  lactase (alpha-galactosidase) cleaves lactose producing galactose and glucose
o Absorption  Galactose and glucose are transported into the mucosal cells by sodium-dependent glucose cotransporter 1
(SGLT-1) & transported from the intestinal mucosal cell into the portal circulation by GLUT-2
o Effect of enzyme deficiency  Diarrhea, abdominal distension, foul smell
o Enzyme deficient  Lactase

B-002 ֍GLUCOSE ENTRY INTO CELL֍

Glucose cannot diffuse directly into cells, but enters by one of two transport mechanisms:
1. Na+-independent, facilitated diffusion transport system
o GLUT-1 is abundant in erythrocytes and blood brain barrier, but is low in adult muscle
o GLUT-2, which is found in the liver, kidney & Pancreas
o GLUT-3 is the primary glucose transporter in neurons.
o GLUT-4 is abundant in adipose tissue and skeletal muscle
o GLUT-1, GLUT -3, and GLUT-4 are primarily involved in glucose uptake from the blood. In contrast, GLUT-2,
which is found in the liver and kidney, can either transport glucose into these cells when blood glucose levels are
high, or transport glucose from these cells when blood glucose levels are low (for example, during fasting)
2. Na+-monosaccharide cotransporter system.
o This type of transport occurs in the epithelial cells of the intestine, renal tubules, and choroid plexus. [Note: The
choroid plexus, part of the blood brain barrier, also contains GLUT-1.]

B-003 ֍HORMONAL CONTROL OF BSL֍

Hormone Metabolic role Excess/Deficiency

Insulin o Facilitates glucose uptake in cells o Deficiency: Diabetes mellitus
o Stimulates glycogen synthesis o Excess: Hypoglycemia
o Inhibits glycogen breakdown
o Inhibits glucose production in the liver
o Promotes protein synthesis
Glucagon o Stimulates glycogen breakdown o Deficiency: Hypoglycemia
o Stimulates glucose production in liver o Excess: Hyperglycemia
Epinephrine o Stimulates glycogen breakdown o Deficiency: Rare, but can lead to hypoglycemia
o Stimulates glucose release from the liver o Excess: Hyperglycemia, hypertension, and tachycardia

B-004 ֍GLYCOLYSIS֍
01. Glycolysis & Its Regulation
1. Differentiate between glucokinase and hexokinase
Features Glucokinase Hexokinase
Site liver parenchymal cells and cells of the pancreas Most tissues
Action Phosphorylation og glucose Phosphorylation of glucose & several hexoses

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 62 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Km High Km thus low affinity for glucose Low Km thus high affinity for glucose
Vmax High Low
Regulation Not directly inhibited by Glu 6-P but rather is indirectly Inhibited by end-product (Glu 6-P)
inhibited by Fru 6-P. In the presence of Fru 6-P,
glucokinase is translocated into the nucleus and binds
tightly to the regulatory protein, thus rendering the enzyme
inactive
Glucokinase functions only when the intracellular concentration of glucose in the hepatocyte is elevated, such as during the brief
period following consumption of a carbohydrate- rich meal, when high levels of glucose are delivered to the liver via the portal vein.
Glucokinase has a high Vmax, allowing the liver to effectively remove the flood of glucose delivered by the portal blood. This
prevents large amounts of glucose from entering the systemic circulation following a carbohydrate rich meal, and thus minimizes
hyperglycemia during the absorptive period

DO YOU KNOW!
Glucokinase functions as a glucose sensor in the maintenance of blood glucose
homeostasis. Mutations that decrease the activity of glucokinase are the cause of a
rare form of diabetes, maturity onset diabetes of the young type 2 (MODY 2).

2. Write the regulatory enzymes with their reactions in glycolysis.

3. Give the regulatory enzymes of hepatic glycolysis, how these are regulated?
4. Write down three irreversible reactions of glycolysis
5. Write down the reaction catalyzed by the enzyme pyruvate kinase.
6. What are the irreversible steps of glycolysis which are reversed during the process of gluconeogenesis?

Regulatory Enzyme Irreversible Reaction Regulation

Activator Inhibitor
Glucokinase Glucose into G 6-P Fru 6-P
Insulin in well fed state Glucagon in fasting state
Phosphofructokinase Fru 6-P into Fru 1,6 BP AMP, Fru 2,6 BP ATP, Citrate
Insulin in well fed state Glucagon in fasting state
Pyruvate Kinase Phosphoenolpyruvate into Fru 1,6 BP Glucagon in fasting state
Pyruvate Insulin in well fed state Epinephrine

7. Give hormonal regulation of glycolysis

 In well-fed state, insulin secretion increases initiates an increase in the amount of

glucokinase, phosphofructokinase, and pyruvate kinase in liver

 In fasting/diabetes state, plasma glucagon is high and insulin is low which decreases the
amount of glucokinase, phosphofructokinase, and pyruvate kinases

 Epinephrine increases cAMP level, activate cAMP-dependant Protein kinase which can
phosphorylate and inactivate the Key enzyme Pyruvate kinase and, thus, inhibit glycolysis.
This is a rapid process and occurs quickly

DO YOU KNOW!
 Arsenic inhibits glycolysis by by competing with inorganic phosphate as a
substrate for glyceraldehyde 3-phosphate dehydrogenase
 When a doctor takes a blood sample in a tube for checking blood sugar level,
gluose in blood doesn't undergo glycolysis because tube contains fluoride that
inhibit enolase enzyme (an ezyme of glycolysis pathway)

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 63 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

7. How irreversible enzymes of glycolysis are bypassed

Irreversible enzyme Bypass mechanism

Hexokinase Glucose can be phosphorylated by glucokinase in the liver, bypassing hexokinase.
Phosphofructokinase-1 Fructose-6-phosphate can be converted into glyceraldehyde 3-phosphate through the pentose
phosphate pathway
Pyruvate kinase Pyruvate can be generated from oxaloacetate through the action of pyruvate carboxylase and
phosphoenolpyruvate carboxykinase in the liver.

8. How is 2,3-Biphosphoglycerate synthesized

Some of the 1,3-BPG is converted to 2,3-BPG by the action of bisphosphoglycerate mutase. 2,3-BPG, which is found in only trace
amounts in most cells, is present at high concentration in red blood cells (increases O2 delivery)

02. Aerobic & Anaerobic Glycolysis

In aerobic metabolism, pyruvate formed by glycolysis enters TCA while in anerobic metabolism pyruvate converts either into lactic
acid or ethanol

03. Pyruvate Kinase Deficiency

1. What is the cause of hemolytic anemia in pyruvate kinase deficiency?

2. What happens in pyruvate kinase deficiency?
The normal mature erythrocyte lacks mitochondria and is, therefore, completely dependent on glycolysis for production of ATP. This
high-energy compound is required to meet the metabolic needs of the red blood cell, and also to fuel the pumps necessary for the
maintenance of the biconcave, flexible shape of the cell, which allows it to squeeze through narrow capillaries. The anemia observed
in glycolytic enzyme deficiencies is a consequence of the reduced rate of glycolysis, leading to decreased ATP production. The
resulting alterations in the red blood cell membrane leads to changes in the shape of the cell and, ultimately, to phagocytosis by the
cells of the reticuloendothelial system, particularly macrophages of the spleen. The premature death and lysis of red blood cells
results in hemolytic anemia

04. Oxidative Phosphorylation vs Substrate level phosphorylation

1. What is substrate level phosphorylation? Elaborate with the help of any two reaction
2. Write two reactions of glycolysis containing substrate level phosphorylation
3. Define substrate level phosphorylation, name three reactions related to this phenomenon.
Production of ATP without involving ETC is known as substrate level phosphorylation
In Glycolysis

In TCA
3. In conversion of succinyl CoA to succinic acid

4. What is meant by oxidation phosphorylation?

Production of ATP is produced via ETC is known as oxidative phosphorylation).

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 64 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

B-005 ֍FATES OF PYRUVATE֍

01. Metabolic Fates of Pyruvate

1. Give different fates of pyruvate.

1. Oxidative decarboxylation of pyruvate into Acetyl CoA
2. Carboxylation of pyruvate to oxaloacetate
3. Reduction of pyruvate to ethanol

02. Pyruvate Dehydrogenase Complex

1. Give different components of pyruvate dehydrogenase complex.

The pyruvate dehydrogenase complex (PDH complex) is a multimolecular aggregate of three enzymes;
1. pyruvate dehydrogenase (PDH or E1, also called a decarboxylase)
2. dihydrolipoyl transacetylase (E2)
3. dihydrolipoyl dehydrogenase (E3)
The PDH complex contains five coenzymes that act as carriers or oxidants for the intermediates of the reactions
1. E1 requires thiamine pyro phos phate (TPP)
2. E2 requires lipoic acid and CoA
3. E3 requires FAD and NAD+

2. Why thiamine deficiency leads to deficient activity of PDH complex?

PDA complex requires Thiamine as a co-enzyme/co-factor so its deficiency causes decreased activity of this complex

3. Why neurological disturbance occur in pyruvate dehydrogenase deficiency?

Brain cells are unable to produce sufficient ATP (via the TCA cycle) if the PDH complex is inactive

4. How pyruvate is converted to acetyl CoA? Give it regulation.

5. A chronic alcoholic has been brought to medical emergency. Blood biochemistry reveals lactic acidosis. Deficiency of pyruvate
dehydrogenase complex is suspected. Give the reaction catalyzed by Pyruvate dehydrogenase complex with its mechanism
Pyruvate is converted into Acetyl Co-A by oxidative decarboxylation & this reaction is catalyzed by enzyme ―Pyruvate
Dehydrogenase Complex‖
Regulation
o The cyclic AMP-independent PDH kinase phosphorylates and inhibits E1,
whereas PDH phosphatase dephosphorylates and activates E1. The kinase itself
is allosterically activated by ATP, acetyl CoA, and NADH. Therefore, in the
presence of these high-energy signals, the PDH complex is turned off.
o Pyruvate is a potent inhibitor of PDH kinase. Therefore, if pyruvate
concentrations are elevated, E1 will be maximally active.
o Calcium is a strong activator of PDH phosphatase, stimulating E1 activity. This
is particularly important in skeletal muscle, where release of Ca 2+ during
contraction stimulates the PDH complex, and thereby energy production.
o Although covalent regulation by the kinase and phosphatase is key, the
complex is also subject to product (NADH, acetyl CoA) inhibition.

03. Lactic Acidosis

1. How lactic acidosis occur in pyruvate dehydrogenase deficiency?

A deficiency in the E1 component of the PDH complex, although rare, is the most common biochemical cause of congenital lactic
acidosis. This enzyme deficiency results in an inability to convert pyruvate to acetyl CoA, causing pyruvate to be shunted to lactic
acid via lactate dehydrogenase

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 65 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

DO YOU KNOW!
Elevated concentrations of lactate in the plasma, termed lactic acidosis, occur when
there is a collapse of the circulatory system, such as in myocardial infarction,
pulmonary embolism, and uncontrolled hemorrhage, or when an individual is in
shock. The failure to bring adequate amounts of oxygen to the tissues results in
impaired oxidative phosphorylation and decreased ATP synthesis. To survive, the
cells use anaerobic glycolysis as a backup system for generating ATP, producing
lactic acid as the endproduct. In many clinical situations, measuring the blood levels
of lactic acid allows the rapid, early detection of oxygen debt in patients and the
monitoring of their recovery

B-006 ֍KREB’S CYCLE֍

1. What is the role of various B-complex vitamins in TCA cycle?

Vitamin Role
Thiamin Co-enzyme for alpha ketoglutarate dehydrogenase
Riboflavin (FAD) Co-enzyme for succinate dehydrogenase
Niacin (NAD+) Electron acceptor for isocitrate dehydrogenase, alpha ketoglutarate dehydrogenase, malate dehydrogenase
Pantothenic acid Cofactor attached to Acetyl CoA & Succinyl CoA

2. What is the significance of TCA cycle?

o TCA cycle is the final pathway of oxidation of glucose, fats and amino acids.
o TCA cycle is the major source of ATP production in the cells, producing a large amount of energy after complete oxidation
of nutrients.
o TCA cycle plays an important role in gluconeogenesis and lipogenesis and interconversion of amino acids.
o Many intermediate compounds are used in the synthesis of amino acids, nucleotides etc

DO YOU KNOW!
TCA cycle is called Amphibolic in nature because it is both catabolic & anabolic

3. Enlist the reactions mediating ATP formation in TCA cycle

4. Write down NADH generating reactions of citric acid cycle.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 66 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

B-007 ֍GLUCONEOGENESIS֍

01. Gluconeogenic Substrates (Precursors)

1. Define gluconeogenesis. Write down its substrates along with their sources.
The formation of glucose or glycogen from noncarbohydrate sources is called gluconeogenesis
Substrate Source
Amino acids hydrolysis of tissue proteins
Lactate exercising skeletal muscle, and by cells that lack mitochondria, such as red blood cells
Glycerol hydrolysis of triacylglycerols

02. Gluconeogenesis & its regulation

1. How do gluconeogenic precursors glycerol, lactate & alanine enter gluconeogenic Pathway?
Glycerol is phosphorylated by glycerol kinase to glycerol phosphate, which is oxidized by
glycerol phosphate dehydrogenase to dihydroxy acetone phosphate—an intermediate of
glycolysis. Reverse glycolysis cycle starts & eventually leads to glucose formation
Lactate is converted to pyruvate by the enzyme lactate dehydrogenase in the liver and
muscles. Pyruvate is then converted to oxaloacetate by the enzyme pyruvate carboxylase.
Oxaloacetate converts into phosphoenolpyruvate (PEP) by phosphoenolpyruvate
carboxykinase. And finaly PEP converts into glucose by reversing of glycolysis cycle
Alanine converts into pyruvate through deamination or transamination. Further process is
same as in above case of lactic acid

DO YOU KNOW!
Oxaloacetate, that is formed from pyruvate in cytosol, cannot cross the
mitochondrial membrane so firstly it is reduced to malate in cytosol. Malate crosses
membrane & get converted back into oxaloactetate in mitochondria

2. Write three specific enzymes which are required to convert amino acids to Glucose
1. Alanine transaminase
2. Pyruvate carboxylase
3. Phosphoenolpyruvate carboxykinase

3. Enumerate the tissue/cellular sites, sources, enzymes, nutritional control and Metabolic sequences of gluconeogenesis.
Tissue/Cellular sites Liver, Kidney cortex, Small intestine, Muscle tissue, Astrocytes of the brain
Sources Lactate, Glycerol, Alanine
Enzymes Alanine transaminase, Pyruvate carboxylase, Phosphoenolpyruvate carboxykinase, Glycerol kinase &
glycerol phosphate dehydrogenase
Nutritional control Glucagon (stimulates gluconeogenesis when blood glucose is low) & Insulin (inhibits gluconeogenesis)
Metabolic sequence Same as in Q1

4. How gluconeogenesis is suppressed after feed and enhanced during fasting?

Feeding Fasting Inducer Repressor

Pyruvate carboxylase ↓ ↑ Glucocorticoids
PEP carboxykinase ↓ ↑ Glucagon Insulin
Glu 6 phosphatase ↓ ↑ Epinephrine
Reference: Harper

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 67 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

5. What is the significance of gluconeogenesis?

1. Gluconeogenesis meets the requirements of glucose in the body when carbohydrates are not available in sufficient amounts from the
diet. Even in conditions, where fat is utilized for energy still certain basal level of glucose is required to meet the need for glucose for
special uses, e.g.
o Source of energy for nervous tissues and erythrocytes,
o Required for maintaining level of intermediates of TCA cycle,
o Source of glyceride-glycerol-P required for adipose tissue,
o It is a precursor of milk sugar (lactose) for lactating mammary gland,
o It serves as only fuel for skeletal muscles in anaerobic conditions.
2. Gluconeogenic mechanisms are required to clear the products of metabolism of other tissues from the blood, e.g.
o Lactic acid produced by muscles and erythrocytes,
o Glycerol which is continuously produced by adipose tissue by lipolysis of TG (triacyl glycerol).

6. Which metabolic pathways are activated to provide energy during period of Starvation?
7. How availability of energy yielding nutrients is regulated in the body during Fasting?
1. Gluconeogenesis
2. Glycogenolysis
3. Fatty acid oxidation
4. Ketogenesis
5. Pentose phosphate pathway

03. Cori Cycle & Glucosaalanine Cycle

Reference: Harper

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 68 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

B-008 ֍GLYCOGEN METABOLISM֍

01. Glycogenesis

1. How the process of glycogenesis occur in the liver? Name the factors affecting glycogen content of the body.

Factors affecting glycogen content

1. Diet & Fasting
2. Exercise & Rest
3. Hormones
4. Certain diseases

02. Glycogenolysis

1. Outline the sequence of reactions involved in the breakdown of glycogen in the skeletal muscles. Explain the purpose served by this
process.

Enzyme Substrate Product

Glycogen phosphorylase Glycogen chains Limit dextran
4:4 transferase Limit dextran Dextran
1:6 glucosidase activity Dextran Free glucose

2. Why is only a little amount of free glucose formed from glycogen degradation in muscles?
Only a little amount of free glucose is formed from glycogen degradation in muscles because muscle cells lack the enzyme glucose-6-
phosphatase, which is necessary to convert glucose-6-phosphate to free glucose

03. Regulation of Glycogenesis & Glycogenolysis

1. How glycogen synthesis and degradation is allosterically regulated especially in liver and muscle?
2. How glycogen synthesis is stimulated & inhibited?
2. What is reciprocal regulation of glycogen metabolism?
A. Hormonal regulation of glycogen synthase and glycogen phosphorylase by
o Insulin Glucagon
o Epinephrine
Please see Fig 11.9 & 11.10 in Lippincot
DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 69 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

B. Allosteric regulation

04. Glycogen Storage Diseases

1. Enlist glycogen storage diseases.

2. What are glycogen storage diseases and what are their biochemical defects?
3. Which disorder occurs due to deficiency of glucose-6-phosphatase?
4. A 4 months old infant was brought to the hospital with jittery spells and irritability several hours after feeding. Physical
examination revealed enlarged liver. The laboratory reports indicated that he developed fasting hypoglycemia. Large deposits of
glycogen with shorter than normal branches were seen in biopsy specimen from the liver. What is the probable diagnosis? Name the
deficient enzyme.

GSD Enzyme Deficient Features

Type I Glucose-6-phosphatase  Normal glycogen structure; increased glycogen stored
VON GIERKE DISEASE  Fasting hypoglycemia–severe
 Fatty liver, hepato- and renomegaly
 Growth retardation and delayed puberty
 Hyperlacticacidemia, hyperlipidemia, and hyperuricemia
TYPE II Lysosomal alpha(14)-  Excessive glycogen concentrations found in abnormal vacuoles
POMPE DISEASE Glucosidase in the lysosomes
 Normal blood sugar levels
 Massive cardiomegaly
TYPE III 4:4 transferase or 1:6  Glycogen has abnormal structure with shorter chains
CORI DISEASE Glucosidase  Fasting hypoglycemia
Type-IV Branching Enzyme  Glycogen has abnormal structure with longer chains
ANDERSON DISEASE  Hepatomegaly, Splenomegaly, Hypoglycemia
 Ascites, cirrhosis of liver and hepatic failure
TYPE V Muscle phosphorylase  Skeletal muscle affected; liver enzyme normal
McARDLE SYNDROME  Temporary weakness and cramping of skeletal muscle after
exercise
 Myoglobinemia and myoglobinuria
Note: Prepare this whole table

B-009 ֍HMP PATHWAY֍

01. Reaction & Regulation of HMP

1. Define oxidative and non-oxidative phase of hexose monophosphate pathway, Giving importance of each.

Features Oxidative phase Non-oxidative phase

Definition Oxidation of glucose and formation of pentose Conversion of pentose phosphates to hexose phosphates
hosphates
Reversibility Irreversible Reversible
Importance NADPH production Permit ribulose 5-phosphate (produced by the oxidative
phase) to be converted either to ribose 5-phosphate (needed
for nucleotide synthesis) or to intermediates of glycolysis—
fructose 6-phosphate and glyceraldehyde 3-phosphate.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 70 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. Give the first two reactions of pentose phosphate pathway.

3. Write down the reaction catalyzed by G6PD

First Reaction is catalyzed by 2 enzymes

o glucose 6-phosphate dehydrogenase
o 6-phosphogluconolactone hydrolase

2nd reaction is catalyzed by

o 6-phosphogluconate dehydrogenase

4. Enumerate functions of pentose phosphate pathway

Though it is oxidation of glucose, but it is not meant for energy.
• Provides NADPH which is required for various reductive synthesis in metabolic pathways
• Provides pentoses required for nucleic acid synthesis
• Deficiency of a particular enzyme leads to haemolytic anaemia, which is of great clinical importance.

5. Write down the uses of NADPH in the body (atleast 5)

1. Fatty acid synthesis
2. Steroid synthesis
3. Drug metabolism
4. Glutathione reduction
5. Generation of superoxide in phagocytes by NADPH oxidase

02. G6PD Deficiency & Hemolytic Anemia

1. What is the biochemical cause of hemolysis in patient with G6PD deficiency?

2. What are the consequences of G6PD deficiency?
3. What is the role of G6PD in RBCs?
The only source of NADPH in rbcs in Glucose 6-P dehydrogenase so if there is deficiency of this enzyme, NADPH production
decreased  reduced glutathione  ROS increases  damage to rbcs  Hemolysis

4. A patient develops severe intravascular hemolysis after taking antimalarian drugs. What is the cause of this hemolysis?
5. A patient after taking antimalarian drugs developed severe intravascular hemolysis. Name the enzyme deficient in this patient. Why
its deficiency leads to hemolysis?
Antimalarial drugs cause G6PD activity deficiency  NADPH production decreased  reduced glutathione  ROS increases 
damage to rbcs  Hemolysis

6. What are Heinz bodies and explain why person with deficiency of the Glucose-6-phosphate dehydrogenase (G6PD) enzyme
develop anemia? Enlist the role of NADPH in the body? [Annual 2024 held in 2025]
Heinz Bodies  Denatured & precipitated hemoglobin
Reason for anemia  G6PD activity deficiency  NADPH production decreased  reduced glutathione  ROS increases 
damage to rbcs  Hemolysis
Role of NADPH
 Reductive biosynthesis
 Reduction of hydrogen peroxide
 Cytochrome P450 monooxygenase system
 Phagocytosis by neutrophils
 Synthesis of NO

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 71 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

B-010 ֍URONIC ACID & SORBITOL PATHWAY֍

Note: There is no past seq from this topic. So prepare it. It is enough

֍METABOLISM OF FRUCTOSE & GALACTOSE֍

NOTE: This topic was included in UHS modular curriculam 2024 but now it is not included. I have added it as it is very corelated and
can be asked in exam.

01. Fructose & Galactose Metabolism

1. Give hepatic metabolism of fructose and its regulation

Hepatic Metabolism
 Conversion of Fructose into Fructose 1-P by Fructokinase in Liver
 Conversion of Fructose-1-P to D-glyceraldehyde & Dihydroxyacetone phosphate by aldolase B
 DHAP can directly enter glycolysis or gluconeogenesis, whereas glyceraldehyde can be metabolized by a number of
pathways
Regulation
 Fructose is more rapidly metabolised by the Liver than glucose. This is due to the fact that it bypasses the step in glucose
metabolism catalysed by Phosphofructokinase-I. Hence fructose metabolism is less slightly regulated

DO YOU KNOW!
Fructokinase activity is not affected by insulin. This explains why fructose
disappears from the blood of diabetic patients at a normal rate

2. How galacatose component of lactose is converted to glycogen in the liver?

o Galactokinase phosphorylates galactose to galactose-1-phosphate
o UDP-glucose reacts with galactose 1-phosphate, producing UDP-galactose and glucose 1-phosphate. The enzyme that
catalyzes this reaction is galactose 1- phosphate uridyltransferase (GALT)
o Glucose-1-phosphate is converted to glucose-6-phosphate by the enzyme phosphoglucomutase.
o Glucose-6-phosphate can then be stored as glycogen through the action of glycogen synthase.

2. Clinical Biochemistry

1. How does high fructose diet leads to flooding of cells with cholesterol and Triacylglycerol? Give the mechanism.
Fructose is more rapidly metabolised by the Liver than glucose. This is due to the fact that it bypasses the step in glucose metabolism
catalysed by Phosphofructokinase-I, at which point metabolic control is exerted on the rate of glucose oxidation. This allows fructose
to flood the pathways in the Liver, leading to enhanced FA Synthesis, increased esterification and VLDL secretion, which increases
serum TG Level.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 72 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. In a controlled study, sucrose fed rats developed more atherosclerosis than the glucose fed rats. Explain the mechanism.
3. How high fructose intake for prolonged time is more atherogenic than Glucose?
Sucrose metabolized into glucose & fructose. Fructose is more rapidly metabolised by the Liver than glucose. This is due to the fact
that it bypasses the step in glucose metabolism catalysed by Phosphofructokinase-I, at which point metabolic control is exerted on the
rate of glucose oxidation. This allows fructose to flood the pathways in the Liver, leading to enhanced FA Synthesis, increased
esterification and VLDL secretion, which increases serum TG Level.

4. What are the enzyme deficiencies in essential fructosuria and hereditary Fructose intolerance? Which one leads to severe
hypoglycemia of fructose and why? What is the cause of Hyperuricema in this condition?
o Deficiency of fructokinase causes essential fructosuria
o Deficiency of aldolase B causes hereditary fructose intolerance
o Hereditary fructose intolerance leads to severe hypoglycemia because there is intracellular traping of Fructose 1-phosphate
o Because there is intracellular traping of Fructose 1-P, resulting in a drop in the level of inorganic phosphate (Pi) and,
therefore, of ATP. As ATP falls, AMP rises. In the absence of Pi, AMP is degraded, causing hyperuricemia

5. What are the biochemical events involved in causation of cataracts in Uncontrolled diabetes mellitus?
o Because insulin is not required for the entry of glucose into the cells of eye, large amounts of glucose may enter these cells
during times of hyperglycemia, for example, in uncontrolled diabetes.
o Elevated intracellular glucose concentrations and an adequate supply of NADPH cause aldose reductase to produce a
significant increase in the amount of sorbitol, which cannot pass efficiently through cell membranes and, therefore, remains
trapped inside the cell.
o Sorbitol accumulates in cells causing strong osmotic effects and, therefore, cell swelling as a result of water retention & leads
to cataract formation

6. Which defect cause galactosemia?

Galactosemia is caused by a deficiency of the enzyme galactose-1-phosphate uridyltransferase (GALT), which is necessary for the
breakdown of galactose. This deficiency leads to the accumulation of galactose and its metabolites, causing damage to various organs
and tissues, including the brain, liver, and eyes.

7. How lactose is synthesized in mammary glands & How will you manage a patient with lactose intolerance?
Lactose Synthesis
o UDP-glucose and UDP-galactose are combined to form lactose through the action of the enzyme lactose synthase (also
known as UDP-galactose:glucose galactosyltransferase)
Management
o Dairy product free diet
o Lactase enzyme provision

B-011 ֍ETHANOL METABOLISM֍

Ethanol consumption causes hypoglycemia
Gluconeogenesis is increased as a result of decreased availability of pyruvate and oxaloacetate (the latter gets converted to malate by
high NADH).
Ethanol consumption causes Fatty liver
Citric acid cycle is impaired since the availability of oxaloacetate and NAD+ is reduced. As a result, acetyl CoA accumulates which
gets diverted towards ketogenesis and fatty acid synthesis. Accumulation of fats leads to fatty liver and hyperlipidemia

B-012 & B-013 ֍ETC֍

01. ETC

1. Define respiratory chain and give its location.

Transfer of electrons from NADH & FADH2 to oxygen via multiple carriers which collectively called respiratory or ETC
o Location  Inner mitochondrial mmebrane

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 73 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. Draw electron transport chain.

3. How the electrons flow through the respiratory chain complexes with entry points of reducing equivalents from important
substrates? Draw diagram.

Reference: Harper

02. Components of Complexes

1. Describe the components and functions of complexes of ETC which act as proton pumps

Complex or Component Proton Pump Function

Complex I Yes o Receive two e- from NADH & tranfer them to CoQ (mobile carrier)
NADH dehydrogenase o Generates e an ATP
Complex II No o Receive two e- from NADH & tranfer them to CoQ (mobile carrier)
Succinate dehydrogenase o No ATP formation as there is no proton pump action
Complex III Yes o Receive two e- from CoQ (mobile carrier) & transfer them to complex IV
Cytochrome bc1 o Generates an ATP
Complex IV Yes o At this site, the transported electrons, O2, and free protons are brought
Cytochrome c oxidase together, and O2 is reduced to water
o Generates an ATP
Note: 3 ATP formed in ETC

2. What is cytochrome oxidase, what is its function?

Complex IV is known as Cytochrome oxidase & consist of cyt a + a3. At this site, the transported electrons, O2, and free protons are
brought together, and O2 is reduced to water. It generates an ATP

3. Enumerate the cytochromes of mitochondrial respiratory chain, mention the free mobile and membrane embedded separately.

Cytochromes Free Mobile Membrane embedded

o Cyt b o Cyt c o Cyt b
o Cyt c1 o Cyt c1
o Cyt c o Cyt a
o Cyt a o Cyt a3
o Cyt a3
Note: CoQ is also a mobile e- carrier & Cyt c involved in apoptosis

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 74 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

03. Inhibitors of ETC

1. Draw a figure showing the sites of inhibition of electron transport chain by drugs.
2. Name any four inhibitors of electron transport chain.
3. At which level of respiratory chain, cyanide acts and blocks energy production?
4. A child accidentally took cyanide and was brought to the hospital in coma. What is the effect of
this poison on mitochondrial respiration?
5. An unskilled worker in a water garden/plant nursery was sent to sweep up a spill of a white powder
in the storage shed. Later he was found with labored breathing and convulsions. On further
examination, the white powder was identified as rotenone. What is the cause of respiratory distress
on rotenone exposure?
6. A worker of H2S gas industry became unconscious and brought to medical emergency where he
was declared a case of H2S gas poisoning. Which complex of mitochondrial respiratory chain is
blocked in this patient?

Complex I Rotenone, Barbiturates

Complex II Malonate, Carboxin, TTFA
Complex III Antimycin, Dimercaprol
Complex IV Cyanide, CO, H2S
Reference: Harper

Reference: Harper

04. Chemiosmotic Hypothesis

1. What is chemiosmotic theory?

2. Write down the chemiosmotic theory of oxidative phosphorylation.
The chemiosmotic hypothesis (also known as the Mitchell hypothesis) explains how the free energy generated by the transport of
electrons by the electron transport chain is used to produce ATP from ADP + Pi.
Proton Pump Electron transport is coupled to the phosphorylation of ADP by the transport (―pumping‖) of protons (H+)
across the inner mitochondrial membrane from the matrix to the intermembrane space at Complexes I, III,
and IV. This process creates a proton gradient.
ATP synthase The enzyme complex ATP synthase (Complex V) synthesizes ATP using the energy of the proton gradient
(F1/Fo) generated by ETC. The chemiosmotic hypothesis proposes that after protons have been pumped to the
cytosolic side of the inner mitochondrial membrane, they reenter the matrix by passing through a channel in
the membrane-spanning domain (Fo) of Complex V, driving rotation of Fo and, at the same time, dissipating
the pH and electrical gradients. Fo rotation causes conformational changes in the extra-membranous F1
domain that allow it to bind ADP + Pi, phosphorylate ADP to ATP, and release ATP

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 75 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. What is the role of ATP synthase in ATP production?

4. Give the mechanism of ATP production by ATP synthase.
5. Describe complex V of ETC & write its 2 inhibitors.
Write answer same as above described (ATP synthase)
Inhibitors of Complex V
1. Oligomycin
2. Atractyloside

05. Uncouplers

1. How uncouplers of oxidative phosphorylation produce their effect?

2. Write down uncouplers of oxidative phosphorylation.
ETC and phosphorylation are thus said to be tightly coupled. Inhibition of one process inhibits the other. These processes can be
uncoupled by
1. Uncoupling proteins found in the inner mitochondrial membrane
o Uncoupling proteins create a ―proton leak,‖ allowing protons to reenter the mitochondrial matrix without capturing
any energy as ATP. The energy is released as heat, and the process is called nonshivering thermogenesis.
2. Synthetic compounds
o uncoupler causes electron transport to proceed at a rapid rate without establishing a proton gradient, much as do the
UCPs. Again, energy is released as heat rather than being used to synthesize ATP
Uncouplers
1. Uncoupling proteins (UCP1, UCP2, UCP3)
2. Synthetic compounds (2,4-dinitrophenol, Aspirin)

06. Glycerol 3-P shuttle & Malate-aspartate shuttle

1. How the reducing equivalents NADH produced in the glycolytic pathway of cytosol are transferred to mitochondria for further
oxidation?
NADH produced in the glycolysis is extramitochondrial, whereas the electron transport chain, where NADH has to be oxidised to
NAD+ is in the mitochondrion. NADH is not permeable to mitochondrial membrane. It is envisaged that NADH produced in cytosol
transfer the reducing equivalents through the mitochondrial membrane via substrate pairs, linked by suitabledehydrogenases by shuttle
systems

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 76 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

B-014 to B-020 ֍NUTRITION֍

B014. Balanced Diet

1. What do you understand by balanced diet and recommended dietary allowance?

A diet that contains variety of foods in such quantities and proportions that need for energy, amino acids, vitamins, minerals, fats,
carbohydrates, and other nutrients is adequately met for maintaining health, vitality and general well-being.
Dietary Factor %age of total energy
Total Fat 25–35%
Saturated & Unsaturated fats  Saturated fats  <10% of total energy intake,
 Unsaturated oils should substitute for the
remaining fat requirements
Carbohydrates 45–65%
Proteins 10–35%
Dietary Fiber Up to 40g/day for adults

2. What are the benefts of taking high fiber diet?

1. Reduces constipation and hemorrhoid formation, softens stools
2. Increases bowel motility, thus reducing exposure of gut to carcinogens
3. Decreases absorption of dietary fat and cholesterol & increases fecal loss of cholesterol
4. Delays gastric emptying, generates sensation of fullness & reduces postprandial blood glucose concentration

3. Diferentate clearly between soluble and insoluble fibers

Soluble fiber is the edible parts of plants that is resistant to digestion and absorption in the human small intestine, but is completely or
partially fermented to short-chain fatty acids in the large intestine while Insoluble fiber passes through the digestive track largely
intact.

B015. Special Nutritional Requirements

1. How can you plan the dietary requirement of various nutrients during pregnancy and lactaton?
A. Follow the recommended dietary allowances for pregnant and lactating women, which are higher than for non-pregnant women
because;
B. Focus on whole, nutrient-dense foods, including:
o Leafy greens (iron, folate)
o Citrus fruits and berries (vitamin C)

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 77 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

o Nuts and seeds (healthy fats, protein)

o Legumes (protein, fiber)
o Whole grains (fiber, B vitamins)
C.
Extra allowance of Pregnancy Lactation
Calories 300-400 C/day 500-700 C/day
Protein 10 gm/day 20 gm/day
Iron 10 mg/day Not recomended
Folic acid 50-200 ug 50 ug
Calcium 500 mg/day 500 mg/day
Vitamin D 400 IU/day 600 IU/day
Reference: Chatterjea

2. What is energy balance equaton? How it can be disturbed?

The energy balance equation is a fundamental concept in physiology and nutrition that describes the relationship between energy
intake and energy expenditure. It is expressed as:
 Energy Balance = Energy Intake - Energy Expenditure
Some common disturbances include:
o Positive Energy Balance  Consuming more energy than expended, leading to weight gain and obesity.
o Negative Energy Balance  Expenditing more energy than consumed, leading to weight loss and potentially malnutrition.
o Consuming excessive or inadequate amounts of carbohydrates, proteins, or fats, leading to metabolic disturbances.
o Changes in hormones like insulin, leptin, and ghrelin can affect energy balance and metabolism.
o Sedentary Lifestyle (Reduced physical activity)
o Certain diseases, such as hypothyroidism or Cushing's syndrome, can impact energy balance.
o Certain drugs, like steroids or antidepressants, can influence energy balance and metabolism.
o Aging
o Environmental toxins, stress, and sleep deprivation can also impact energy balance.

B016 & B020. PEM

1. An 8 months old daughter of a widow house servant presents with exhaustion and excess starvaton secondary to defcient intake of
calories and protein & some clinical reasons in this case breast feeding is not possible. She has to give her diluted cow milk but in
inadequate quantities. What is the syndrome with defciency of both calories and protein called?
Marasmus

2. Tabulate the diference between kwashiorkor and marasmus

Features Kwashiokor Marasmus

Weight for age 60-80% <60%
Weight for height Normal or decreased Markedly decreased
Edema Present Absent
Albumin Markedly reduced Mildly reduced
Mood Irritable when picked up; apathetic Alert, irritable
when left alone
Appetite Poor Good
Skin & Hair changes? Yes No
Fatty liver Common Not common

DO YOU KNOW!
Why there is marked muscle wasting in Marasmus but not in Kwashiorkor?
Because there is protein + calories deficiency in marasmus but only protein
deficiency in kwashiorkor

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 78 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. Describe the protein energy malnutriton in children

In developing countries, an inadequate intake of protei and/or energy is the primary cause of PEM. Two extreme forms of PEM are
kwashiorkor and marasmus. Draw table from above question.

DO YOU KNOW!
The dietary protein requirement is influenced by the carbohydrate content of the
diet. When the intake of carbohydrates is low, amino acids are deaminated to
provide carbon skeletons for the synthesis of glucose that is needed as a fuel by the
central nervous system. Therefore, carbohydrate is considered to be protein-
sparing.

B017. Caloric Requirement

1. What is RQ value of carbohydrate, protein and fat & mixed diet in human body?

Calories per gram RQ

Carbohydrate 4 1.0
Protein 4 0.80
Fat 9 0.70
Mixed diet 0.85
Alcohol 7

2. What is respiratory quotent (RQ)? Name two different methods to determine the RQ.
RQ is the ratio of the volume of CO2 produced by the volume of O2 consumed (i.e. CO2/O2) during a given time.
Methods to determine
1. Indirect Calorimetry  measures the exchange of gases (O2 and CO2) between the body and the environment
2. Gas Exchange Analysis  analyze the expired gases (breath-by-breath or minute ventilation) using a gas analyzer, which
measures the concentrations of O2 and CO2.

3. A shopkeeper consumed 85 liters of oxygen in one hour, his RQ during this period was found to be 1.0, what was his CO2
producton?
RQ = CO2 produced / O2 consumed
CO2 produced = RQ x O2 consumed = 1 x 85 = 85

B018 & B019. BMR, BMI & Obesity

1. Define the following terms:

1. Body mass index (BMI) BMI is a measure of body fat based on height and weight. It is calculated by dividing weight in
kilograms by the square of height in meters. BMI categories:
o Underweight: <18.5
o Normal weight: 18.5-24.9
o Overweight: 25-29.9
o Obese: ≥30
2. Basal metabolic rate (BMR) BMR is the number of calories the body needs to function at rest, accounting for basic
physiological processes like breathing, digestion, and heart rate. It is measured after 12h fasting
3. Waist to hip ratio (WPR) WHR is a measure of body fat distribution, calculated by dividing the circumference of the
waist by the circumference of the hips
o WHR > 0.8 for women & > 1.0 for men is defined as android, ―apple-shaped
o WHR < 0.8 for women & <1.0 for men is defined as gynoid, ―pear-shaped
4. Resting metabolic rate RMR is similar to BMR but is measured under less restrictive conditions, allowing for some
(RMR) physical activity. It represents the energy expenditure of the body at rest, but not in a fasting

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 79 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

state.
5. Diet induced thermogenesis The production of heat by the body increases as much as 30% above the resting level during the
digestion and absorption of food. This effect is called the thermic effect of food or diet-induced
thermogenesis

2. Which factors affect BMR?

Age With advancing age, BMR gradually falls

Sex Women normally have a lower BMR than men
Surface area BMR is directly proportional to the body surface.
Climate In colder climates, the BMR is high and in tropical climates, the BMR is proportionally low.
State of nutrition BMR is lowered in conditions of malnutrition, starvation and wasting diseases
Body temperature The BMR increases by about 12% with the rise of 1 oC
Pregnancy The BMR of pregnant mother after six months of gestation rises. It may be noted in pregnancy, the BMR of
the mother is the sum total of Her own metabolism as in her nonpregnant state and Combined with that of the
foetus. Hence, pregnancy exerts no specific effect upon BMR

3. What is leptin? Give its role in maintenence of fat stores in the body
Leptin is an adipocyte hormone that is secreted in proportion to the size of fat stores.
o When leptin levels are high, it signals to the brain that the body has sufficient energy stores, and appetite is suppressed
o When leptin levels are low, it signals to the brain that the body needs more energy, and appetite is increased

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 80 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

֍Practice MCQs֍

Biological Oxiation & Carbohydrate Metabolism

1. A young black man entered his physician‘s office complaining of bloating and diarrhea. His eyes were sunken and the physician
noted additional signs of dehydration. The patient‘s temperature was normal. He explained that the episode had occurred followinga
birthday party at which he had participated in an ice cream eating contest. The patient reported prior episodes of a similar nature
following ingestion of a significant amount of dairy products. This clinical picture is most probably due to a deficiency in:
A. Salivary amylase. C. Sucrase.
B. Pancreatic amylase. D. Lactase.
2. Which one of the following statements concerning glycolysis is correct?
A. The conversion of glucose to lactate requires the presence of oxygen.
B. Hexokinase is important in hepatic glucose metabolism only in the absorptive period following consumption of a carbohydrate
containing meal.
C. Fructose 2,6-bisphosphate is a potent inhibitor of phosphofructokinase.
D. The regulated reactions are also the irreversible reactions.
3. The reaction catalyzed by phosphofructokinase-1:
A. is activated by high concentrations of ATP and citrate. C. is the rate-limiting reaction of the glycolytic pathway.
B. uses fructose 1-phosphate as substrate. D. is inhibited by fructose 2,6-bisphosphate
4. A 43-year-old man presented with symptoms of weakness, fatigue, shortness of breath, and dizziness. His hemoglobin level was
less than 7 g/dl (normal for a male being greater than 13.5 g/dl). Red blood cells isolated from the patient showed abnormally low
level
of lactate production. A deficiency of which one of the following enzymes would be the most likely cause of this patient‘s anemia?
A. Phosphoglucose isomerase C. Pyruvate kinase
B. Phosphofructokinase D. Lactate dehydrogenase
5. The synthesis of glucose from pyruvate by gluconeogenesis:
A. occurs exclusively in the cytosol. C. requires the participation of biotin.
B. is inhibited by an elevated level of glucagon. D. involves lactate as an intermediate.
6. Which one of the following statements concerning gluconeogenesis is correct?
A. It occurs in muscle.
B. It is stimulated by fructose 2,6-bisphosphate.
C. It is inhibited by elevated levels of acetyl CoA.
D. It is important in maintaining blood glucose during the normal overnight fast.
7. A 2-year-old boy was brought into the emergency room, suffering from severe fasting hypoglycemia. On physical examination, he
was found to have hepatomegaly. Laboratory tests indicated that he also had hyperlacticacidemia and hyperuricemia. A liver biopsy
indicated that hepatocytes contained greater than normal amounts of glycogen that was of normal structure. Enzyme assay likely
confirmed a deficiency in which of the following enzymes?
A. Glycogen synthase [Link] 6-phosphatase
B. Glycogen phosphorylase [Link] alpha(16)-glucosidase
8. Following the intravenous injection of lactose into a rat, none of the lactose is metabolized. However, ingestion of lactose leads to
rapid metabolism of this disaccharide. The difference in these observations is a result of:
A. the presence of lactase in the serum. [Link] absence of maltase in the serum.
B. the absence of hepatic galactokinase. D. the presence of lactase in the intestine.
9. A 5-month-old boy is brought to his physician because of vomiting, night sweats, and tremors. History revealed that these
symptoms began after fruit juices were introduced to his diet as he was being weaned off breast milk. The physical examination was
remarkable for hepatomegaly. Tests on the baby‘s urine were positive for reducing sugar but negative for glucose. The infant most
likely suffers from:
A. aldolase B deficiency. C. galactokinase deficiency.
B. fructokinase deficiency. D. Galactosidase deficiency.
10. In preparation for a trip to an area of India where malaria is endemic, a young man is given primaquine prophylactically. Soon
thereafter, he develops a hemolytic condition. The most likely cause of the hemolysis is a less-than-normal level of which of the
following?
A. Glucose 6-phosphate C. Reduced form of glutathione
B. Oxidized form of NAD D. Ribose 5-phosphate

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 81 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

11. Electron transport chain carriers are located in the mitochondria:

A. In mitochondrial matrix C. In the intermembrane space
B. On the inner surface of the outer mitochondrial membrane D. In the inner mitochondrial membrane
12. Cyanide is poisonous as it stops respiration because of its:
A. Inhibition of TCA cycle C. Inhibition of myoglobin
B. Combination with RB cell membrane D. Inhibition of cytochrome oxidase
13. The oxidation and phosphorylation in intact mitochondria is blocked by:
A. Puromycin C. Gentamicin
B. Oligomycin D. Streptomycin
14. MacArdle‘s disease involves a deficiency of the which enzyme?
A. Acid maltase C. Hepatic phosphorylase
B. Glucose-6-phosphatase D. Muscle phosphorylase
15. In the normal resting state of humans, most of the blood glucose brunt as ‗fuel‘ is consumed by:
A. Liver C. Kidneys
B. Brain D. Muscles
16. A specific inhibitor for succinate dehydrogenase is:
A. Arsenite C. Citrate
B. Malonate D. Fluoride
17. In Rapaport-Leubering shunt in erythrocytes, 2,3-biphosphoglycerate (2,3-BPG) is produced from which intermediate in glycolytic
pathway?
A. 3-phosphoglycerate C 1,3-biphosphoglycerate
B. 2-phosphoglycerate D. Glyceraldehyde-3-P
18. A liver biopsy from an infant with hepatomegaly, stunted growth, hypoglycaemia, lactic acidosis, hyperlipidaemia revealed
accumulation of glycogen having normal structure. A possible diagnosis would be:
A. Branching enzyme deficiency C. Debranching enzyme deficiency
B. Liver phosphorylase deficiency D. Glucose-6-phosphatase deficiency
19. Out of 24 mols of ATP formed in citric acid cycle, two molecules of ATP can be formed at ―substrate level‖, by which of the
following reaction?
A. Citric acid to isocitric acid C. Succinic acid to fumarate
B. Isocitrate to oxalosuccinate D. Succinyl-CoA to Succinic acid
20. Which of the following glucose transporters are important in fructose transport in the intestine?
A. GLUT5 C. GLUT4
B. GLUT3 D. GLUT7
21. During prolong starvation, which of the following hormone is responsible for increasing gluconeogenesis in the liver
A. Insulin C. TSH
B. Glucagon D. Thyroxine
22. Gluconeogenesis is the production of glucose from non-carbohydrate molecules. Which of the following is not substrate for
gluconeogenesis?
A. Lactate C. Glycerol
B. Alanine D. Acetyl CoA
23. A breast-fed infant began to vomit frequently and lose weight. Several days later she developed jaundice, hepatomegaly, and
bilateral cataract. What is the possible cause of these symptoms?
A. Galactosemia C. Juvenile diabetes Mellitus
B. Von-Gierke's disease D. Hereditary fructose intolerance
24. Which of the following enzymes of the glycolytic pathway catalyzes the step, which is a oxidative phosphorylation at the substrate
level, ie carries out the synthesis of ATP when a metabolite is oxidized?
A. Phosphofructokinase 1 C. Pyruvate kinase
B. Hexokinase D. Phosphoglucomutase
25. Which of the following enzyme is inhibited by sodium fluoride that is used as anticoagulant during blood collection and transport?
A. Glyceraldehyde-3-phosphate dehydrogenase C. Enolase
B. 3-phosphoglycerate mutase D. AMP
26. Which of the following co-enzymes does not participate in the pyruvate dehydrogenase complex:
A. pyridoxalphosphate C. coenzyme-A
B. thiamine pyrophosphate D. Lipoic acid

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 82 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

27. The major metabolic product produced under normal circumstances by erythrocytes and by muscle cells during intense exercise is
recycled through the liver in the Cori cycle. The metabolite is
A. Oxaloacetate C. Glycerol
B. Alanine D. Lactate
28. Which of the following enzymes involved in the glycolysis is the major regulatory enzyme of this pathway:
A. Phosphofructokinase-2 (PFK-2) C. Phosphoglycerate kinase
B. Aldolase D. Phosphofructokinase-1 (PFK-1)
29. Which of the following enzyme catalyses the conversion of glucose to glucose-6- phosphate in muscle cells?
A. Glucose-6-phosphatase C. Phosphoglucomutase
B. Glucokinase D. Hexokinase
30. Fructose is the second most common sugar in the human adult diet and its metabolism parallels glycolysis. Which one of the
following substances is found in both the fructose metabolic pathway and the glycolytic pathway?
A. Glucose 1-P C. Fructose 6-P
B. Fructose 1-P D. Glyceraldehyde 3-P
31. The red blood cells require ATP in order to maintain ion gradients across their membrane. In the absence of these ion gradients,
the red blood cells will swell and burst, bringing about a hemolytic anemia. Red cells generate their energy via which one of the
following?
A. Substrate-level phosphorylation C. Oxidative phosphorylation
B. TCA cycle D. Electron transfer to oxygen
32. Which of the following co-enzymes serve as such of the enzyme of the pentose phosphate pathway, transketolase, and by
measuring the enzymatic activity of transketolase is diagnosed a possible deficiency of this vitamin in the body?
A. pyridoxal phosphate C. NADP
B. thiamine pyrophosphate D. FAD
33. A 3-month-old infant presents with hepatosplenomegaly and failure to thrive. A liver biopsy reveals glycogen with an abnormal,
amylopectins like structure with long outer chains and missing branches. Which of the following enzymes would most likely be
deficient?
A. Alpha-Amylase C. Debranching enzyme
B. Branching enzyme D. Glycogen phosphorylase
34. Which of the following hormones stimulates the gluconeogenesis by inducing biosynthesis of phosphoenolpyruvate-carboxykinase
(PEPKK) and other specific enzymes of gluconeogenesis:
A. Cortisol C. Aldosterone
B. Insulin D. ACTH
35. Which of the following metabolites of the citrate cycle can be directly converted to phosphoenolpyruvate, and thus be incorporated
into the gluconeogenesis?
A. Citrate C. α- -Ketoglutarate
B. Oxaloacetate D. Fumarate
36. Which of these metabolites is the allosteric activator of phosphorylated glycogen synthase b?
A. АTP C. glucose-6-phosphate
B. АМP D. fructose-2,6-bisphosphate
37. Glycerol is a non-carbohydrate precursor for the synthesis of glucose in gluconeogenesis. To which of the listed metabolites of
gluconeogenesis turns the glycerol to?
A. Pyruvate C. Phosphonenolpyruvate
B. Dihydroxyacetone phosphate D. Fructose-6-phosphate
38. Which of the following enzymes is not present in the muscles that could explain the fact that skeletal muscles do not release blood
glucose after the breakdown of glycogen?
A. kinase of phosphorylase C. glucose-6-phosphatase
B. phosphoglucomutase D. glycogen phosphorylase
39. Fructose feeding increases lipogenesis because it
A. activates acetyl CoA carboxylase C. increases insulin secretion
B. bypasses the PFK control point D. decreases serum free fatty acid levels
40. Which of the following is not a source of high energy phosphate?
A. TCA C. Oxidative phosphorylation
B. Glycolysis D. HMP

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 83 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

41. By which of the following anticoagulants used in estimating blood glucose, glycolysis is prevented ?
A. EDTA C. Sodium fluoride
B. Heparin D. Sodium citrate
42. NADPH is produced by?
A. Glycolysis C. Hexose Monophosphate Shunt
B. Citric acid cycle D. Glycogenesis
43. NADPH is required in
A. Glycolysis C. Gluconeogenesis
B. Glycogenolysis D. Fatty acid synthesi

ANSWER KEY
1. D 2. D 3. C 4. C 5. C 6. D 7. C 8. D 9. A 10. C
11. D 12. D 13. B 14. D 15. B 16. B 17. A 18. D 19. D 20. A
21. B 22. D 23. A 24. C 25. C 26. A 27. D 28. D 29. D 30. D
31. A 32. B 33. B 34. A 35. B 36. C 37. B 38. C 39. B 40. D
41. C 42. C 43. D 44. B 45. C 46. D 47. D 48. D 49. B 50. D

1. The physical symptoms suggest a deficiency in an enzyme responsible for carbohydrate degradation. The symptoms observed
following the ingestion of dairy products suggest that the patient is deficient in lactase.
2. Hexokinase, phosphofructokinase, and pyruvate kinase are all irreversible and are the regulated steps in glycolysis
3. Phosphofructokinase-1 is the pace-setting enzyme of glycolysis. It is inhibited by ATP and citrate, uses fructose 6-phosphate as
substrate. The reaction is activatedby fructose 2,6-bisphosphate
4. Decreased lactate production in the erythrocyte indicates a defect in glycolysis. Among patients exhibiting genetic defects of
glycolytic enzymes, about 95% show a deficiency in pyruvate kinase. Pyruvate kinase deficiency is the second most common cause
(after glucose 6-
phosphate dehydrogenase deficiency) of enzyme deficiency– related hemolytic anemia
5. Biotin is the coenzymeprosthetic group of pyruvate carboxylase. The carboxylation of pyruvate occurs in the mitochondria.
Glucagon stimulates gluconeogenesis. Lactate is not an intermediate in the conversion of pyruvate to glucose; however, pyruvate can
be produced from lactate.
6. During the overnight fast, glycogen is partially depleted and gluconeogenesis provides blood glucose. Gluconeogenesis is inhibited
by fructose 2,6- bisphosphate and stimulated by elevated levels of acetyl CoA. Degradation of fatty acids yields acetyl CoA, which
cannot be converted to glucose. This is because there is no net gain of carbons from acetyl CoA in the TCA cycle, and the PDH
reaction is physiologically irreversible.
7. Please see B008 Topic 04
8. Lactase and maltase are intestinal enzymes not found in the serum. Therefore, ingested lactose is degraded, but injected lactose is
not. If hepatic galactokinase is absent, the galactose segment of the lactose is not metabolized, but the glucose segment of the lactose
can still be metabolized.
9. The symptoms suggest fructose intolerance, a deficiency in aldolase B
14. Please see B008 Topic 04
18. Please see B008 Topic 04
21. Gluconeogenesis occurs in the liver and kidneys. Gluconeogenesis supplies the needs for plasma glucose between meals.
Gluconeogenesis is stimulated by the diabetogenic hormones (glucagon, growth hormone, epinephrine, and cortisol). Gluconeogenic
substrates include glycerol, lactate, propionate, and certain amino acids. PEP carboxykinase catalyzes the rate-limiting reaction in
gluconeogenesis. The dicarboxylic acid shuttle moves hydrocarbons from pyruvate to PEP in gluconeogenesis. See B007 Topic 02
23. The clinical manifestations are typical of classical Galactosemia. Bilateral cataract rules out the possibility of Von Gierke's disease
and hereditary fructose intolerance, although other symptoms are there in both these diseases. In juvenile diabetes mellitus, jaundice
and hepatomegaly are not observed.
27. See B007 Topic 03
30. Fructose 1-P is found only in fructose metabolism. Glucose 1-P is derived from glycogen degradation. Fructose 6-P found in
glycolysis but not in fructose metabolism. Both fructose and glucose are converted to glyceraldehyde 3-P, and this is where the two
pathways intersect. Their continued metabolism is identical from this point on.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 84 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION
31. Red blood cells do not contain mitochondria and can only generate energy via anaerobic mechanisms. Without mitochondria,
aerobic glycolysis cannot occur through the TCA cycle or oxidative phosphorylation. Only anaerobic glycolysis can occur with
production of lactate and production of ATP by substratelevel phosphorylation. The ETC occurs within the mitochondria
33. Please see B008 Topic 04
34. See B007 Topic 02
35. See B007 Topic 02 Q1
36. B008 Topic 3
37. See B007 Topic 02 Q1
38. Skeletal muscles lack glucose-6-phosphatase, which is necessary to convert glucose-6-phosphate to glucose, the form in which
glucose is released into the bloodstream. This is why skeletal muscles do not release glucose into the bloodstream after glycogen
breakdown.
39. See B011 Topic 02

֍Past MCQs֍

1. An abnormal disease in the flow of saliva is called:

A. Ptyalism C. Salivation
B. Xerostomia D. Sialadenitis
2. Most of the Enzymes Secreted in Human Gastrointestinal Tract are;
A. Oxidoreductases C. Hydrolases
B. Lyases D. Transferases
3. The Primary Function of Salivary Amylase is designated to be;
A. Hydrolysis of Dietary Starch C. Hydrolysis of Dietary Glycogen
B. Hydrolysis of Bacterial Cell Walls D. Hydrolysis of Mucopolysacchrides
4. Which of the Following are Metabolic Functions are Related to Hexose Monophosphate Shunt Pathway?
A. Ribose-5-Phosphate Synthesis, Fructose-6-Phosphate Synthesis and Reducing Equivalents for Cholestrogenesis.
B. Biosynthesis of Amino Acids, Formation of Acetyl CoA and ATP Production.
C. Formation of Lactate and Synthesis of Glyceraldehyde-3-Phosphate.
D. Formation of Glucuronate, Ascorbic Acid & Oxalates.
5. Final common oxidative pathway which integrates oxidative products of fats, proteins and carbohydrate is also known as;
A. Ketogenesis C. Citric Acid Cycle
B. Glucuronic Acid Pathway D. Gluconeogenesis
6. Retenone blocks
A. Complex I C. Complex III
B. Complex II D. Complex IV
7. Main products of hexosmonophosphate shunt are.
A. NADH + NADH2 C. NADPH + glucose 6-phosphatte
B. NAPH + ATP D. NADPH+ Ribose 5-phospate
8. Pyruvate carboxylase converts the pyruvate to which of the following products?
A. Oxaloacetate C. Glycerol
B. Lactate D. Glucose
9. Glycogen synthesis is inactivated by.
a. cAMP C. Glucose 6 P
b. ATP d. Glucose
10. Fe in complex I & II is attached to the sulphur of
A. Alanine C. Serine
B. Cysteine D. Arginine
11. Isocitrate dehydrogenase is allosterically activated by:
A. Citrate C. a-Ketoglutarate
B. ADP D. NAD

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 85 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

12. H2S inhibit

A. Complex I C. Complex III
B. Complex II D. Complex IV
13. Glucose 6-phosphate is converted to which molecule in the Hexose Monophosphate (HMP) pathway?
A. Ribose 5-phosphate C. Fructose 6-phosphate
B. Ribulose 5-phosphate D. Glucose 1-phosphate
14. McArdle syndrome, a glycogen storage disease, is characterized by which of the following symptoms?
A. Hyperurecemia C. Developmental delays
B. Liver enlargement D. Muscle cramps
15. Curdling of milk in stomach is due to action of
A. HCl C. Pepsin
B. Rennin D. Rennin
16. Alpha-Ketoglutarate dehydrogenase is allosterically inhibited by:
A. Ca++ C. FAD
B. Succinyl CoA D. Succinate
17. In citric acid cycle, FAD is reduced by:
A. Isocitrate dehydrogenase C. Succinate dehydrogenase
B. a-Ketoglutarate dehydrogenase D. Malate dehydrogenase
18. Pyruvate dehydrogenase complex is located in:
A. Cytosol C. Mitochondria
B. Lysosomes D. Endoplasmic reticulum
19. Pyruvate dehydrogenase kinase is inhibited by:
A. Acetyl CoA C. ATP
B. NADH D. Pyruvate
20. Glycolytic pathway is located in:
A. Mitochondria C. Microsomes
B. Cytosol D. Nucleus
21. Lactase, the enzyme that breaks down lactose, is primarily released from which part of the git?
A. Duodenum C. Jejunum
B. Pancreas D. Pylorus
22. Which of the following substances is absorbed through secondary active transport in the gastrointestinal tract?
A. Amino acids C. Glucose
B. Fatty acids D. Water
23. During fasting, glucose is phosphorylated mainly by:
A. Hexokinase C. Phophoglucommutase
B. Glucokinase D. UDPG pyrophosphorylase
24. Fluorde ions inhibits:
A. Aldolase C. Glucokinase
B. Enolase D. Pyruvate kinase
25. Glycolysis is always anaerobic in:
A. Liver C. Kidneys
B. Brain D. Erythrocytes
26. Biphosphoglycerate mutase is present in:
A. Liver C. Brain
B. Muscles D. Erythrocytes
27. Glucose-I-Phosphate liberated from glycogen cannot be converted into free glucose in:
A. Liver C. Muscle
B. Kidneys D. Brain
28. Lactate formed in muscles can be utilized through:
A. Rapoport-Luebering cycle C. Cori cycle
B. Glucose-alanine cycle D. Citric acid cycle
29. Glucose uptake by liver cells is:
A. Energy-dependent C. Sodium-dependent
B. Pri active transport D. Insulin-independent

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 86 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

30. Fructose requires ------ for its absorption

A. GLUT5 C. SGLT5
B. SGLT1 D. GLUT1
31. In glycolysis, how many ATPs are used?
A. 1 C. 3
B. 2 D. 4
32. Which one have highest tendency for accepting electron in ETC?
A. Oxygen C. CoQ
B. NAD+ D. Cyt c
33. An average daily protein requirement for adult per Kg
A. 0.8 g C. 4 g
B. 2 g D. 0.3 g
34. Calcium requirement in a pregnant lady:
A. 500mg/day C. 700mg/day
B. 1200mg/day D. 300mg/day
35. Leptin is produced by:
A. Adipocytes C. Muscle cells
B. Hepatocytes D. Pancreatic beta cells
36. Insulin induces which glycolytic enzyme?
A. Glucokinase C. G3PD
B. Hexokinase D. Phosphoglucomutase
37. Which enzyme deficiency is most commonly associated with hemolysis?
A. Pyruvate Kinase C. Glucose-6-phosphate Dehydrogenase
B. Phosphofructokinase D. Lactate Dehydrogenase
38. Von Gierke disease is caused by a deficiency of which enzyme?
A. Glucose 6 Phosphatase C. Phosphoglucomutase
B. Glucose 1 Phosphatase D. Glucokinase
39. A baby vomits after milk feeding. Suspected diagnosis:
A. Lactose intolerance C. Tropical spru
B. Celiac disease D. Cystic fibrosis
40. G6PD is a regulatory enzyme of which pathway?
A. Glycolysis C. Glycogenolysis
B. Gluconeogenesis D. Pentose phosphate pathway
41. Arsenic poison inhibits the action of:
A. Coenzyme A C. Lipoic acid
B. Pyruvate kinase D. Phosphofructokinase
42. Which hormone increases pancreatic secretion rich in enzymes?
A. Secretin C. Gastrin
B. Cholecystokinin (CCK) D. Insulin
43. Secretion containing no enzyme:
A. Bile C. Gastric juice
B. Saliva D. Pancreatic juice
44. In anerobic respiration when lactic acid is produced, how many ATP formed?
A. 0 C. 2
B. 1 D. 3
45. The product of pyruvate carboxylase enzyme is
A. Glucose C. Acetyl-CoA
B. Pyruvate D. OAA
46. An example of substrate-level phosphorylation is:
A. Ketoglutarate → Succinate C. Pyruvate → Acetyl-CoA
B. Succinyl-CoA → Succinate + CoA + ATP D. Glucose → Glucose-6-phosphate
47. Energy obtained from 1 mole of NADH
A. 1 ATP C. 3 ATP
B. 2.5 ATP D. 4 ATP

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 87 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

48. In fed state, source of blood glucose:

A. Stored glycogen C. Stored fats
B. Muscle protein D. Dietry glucose
49. Which molecule is transported through passive transport (facilitated diffusion) at the luminal and basolateral membrane of
enterocytes in the small intestine?
A. Glucose C. Galactose
B. Fructose D. Amino acids
50. Oligomycin blocks
A. Complex I C. Complex IV
B. Complex II D. Complex V
51. Complex NADH dehydrogenase (also known as Complex I) is present
A. Inner side of inner mitochondrial membrane C. Inner side of outer mitochondrial membrane
B. Outer side of inner mitochondrial membrane D. Outer side of outer mitochondrial membrane

54. Insulin does not regulate which enzyme?

A. Glucokinase C. Pyruvate kinase
B. Phosphofructokinase-1 D. Pyruvate carboxylase
55. The source of NADPH in lipogenesis (fatty acid synthesis) is
A. HMP C. Glycogenolysis
B. Glycolysis D. Citric acid cycle
56. In the well-fed state, the source of pyruvate for the TCA cycle:
A. Glycolysis & Malate C. Citric acid cycle & Glycolysis
B. Glycolysis & Pyruvate carboxylase D. HMP & Glycolysis
57. Insulin regulates the following enzymes of glycolysis:
A. PFK-1, PK, & Glucokinase C. Glucokinase, Pyruvate kinase, & Phosphoglucomutase
B. PFK-1, PK, & Pyruvate carboxylase D. Hexokinase, PFK-1, & Pyruvate kinase
th
58. How much extra calories are required in a lactating woman? (4 year Cmed Past repeating mcq)
A. 200 C. 600
B. 400 D. Not required
th
59. 1 g fibers give how much calories? (4 year Cmed past mcq)
A. 4 Kcal C. 1 Kcal
B. 9 Kcal D. 0 Kcal
60. How much total extra iron requirement in a pregnant lady?
A. 10mg C. 2700mg
B. 900mg D. 1200mg

ANSWER KEY
1. B 2. C 3. A 4. A 5. C 6. A 7. D 8. A 9. A 10. B
11. B 12. D 13. B 14. D 15. D 16. B 17. C 18. C 19. D 20. B
21. C 22. C 23. A 24. B 25. D 26. D 27. C 28. C 29. D 30. A
31. B 32. A 33. A 34. B 35. A 36. A 37. C 38. A 39. A 40. D
41. C 42. B 43. A 44. C 45. D 46. B 47. B 48. D 49. B 50. D
51. A 52. B 53. D 54. D 55. A 56. A 57. A 58. C 59. D 60. B

2. Most of the enzymes secreted in the human gastrointestinal tract are hydrolases, which are responsible for breaking down nutrients
such as proteins, carbohydrates, and fats into smaller molecules that can be absorbed and utilized by the body.
9. See B008 Topic 03
11. The enzyme is inhibited by ATP and NADH, and activated by ADP and Ca2+.
16. The enzyme is very similar to pyruvate dehydrogenase and uses the same coenzymes. a-Ketoglutarate dehydrogenase complex is
activated by calcium and inhibited by NADH and succinyl CoA, but is not covalently regulated.
19. See B005 Topic 02
23. Glucokinase is primarily involved in glucose phosphorylation in the liver after a meal, not during fasting

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 88 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

29. The liver has a unique role in glucose metabolism, and its glucose uptake is not regulated by insulin, unlike other tissues like
muscle and adipose tissue. Instead, the liver takes up glucose through a process called facilitated diffusion, which is mediated by the
GLUT2 transporter (Na independent Facilitated diffusion)
41. Arsenic poison inhibits the action of lipoic acid, thus causes inactivation of PDH complex by binding to lipoic acid.
49. Galactose and glucose are transported into the mucosal cells by secondary active transport (SGLT-1) & transported from the
intestinal mucosal cell into the portal circulation by facilitated diffusion (GLUT-2) while Fructose is transported into the mucosal cells
by facilitated diffusion (GLUT-5) & transported from the intestinal mucosal cell into the portal circulation by facilitated diffusion
GLUT-2.

59. Dietary fiber is not digestible by human enzymes and does not provide any calories

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 89 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Pa001 – Pa002
GIT PATHOLOGY
Pa-001 ֍GASTRITIS֍
Gastritis is the Inflammation of the Gastric Mucosa
Acute gastritis
It is short-term infection characterized by severe symptom like abdominal pain, nausea & vomiting. It resolves without significant
complications
Chronic gastritis
When the acid-producing parietal cells of the stomach are destroyed, which frequently occurs in persons with chronic gastritis leads to
achlorhydria (lack of stomach acid secretion) & pernicious anemia because of failure of maturation of the red blood cells in the
absence of vitamin B12 stimulation of the bone marrow. It does not produce severe symptoms like acute gastritis.
Features H-pylori associated gastritis Autoimmune gastritis
Incidence 90% 10%
Location Antrum Body
Inflammatory Neutrophils, subepithelial plasma cells Lymphocytes, macrophages
infiltrates
Rugal folds Thickened Lost
Serology Antibodies to H. pylori Antibodies to parietal cells (H+ ,K+ -
ATPase, intrinsic factor)
Association Low socioeconomic status, poverty, Autoimmune disease; thyroiditis, diabetes
residence in rural areas mellitus, Graves disease
Complication Peptic ulcer, adenocarcinoma, MALToma Atrophy, pernicious anemia,
adenocarcinoma, carcinoid tumor

1. A 35 year old female presents to medical OPD with complaints of heartburn, regurgitation and pain in chest after taking meal.
Compare characteristic features of H-pylori associated and autoimmune gastritis on the basis of location, inflammatory infiltrate,
serology, associations and complications. [Annual 2023]
See above table

2. Enumerate the complications of long-term chronic gastritis.

See in above table

3. 31-year-old male presents with history of relapses and recurrence of nausea and upper abdominal discomfort, sometimes with
volume for the last many months. The attending gastroenterologist performs gastric endoscopy and makes provisional diagnosis of
chronic gastritis. [Annual 2015]
a) Enlist four types/forms of chronic gastritis. (2)
1) H-pylori induced
2) Autoimmune
3) Eosinophilic gastritis
4) Lymphocytic gastritis
5) Granulomatous gastritis
Note: No need to do detail of Eosinophilic, lymphocytic & granulomatous gastritis
b) What are the microscopic characteristics of Helicobacter Pylori associated gastritis?? (3)
 Abundant Spiral shaped or curved bacilli (H-pylori)
 Neutrophilic & subepithelial plasma cells
 Thickeneing of rugal folds
 Subepithelialy lymphoid aggreagtes with germinal centres (induce MALT)

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 90 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Pa-002 ֍PEPTIC ULCER DISEASE֍

Etiology
o H. pylori – cause of around 90% of duodenal ulcers & 70% of gastric ulcers
o NSAIDs – 2nd common cause
o Zollinger Ellison syndrome
o Cigarette smoking
o Alcoholism
o Corticosteroids
o Stress

Type Clinical Features Most common site

Gastric ulcer Epigastric pain, Nausea, Vomiting + Pain become worse on taking food Lesser curvature
Duodenal ulcer Epigastric pain, Nausea, Vomiting + Pain get relief on taking food First part of duodenum
Usually person awake from sleep during night

Pathogenesis
Cause Pathophysiology
NSAID (Aspirin) decrease prostaglandin synthesis  impairs mucosal blood flow and healing  peptic ulcer
Zollinger-Ellison syndrome uncontrolled release of gastrin  massive acid production  peptic ulcer
H-pylori H-pylori infection causes pangastritis or predominantly antral gastritis by Cag-A toxin 
increased gastrin production from G cells due to destruction of somatostatin producing cell 
increased acid production from parietal cells (parietal cell hyperplasia)  increased acid load
causes ulcer in duodenum. H-pylori protect itself from acidic environment of stomach by urease
enzyme
Smoking Increased nervous stimulation of the stomach secretory glands
Alcohol Break down the mucosal barrier
Morphology
o Gross  Solitary, round to oval, Punched out lesion
o Microscopic  Necrosis & Inflammatory cells

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 91 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

1. A 32 years old female presents with burnig / aching epigastric pain 2-3 hours after meal. His pain is relieved by taking some food or
milk. He also sometimes feels nausea, bloating & Blenching. What is most likely diagnosis. Briefly describe its pathogenesis. (2.5)
[Supple 2021]
Diagnosis  Peptic ulcer (Duodenal ulcer)
Pathogenesis
Cause Pathophysiology
NSAID (Aspirin) decrease prostaglandin synthesis  impairs mucosal blood flow and healing  peptic ulcer
Zollinger-Ellison syndrome uncontrolled release of gastrin  massive acid production  peptic ulcer
H-pylori H-pylori infection causes pangastritis or predominantly antral gastritis by Cag-A toxin 
increased gastrin production from G cells due to destruction of somatostatin producing cell 
increased acid production from parietal cells (parietal cell hyperplasia)  increased acid load
causes ulcer in duodenum. H-pylori protect itself from acidic environment of stomach by urease
enzyme
Smoking Increased nervous stimulation of the stomach secretory glands
Alcohol Break down the mucosal barrier

2. A 33 years old male who is smoker and has been on NSAIDs for many months. He develops epigastric pain for a couple of weeks
and also spitted out blood for two to three times. Endoscopy shows a sharp punched out defect in gastric antral mucosa. (Annual 2020)
a) What is the most likely diagnosia?
Answer: Peptic ulcer disease (PUD)
b) What are the microscopic findings/features in the biopsy from the defect?
Necrotic zone It is most superficial zone.
Superficial exudative zone It consists of fibrinopurulent exudates with predominantly neutrophilic infiltrate
Granulation tissue zone It consists of granulation tissue infiltrated with mononuclear infiltrate.
Zone of cicatrization It consists of fibrous tissue or collagenous scar which forms base of the ulcer and
may show chronic inflammatory cells.
c) Ennumerate associated/possible complications.
o Frank hemorrhage (Iron deficiency anemia)
o Perforation
o Obstruction

3. A 45-year-old man has had vague abdominal pain for the past three years. He has no difficulty swallowing and no heartburn
following meals. Upper GI endoscopy revealed antral mucosal erythema, but no ulcerations or masses. Microscopically there is a
chronic gastritis with curved organism in lumen. [Supple 2019 held in 2020]
a) What is the most likely diagnosis? (0.5)
Answer: H. pylori (Chronic) gastritis
b) Briefly describe the pathogenesis of H. pylori infection. (2)
o H-pylori infection causes pangastritis or predominantly antral gastritis by Cag-A toxin  increased gastrin
production from G cells due to destruction of somatostatin producing cell  increased acid production from
parietal cells (parietal cell hyperplasia)  increased acid load causes ulcer in duodenum.
o H-pylori protect itself from acidic environment of stomach by urease enzyme

4. A 24-year-old male presents with repeated episodes of nausea, vomiting, epigastric pain & discomfort. Routine laboratory tests are
normal, while urea breath test is positive. Gastroscopy reveals hyperemic mucosa of the pyloric antrum. Multiple biopsies taken from
this region which reveal chronic inflammation on microscopic examination. What is the most likely diagnosis? Describe its
pathogenesis. (1+4) [Supple 2018 held in 2019]
Diagnosis H-pylori (chronic) gastritis
Pathogenesis See in Q3

5. A 33-year-old man has had upper abdominal pain for over 10 weeks. For the past week, he complains of nausea. His stool sample is
positive for occult blood. Upper GI endoscopy reveals no esophageal lesions but there is solitary 2 cm diameter shallow sharply
demarcated ulcer in the gastric antrum. [Annual 2017]

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 92 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

a) What is most likely diagnosis?

Answer: Peptic ulcer disease (Gastric ulcer)
b) Describe pathogenesis of this disease.
See Q1b

6. A 25 years old male gave few months history of dyspepsia. On gastroscopy, ulcer was seen. The gastric biopsy revealed heavy
colonization by small curved spiral organism on the surface of mucosa. [Annual 2009]
Name the causative organism.
Answer: H-pylori.
What is the role of this microorganism in producing this pathology?
Answer: See in Q3b

Pa-003 ֍INFECTIOUS DIARRHEAL AGENT֍

Cause Clinical Features Pathogenesis

Non-bloody Staphylococcus aureus  Gram positive cluster cocci Enterotoxin  G protein 
diarrhea  Short incubation period because of preformed ↑cAMP in enterocytes 
toxins Outpouring of fluid &
Clostridium  Gram positive bacilli electrolytes from enterocytes
difficiliVibrio cholera  Diarrhea is associated with use of antibiotics into lumen of git  watery
Bacillus cereus  Gram positive bacilli diarrhea
 Eating reheated rice leads to diarrhea
Rota virus Very common cause in children therefore
vaccination is recommended for less than 2 years
children
Vibrio cholera  Gram negative rod (curved shaped)
 Rice water stool
E. coli  Gram negative rod
 Traveler‘s diarrhea
Salmonella  Gram negative rod
 Incubation period of 12 to 48 hours
 Also causes typhoid fever
Bloody Shigella  Gram negative rod Direct invasion of git mucosa or
diarrhea  Bloody diarrhea (Bacillary dysentery) by enterotoxin (Shiga toxin)
E. coli  Gram negative rod Shiga toxin inhibits protein
synthesis in enterocytes by
 Hemolytic uremic syndrome
removing adenine from 28S
ribosomal RNA
Entamoeba Histolytica  Bloody diarrhea (Amoebic dysentery)
Direct invasion of git mucosa
 Flask shaped ulcer in colon
*Hemolytic uremic syndrome = Hemolysis (Anemia) + Thromocytopenia + Acute kidney injury (AKI)

1. You are a medical officer at camp for IDPs where an outbreak of diarrhea occurred. Patients complain of excessive watery stools
with no bleeding. Gram stain of stool showed curved gram-negative rods. [Supply 2015]
a. Name the most likely diagnosis. Name the causative bacteria.
The most likely diagnosis is Cholera. The causative bacteria are Vibrio cholerae.
b. Briefly discuss its pathogenicity.
See in above table

2. Nine people from a village in the province of Punjab presents with sudden onset of vomiting and massive watery
diarrhea. They observed rice water stools with flecks of mucous. Culture reveals motile gram-negative curved bacilli.
Name the most likely pathogen and discuss the mode of action of its enterotoxin (exotoxin) leading to watery diarrhea.
See Q1

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 93 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

3. A boy has cramping abdominal pain. He is passing stool containing pus cells and red blood cells. [Supply 2017 held in
2018]
a) Name microorganisms responsible for exudative disease resulting in the appearance of blood in stool.
 Shigella
 [Link]
b) Give the mechanism of action of Shiga toxin.
Shiga toxin inhibits protein synthesis in enterocytes by removing adenine from 28S ribosomal RNA
c) Enlist dysentery causing organisms.
 Shigella
 [Link]
 Entamobea histolytica
 Salmonella (usually it causes watery diarrhea)

4. A 50 years old man develops intense rice water diarrhea 24 hours after leaving his village. The stools are thin and
watery, containing flakes of mucous no pus or blood cells. Stool culture reveals rapid growth at the surface of alkaline
peptone water. [Supply 2018 held in 2019]
a) Name the most likely microorganism responsible for this diarrhea.
Vibrio cholerae
b) What is the mode of action of enterotoxin of this pathogen?
See in table

5. At tea party the guests were served with sandwiches, salad drinks. After six hours of eating at the party a few of the guests started
perfuse vomiting and diarrhoea.
a) What organism is responsible for these symptoms.
Staphylococcus aureus
b) Write incubation period of Salmonella
12 – 48 hours

6. Three persons of a family presented with sudden onset of massive watery diarrhea. Grossly stool has appearance of ―rice water‖.
Cultures of the patient‘s stool grew gram negative highly motile curved rods. (SUPPLY 2022)
A) Name the most likely causative agent for this diarrhea?
Vibrio cholera
b) Explain the mechanism of action of the enterotoxin produced by this pathogen
See in table

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 94 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

֍Practice & Past MCQs֍

1. A 33 years old male who is smoker and has been on NSAIDs for many months. He develops epigastric pain for a couple of weeks
and also spitted out blood for two to three times. Endoscopy shows a sharp punched out defect in gastric antral mucosa. What is the
diagnosis?
A. Gastric ulcer C. Gastric carcinoma
B. Duodenal ulcer D. GERD
2. What is the most common site for gastric ulcer?
A. Greater curvature C. Pylorus
B. Lesser curvature D. Cardia
3. A 32 years old female presents with burning / aching epigastric pain 2-3 hours after meal. His pain is relieved by taking some food
or milk. He also sometimes feels nausea, bloating & Blenching. What is most likely diagnosis?
A. Gastric ulcer C. Gastric carcinoma
B. Duodenal ulcer D. GERD
4. Most common cause of peptic ulcer:
A. NSAIDs C. Alcoholism
B. H. pylori D. Corticosteroids
5. A very common cause of watery diarrhea in infants:
A. Rota virus C. Shigella
B. E. coli D. Salmonella
6. Which organism causes rapid diarrhea because of preformed toxins?
A. Rota virus C. Shigella
B. E. coli D. Staphylococcus
7. What is the pathogenesis of Bacillary dysentery?
A. By reducing c-AMP in enterocytes C. Release of endotoxins
B. Direct invasion of git mucosa D. Release of exotoxins
8. Which of the following is NOT a causative agent for a peptic ulcer?
A. NSAIDs C. Physiological Stress
B. H. pylori D. Augmentin
9. A man just after landing on airport collapses. His colleague told that he had severe rice watery stool. What is the causative agent?
A. Rota virus C. Shigella
B. E. coli D. Vibrio cholera
10. Three friends after eating street food 4 hours back, present with complaint of diarrhea, vomiting & abdominal pain. What may be
the cause of this food poisoning?
A. Salmonella C. Shigella
B. Staphylococcus D. [Link]
11. Which of the following bacteria is most commonly associated with traveler's diarrhea?
A) E. coli C) Shigella
B) Salmonella D) Vibrio cholerae
12. What is the primary mechanism of pathogenesis of Vibrio cholerae in causing diarrhea?
A. Inflammation and tissue damage C. Adherence and colonization
B. Toxin production and secretion D. Invasion and intracellular multiplication
13. Which of the following bacteria produces a toxin that increases cAMP levels in intestinal cells, leading to diarrhea?
A. Vibrio cholerae C. Salmonella
B. Entamoeba histolytica D. Shigella
14. What is a protective mechanism that helps prevent gastric ulcers?
A. Increased gastric acid secretion C. Reduced prostaglandin production
B. Enhanced blood flow to the gastric mucosa D. Increased pepsin activation
15. A 45-year-old male patient presents with a history of epigastric pain and heartburn. Endoscopy reveals a gastric ulcer. The patient
has a history of NSAID use for chronic back pain. Which of the following protective factors is most likely compromised in this
patient, contributing to the development of the gastric ulcer?
A. Mucin production C. Gastric bicarbonate secretion
B. Prostaglandin E2 synthesis D. Blood flow to the gastric mucosa

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 95 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

16. Damage to the gastric mucosal barrier is a forerunner of a gastric ulcer. Which substance can both damage the gastric mucosal
barrier and stimulate gastric acid secretion?
A) Bile salts C) Gastrin
B) Epidermal growth factor D) H. pylori
17. From which part of stomach, biopsy should be taken for H. pylori associated gastritis?
A. Antrum C. Fundus
B. Cardia D. Body
18. Which of the following is a complication of Autoimmune gastritis?
A. Peptic ulcer C. MALToma
B. Atrophic gastritis D. Diabetes
19. What is the most common form of chronic gastritis?
A. [Link] induced gastritis C. Granulomatous gastritis
B. Autoimmune gastritis D. Eosinophilic gastritis
20. Common cause of antibiotic-associated diarrhea;
A. Clostridium difficili C. Salmonella
B. [Link] D. Staph aureus

ANSWER KEY
1. A 2. B 3. B 4. B 5. A 6. D 7. B 8. D 9. D 10. B
11. A 12. B 13. A 14. B 15. B 16. D 17. A 18. B 19. A 20. A

15. NSAIDs, like those used by the patient for chronic back pain, inhibit the enzyme cyclooxygenase (COX), which is necessary for
the production of prostaglandins, including Prostaglandin E2 & I2. Prostaglandin plays a crucial role in protecting the gastric mucosa
by:
 Stimulating mucus production
 Enhancing blood flow to the gastric mucosa
 Inhibiting gastric acid secretion
Reference: Big Robbins

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 96 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Ph001
GIT PHARMACOLOGY
Ph-001 ֍ANTI-DIARRHEAL DRUGS֍

Drug Mechanism Use against Side effects

Opioids (most effective) Reduce motility by acting on mu Non-specific diarrhea Mild abdominal cramp
o Loperamide opioid receptor in enteric nervous Constipation
system
o Diphenoxylate atropine CNS toxicity with
o Codeine diphenoxylate atropine

Kaolin + Pectin Absorbs bacterial toxins & fluid Diarrhea due to Little adverse effect
diverticular disease
Bismuth subsalicyclate Form protective coating on Traveler‘ diarrhea Black stools
ulcerated mucosa & absorbs toxins
Octreotide Somatostatin analogue that reduces Diarrhea due to carcinoid Hypo/Hyperglycemia
motility + secretions & VIP tumors
Note: No need to do Pharmacokinetics.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 97 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

֍ Practice & Past MCQs֍

1. Which of the following anti-diarrheal drugs works by decreasing the motility of the intestines?
A) Loperamide C) Kaolin
B) Bismuth subsalicylate D) Metronidazole
2. Which anti-diarrheal drug has antibacterial properties and is used to treat traveler's diarrhea?
A) Loperamide C) Kaolin
B) Bismuth subsalicylate D) Octreotide
3. What is the primary mechanism of action of loperamide?
A) Inhibition of intestinal secretion C) Inhibition of bacterial growth
B) Reduction of intestinal motility D) Absorption of toxins
4. Which of the following is a common adverse effect of loperamide?
A) Black tongue C) Abdominal pain
B) Diarrhea D) CNS toxicity
5. Which of the following anti-diarrheal drugs is a mu-opioid receptor agonist?
A) Loperamide C) Kaolin
B) Bismuth subsalicylate D) Diphenoxylate
6. Which anti-diarrheal drug is a non-opioid receptor agonist that reduces intestinal secretion and motility?
A) Loperamide C) Bismuth subsalicylate
B) Octreotide D) Kaolin
7. Which of the following is a common adverse effect of bismuth subsalicylate?
A) Black tongue C) Constipation
B) Black stools D) Diarrhea
8. On your way to an examination, you experience the vulnerable feeling that an attack of diarrhea is imminent. If you stopped at a
drugstore, which one of the following antidiarrheal drugs could you buy without a prescription even though it is related chemically to
the strong opioid analgesic meperidine?
A. Aluminum hydroxide C. Loperamide
B. Diphenoxylate D. Magnesium hydroxide
9. The most effective anti-diarrheal drugs are
A. Opioids C. Octreotide
B. Metronidazole (Flagyl) D. Ondansetron
10. Somatostatin analogue used to treat diarrhea related to VIP syndrome:
A. Opioids C. Octreotide
B. Metronidazole (Flagyl) D. Ondansetron
11. Which drug paralyze GIT nerve plexues, limit gastic motility and thus used in managing diarrhea?
A. Antimuscurinic (Atropine) C. Bismuth sulfate
B. Octreotide D. Parasympathomimemtic

ANSWER KEY
1. A 2. B 3. B 4. C 5. A 6. B 7. B 8. C 9. A 10. C
11. A

11. I have mentioned about Atropine in physiology section. It is used in combination with diphenoxylate for treating diarrhea

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 98 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Bs001-Bs005
GIT BEHAVIOURAL SCIENCES
Bs-001 ֍HEALTH RELATED BEHAVIORS֍

01. Eating & Additive Patterns

A. Eating Patterns
1. Bullemia Nervosa It is an eating disorder marked by binge eating i.e. out of control eating, followed by purging, such as
vomiting, taking laxative, and/or excessive activity to prevent the individual from gaining weight.
2. Anorexia Nervosa Anorexia nervosa (AN) is an eating disorder defined as an abnormally low body weight associated with
intense fear of gaining weight and distorted cognitions regarding weight, shape, and drive for thinness.
B. Addictive patterns
1. Drug dependance A psychic and physical state resulting from interaction between a living organism and a drug,
characterized by behavioral and other responses that always include a compulsion to take the drug on
continuous and periodic basis in order to experience its psychic effects and sometimes to avoid the
discomfort of its absence.
2. Drug Abuse The use of illegal drugs or the use of prescription or over-the-counter drugs for purposes other than those
for which they are meant to be used, or in excessive amounts.

02. Learning Principles

Operant Conditioning Learning new behaviors or changes in behaviors occur on the basis of the environmental conditions or
responses to it.
Shaping It involves rewarding closer and closer approximations of the wanted behavior until the correct behavior is achieved.
Modeling It is a type of observational learning. That is what occurs when a student talks, walks, dress and behave in a manner
similar to that of an inspiring teacher.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 99 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

Extinction It is a process in which conditioned response decreases when conditioned stimulus is never again paired with the
unconditioned stimulus.

03. Applications of Learning Principles

Eating Patterns
 Encourage individuals to keep a food diary to identify triggers for unhealthy eating and apply reinforcement techniques to
modify behavior.
 Gradually introduce healthier food options and reinforce their consumption through positive feedback and rewards.
Addictive Patterns
 Implement gradual exposure and desensitization techniques to reduce cravings and reliance on addictive substances or
behaviors.
 Provide support networks and resources for individuals seeking to overcome addictive patterns, utilizing principles of
reinforcement and modeling to promote success.

Bs-002 ֍HEALTH RELATED BELIEVES֍

01. Application of Health Belief Model in Managing GIT presentation

The HBM suggests that an individual's belief in a personal threat of a health problem, combined with their belief in the effectiveness
of a particular action, will influence their likelihood of taking that action to prevent or treat the health problem

Lets take an example of peptic ulcer

Perceived Susceptibility Patients with a family history of peptic ulcer disease may perceive themselves as susceptible to
developing peptic ulcer.
Perceived Severity Understanding the potential consequences of untreated peptic ulcer can help patients recognize the
severity of the condition
Perceived Benefits Patients may be more likely to adhere to lifestyle modifications (e.g., dietary changes) and
medications (e.g., proton pump inhibitors) if they believe these interventions will effectively manage
their symptoms and prevent complications.
Perceived Barriers Identifying barriers to adherence, such as the cost or side effects of medications, can help healthcare
providers address these concerns and provide alternative strategies

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 100 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

02. Transtheoretical Model of Chaninging Behavior to Modify Disease Pattern

Bs-003 ֍Management of Obesity by Motivational Interviewing֍

Motivational Interviewing (MI) is a goal-oriented, patient-centered approach to elicit and strengthen an individual's motivation.
It focuses on exploring and resolving ambivalence, rather than imposing advice or guidance.
Key principles of MI:
1. Express empathy and understanding
2. Develop a non-judgmental and supportive atmosphere
3. Explore and identify the individual's motivations and goals

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 101 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

4. Elicit and strengthen the individual's commitment to change

5. Roll with resistance, rather than opposing it
6. Support self-efficacy and confidence6. Support self-efficacy and confidence

Ask  Ask for permission to discuss body weight.

 Explore readiness for change
Assess  Assess BMI, waist circumference, and obesity stage.
 Explore drivers and complications of excess weight.
Advice  Advise the patient about the health risks of obesity, the benefits of modest weight loss (i.e., 5-10
percent), the need for long-term strategy, and treatment options.
Agree  Agree on realistic weight-loss expectations, targets, behavioral changes, and specific details of the
treatment plan.
Arrange/Assist  Assist in identifying and addressing barriers; provide resources; assist in finding and consulting with
appropriate providers; arrange regular follow-up.

Bs-004 ֍MEDICALLY UN-DESCRIBED SYPTOMS֍

01. MUS Symptoms

Medically Unexplained Symptoms (MUS) refer to physical symptoms that cannot be attributed to a specific medical condition or
disease, despite thorough medical evaluation and testing.
Characteristics of MUS:
1. Persistent and distressing symptoms
2. No clear medical explanation or diagnosis
3. Normal test results and physical examination
4. Significant impairment in daily functioning
5. Often accompanied by anxiety, depression, or other mental health concerns
Examples of MUS:
1. Chronic pain (e.g., fibromyalgia)
2. Fatigue (e.g., chronic fatigue syndrome)
3. Gastrointestinal issues (e.g., irritable bowel syndrome)
4. Neurological symptoms (e.g., headaches, numbness, or tingling)
5. Respiratory symptoms (e.g., chronic cough or shortness of breath)
Distinguishing MUS from other conditions:
1. Differentiate from Factitious disorder where symptoms are intentionally produced or feigned physical symptoms
2. Differentiate from somatic symptom disorder, where symptoms are exaggerated or feigned for attention or secondary gain.
3. Distinguish from psychological disorders, such as anxiety or depression, which may present with physical symptoms.
4. Consider cultural and social factors that may influence symptom presentation and interpretation
5.
02. Association of Psychological Factors

1. Psychological distress Psychosocial factors such as stress, anxiety, depression, and trauma are commonly
associated with MUS.
2. Cognitive factors Cognitive processes, including attention, perception, memory, and interpretation of bodily
sensations, play a significant role in the experience and manifestation of MUS.
3. Personality Traits Certain personality traits, such as neuroticism or alexithymia (difficulty in identifying and
expressing emotions), have been linked to MUS.
.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 102 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

4. Social & environmental factors Social and environmental factors, including adverse life events, interpersonal conflicts,
socioeconomic status, and cultural influences, can contribute to the onset and exacerbation
of MUS.
5. illness Beliefs and behaviors Beliefs about illness and health-seeking behaviors can influence the experience and
persistence of MUS. Factors such as illness attribution (e.g., believing symptoms are due to
a serious medical condition), illness behavior (e.g., frequent medical consultations), and
illness perceptions (e.g., perceived control over symptoms) can impact the course and
management of MUS.
6. Biopsychosocial Model The biopsychosocial model provides a comprehensive framework for understanding MUS
by considering the interplay between biological, psychological, and social factors.

03. Management plan according to Biopsychosocial Model

You have already studied Biopsychosocial model in first block.
1. Biological Avoid excessive investigations and medications
Give symptomatic management for symptoms (diarrhea, nausea/vomiting, and pain)
Give Antidepressants (SSRI) and Anti-psychotics (if required)
2. Psychological Counseling, CBT
3. Social Family support, educate family members regarding patient's condition

04. Role of Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) plays a vital role in managing Medically Unexplained Symptoms (MUS) by addressing
maladaptive thought patterns, promoting coping strategies, enhancing self-efficacy, and reducing symptom severity. It helps
individuals challenge distorted beliefs about their symptoms, develop effective coping skills, and improve overall well-being. CBT is
an evidence-based approach that empowers individuals to manage MUS by targeting both psychological and behavioral factors.

Bs-005 ֍NUTRITIONAL DEFICIENCIES & MENTAL DEVELOPEMENT֍

Minerals Effect of deficiency in mental development

A. Vitamins
B1 Reduced levels of brain GABA, glutamate and aspartate
B2 Impaired performance on psychomotor tests, neuromotor coordination and personality changes
B3 Loss of memory, nervousness, easy distractibility and schizophrenia
B6 Depression, irritability, loss of memory, inability to concentrate, peripheral neuritis
B12 Loss of memory, disorientation and emotional instability
B9 (Folic Acid) Memory loss, forgetfulness, depression, irritability, introversion, lack of confidence
C Reduced score for IQ, memory, abstract thinking and nonverbal intelligence, altered behavior
E Poor memory and attention span
B. Minerals
Iodine Poor somatic and central nervous system growth, sluggishness, inactivity, lethargy, poor concentration
Iron Listlessness, apathy, lack of vigor and enthusiasm, lower scores on motor development and cognitive tests
and poor school grades
Less myelinization and altered neurotransmitter function
Zinc Lethargy, decreased visual memory, impaired cognitive development, and neuropsychological problems
Selenium Depression, low mood, low energy level, anxiety and stress
Chloride Poor memory and mental functioning
DHA Short memory span, hostility, learning disability, dyslexia, attention deficit disorder

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 103 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

֍Practice & Past MCQs֍

1. Ahmad is trying to quit smoking cigarettes. Whenever he successfully goes a day without smoking, he treats himself to a movie
night with his favorite snacks. What principle of learning is Ahmad utilizing?
a. Negative reinforcement c. Active avoidance
b. Positive reinforcement d. Modeling
2. A patient of diabetes increased his time spend in exercise in order to reduce the number of insulin injections. The increased
exercising behavior is most likely result of:
a. Negative reinforcement c. Punishment
b. Positive reinforcement d. Modeling
3. Sarah is trying to overcome her addiction to online shopping. She decides to replace her shopping habit with reading and spending
time outdoors. Which principle of learning is Sarah utilizing?
a. Negative reinforcement c. Extinction
b. Positive reinforcement d. Modeling
4. A father scolds his son when he eats junk food. The son eventually stops eating junk food. This is an example of:
a. Negative reinforcement c. Punishment
b. Positive reinforcement d. Modeling
5. Farhan, a chain smoker happens to join a group of good boys. After some days he decided to quite smoking and other bad habits.
This is an example of:
a. Negative reinforcement c. Punishment
b. Positive reinforcement d. Modeling
6. Ayesha wants to encourage her children to eat more fruits and vegetables. She decides to offer them a small reward whenever they
finish their servings of fruits and vegetables. Which principle of learning is Ayesha applying?
a. Negative reinforcement c. Punishment
b. Positive reinforcement d. Modeling
7. Aleena wants to break her habit of eating sweets late at night. She decides to remove all sugary snacks from her kitchen cabinets.
What principle of learning is Aleena applying?
a. Negative reinforcement c. Punishment
b. Positive reinforcement d. Extinction
8. Which nutrient deficiency during pregnancy is associated with an increased risk of neural tube defects in the developing fetus?
a. Vitamin C c. Vitamin D
b. Folic acid d. Iron
9. A child presents with poor growth, delayed motor development, and impaired language skills. Which nutrient deficiency is most
likely to be the cause?
a. Vitamin A c. Vitamin D
b. Vitamin B6 d. Iron
10. What is the primary goal of motivational interviewing in the management of obese and diabetic patients?
a) To force patients into immediate behavior change c) To provide strict dietary and exercise guidelines
b) To explore and resolve ambivalence towards change d) To shame patients into adopting healthier habits
11. Which of the following is a key principle of motivational interviewing?
a) Providing unsolicited advice c) Rolling with resistance
b) Using confrontation to evoke change d) Assuming that the patient is ready to change
12. Which of the following statements best describes the spirit of motivational interviewing?
a) Coercing patients into compliance with medical advice c) Ignoring patient autonomy and preferences
b) Collaboration and partnership between the patient and d) Using scare tactics to motivate behavior change
healthcare provider
13. Usman presents with chronic fatigue and frequent headaches, but medical tests show no abnormalities. What term best describes
his symptoms?
a. Migraine c. Chronic illness
b. Iron deficiency anemia d. Medically unexplained symptoms
14. Fatima experiences recurrent abdominal pain and gastrointestinal discomfort. She recently went through a divorce and has been
feeling stressed. Which psychosocial factor might be contributing to her symptoms?
a. Anxiety c. Peptic ulcer disease
b. Depression d. Panic disorder

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 104 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

15. According to the Transtheoretical Model (TTM) of behavior change, which stage involves the individual being unaware or under-
aware of the need for change?
a. Preparation c. Precontemplation
b. Contemplation d. Action
16. According to the Transtheoretical Model (TTM), what does the term "self-efficacy" refer to?
a. The belief in one's ability to change a behavior c. The acknowledgment of needing to change a behavior
b. The readiness to change a behavior d. The action of changing a behavior
17. An over-weight lady was advised by a doctor to reduce her weight. Doctor told her that she was attractive but would be more
smart and attractive if she reduced her weight about 20 lbs. Which principle of health education was used by the doctor:
a. Interest c. Re-inforcement
b. Comprehension d. Motivation
18. A student has a terrible headache after an intense test preparation period. He takes two aspirin to make it go away. It is an example
of;
a. Modeling c. Negative Reinforcement
b. Rewarding d. Positive Reinforcement
19. Behavioural modification involves:
a) Solving problems through insight c) Demonstrating learning in the absence of reinforcement
b) Bringing behaviours under stimulus control d) Application of learning principles to change behaviour.
20. Negative reinforcement means:
a) To extinguish a behaviour. c) To eliminate desirable response
b) To increase desired response rate. d) To decrease the frequency of a behaviour
21. To teach your dog to roll over on command, which of the following techniques would you use?
a) shaping c) Lateral learning
b) modelling d) imprinting
22. A father scolds his son when he hits his little sister. The son stops hitting the sister. This change in the child‘s behaviour is a result
of:
a) punishment c) positive reinforcement
b) negative reinforcement d) shaping
23. Modelling:
a) Is a form of learning that occurs when two stimuli that are ―paired‖ –presented together – become associated with each other.
b) Is observational form of learning.
c) Occurs when a behaviour is determined by the consequences for the individual.
d) Refers to knowledge people have about their own thought processes.
24. Mr. Riaz is 50 years old and has never undergone colorectal cancer screening. He is unaware of the potential consequences of
untreated colorectal cancer and does not perceive himself as at risk. Which component of the Health Belief Model is Mr. Riaz
LACKING?
A. Perceived susceptibility C. Perceived susceptibility & severity
B. Perceived severity D. Perceived barrier
25. Self administration of drug for non medical reasons which may impair an individual' ability to function effectively and may result
in social, physical or emotional harm is known as
A. Drug abuse C. Drug habbit
B. Drug dependence D. Drug misuse
26. A 24-year-old girl presented in OPD with complaints of being overweight. She says that she lacks self-control and indulges in
overeating. After recurrent bouts of binge eating, she engages in self-induced vomiting. On general examination, she appears to be a
young girl with normal weight and vitals. What is the diagnosis?
A. Anorexia nervosa C. Generalized anxiety disorder
B. Bulimia nervosa D. Panic disorder
27. Most effective therapy for managing a patient with Bulimia Nervosa?
A. Desensitization technique C. Heavy exercise
B. Antidepressants D. Positive Reinforcement technique
28. In the management of psychiatric disorders it is good clinical practice to consider strategies with what framework?
A. Bio-psycho-holistic C. Medico-psycho-holistic
B. Bio-psycho-social D. Medico-psycho-social

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 105 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

ANSWER KEY
1. B 2. A 3. C 4. C 5. D 6. B 7. D 8. B 9. D 10. B
11. C 12. B 13. D 14. A 15. C 16. A 17. D 18. C 19. D 20. B
21. A 22. A 23. B 24. C 25. A 26. B 27. D 28. B

2. In active avoidance, a patient adopts a behavior to avoid noxious stimuls. In this scnerio, patient adopts exercise to decress insulin
injection. Active avoidance is a type of Negative reinforcement
3. Extinction involves reducing the frequency of a behavior by removing the reinforcement that previously followed it. In this case,
Sarah is trying to overcome her addiction to online shopping by replacing it with reading and spending time outdoors, which removes
the reinforcement (online shopping) associated with her previous behavior
18. The student takes aspirin to eliminate the headache (an unpleasant stimulus). When the headache goes away, the student feels
relieved. This is an example of negative reinforcement, where the removal of an unpleasant stimulus (headache) follows a behavior
(taking aspirin), increasing the likelihood of the behavior occurring again in the future
24. Patient is not considering himself susceptible to colorectal cancers. It means he is lacking perceived susceptibility. He is also
unaware of yhe consequences of untreated cancer. It means he is also lacking perceived severity
25. Drug dependence: A state in which an individual experiences withdrawal symptoms when the drug is stopped or reduced.
Drug habit: A pattern of regular drug use, which may not necessarily involve physical dependence or harm.
Drug misuse: A broader term that encompasses both drug abuse and other forms of inappropriate drug use, such as using
prescription medications for non-medical purposes. For example; A quack prescribed aspirin to a patient who was suffering from
peptic ulcer.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 106 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

CM 001 - 002
GIT COMMUNITY MEDICINE
CM-001 ֍EPIDEMIOLOGY OF INTESTINAL INFECTION֍

01. Prevention & Control of……..

Polio  Caused by polio virus & transmits via feco-oral oral

 It is motor neuron disease thus no sensory loss.
 It hase following types
o Abortive Polio  self limiting
o Non-paralytic polio  fever, sorethroat, headache
o Paralytic polio  above features + loss of reflexes + tripod sign (neck pain & stiffness)
 It can be prevented by Vaccination of a child
o Live Oral polio vaccine (4 doses) is given at birth, 6 th, 10th & 14th week of life
o Inactivated polio vaccine (3 doses) is given I/M at 14th week, 9th month & 20th – 23th month
Hepatitis A Vaccine & Immunoglobulins
Cholera Primary prevention
 Health promotion by health education, sanitary and personal hygiene
 Specific protection by immunization
Secondary prevention
 Early diagnosis
 Prompt treatment with
o Oral rehydration rehydration therapy for mild diarrhea
o I/V fluids for severe diarrhea
Typhoid  Caused by Salmonella bacteria
 Characterized by high grade fever (stepladder pattern), abdominal pain, red spots on abdomen, relative
bradycardia
Three lines of control
1. Control of reservoir Case -- early diagnosis, notification, isolation, treatment, disinfection
2. Control of Sanitation by health education, food hygiene and improved sanitation
3. Immunization
o Conjugate vaccine is given at 9th month of age I/M
Food Poisoning Food sanitation by Health education, Personal hygiene, Sanitary improvement, Food inspection, and Food
handling techniques Thorough cooking Milk pasteurization

1. For the last many years, Pakistan has been trying to eradicate polio without much success. Many cases of polio have been reported
from KPK, South Punjab, and a few from other provinces. Enlist the causes of resurgence of polio in Pakistan. [Supple 2019 held in
2020]
1. Misconceptions about polio vaccine
2. Poor routine EPI (expanded programme on immunization) schedule
3. Non availability of female worker
4. Cold chain boxes (to carry vaccine) not available / not maintained
5. Cultural issues
6. Political barriers

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 107 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. Pakistan is still having poliomyelitis. [Supple 2015 held in 2016]

a) What are the causes of failure in eradication of poliomyelitis in Pakistan?
Answer: See Q1
b) How can we achieve eradication of polio in near future?
We can achieve eradication of polio in near future by
1. Introduction of effective vaccine (bivalent polio vaccine)
2. Improvement in monitoring system
3. Development of comprehensive district specific plan
4. Intersectoral collaboration
5. Well function polio laboratory

3. A patient reported you in a Basic Health Centre with chills, high fever and headache along with abdominal pain. The fever was in
step-ladder fashion. On physical examination, there was relative bradycardia and abdominal tenderness. [Annual 2019]
a) What is the most likely diagnosis? (1)
Answer: Typhoid fever
b) The control of this disease is within the scope of public health. Explain three main lines of defense against this disease
especially vaccination, if available. (4)
See in table above

4. [Annual 2010]
a) What are the five „Fs‟ of feco-oral transmission of disease?
1. Food 2. Finger 3. Fomites 4. Flies 5. Faeces
b) Apply the above five to control typhoid (enteric fever) in a household.
1. Food – food hygiene, thorough cooking
2. Finger – proper hand washing
3. Fomites – proper cleansing/washing of subjects under normal use of life
4. Flies – control of flies by insecticides and covering of the food
5. Faeces – Proper waste disposal

5. Ten boys went to a hotel to celebrate their friend‘s birthday. They ate salad and burgers. Within four hours of meal, eight boys
develop severe vomiting and profuse diarrhea with mild fever and chills. [Annual 2009]
(a) Give the likely diagnosis.
Food Poisoning
(b) Which health promotive measures will you adopt regarding the above condition?
(1) Health Education:
 Educate the people to wash the foods & vegetables before eating them raw
 Educate the people about the importance of proper cooking of food (In context of prevention of Food borne diseases)
(2) Standards of Restaurants and Eating Places:
 Appropriate location
 Cleanliness and Hygiene
 Proper storage of cooked & uncooked Food stuff
 Appropriate disposal of the refuse
 Independent and pure water supply
 Washing facilities should be good
 Insect and rodents control measures should be applied
(3) Instructions about Food Handlers:
 Complete medical examination of Food handlers before employment
 Maintenance of personal hygiene e.g., Frequent hand washing , nailcutting, use of caps, gloves & facemasks
(4) Food Inspection by Health Professionals:
 Food safety & Security measures should be appropriately applied
 Collection of samples of food and proper laboratory examination
 Action should be taken at the spot if conditions are unhygienic & non-safe.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 108 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

02. Prevention & Control of……..

Amoebiasis  Causes bloody diarrhea (amoebic dysentery)

Ascaris  Ascariasis (round worm) causes intestinal obstruction
& Hookworm infestation  Ancylostoma duodenale) causes anemia

1. Soil transmitted helminth infections are most common infections worldwide. Over 270 million preschool children and over 600
million school-age children are in need of treatment and preventive interventions. [Annual 2017]
a) Enlist soil transmitted helminths. (1)
1. Ascaris (round worm)
2. Hook worm (Ancylostoma duodenale)
b) What is mode of transmission of hookworm? (2)
1. Transmitted by faeco-oral route
2. Ancylostoma enter body by penetrating feet skin
c) Write primary prevention of soil transmitted helminths? (2)
 Health education
 Good hygienic measures
 Sanitary improvement
 Proper disposal of Faeces i.e., Prevent fecal contamination of soil
 Interrupting transmission
 Provision of safe drinking water
 Wearing protective footwear

2. Worldwide infections with soil transmitted parasitic worm are among the most common infection. [Annual 2015]
a) Enumerate two species which most infect people in Pakistan. (1)
b) How they are transmitted? (2)
c) How can we control and prevent these infections? (2)
See Q1c

3. A patient reported to you complaints of abdominal discomfort, anorexia and chronic indigestion. On inquiry, he gave history of
passing segments of parasite during defecation. [Annual 2013]
a) What is the most probable diagnosis?
Answer: Soil transmitted Helminthic Infection
b) List at-least four measures against this parasite.
Answer: See Q1c

4. An 18-year-old farmer who works barefooted 10-12 hours on his field daily, complains of weakness, breathlessness on exertion and
diminished capacity for sustained hard work. On examination, he looks pale. [Annual 2009]
a) What is the diagnosis?
Answer: Helminthic infection (Hookworm)
b) How do you prevent and control this problem?
Answer: Q#1c

5. Parasitic infection occurs in persons with unhygienic habits. The commonest & most widespread worm infestation in all tropical
countries is transmitted feco-orally, common among children and affect the nutritional status, growth and often causing intestinal
obstruction. [Supple 2021 held in 2022]
a) Name the parasite?
Answer: Ascaris (round worm)

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 109 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

b) Enlist the factors responsible for this parasitic infestation?

1. Agent – Ascaris lumbricoides
2. Host – Children
3. Environment – Soil, Feces containing fertilized eggs, Optimum temp, Presence of moisture, Rainfall
c) How can we prevent and control this parasitic infestation?
 Health education
 Good hygienic measures
 Sanitary improvement
 Proper disposal of feaces i.e Prevent faecal contamination of soil
 Interupting transmission
 Provision of safe drinking water

CM-002 ֍PREVENTIVE MEDICINE IN PEDRIATRICS֍

01. Breastfeeding, Weaning & Childhood

Advice
Breastfeeding  Breastfeeding should be started soon after delivery
 There should not be any pre-lacteal feeding e.g. honey, water, and ghutti.
 No pacifier (rubber/plastic nipple) should be introduced
 Breast-feeding should be on demand
 The interval may be 1-4 hours
 Breast milk should be the only food in the first 4-6 months of child.
Weaning Definition of weaning: [Derived from the ancient word “Accustom” – means getting familiar]
“It is a gradual process during which child gets accustomed/familiar to food other than breast milk”.
Need of Weaning:
 As the child grows, his / her caloric requirement also increases
 So, breastfeeding alone cannot meet all the caloric requirements of the baby after 4–5 months
 That‘s why after 4 months up to 2 years, weaning is necessary for the optimal growth & development
of the baby and also for preventing Infections (diarrhea) and Malnutrition (Kwashiorkor &
Marasmus).
For the Purpose of weaning, the Following Foods can be used: Cow‘s Milk, Cereals, Bananas, Soft cooked
rice, Daliya, Juice, and Yogurt

Childhood  Breastfeed the Child properly

 Proper weaning of the child – Use cereals, banana, daliya, Juice and yogurt
 Proper distribution of food among the family members
 Immunization of the child should be complete
 For any bacterial / Parasitic infection, Consult the doctor & get appropriate treatment
 Maintain hygiene
 Environmental sanitation should be good
 If belong to poor socioeconomic status, use family planning measures to reduce the size of family

1. A mother visits MCH center to seek advice regarding feeding of her breast fed 6- month-old baby. She wants to know: [Supple
2011 held in 2012]
(a) What is weaning and why is it needed?
(b) What supplementary foods could be advised at his age?
See above

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 110 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. Give the advantages of breastfeeding. [Supple 2008 held in 2009]

Advantages of Description
Breast feeding
For Baby  Clean, safe, hygiene and cheap
 Meets complete requirements of the baby till 4–5 months
 Easily digestible
 Contains Anti-Microbial Factors e.g., IgA, IgG, Lysozyme, Lactoferrin
 Reduce risk of Allergy and Infant mortality
 Prevents development of neonatal Hypocalcemia
 Less chances of Malnutrition if Proper breast feeding is done
For Mother  Helps Child spacing by prolonging the period of infertility
 Promotes involution of uterus
 Prevents mastitis
 Decrease risk of breast cancer
 Formation of close relationship between mother & her child
 Psychological satisfaction to the mother

02. Protein Energy Malnutrition (PEM)

1. Mother took her child of 2 years in a hospital. She gave history of generalized muscle wasting and Loss of subcutaneous fat. There
was no sign of edema and weight was below 60% of WHO standard. The mother also told that she is very poor and has a large family
so she is unable to give enough protein and other nutrients to her child after 6 months of age.
a) Name the likely condition and gives its risk factors.
Marasmus
Causes/Risk factors
Main Etiological Factors  Nutritional Imbalance / Deficiency
 Bacterial / Parasitic Infection
 Non-Fulfilment of caloric requirements
 Deprivation of Child From Breast feeding
Contributory Etiological Factors  Erroneous weaning by the Ignorant Mother
 Early weaning due to 2nd pregnancy
 Poor environmental sanitation
 Wrong distribution of food among family members

b) What measures should be taken to overcome this problem in children?

Level of Prevention Interventions & Measures
Primary Health Promotion
 Health Education – Creation of Public awareness & Nutrition education
 Provision of adequate Food supplements to pregnant & Lactating mothers
 Promotion of Breast feeding
 Development of Low-cost Weaning Foods
 Family Planning
Specific Protection
 Prophylactic Supplementation of Fortified Foods
 Immunization of the child against major communicable diseases
 Balanced diet
Secondary Early Diagnosis & Prompt Treatment
 Periodic Surveillance
 Development of Programs for early Rehydration of dehydrated children
 Deworming of heavily infested children
 Early diagnosis of any Lag in growth

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 111 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. A mother reports to you with her two-year-old child with the complains of skin pigmentation and cracks and changes in hair color.
Examination showed weight slightly below the standard for age but it was marked by generalized body edema. [Supple 2011 held in
2012]
(a) What will be your probable diagnosis?
Kwashiorkor
(b) List at-least two common micronutrient deficiencies associated with PEM.
 Iron
 Fat soluble vitamins e.g., Vitamin A
 Iodine
 Zinc

3. The 2nd year MBBS class was assigned a task to visit a peri-urban area of a city ‗A‘ to assess the nutritional status of pre-school
children by applying anthropometric methods. Enumerate four socio-cultural factors affecting the nutritional status of these children.
[Supple 2017 held in 2018]
Socio-economic Factors:
 Poverty
 Lack of breast feeding
 Ignorance of Child Nutrition
 Poor health Education
 Lack of knowledge of nutritive value of various foods
 Poor sanitary environment
 Large family size
Cultural Factors:
 Food Habits
 Customs & Traditions
 Beliefs & Attitudes
 Religion
 Food Fads (personal likes & Dislikes regarding foods)
 Cooking practices

4. You are asked to assess the nutritional status of under-five children in your village with the objective to identify the prevalent
nutritional problems. [Annual 2014]
(a) Which anthropometric measurements are required to be done in this age group?
 Weight for age (wt/age)
 Height for age (ht/age)
 Skin Fold thickness
 Chest / Head circumference ratio
 Upper (Mid) Arm circumference
(b) How these measurements are used to determine the nutritional status?
Parameter “Description”
(1) Weight for age (wt/age) Wt/age Nutrtional status
<60% Severe (3rd degree) Malnutrition
60-74% Moderate (2rd degree) Malnutrition
75-89% Mild (1rd degree) Malnutrition
90-110% Normal
(2) Height for age (ht/age)  According to water-low‘s classification of PEM, if drop in Ht/Age is <90%, then
growth is said to be stunted
(3) Skin Fold thickness  Used to determine the Amount of body fat
(4) Chest / Head circumference  Useful to diagnose Protein Energy Malnutrition (PEM) in early child hood
ratio  Chest & head circumferences are Equal at about 6 months of age

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 112 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

 After this, head grows slowly while chest grows rapidly

(5) Upper (Mid) Arm  Useful to diagnose early Protein Energy Malnutrition when muscle mass is more
circumference reduced than body weight
Interpretation
Color of Tape Mid arm circumference (cm) Inference / Nutritional status
Red < 12.5 “Gross Undernutrition”
Yellow 12.5–13.5 “Mild Undernutrition”
Green > 13.5 “Good Nutrition”
.

(6) Serum Albumin  It is the best method for assessment of PEM. For example serum albumin < 3g/dl
indicates severe malnutrition
Note: wt/age is indicator of acute PEM while ht/age is indicator of chronic PEM

5. The 2nd year MBBS class was assigned a task to visit a peri-urban area of a city ‗A‘ to assess the nutritional status of pre-school
children by applying anthropometric methods. Name these methods of anthropometric assessment for this group. (5) [Supple 2017
held in 2018]
See Q4a

03. Balanced Diet for Obesity & Adults

Balanced diet A diet that contains variety of foods in such quantities and proportions that need for energy, amino acids, vitamins,
minerals, fats, carbohydrates, and other nutrients is adequately met for maintaining health, vitality and general well-being.

1. For development of a country, a healthy nation is pivot. To keep people healthy, nutritional and food policy formation is essential.
WHO has recommended various dietary goals (prudent diet). Write dietary goals.

Dietary Factor %age of total energy

Total Fat 25–35%
Saturated & Unsaturated fats  Saturated fats  <10% of total energy intake,
 Unsaturated oils should substitute for the
remaining fat requirements
Carbohydrates 45–65%
Proteins 10–35%
Dietary Fiber Up to 40g/day for adults

CM-003 ֍NUTRITION & HEALTH֍

01. Growth Chart for < 5 years children

It is a visual display of child‘s physical growth and development.
Features
1. On X-axis child‘s age in months, and on Y-axis weight in kg is mentioned.
2. There is a reference curve on growth chart for comparison (upper curve for boys and lower curve for girls)
3. Periodic weighting is plotted on chart and a curve is obtained which indicates child health.
On growth chart space is given for
1. Identification and registration of child
2. Immunization status of child
3. Immunization of mother against tetanus
4. Birth date and weight
5. Child health record
6. ORS preparation method is written in Urdu, so it is easier to understand by people
Uses of Growth Chart
1. Growth monitoring of child

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 113 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

2. Diagnostic tool for mortality, morbidity and health status

3. Planning and policy making by grading malnutrition
4. Mother can be educated regarding care of her child
5. It helps the health worker to determine type of intervention needed
6. It provides a good method to evaluate the effectiveness of corrective measures
7. Growth chart also gives information like Birth date and weight, Immunization of child, Immunization of mother is done or
not, Child health record

02. Prevention & Control of Vit A & D deficiency

1. A mother brought her 3 years old child at a medical center with the complaints of difficulty in walking and generalized weakness.
On physical examination, the child had curved legs, knock knees and slightly pigeon shaped chest.
a) What is the most likely diagnosis?
Rickets due to Vitamin D deficiency
b) Give appropriate measures for the prevention and control of this health problem in the community.
Level of Prevention Interventions & Measures
Primary Health Promotion
 Health Education – Educating the Parents to expose their children
regularly to sunshine
 Provision of adequate nutrition / Foods that are good source of Vitamin
D especially during early years of growth & development – e.g., Milk,
Butter, Fish oil & Eggs
 Daily Vit D requirement in is 200 IU
Specific Protection
 Periodic dosing (Prophylaxis) of young children with Vitamin D
 Vitamin D Fortification of the foods e.g., Milk.
Secondary Early Diagnosis & Prompt Treatment
 With orally supplemented Vitamin D supplements

1. A mother brings her 2-year-old child to Paediatric OPD with complaints of inability to see in the evening & having dry eyes,
wrinkly eyes. He was diagnosed as a case of vitamin A deficiency.
a) Write down the ocular manifestations of vitamin A deficiency?
1. Night blindness
2. Xerophthalmia
3. Bitot spot
4. Keratomalacia
b) How would you treat this child?
Vitamin A supplement (Red capsule containing 2 Lac units)
c) Enumerate ways to prevent this deficiency in the population?
1. Health promotion by
o Nutritional education  consumption of vitamin A-rich foods such as liver, eggs, dairy products, and colorful fruits
and vegetables)
o Supplementation programs  targeting high-risk groups like pregnant women and children in regions with known
deficiency
o Promotion of breastfeeding to ensure infants receive adequate vitamin A.
2. Specific protection
o Fortification of staple foods with vitamin A, such as fortified milk and cooking oils
o Implementation of public health interventions such as vitamin A supplementation campaigns and nutrition education
programs
3. Early detection and treatment of conditions that impair vitamin A absorption or utilization

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 114 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

֍Practice & Past MCQs֍

1. Which of the following is a correct daily requirement of dietary fiber?

a. 20 g c. 40 g
b. 30 g d. 50 g
2. Which of the following is recommended daily requirement of Vitamin D?
a. 100 IU c. 300IU
b. 200 IU d. 400IU
3. Which of the following is Most sensitive/early indicator of growth?
a. Weight for age c. Height for age
b. Weight for height d. All of he above
4. What is the primary tool for protection against hepatitis A & Polio?
a. Face mask c. Avoiding raw milk
b. Vaccination d. Safe water & proper hygiene
5. What is a common mode of transmission for hookworm?
a. Contaminated water c. Ingesting contaminated food
b. Skin contact with contaminated soil d. Direct contact with an infected person
6. What is the primary mode of transmission for amoebiasis?
a. Contaminated food and water c. Vector-borne (mosquitoes)
b. Direct contact with an infected person d. Airborne
7. What is the primary purpose of a growth chart for children under 5?
a. To track weight gain only c. To assess overall growth and development
b. To monitor height/length only d. To diagnose specific health conditions
8. Which group is most vulnerable to PEM?
a. Children under 5 years c. Elderly individuals
b. Pregnant women d. Adolescents
9. What is the recommended duration for exclusive breastfeeding to prevent PEM?
a. 3 months c. 12 months
b. 6 months d 24 months
10. What is the most effective way to prevent PEM?
a. Vitamin supplementation b. Nutrition education
c. Immunizations d. Exclusive breastfeeding and appropriate complementary
feeding
11. Amoebic dysentery is due to:
a. Contact transmission of the causative agent c. Respiratory transmission of the causative agent
b. Faeco-oral transmission of the causative agent d. Sexual transmission of the causative agent
12. The most effective personal hygiene measure for prevention
a. Daily bathing c. Repeated hand washing
b. Wearing appropriate footwear d. Use of hander-chief when sneezing
13. Which diseases can be prevented by vaccination?
a. Polio & Cholera c. Ascariasis & Typhoid
b. Ascariasis & AIDS d. Cholera & Malaria
14. Daily milk secretion is
a. 450 ml c. 1000 ml
b. 250 ml d. 750 ml
15. Princple of growth chart:
a. weight for age c. height for age
b. weight for height d. height for weight
16. The nutrients often called as "proximate principles" include the following: [Annual 2023 4th year]
a) Carbohydrates c) Dietary fibers
b) Riboflavin d) Thiamine
17. A mother has brought her 5 years old girl to BHU with complaints of poor appetite and diarrhea off and on. She has failure to
thrive. On examination she is irritable, moaning and apathetic. She has low weight for her height. There is edema both legs and skin is

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 115 ]
 nd
CHAPTER 2 © 2 edition MODULE 6: GIT & NUTRITION

dry and her hair are sparse and brittle. Her serum albumin is less than 3gm/dl of blood. The most likely diagnosis is: [Annual 2023 4th
year]
a) Cretinism c) Kwashiorkor
b) Growth retardation d) Marasmus
18. Which of the following is the best measure to detect PEM?
a) Serum albumin c) Weight for age
b) mid-arm circumference d) Height for age
19. Among patients who require nutritional resuscitation in an intensive care unit, the best evidence that nutritional support is adequate
a. Urinary nitrogen excretion levels c. Serum albumin level
b. Total serum protein level d. Serum transferrin levels
20. During nutritional assessment of a surgical patient, the status of muscle of muscle protein is indicated by which one of the
following parameters:
a. Serum albumin c. Mid-arm circumference
b. Triceps skinfold thickness d. Hb level
21. Which of the following is not a feature of poliomyelitis?
a. Sensory loss c. neck stiffness
b. motor loss d. muscle weakness
22. A health career visited a home for Polio vaccine. A newborm was born 6 weeks back. By which route polio vaccine would be
given?
a. Oral c. Intramuscular
b. Intravenous d. Intradermal

ANSWER KEY
1. C 2. B 3. A 4. B 5. B 6. A 7. C 8. A 9. B 10. D
11. B 12. C 13. A 14. A 15. A 16. A 17. C 18. A 19. C 20. C
21. A 22. A

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 116 ]
 nd
CHAPTER 2 © 2 edition BLOCK-4: MODULE 6: GIT & NUTRITION

001
GIT AGING
001 ֍PREVENTIVE MEDICINE IN GERIATICS֍

01. Causes & Risk factors for Malnutrition

1. Poor Appetite
2. Chronic Illnesses
3. Physical and Mental Health Issues (Mobility limitations, depression, dementia, and cognitive decline can impact the ability to
shop for groceries, prepare meals, and eat independently.)
4. Social Isolation (it may reduce motivation to cook and eat nutritious meals.)
5. Financial Constraints
6. Polypharmacy (Taking multiple medications can interfere with nutrient absorption and cause side effects like nausea,
vomiting, or loss of appetite.)
7. Functional Decline (Difficulty swallowing (dysphagia) or chewing due to oral health problems can affect food intake.)

02. Management of Malnutrition

1. Nutritional Assessment
2. Dietary Counseling
3. Oral Health Care (Address dental problems and provide assistance with denture care to improve chewing ability and food
intake.)
4. Meal Assistance (Offer assistance with meal preparation, grocery shopping, and feeding if needed.)
5. Nutritional Supplements
6. Multidisciplinary Approach (Involve a multidisciplinary team including dietitians, physicians, nurses, occupational
therapists, and social workers to address medical, functional, and psychosocial factors contributing to malnutrition.)
7. Social Support
8. Monitor and Evaluate nutritional status and dietary intake, and adjust the management plan as needed to achieve and
maintain optimal nutritional status.

DR. ABDUL MANAN, DR. AAYBAAD AHMAD & DR. GHULAM DASTGEER
[ 117 ]