28-30 GI Hormones, Esophagus, Stomach Flashcards
1
Q
What are the 2 target cells of Gastrin?
A
parietal cells and chief cells
2
Q
What 3 things are increased as a result of Gastrin?
A
HCI, intrinsic factor and pepsinogen
3
Q
Somatostatin is produced by what cells and where?
A
D cells in the antrum
4
Q
What stimulates the secretion of somatostatin?
A
acid in duodenum
5
Q
What is somatostatin also called?
A
the great inhibitor
6
Q
What drug can be used to decrease pancreatic fistula output?
A
octreotide
7
Q
What cells produce gastric inhibitory peptide and where?
A
K cells in duodenum
8
Q
What are the 2 target cells of gastric inhibitory peptide? and response stimulated?
A
parietal cells of stomach and beta cells of pancreas
decreases HCl secretion and pepsin; increases insulin release
9
Q
What cells produce CCK and where?
A
I cells of duodenum and jejunum
10
Q
What cells produce secretin and where?
A
S cells in duodenum
11
Q
What is the response caused by secretion of secretin?
A
increased pancreatic HCO3-, increased bile flow, inhibits gastrin release (this is reversed in pts with gastrinoma)
12
Q
What cells in the pancreas release insulin? and glucagon?
A
beta cells, alpha cells
13
Q
What cells produce pancreatic polypeptide? and what is the response?
A
islet cells in pancreas
decreases pancreatic and gallbladder secretion
14
Q
Released from terminal ileum following a fatty meal → inhibits acid secretion and stomach contraction; inhibits gallbladder contraction and pancreatic secretion
A
Peptide YY
15
Q
What is the time from for recovery of small bowel? stomach? large bowel?
A
Small bowel 24 hours
Stomach 48 hours
Large bowel 3–5 days
16
Q
What are the layers of the esophagus?
A
stratified squamous epithelium (mucosa), circular inner muscle layer, outer longitudinal muscle layer; no serosa
17
Q
What is the blood supply of the cervical esophagus? and abdominal esophagus?
A
Cervical esophagus – supplied by the inferior thyroid artery
Abdominal esophagus – supplied by the left gastric artery and inferior phrenic arteries
18
Q
Which direction does the lymphatics of the esophagus drain?
A
upper 2/3 drains cephalad, lower 1/3 caudad
19
Q
What kind of muscle is in the upper esophagus? lower esophagus?
A
striated muscle, smooth muscle
20
Q
Right vagus nerve – travels on ____ portion of stomach as it exits chest; becomes ____ plexus; also has the criminal nerve of ___ → can cause persistently high acid levels postoperatively if left undivided
A
posterior, celiac, Grassi
21
Q
Left vagus nerve – travels on ____ portion of stomach; goes to liver and biliary tree
A
anterior
22
Q
The upper esophageal sphincter is how far from the incisors? and lower?
A
15 cm, 40 cm
23
Q
What is the most common site of esophageal perforation (usually occurs with EGD)?
A
cricopharyngeus muscle
24
Q
What muscle comprises the upper esophageal sphincter and prevents air swallowing?
A
cricopharyngeus muscle
25
What are the 3 anatomic areas of narrowing of the esophagus?
cricopharyngeus muscle,
compression by the left mainstem bronchus and aortic arch,
diaphragm
26
What is the surgical approach to the cervical esophagus? upper 2/3 thoracic? Lower 1/3 thoracic?
Cervical esophagus – left
Upper ⅔ thoracic – right (avoids the aorta)
Lower ⅓ thoracic – left (left-sided course in this region)
27
What is the cause in primary esophageal dysfunction? secondary?
unknown in primary
secondary includes systemic disease, gastroesophageal reflux disease (GERD; most common), scleroderma, polymyositis
28
What is the diagnostic procedure of choice for dysphagia and odynophagia?
barium swallow (better at picking up masses)
29
What is the usual cause of cervical esophageal dysphagia?
plummer-vinson syndrome
30
What is the 3 parts of tx for plummer-vinson syndrome?
dilation, Fe, screen for oral CA
31
What can occur between the cripharyngeus and pharyngeal constrictors?
Zenker's diverticulum
32
What is the tx for Zenker's diverticulum?
cricopharyngeal myotomy; Zenker's itself can either be resected or suspended
33
What do you get on POD #1 after a cricopharyngeal myotomy for Zenker's?
esophagogram
34
How is a traction diverticulum different from Zenker's?
Zenker's is a false diverticulum and lies posterior; traction is a true diverticulum is usually lateral in the mid esophagus
35
What is the tx for a traction diverticulum of the esophagus?
excision and primary closure; may need palliative therapy if due to invasive CA
36
What is caused by failure of peristalsis and lack of LES relaxation after food bolus, and is secondary to neuronal degeneration in muscle wall?
Achalasia
37
What is the medical tx for achalasia (2)? what is next step?
CCB, nitrates
LES dilation (effective in 60%)
38
What is the next step in tx of achalasia if CCB, nitrates and LES dilation fail?
Heller myotomy
39
What infection can produce similar sx to achalasia?
T. cruzi
40
Chest pain; other sx similar to achalasia. May have psych history, normal LES tone, strong unorganized contractions.
Diffuse esophageal spasm
41
What are 4 types of tx for diffuse esophageal spasm?
CCB, nitrates, antispasmotics, Heller myotomy
42
Causes dysphagia, loss of LES tone; most have strictures, fibrous replacement of smooth muscle ■ Tx: esophagectomy; Nissen may be effective in some
Scleroderma
43
GERD sx with bloating suggests what?
aerophagia and delayed gastric emptying
44
What is the best test for GERD?
pH probe
45
What is the surgical tx for GERD?
Nissen
46
The key maneuver in Nissen is identifcation of what?
left crura
47
What is name of the approach through the chest in a Nissen?
Belsey
48
During a Nissen, when not enough esophagus exists to pull down into abdomen, can staple along stomach and create a “new” esophagus. What is this called?
Collis gastroplasty
49
Name the type of hiatal hernia:
Sliding hernia from dilation of hiatus (most common); often associated with GERD
Type I
50
Name the type of hiatal hernia:
Paraesophageal; hole in the diaphragm alongside esophagus, normal GE junction.
Type II
51
What is a Type III hiatal hernia? and type IV?
Type III – combined ■ Type IV – entire stomach in the chest plus another organ (i.e., colon, spleen)
52
Almost all pts with Schatzki's ring have an associated ___
sliding hiatal hernia
53
What is the tx for Schatzki's ring?
dilatation of the ring usually sufficient; may need antireflux procedure
54
What is the transformation in pts with Barrett's esophagus?
squamous metaplasia to columnar epithilium
55
Pts with Barrett's esophagus are at 50x increased risk for what?
adenomcarcinoma
56
Severe Barrett's dysplasia is an indication for what?
esophagectomy
57
Uncomplicated Barrett's can be treated like GERD with PPI or Nissen and surgery will decrease esphagitis and further metaplasia but it will not prevent what?
malignancy or cause regression of the columnar lining
58
Pts with Barrett's esophagus who get a Nissen still need careful lifetime follow up with what?
EGD
59
Esophageal tumors are almost always malignant. How does it spread?
submucosal lymphatic channels
60
What is the best test for unresctablity in esophageal CA?
Chest/abdominal CT
61
What is the #1 esophageal CA? What type occurs most often in the upper 2/3?
Adenocarcinoma
Squamous cell carcinoma
62
Supraclavicular nodes in esophageal CA indicate what?
unresectability
63
Distant metastases with esophageal CA is a contraindication to what? what is the survival?
esophagectomy, < 12 mos
64
What is the mortality from surgery in esophagectomy for CA? and what percentage is it curative?
5%, 20%
65
What is the primary blood supply to stomach after replacing esophagus in esphagectomy?
right gastroepiploic artery (have to divide left gastric and short gastrics)
66
What is the name of the type of esophagectomy with an abdominal incision and right thoracotomy -> exposes all of the esophagus; intrathoracic anasomsis
Ivor Lewis
67
What type of esophagectomy may be choice in young pts with benign disease when you want to preserve gastric function.
Colonic interposition
68
What do you need after esophagectomy on post op day 7?
contrast study to rule out leak
69
Name two chemo agents that can be used with esophageal CA for node positive disease or use preop to shrink tumors?
5FU and cisplatin
70
In esophageal CA with malignant fistulas, most die within 3 months due to what?
aspiration
71
What is the most common benign tumor of the esophagus?
Leiomyoma
72
Diagnosis of Leiomyoma is esophogram, endoscopy to rule out CA. Why don't you bx?
can form scar and make subsequent resection difficult
73
Tx for Leiomyoma of the esophagus is excision via thoractomy. What are the 2 indications?
>5 cm or sx
74
Caustic esophageal injury:
NG tube?
Induce vomiting?
Irrigation?
no, no, no
75
What is first step in dx in caustic esophageal injury? then what?
CXR and AXR to look for free air,
endoscopy to assess lesion (but not with suspected perforation)
76
What is the most common cause of esophageal perforation?
EGD
77
What is the most common site of esophageal perforation?
cricopharyngeus muscle
78
How to dx esophageal perforation?
gastrograffin swallow followed by barium swallow
79
What is the tx for esophageal perforation that is contained, self-draining and no systemic effects?
Conservative: IVF, NPO, spit
80
What type of flap can be used with repair of esophageal perforation to help the area heal?
intercostal muscle pedicle flap
81
What is Hartmann's sign?
mediastinal crunching on ascultation
82
How to dx Boerhaave's syndrome?
gastrofrafin swallow
83
What is the stomach transit time?
3-4 hours
84
Where does peristalsis occur in the stomach?
only in the distal stomach
85
What are the branches of the Celiac trunk?
left gastric, common hepatic, splenic
86
Left gastroepiploic and short gastrics are branches of what artery?
splenic
87
What is the blood supply of the greater curvature of the stomach?
right and left gastroepiploics, short gastrics
88
What is the blood supply of the lesser curvature of the stomach?
right and left gastrics
89
The right gastric is a branch of what artery?
common hepatic
90
What is the blood supply of the pylorus?
gastroduodenal artery
91
What is the mucosa of the stomach lined with?
simple columnar epithelium
92
What is the first enzyme in proteolysis and what cell secretes it?
Pepsinogen, secreted by chief cells
93
What do the parietal cells secrete?
H+ and intrinsic factor
94
What 2 things do Brunner's glands in the duodenum secrete?
pepsinogen and alkaline mucus
95
Antrectomy with gastroduodenal anastomosis?
Billroth I
96
Antrectomy with gastrojejunal anastomosis?
Billroth II
97
____ ulcer is a vascular malformation in the stomach
Dieulafoy's
98
____ disease is mucous cell hyperplasia, increased rugal folds of the stomach.
Menetrier's
99
What is the tx for gastric volvulus?
reductiona and Nissen
100
Associated with type II (paraesophageal) hernia ■ Nausea without vomiting; severe pain.
Gastric volvulus
101
Where is the tear usually located in a Mallory-Weiss tear?
near lesser curvature of the stomach near GE junction
102
What is the result of a vagotomy
vagal denervation all forms increase liquid emptying -> vagally mediated receptive relaxation is removed, results in increased gastric pressure that accelerates liquid emptying
103
In complete vagotomy (truncal or selective) there is decreased emptying of solids. In highly selective vagotomy there is normal emptying of solids. Addition of what procedure to either results in increased solid emptying?
Pyloroplasty
104
What is the most common problem following vagotomy (30-50%)?
diarrhea
105
Upper GI bleed and having trouble localizing source with EGD. What can be done next?
tagged RBC scan
106
What is the biggest risk factor for rebleeding of an upper GI bleed at the time of EGD?
spurting blood vessel
107
In a pt with liver failure, what is the most likely source of an upper GI bleed?
esophageal varices
108
What is the tx for a bleeding esophageal varices?
EGD with sclerotherapy or TIPS, not OR
109
What location of duodenal ulcers usually perforate? what location bleed from GDA?
anterior ulcers perforate, posterior ulcers bleed from GDA
110
Describe the incision and closure of a Heineke-Mikulicz pyloroplasty.
longitudunal incision of the plyloric sphincter followed by a transverse closure
111
What is the most frequent complication of duodenal ulcers?
bleeding
112
The 1st surgical option for bleeding duodenal ulcer is duodenstomy and what? what if the pt has been on PPI therapy?
GDA ligation,
truncal vagotomy and pyloroplasty
113
With GDA ligation for bleeding duodenal ulcer, it is important to avoid hitting what structure?
common bile duct
114
What is the initial treatment of choice for obstruction due to duodenal ulcer?
serial dilation
115
Pt on H-pump inhibitor develops a perforated duodenal ulcer. What is the best surgical option? what if they were not on H-pump inhibitor?
Graham patch and highly selective vagotomy; just do Graham patch and place on omeprazole
116
What is the test for Zollinger-Ellison Syndrome?
Secretin test results in high gastrin level
117
In Zollinger-Ellison syndrome, what size tumors can be enucleated?
<2 cm
118
What is the most common location for gastric ulcers? and the most common cause?
lesser curvature; decreased mucosal defense (normal acid secretion)
119
Hemorrhage is associated with higher mortality in duodenal or gastric ulcers?
gastric
120
What location in the stomach is the bx for H. pylori taken?
antrum
121
List the locations of gastric ulcers types I-V
Type I - lesser curve along body of stomach
Type II - 2 ulcers, lesser curve and duodenal
Type III - prepyloric
Type IV - lesser curve high along cardia of stomach
Type V - associated with NSAIDs
122
What is the timing after event for stress gastritis?
3-10 days after event
123
Chronic gastritis has types A and B what is their location and what are they associated with?
```
Type A (fundus) – associated with pernicious anemia, autoimmune disease
Type B (antral) – associated with H. pylori
```
124
Where are 40% of gastric cancers located?
antrum
125
What is the difference in the pain with gastric cancer vs gastric ulcer?
gastric ulcer pain is relived by eating but recurs 30 min later.
126
What blood type is a risk factor for gastric cancer?
type A
127
What is Krukenberg tumor?
gastric cancer with mets to ovaries
128
What is Virchow's nodes?
gastric cancer with metastases to supraclavicular nodes
129
What size margins in subtotal gastrectomy for gastric cancer?
5 cm
130
What is diffuse gastric cancer called?
linitis plastica
131
What is the surgical tx for linitis plastica?
total gastrectomy
132
In palliation for gastric cancer, proximal obstruction can be treated with what? and distal?
proximal can be stented, distal lesions can be bypassed with gastrojejunostomy
133
What is the most common benign gastric neoplasm? aka?
gastric leiomyomas, also called gist tumors
134
What is the chemotherapy agent and MOA for gastric leiomyomas?
Gleevec (tyrosine kinase inhibitor)
135
What is the proto-oncogene are most gastric leiomyomas positive for?
c-kit (CD117)
136
What route does gastric leiomyosarcoma spread?
hematogenous
137
What is the tx for mucosa associated lymphoid tissue lymphoma (MALT lymphoma)? and if it does not regress?
Triple therapy abx for H. pylori; CHOP
138
What are the surgical eligibility criteria for bariatric surgery?
BMI >40 kg or BMI >35 kg with coexisting comorbiditiies
139
What is the medical and surgical tx for dumping syndrome?
octreotide may be effective. Surgery is rarely needed but includes converting a billroth I or II to a roux-en-Y gastrojejunostomy. Or increasing the gastric reserve with a jejunal pouch or increasing emptying type with a reversed jejunal loop
140
What is the dietary tx for dumping syndrome?
small, low-fat, low-carb, increased-protein meals; no liquids with meals; no lying down after meals
141
What are two surgical options for treating dumping syndrome after gastrectomy?
conversion of billroth I or billroth II to Roux-en-Y gastrojejunostomy
Operations to increase gastric reservoir (jejunal pouch) or increase emptying time (reversed jejunal loop)
142
After a gastrectomy there is postprandial epigastric pain associated with N/V; pain not relived with vomiting. Evidence of bile reflux into stomach and histologic evidence of gastritis. Dx?
Alkaline reflux gastritis
143
What are 3 medical options for the tx of alkaline reflux gastritis after gastrectomy?
H2 blockers, cholestyramine, metoclopramide
144
What is the surgical option for treating alkaline reflux gastritis after gastrectomy?
Conversion of Billroth I or Billroth II to Roux-en-Y gastrojejunostomy with afferent limb 60 cm distal to original gastrojejunostomy
145
In roux-en-y which limb is the roux limb? Which is the afferent limb?
The roux limb goes from the gastrojejunostomy to the jejunojenuostomy. The afferent limb is the portion of duodenum and jejunum feeding the jejunojenunostomy.
146
What is the cause of roux stasis?
stasis of chyme in Roux limb due to loss of jejunal motility.
147
How do you dx Roux stasis?
EGD, emptying studies
148
What are 2 treatment options for Roux stasis?
metoclopramide/prokinetics
shorten Roux limb to 40 cm
149
What is caused by delayed gastric emptying after vagotomy?
chronic gastric atony
150
What is the surgical treatment for chronic gastric atony after gastrecomy?
near total gastrectomy with Roux-en-Y
151
What is the surgical option for small gastric remnant and early satiety after gastrectomy?
jejunal pouch reconstruction
152
After Billroth II or Roux-en-Y, symptoms include pain, diarrhea, malabsorption, B12 deficiency, steatorrhea. Caused by bacterial overgrowth and stasis in affarent limb.
Blind-loop syndrome
153
What is the medical and surgical treatment options for blind-loop syndrome?
tetracycline, Flagyl, metoclopramide
reanastomosis with shorter (40 cm) afferent limb
154
Whiteout on CXR:
Midline shift toward whiteout is most likely collapse. Needs what tx?
No shift - do CT to figure it out
Midline shift away from whiteout likely effusion. Needs what tx?
collapse needs bronchoscopy to remove plug
effusion needs chest tube
155
Bronchiectasis is acquired from infection, tumor or what other condition?
cystic fibrosis
156
Noncaseating granulomas are seen in what lung condition?
sarcoidosis
157
What is the pleural fluid protein to serum ratio seen in an exudate? and the pleural fluid LDH to serum ratio seen in exudate?
> 0.5
> 0.6
158
Recurrent pleural effusions can be treated with what?
mechanical pleurodesis (talc pleurodesis for malignant pleural effusions)
159
Airway fires are usually associated with the laser. What is the tx?
stop gas flow, remove ET tube, reintubate for 24 hrs; bronchoscopy
160
AVMs, connections between the pulmonary arteries and pulmonary veins; usually occurs in the lower lobes and in pts with what disease?
Osler-Weber-Rendu disease
161
What is the tx for AVMs in the lung?
embolization
162
What is the most common benign chest wall tumor? and malignant?
benign - osteochondroma
| malignant - chondrosarcoma
