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Senior - Surgery 1 > 5 - Esophagus Stomach SB > Flashcards

5 - Esophagus Stomach SB Flashcards

1
Q

MC patient populations for swallowed foreign bodies:

A

Kids (80% of cases)
Prisoners
Psych patients
Edentulous adults

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2
Q

Workup for swallowed FB:

A

Head and neck films

If object radiolucent, CT or MRI

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3
Q

If FB is able to clear the esophagus:

A

May observe if asymptomatic

Most FB’s will pass through GI tract

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4
Q

Which objects should be removed?

A

Batteries, magnets, sharp objects

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5
Q

Concerning signs with FBO:

A 
Stridor
Dysphagia
Odynophagia
Drooling
Perforation -> SubQ emphysema
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6
Q

2 common sites of obstruction:

A

Cricopharyngeus muscle (drains into right chest)

GE junction (drains into left chest)

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7
Q

Txt for FBO:

A

If lodged in esophagus, get it out endoscopically

Less than one percent require surgical removal

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8
Q

Causes of esophageal perforation?

A

Instrumentation (NG/ET tubes)

Swallowed foreign body

Penetrating neck trauma

Esophageal CA

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9
Q

Boerhaave’s syndrome

A

Full thickness tear of esophageal mucosa

Normally in left posterior esophagus

Rapidly progresses to septic shock

MC in alcoholics (vomiting)

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10
Q

Txt for esophageal perforation

A

Txt the septic shock

Fluids

IV ABX

Thoracostomy

NPO but avoid NGT suctioning

High mortality rate if delayed dx / tx

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11
Q

Mallory-Weiss tear

A

Partial erosion of the esophageal mucosa

2/2 vomiting and increased ABD pressure

Think: hiatal hernia, EtOH abuse

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12
Q

Mallory-Weiss tear txt

A

Most resolve spontaneously

Or

Use the EGD to:
Inject epinephrine
Electrocoagulation
Hemoclips
Band ligation
Then PPI
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13
Q

If battery acid or toilet bowl cleaner ingested, causes:

A

Coagulation necrosis injuries (less likely to perforate)

Upper airway injuries 2/2 aspiration

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14
Q

Drain cleaners, oven cleaners (alkali) causes:

A

Liquifaction necrosis (more likely to perforate)

Worse injury to throat versus stomach

Bleach is MC cause

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15
Q

Management of corrosive esophagitis

A

Fluids, supportive care

Find the MSDS for the substance involved (or call poison control for info)

Consult GI

Do NOT induce emesis, blindly neutralize chemical or insert NG tube

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16
Q

Acute complications of corrosive esophagitis

A

Transdermal burns -> surgery

Delayed perforation - normally within 7 days

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17
Q

Later complications of corrosive esophagitis

A

Esophageal stricture - serial dilations

Dysplasia

Esophageal CA

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18
Q

Risk factors for esophageal squamous cell carcinoma

A

50 - 70 yrs old

Male

EtOH

Tobacco

Hot drinks

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19
Q

Risk factors for esophageal adenocarcinoma

A

Male

Associated with Barrets, GERD, obesity, tobacco

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20
Q

Cure rate for esophageal CA?

A

Shitty - usually dx’d late stage

15% cure rate

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21
Q

Esophageal CA - Dx

A 
Barium swallow
EGD (Bx mass)
Bronchoscopy
CT chest/ABD
Thoracoscopy (hunting for mets)
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22
Q

Txt of esophageal CA

A

Advanced dz - palliative

Chemo
Rads
Stent (not cardiac - esophageal, to enable swallowing)

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23
Q

GERD tx flow overview

A

GERD sxs - use daily PPI

No response, try BID PPI

No response: esophagography, upper endoscopy, pH study, esophageal manometry

Possible surgical intervention last

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24
Q

MC type of hiatal hernia?

A

Sliding (Type 1)

GE junction rises above diaphragmatic hiatus

May be associated with acid reflux (up to 80% of patients with symptomatic GERD)

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25
Q

Describe para-esophageal hernias:

A

Types II through IV

Much less common

Increased risk for incarceration and strangulation

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26
Q

Presentation of hiatal hernia?

A

Early satiety
Epigastric pain
May or may not have acid reflux-GERD

27
Q

Workup for hiatal hernia?

A

CXR may show air fluid level in chest

UGI is usually more definitive

EGD is normally difficult

28
Q

Txt for hiatal hernia

A

Linx device - magnet chain to prevent GERD at GE junction

Nissen fundoplication to prevent incarceration - strangulation

29
Q

Zenker’s diverticulum

A 
Older men
Halitosis or regurgitation of undigested food 
Dysphagia
Nocturnal cough
Recurrent aspiration pneumonia 
Neck mass may reduce with pressure
30
Q

Txt for Zenker’s diverticulum

A

Cricopharyngeal myotomy

31
Q

Gastric ulcers can be caused by:

A

H. Pylori
NSAIDs
ZES

32
Q

Which is more common - gastric ulcers or duodenal ulcers?

A

Duodenal ulcers

33
Q

Gastric ulcer patient presentation

A

Nausea
Epigastric burning, tenderness
Often aggravated by meals
Hematemesis

34
Q

Workup for gastric ulcers

A

Endoscopy
Bx to check for CA (Bx can also check for h. Pylori)

UGI for pts who can’t do endoscopy
- barium uptake in ulcer niche

Labs

H. Pylori testing

35
Q

Txt for gastric ulcers

A

Eradicate h. Pylori if present

GI bleed may be controlled without surgery (hemoclips, inject epi, cautery)

Surgery - gastric outlet obstruction from PUD inflammation or scarring)

36
Q

Different types of gastric ulcer surgeries

A

Oversew, pyloroplasty, vagotomy

Ulcer resection

Graham patch

Slide 24

37
Q

Risk factors for gastric CA

A

Age 70-80yrs

Chronic atrophic gastritis -> metaplasia

H. Pylori -> long term inflammation

38
Q

Why is gastric CA so bad?

A

Often delayed dx, vague symptoms

39
Q

Txt for gastric CA

A

If isolated -> endoscopic mucosal resection (EMR)

If transmural -> gastric resection with regional lymph nodes (more involved if found proximal and involve distal esophagus)

Chemo + rads

40
Q

Flow chart fro gastric CA

A

Slide 26

41
Q

Describe Zollinger-Ellison Syndrome (ZES) - Gastrinoma

A

Tumor near pancreas which produces excess gastrin -> hypersecretion of gastric acid -> multiple gastric/duodenal ulcers

42
Q

Txt for ZES gastrinoma

A

Meds to decrease acid production, initially

Surgical resection is TOC

43
Q

Describe duodenal ulcers:

A

30-40 yrs old
Associated with hyperacidity
Gastrin and vagal stimulation

NOT associated with CA (gastric ulcers are the ones associated with CA)

Overall on the decline

44
Q

Common duodenal ulcer presentation:

A

Burning, dull, gnawing epigastric pain

Worse with fasting

Relieved with antacids or food

Appx 40% also have GERD

45
Q

Workup for duodenal ulcer

A

EGD - direct visualization

UGI - look for pool of barium in ulcer bed

46
Q

If duodenal ulcers hemorrhage:

A

EGD within 24hrs
Cautery, hemostatic clips

Consider interventional radiology consult

47
Q

Duodenal ulcers - indications for surg:

A

Pneumoperineum

Angiography with embolization not successful

Refractory hypovolemia / blood loss anemia

Re-bleed

> 3 units of PRBC

Refractory to medical tx (6-12 weeks)

48
Q

Describe hypertrophic pyloric stenosis

A

Gastric contents cant’s pass through

Presents c projectile vomiting of NON-bilious emesis

Normally 2-6 weeks old

Palpable “olive pit” in epigastrium

49
Q

Txt of hypertrophic pyloric stenosis

A

Pylormyotomy

50
Q

Complications of upper GI surgery

A

Loss of reservoir function
Small gastric pouch
Smaller frequent meals
Gastric atony (delayed gastric emptying)(requires NG suctioning)

51
Q

What is bezoar?

A

Undigested material in the GI tract

Sxs - early satiety, N/V

Endoscopic removal or surgery

52
Q

3 major types of bariatric surgery

A

Lap band (reversible)

Sleeve gastrectomy (portion of stomach removed)(gaining in popularity)

Roux-en-Y (bypass)

53
Q

Causes of SBO

A

MC - adhesions from prior surgery or incarcerated hernia

Volvulus
Intussusception
Internal hernia
Gallstone ileus
Crohn’s dz
Malignancy
54
Q

SBO presentation

A

Colicky abdominal pain
Abdominal distention
Nausea / vomiting
Air fluid levels on upright films

55
Q

Txt for SBO

A 
Admit, resuscitate 
NPO 
mIVF
Serial abdominal exams
Most resolve spontaneously
56
Q

Describe adhesions

A

Adhesive band “kinks” the bowel, prevents forward propulsion of gastric contents

Distention -> pain -> N/V

Active bowel sounds

57
Q

Describe incarcerated hernia

A

Bowel herniates through abd wall and non-reducible

Sxs - pain, N/V, unreducible hernia

Surgery ASAP

58
Q

Describe volvulus

A

Acute onset colicky pain, ABD distention, N/V

Similar to other SBO but no air fluid levels

Urgent surgery to prevent bowel necrosis

59
Q

Describe intussusception

A

Telescoping of the small bowel into another section

ABD pain, distention, N/V

Air and fluid cannot pass

60
Q

Diagnostic study of choice for intussusception ?

A

Barium enema

61
Q

Describe internal hernia

A

Strangulation of the bowel by trapping in a mesenteric defect (bucket handle tear) or protrusion into the retroperitoneal fossa

Can be caused by nasty car accidents (high speed)

62
Q

Describe gallstone ileus

A

Truly an obstruction

Gallstone erodes through GB wall and into SB

Migrates through SB and, if large enough, can obstruct at ileocecal valve

63
Q

Features of Crohn’s dz (in the context of obstruction)

A

Cobblestoning
Skip lesions
Transmural

Txt 5-ASA drugs, steroids, ABX

Surgery is palliative

64
Q

URINE:

A

opposite of you’re out

Senior - Surgery 1 (8 decks)

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