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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
Describe para-esophageal hernias:
Types II through IV Much less common Increased risk for incarceration and strangulation
26
Presentation of hiatal hernia?
Early satiety Epigastric pain May or may not have acid reflux-GERD
27
Workup for hiatal hernia?
CXR may show air fluid level in chest UGI is usually more definitive EGD is normally difficult
28
Txt for hiatal hernia
Linx device - magnet chain to prevent GERD at GE junction Nissen fundoplication to prevent incarceration - strangulation
29
Zenker’s diverticulum
``` Older men Halitosis or regurgitation of undigested food Dysphagia Nocturnal cough Recurrent aspiration pneumonia Neck mass may reduce with pressure ```
30
Txt for Zenker’s diverticulum
Cricopharyngeal myotomy
31
Gastric ulcers can be caused by:
H. Pylori NSAIDs ZES
32
Which is more common - gastric ulcers or duodenal ulcers?
Duodenal ulcers
33
Gastric ulcer patient presentation
Nausea Epigastric burning, tenderness Often aggravated by meals Hematemesis
34
Workup for gastric ulcers
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
Txt for gastric ulcers
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
Different types of gastric ulcer surgeries
Oversew, pyloroplasty, vagotomy Ulcer resection Graham patch Slide 24
37
Risk factors for gastric CA
Age 70-80yrs Chronic atrophic gastritis -> metaplasia H. Pylori -> long term inflammation
38
Why is gastric CA so bad?
Often delayed dx, vague symptoms
39
Txt for gastric CA
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
Flow chart fro gastric CA
Slide 26
41
Describe Zollinger-Ellison Syndrome (ZES) - Gastrinoma
Tumor near pancreas which produces excess gastrin -> hypersecretion of gastric acid -> multiple gastric/duodenal ulcers
42
Txt for ZES gastrinoma
Meds to decrease acid production, initially Surgical resection is TOC
43
Describe duodenal ulcers:
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
Common duodenal ulcer presentation:
Burning, dull, gnawing epigastric pain Worse with fasting Relieved with antacids or food Appx 40% also have GERD
45
Workup for duodenal ulcer
EGD - direct visualization UGI - look for pool of barium in ulcer bed
46
If duodenal ulcers hemorrhage:
EGD within 24hrs Cautery, hemostatic clips Consider interventional radiology consult
47
Duodenal ulcers - indications for surg:
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
Describe hypertrophic pyloric stenosis
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
Txt of hypertrophic pyloric stenosis
Pylormyotomy
50
Complications of upper GI surgery
Loss of reservoir function Small gastric pouch Smaller frequent meals Gastric atony (delayed gastric emptying)(requires NG suctioning)
51
What is bezoar?
Undigested material in the GI tract Sxs - early satiety, N/V Endoscopic removal or surgery
52
3 major types of bariatric surgery
Lap band (reversible) Sleeve gastrectomy (portion of stomach removed)(gaining in popularity) Roux-en-Y (bypass)
53
Causes of SBO
MC - adhesions from prior surgery or incarcerated hernia ``` Volvulus Intussusception Internal hernia Gallstone ileus Crohn’s dz Malignancy ```
54
SBO presentation
Colicky abdominal pain Abdominal distention Nausea / vomiting Air fluid levels on upright films
55
Txt for SBO
``` Admit, resuscitate NPO mIVF Serial abdominal exams Most resolve spontaneously ```
56
Describe adhesions
Adhesive band “kinks” the bowel, prevents forward propulsion of gastric contents Distention -> pain -> N/V Active bowel sounds
57
Describe incarcerated hernia
Bowel herniates through abd wall and non-reducible Sxs - pain, N/V, unreducible hernia Surgery ASAP
58
Describe volvulus
Acute onset colicky pain, ABD distention, N/V Similar to other SBO but no air fluid levels Urgent surgery to prevent bowel necrosis
59
Describe intussusception
Telescoping of the small bowel into another section ABD pain, distention, N/V Air and fluid cannot pass
60
Diagnostic study of choice for intussusception ?
Barium enema
61
Describe internal hernia
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
Describe gallstone ileus
Truly an obstruction Gallstone erodes through GB wall and into SB Migrates through SB and, if large enough, can obstruct at ileocecal valve
63
Features of Crohn’s dz (in the context of obstruction)
Cobblestoning Skip lesions Transmural Txt 5-ASA drugs, steroids, ABX Surgery is palliative
64
URINE:
opposite of you’re out

Senior - Surgery 1 (8 decks)

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