ALIMENTARY

Question 1

Greatest RF for bleeding peptic ulcer

Answer 1

NSAID use

Question 2

Current recommendations for antibiotic prophylaxis in clean-contaminated cases where there is preceding biliary colic within 30 days

Answer 2

Ancef x 1

Question 3

In POEM which muscle layer is divided

Answer 3

After creating a longitudinal mucosal incision and creating a submucosal tunnel into the proximal stomach, the endoscopist divides the circular muscle layer of the esophagus, leaving the longitudinal layer intact

Question 4

volume of fluid produced by stomach

Answer 4

1500 mL daily

Question 5

volume of fluid produced by pancreas

Answer 5

1000 mL daily

Question 6

volume of fluid produced by biliary system

Answer 6

1000 mL daily

Question 7

volume of fluid produced from small bowel

Answer 7

2000 mL

Question 8

RF assoc with poorer prognosis/increased recurrence with SCC of the anus

Answer 8

• tumor size > 5 cm
• > 2/3 involvement of anal canal circumference Additional identified predictors of decreased survival include male sex, presence of nodal disease, and hemoglobin less than 13 g/dL.

Question 9

what type of calcium deposits should prompt you to consider prophylactic cholecystectomy in pts with porcelain gallbladder

Answer 9

More extensive intramural deposits cause mucosal sloughing, which reduces the rate of adenocarcinoma while the selective calcification yields to a continued inflammatory stimulus. Thus, a stronger recommendation for prophylactic cholecystectomy is made for the selective mucosal calcification pattern in an asymptomatic patient.

Question 10

best predictor of local recurrence in rectal cancer

Answer 10

Initial t stage

Question 11

Lateral anal fissure should raise concern for

Answer 11

Crohn disease, syphilis, anal carcinoma, or tuberculosis.

Question 12

Nuclear scintigraphy detects acute bleeding at a rate of

Answer 12

0.04 mL/minute

Question 13

Mesenteric angio requires bleeding rate of

Answer 13

0.5 mL/minute

Question 14

An esophageal stricture is refractory if

Answer 14

diameter of 14 mm cannot be achieved over 5 sessions at 2-week intervals

Question 15

An esophageal stricture is recurrent if

Answer 15

satisfactory diameter cannot be maintained for 4 weeks once the target diameter of 14 mm has been achieved.

Question 16

CT angiography can detect bleeding at rates of

Answer 16

as low as 0.3 mL/minute, which is better than angiography and only slightly worse than tagged red cell scans.

Question 17

tagged RBC scan detection rates

Answer 17

This method will identify bleeding rates as low as 0.1 mL/minute.

Question 18

mgmt of “mini GISTs”

Answer 18

Tumors that are 1 cm in size are referred to as mini GISTS. These tumors have very low malignant potential and are managed by endoscopic ultrasound surveillance.

Question 19

High risk features of “mini GIST”

Answer 19

High-risk features include the presence of echogenic foci, irregular borders, or ulceration.

Question 20

Gastric carcinoids occur due to

Answer 20

Gastric carcinoids are tumors of the stomach that occur due to hypergastrinemia that occurs with achlorhydria due to proton pump inhibitors.

Question 21

Mgmt of gastric carcinoid

Answer 21

These tumors can be managed by stopping proton pump inhibitors.

Question 22

Imatinib is used in tx of GIST and what else

Answer 22

CML

Question 23

MC site of internal hernia after Roux en Y

Answer 23

Mesojejunal mesenteric window (56%) followed by Petersen defect

Question 24

Petersen defect

Answer 24

mesenteric defect posterior to the roux jejunal limb

Question 25

surveillance after complete resection of a cancerous polyp with a margin greater than 2 mm.

Answer 25

cscope at 1 year

Question 26

what structure is used to guide the dissection of levator ani muscles from perineum into pelvis

Answer 26

coccyx

Question 27

if pt has previous gastric surgery but requires anti reflux surgery (inadequate fundus for fundoplication)

Answer 27

Hill esophagogastropexy

Question 28

What is hill esophagogastropexy

Answer 28

plication of lesser gastric curvature around right side of esophagus with esophagogastropexy to median arcuate ligaemnt -intraop manometry required

Question 29

slow transit constipation who have failed medical mgmt

Answer 29

total abdominal colectomy with ileorectal anastomosis

Question 30

more than 95% perirectal abscesses arise from

Answer 30

anal glands

Question 31

what is major reason left sided approach is preferred in approach to ecervical esophagus

Answer 31

right RLN has more variable course thus more prone to inadvertent injury

Question 32

bland spindle cells with elongated nuclei

Answer 32

GIST

Question 33

zenkers diverticulum - true or false

Answer 33

false (mucosa and submucosa only)

Question 34

where does zenkers diverticulum occur

Answer 34

area of weakness just superior to cricopharyngeus

Question 35

MC short term complication after roux en y gastric bypass

Answer 35

dehydration (also MC overall)

Question 36

function of secretory IgA

Answer 36

blocks absorption of antigens from the gut

Question 37

nutcracker esophagus - typical amplitude pressures

Answer 37

>180-400 mmHg with long (>6 sec) duration contraction wave

Question 38

high risk GIST

Answer 38

>5 mitosis per HPF or >3 cm

Question 39

what structure should surgeons be cognizant of when dividing gastrohepatic ligament

Answer 39

hepatic breanch of vagus nerve (ligament runs superior to it) also aberrant left hepatic artery

Question 40

cornerstone of initial GOO mgmt

Answer 40

endoscopic dilation and potential H pylori eradiction

Question 41

most excess weight loss procedure

Answer 41

duodenal switch with biliopancreatic diversion

Question 42

selenium deficiency can lead to

Answer 42

cardiomyopathy and weakness

Question 43

vitamin E deficiency

Answer 43

hemolytic anemia | neurologic abnormalities

Question 44

Initial therapy for bowen disease

Answer 44

Topical x like imiquimod

Question 45

Surgical excision for bowen disease - what margins

Answer 45

4 mm low risk | 6 mm high risk

Question 46

corkscrew esophagus on UGI

Answer 46

DES

Question 47

most consistent predictor of good prognosis after hepatic resection in metastatic colon CA

Answer 47

positive response to preop chemotherapy

Question 48

RF that predict poor survival after hepatic resection in metastatic colon CA

Answer 48

``` node positive primary tumor disesase free interval <12 months multiple liver mets largest liver met >5 cm serum CEA >200 ```

Question 49

stenosis of GJ after roux en y most typically occurs after what kind of anastomosis

Answer 49

circular end to end

Question 50

greatest risk of met in GI carcinoid

Answer 50

tumor size <1 cm fewer than 5% will have mets >2 cm most will have mets

Question 51

tx of horseshoe abscess

Answer 51

modified Hanley procedure small incision between tip of coccyx and anal verge, tissues of external sphincter gently separted using a hemostat tto get into the postanal space, abscess is drained, seton placed around sphincter complex and two lateral counterdrainage incisions are made with setons placed in each

Question 52

primary transthoracic operation used to treat GERD

Answer 52

Belsey Mark IV

Question 53

Belsey Mark IV

Answer 53

transthoracic anterior 240 degree plication of fundus buttressed by diaphragmatic crura

Question 54

excess weight loss at 2 years after gastric band

Answer 54

50%

Question 55

truncal vagotomy - what is ligated? pyloric drainage procedure needed?

Answer 55

main trunk of vagus including celiac and hepatic branches | pylorus is denervated --> needs drainage procedure

Question 56

selective vagotomy - what is ligated? pyloric drainage procedure needed?

Answer 56

anterior and posterior gastric nn of Laterjet | pyloric drainage procedure needed

Question 57

highly selective vagotomy aka

Answer 57

parietal cell vagotomy, proximal cell vagotomy

Question 58

tx of pharmacobezoar

Answer 58

activated charcoal

Question 59

tx of phytobezoar

Answer 59

initial try chemical dissolution

Question 60

factors assoc with regression of Barretts

Answer 60

short segment, smoking cessation and PPI use

Question 61

mgmt of low grade dysplasia Barretts

Answer 61

radiofrequency ablation

Question 62

what feature distinguishes IPMN from mucinous cystic neoplasm

Answer 62

communication with pancreatic duct

Question 63

which complications of hemorrhoidectomy are more common in stapled hemorrhoidectomy vs others

Answer 63

tensemus and septic complications and rectal prolapse

Question 64

what is tenesmus s/p hemorrhoidectomy from

Answer 64

likely presence of low rectal suture

Question 65

most common complication of stapled hemorrhoidopexy

Answer 65

early bleeding

Question 66

predictors of response to tx in MALT lymphoma

Answer 66

depth of penetration of gastric wall (deep to mucosa is less responive) absence of AP-12-MALT 1 translocation gastric site (proximal is more worrisome) microsatellite instability advanced age

Question 67

tx for MALT lymphoma after failed response to H pylori tx

Answer 67

XRT with chemo as salvage for XRT failure

Question 68

why are multiple biopsies required in gastric NETs

Answer 68

larger tumors >1 cm can be a/w synchronous gastric adenoCA

Question 69

serum gastrin > what is sensitive and specific for gastric carcinoid

Answer 69

120 pg/mL

Question 70

Choledocho is most likely with bili greater than what level

Answer 70

4 mg/dL

Question 71

surveillance for GB polyp <5 mm

Answer 71

may not be necessary

Question 72

MC site of aortoenteric fistula

Answer 72

duodenum

Question 73

diagnostic modality of choice in hemodynamically abnormal pts with suspected AEF

Answer 73

CTA (sensitivity approaches 94%)

Question 74

chemo for carcinoid and when do you give it

Answer 74

streptozocin and 5FU | unresectable disease

Question 75

tx of flushing in carcinoid syndrome

Answer 75

alpha bl;ockers like phenothiazine

Question 76

what can give false elevation in 5 HIAA

Answer 76

fruits

Question 77

if you perform liver resxn for carcinoid met what else should you do

Answer 77

cholecystectomy in case of future embolization

Question 78

highest sensitivity for detecting carcinoid tumor

Answer 78

chromogranin A level

Question 79

hallmark sx of carcinoid syndrome

Answer 79

intermittent flushing (kallikrein) and diarrhea (serotonin)

Question 80

serotonin produced by

Answer 80

Kulchitsky cells (Enterochromaffin cell or argentaffin cell)

Question 81

Endoscopic classification after esophageal injury with ulcers

Answer 81

2A or B (siperficial vs deep)

Question 82

Endoscopic classification after esophageal injury with necrosis

Answer 82

3A-B | A (focal) B (extensive)

Question 83

next step after noting grade 3 esophageal injury

Answer 83

CT to identify injuries that are nt transmural (camndidates for esophageal preservation)

Question 84

characteristics of high risk malignant polyp

Answer 84

``` poor differentiation lymphovascular invasion submucosal invasion >1 mm margin <1 mm resection in pieces making margin assessment ddifficult ```

Question 85

polyps in stomach that are dome shaped 0.5-1.5 cm

Answer 85

hyperplastic

Question 86

polyps in stomach that are sessile and occur exclusively in the gastric fundus (0.1-0.8 cm)

Answer 86

fundic

Question 87

presence of fundic gland polyps a/w

Answer 87

PPI use hypergastrinemia FAP

Question 88

adenomatous polyps in stomach

Answer 88

may be sessile or polypoid in shape usually <2 cm and solitary can occur spont or as part of familial syndromes such as FAP

Question 89

Tx for esophageal dysmotility in scleroderma

Answer 89

PPI + Reglan

Question 90

Long term CA risk after caustic ingestion

Answer 90

Increased risk of SCC

Question 91

Inner layer of esophagus is what direction and an extension of what

Answer 91

circular inner layer extension of cricopharynxgeus

Question 92

cervical esophagus blood suppl

Answer 92

thyrocervical trunk off subclavian artery (inferior thyroid artery)

Question 93

branches of thyrocervical trunk

Answer 93

STAT Suprascapular artery Transverse cervical artery Ascending cervical artery Inferior thyroid artery

Question 94

Thoracic esophagus arterial supply

Answer 94

branches directly off aorta and branches of bronchial aa

Question 95

ASPECT trial demonstrated that

Answer 95

high dose PPI and ASA chemo prevention therapy especially in combo reduces rate of cancer progression in pts with Barretss

Question 96

Abnormal resting pressure of LES

Answer 96

<6 mmHg

Question 97

Abnormal LES overall length

Answer 97

<2 cm

Question 98

abdominal esophagus blood supply

Answer 98

branches of left gastric nd left inferior phrenic, Belseys, sometimes splenic

Question 99

classic manometry findings for nutcracker esophagus

Answer 99

amplitude pressure >200 mm with long duration (>6 sec) contraction waves

Question 100

Sx of vagal nerve injury after nissen

Answer 100

gastroparesis, delayed gastric emptying, recurrent reflux, diarrhea

Question 101

Killian's triangle

Answer 101

inferior to thyropharyngeus/inferior pharyngeal constrictor and superior to cricopharynxgeus

Question 102

inadequate fundus due to previous gastric surgery

Answer 102

Hill esophagogastropexy Plication of lesser gastric curve around R side of esophagus with an esophagogastropexy to the median arcuate ligament

Question 103

Modified LA Classifcication of Esophagitis: 1+ mucosal break <5 mm in length that does not extend between tops of 2 mucosal folds

Answer 103

Class A

Question 104

Modified LA Classification of Esophagitis: 1+ mucosal break >5 mm that does not extend between the tops of 2 mucosal folds

Answer 104

Class B

Question 105

Modified LA Classification of Esophagitis: 1+ mucosal break that is continuous between tops of 2+ mucosal folds but involves <75% of circumference

Answer 105

Class C

Question 106

Modified LA classification of Esophagitis: 1+ mucosal break that involves at least 75% of circumference

Answer 106

Class D

Question 107

Manometry findings in scleroderma

Answer 107

absent peristaltic contractions with normal or decreased LES

Question 108

T stage of esophageal adenocarcinoma which invades the muscular propria

Answer 108

T2

Question 109

Surgical mgmt for refractory DES

Answer 109

Laparoscopic Heller-for OR a long esophagomyotomy