Casefiles 5: GERD, esophageal rupture/cancer, PUD, SBO

Question 1

get ? for GERD to measure the pattern and severity of acid reflux
get ? to confirm that the patient has LES dysfunction and that there is no esophageal dysmotility

Answer 1

ambulatory pH monitoring

esophageal manometry

Question 2

A very commonly selected surgical option for GERD patients in the United States is ?

Answer 2

a complete (360°) fundoplication procedure (Nissen fundoplication) performed by the laparoscopic approach.

Question 3

Hiatal hernia types

Answer 3

Type I hiatal hernia is a sliding hernia where the GE junction slides above the diaphragmatic opening.
Type II hiatal hernia is a rolling hernia where the GE junction remains in its normal location and the intra-abdominal contents such as stomach and colon herniate above the diaphragm and can produce obstructive symptoms.
Type III hernia is a combination of type I and II hernias

Question 4

Barrett’s esophagus is reported to be associated with a 40-fold increase in the risk of ?

Answer 4

adenocarcinoma

Question 5

endoscopy

Answer 5

Evaluates for erosive esophagitis or Barrett esophagus, or alternative pathology.
Biopsy for suspected dysplasia or malignancy.

Question 6

barium esophagogram

Answer 6

Identifies the location of the GE junction in relation to the diaphragm.
Identifies a hiatal hernia or shortened esophagus.
Evaluates for gastric outlet obstruction (in which case fundoplication is contraindicated).
Can demonstrate spontaneous reflux.

Question 7

pH monitoring for 24h

Answer 7

Correlates symptoms with episodes of reflux.

Quantitates reflux severity.

Question 8

pharyngeal pH monitoring

Answer 8

Correlates respiratory symptoms with abnormal pharyngeal acid exposure.

Question 9

manometry

Answer 9

Evaluates the competency of the lower esophageal sphincter.
Evaluates the adequacy of peristalsis prior to planned antireflux surgery. Partial fundoplication may be indicated if aperistalsis is noted.
Can diagnose motility disorders such as achalasia or diffuse esophageal spasm.

Question 10

nuclear scintigraphy

Answer 10

May confirm reflux if pH monitoring cannot be performed.

Evaluates gastric emptying.

Question 11

pneumomediastinum is often associated with ?

most commonly diagnosed by ?

Answer 11

tracking of air into the neck, therefore a physical finding that is sometimes present is soft tissue crepitus in the neck
CXR or CT

Question 12

esophageal perforation score

Answer 12

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=130867773&gbosContainerID=92&gbosid=246078

Question 13

Treatment options for esophageal perforation

Answer 13

NPO + antibiotics, NPO + antibiotics + drainage, NPO + antibiotics + endoscopic repair or endoscopic stent placement, NPO + antibiotics + surgical debridement, repair, and drainage

Question 14

Perforations that are associated with underlying esophageal pathology (such as esophageal cancer and achalasia) generally carry a worse prognosis and are more likely to require ?

Answer 14

stent placement, resection, or repairs and myotomies

Question 15

Indicative findings of esophageal perforation include ?

Chest radiograph demonstrating ? are common

Answer 15

subcutaneous crepitus over the neck and Hamman’s sign on chest auscultation
pneumomediastinum and/or left pleural effusion

Question 16

what is the best diagnostic study to help confirm esophageal perforation?

Answer 16

Esophagram with water-soluble contrast
also helps us to determine if the leakage is large and whether it is contained.
can identify a perforation and provide information regarding its size and location

Question 17

the current preferred imaging modality for assessment of the local extent of esophageal and GE-junction tumors (T stage) and for the assessment of regional lymph nodes (N stage)

Answer 17

endoscopic US (EUS)

EUS-guided fine-needle aspirations of the regional lymph nodes can be performed for cytologic diagnosis

Question 18

Siewert classification of GE junction tumors: Type I

Answer 18

centered in the esophagus, at more than 1 cm above the GEJ

surgical treatment typically is an esophagectomy

Question 19

Siewert classification of GE junction tumors: Type II

Answer 19

“at the GE junction”, within 1 cm above the GEJ and up to 2 cm distal to GEJ
surgical resection consists of esophagectomy with resection of the proximal stomach

Question 20

Siewert classification of GE junction tumors: Type III

Answer 20

located in the cardia of the stomach, more than 2 cm distal to the GEJ
treatment consists of total gastrectomy

Question 21

? continues to account for the majority of esophageal cancers encountered in developing countries, ? is the predominant cancer encountered in North America (about 70%)

Answer 21

squamous cell carcinoma

adenocarcinoma

Question 22

sandwich therapy for esophageal adenocarcinoma

Answer 22

preoperative chemotherapy (epirubicin, cisplatin, 5-FU) followed by surgical resection and then postoperative chemotherapy

Question 23

other esophageal cancer treatments

Answer 23

preoperative chemoradiation therapy (carboplatin + external beam radiation) followed by surgery
chemotherapy + trastuzumab (if HER2 overexpression)

Question 24

surgical options for esophageal cancer

Answer 24

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=130867912&gbosContainerID=92&gbosid=246079

Question 25

palliative measures for esophageal cancer

Answer 25

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=130867916&gbosContainerID=92&gbosid=246079

Question 26

noninvasive tests for H. pylori

Answer 26

immunoglobulin G serology test (does not correlate necessarily with active infection)
urea breath test (is highly specific in detecting active infection)

Question 27

invasive tests for H. pylori

Answer 27

rapid urease assay performed on biopsy specimens and histologic studies performed on biopsy samples

Question 28

Common treatment regimens for H. pylori

Answer 28

OAC, OMC, and OAM (O, omeprazole or other PPI; A, amoxicillin; C, clarithromycin; and M, metronidazole) for a treatment duration of 1 to 2 weeks

Question 29

treatment for patients with PUD who are H. pylori negative?

if the patients are taking NSAID?

Answer 29

PPI or H2 blocker

if taking NSAID, co-therapy with misoprostol (a prostaglandin analogue) is helpful to improve ulcer healing

Question 30

PUD evaluation and treatment algorithm

Answer 30

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=130868049&gbosContainerID=92&gbosid=246080

Question 31

mechanism of Sucralfate

Answer 31

Complexes with pepsin and bile salts and binds to proteins in mucosa

Question 32

mechanism of PPIS

Answer 32

Inhibits H+-K+-adenosine-triphosphatase pump

Question 33

Ulcer disease is generally considered intractable if ?

Answer 33

the process persists for 3 months despite appropriate medical therapy
OR the ulcer recurs within 1 year after initial healing despite appropriate maintenance therapy
OR the ulcer disease is characterized as having cycles of prolonged activity with only brief periods of remission

Question 34

magnitude of operations for PUD ranges from ?

Answer 34

highly selective vagotomy to truncal vagotomy with gastric drainage to vagotomy + antrectomy to subtotal gastrectomy to total gastrectomy

Question 35

Surgical treatment of type I gastric ulcers can be accomplished with ?

Answer 35

distal gastrectomy to include the area of the ulcer and reconstruction with a gastroduodenostomy (Bilroth I) or a gastrojejunostomy (Bilroth II)
an alternative procedure is ulcer excision with vagotomy and pyloroplasty (for pts who cannot tolerate long sx)

Question 36

Type V gastric ulcers are related to ?

Answer 36

NSAIDs or aspirin use, and these ulcers rarely need surgical therapy

Question 37

The indications for surgery for PUD are ?

Answer 37

obstruction, hemorrhage, perforation, and intractable symptoms

Question 38

Acid-reduction therapy such as PPI and surgery can be beneficial for patients with ulcers that are not related to hyperacidity (eg, type I gastric ulcer), and the reason is that ?

Answer 38

acid aggravates the healing of these ulcers.

Question 39

Patients who develop recurrent ulcers following vagotomy and antrectomy suggest unusual causes of their ulcer diseases such as ?

Answer 39

excess gastrin production related to gastrinomas (Zollinger–Ellison syndrome)

Question 40

next step after diagnosing SBO with XR/CT

ultimate therapy?

Answer 40

Place an NG tube to help decompress his stomach and relieve his vomiting, initiate fluid resuscitation, place a Foley to monitor UOP and determine his response to fluid resuscitation
Exploratory laparotomy/laparopscopy

Question 41

common etiologies of SBO

Answer 41

postoperative intra-abdominal adhesions, incarcerated hernias, IBD: Crohn disease, and tumors/malignancies, gallstone ileus

Question 42

abdominal XR with SBO may show

Answer 42

dilated small bowel and a paucity(lack) of air in the colon

Question 43

persistent pain associated with SBO raises the concern for ?

Answer 43

bowel ischemia or severe bowel distension

as it is typically colicky pain

Question 44

abdominal CT is useful in SBO, how so?
(first make sure intravascular volume depletion is corrected with fluid resuscitation to prevent risk of contrast-associated AKI)

Answer 44

provide valuable information regarding whether a tumor or Crohn disease may be the reason for the SBO
assess the perfusion status of the bowel wall, intestinal distension, and/or determine the severity and location of the obstruction
can help identify intestinal necrosis and high-risk features indicating high-grade obstruction, and intestinal volvulus

Question 45

concerning clinical features for complicated SBO (bowel ischemia and/or strangulation)

Answer 45

pain out of proportion to clinical examination, fever, tachycardia, hypotension, peritonitis, leukocytosis, localized abdominal tenderness, reduced serum bicarbonate, and elevated serum lactate or amylase
no improvement of fever and tachycardia with initial fluid resuscitation and NG decompression

Question 46

Ileus

Answer 46

Distension of the small intestine and/or colon due to non obstructive causes:
inflammatory/infectious processes, metabolic derangements, recent abdominal surgery/trauma, and meds
may be associated with acute pancreatitis, appendicitis abscess, or may be postop ileus.

Question 47

The usual passage of the gallstone in gallstone ileum is through an opening between the gallbladder and ?
The obstructive point is most commonly in ?
what should raise suspicion for this diagnosis?

Answer 47

the adjacent duodenum (cholecysto-duodenal fistula)
the distal ileum where the luminal diameter is smaller
Air in the biliary tree or in the gallbladder in a patient with SBO (pneumobilia)

Question 48

a diagnostic and therapeutic maneuver for SBO involving infusion of a water-soluble contrast material into the bowel (by NG tube)

Answer 48

Gastrografin Challenge
(datrizoatemeglumine/diatrizoate sodium)
causes fluid to shift into the bowel lumen, decreasing the edema within the intestinal wall and may promote resolution of the obstruction

Question 49

most common causes of SBO in neonates, infants, and young children

Answer 49

hernias, malrotation, meconium ileus, Meckel diverticulum, intussusception, and intestinal atresia

Question 50

if SBO inquire about

Answer 50

history of prior abdominal sx, prior GI or GU malignancies, IBD, prior SBO, and hernias

Question 51

ddx SBO from ileus

Answer 51

patients with SBO will generally describe cramp-like pain, while patients with ileus generally will complain of constipation and distension without cramps
(intestinal peristalsis often remains intact in obstruction despite intestinal narrowing or blockage)

Question 52

Laboratory studies for patients with suspected SBO

Answer 52

CBC with diff, serum electrolytes and amylase, U/A, ABG, lactate (indicator of already present bowel ischemia, but not impending)

Question 53

CT scan is helpful to differentiate SBO from ileus, because it can identify ?

Answer 53

a point of caliber change in the small bowel (“transition point”)

Question 54

CT feature suggestive of complicated SBO includes ?

Answer 54

intraperitoneal free fluid, decreased bowel wall perfusion, and presence of a swirl sign