COACH PRACTICE TEST Flashcards
Esophogeal muscle by location
upper one third are striated,
lower two thirds are smooth muscle.
Barrett esophagus refers to the pathologic change from
squamous to columnar epithelium
key elements for the manometric diagnosis of achalasia are
aperistalsis of the esophagus
and failure of relaxation of the lower esophageal sphincter - regardless of overall pressure
relative contraindications for studies of Zenker diverticulum
endoscopy
Manometry nonhelpful preoperatively
Predictors of a successful outcome in patients with achalasia treated by myotomy and fundoplication include :
A. Age >40 years
B. Female sex
C. Presence of esophageal dilation
D. Lower esophageal sphincter pressure >35 mm Hg
Predictors of a poor outcome in patients with achalasia treated by myotomy and fundoplication i including operative complications
younger age,
male sex,
LACK of esophageal dilation,
<35 mm HG lower esophageal sphincter pressure.
Predictors of increased operative complications include prior pneumatic dilations and botulinum A (Botox®) injections
risk for adenocarcinoma of the esophagus
obesity - reflux and estrogen up
tobacco for both adenocarcinoma and squamous cell
risk for squamous cell carcinoma of the esophagus
Cuastic direct tissue injuries:
A. Prior head and neck cancer
B. Caustic injury
C. Alcohol abuse
D. Achalasia
T stage for an esophageal cancer that extends into, but not through, the muscularis propria?
T2
stage like colorectal
adjuvant chemoradiation esophageal carcinoma
only stage III and above
stage I AND stage II treated with surgery alone
careful, stage II has nodes but they are along the esophagus
The preferred treatment for an instrumental perforation of the esophagus above a long stricture is
esophagectomy and immediate reconstruction if caught early
Drain the chest
characteristic pain pattern in patients with uncomplicated gastric ulcers is
believed to be caused by acid secretion. About one third of patients also report nocturnal pain, again related to acid secretion
characteristic pain pattern in patients with uncomplicated Duodenal ulcers is
relieved by eating
Stimulate release of bile and bicarbonate to neutralize acid
most common gastric ulcer type
I
Type I 60%, Type II 15%, Type III 20%, Type IV <10%
gastric ulcer type locations
Type I
ulcers are located on the lesser curvature to incisura;
Type II
in the body of the stomach,
typically around the incisura,
associated with a duodenal ulcer
Type III
in the prepyloric region;
IV gastric ulcers are juxtoesophageal. Type V ulcers may be located anywhere in the stomach
intractable duodenal ulcer should be treated with
an acid-reducing operation. This can be a truncal or highly selective vagotomy, with or without an antrectomy.
was common cause of death from gastric ulcer
perforation
was common complication of gastric ulcer
hemorrhage
operation for obstructing duodenal ulcer
Billroth II Vagotomy Antrectomy draining gastrostomy Feeding J.
most common cause of marginal ulceration is in patients with
Roux-en-Y gastric bypass
Bilroth II operations. Marginal ulcerations do not occur unless the jejunum is anastomosed to the stomach
medication to inhibits gastrin release
beta-blockade
counterintuitive-stress adrenaline state increases acid secretion “your going to get an ulcer”
stimulation of gastrin
A. Digestive proteins B. Calcium C. Achlorhydria D. epinephrine E. Gastric distention
the initial biochemical cure rate of sporadic ZES cases?
only 50%!
The tear of the mucosa in cases of the Mallory-Weiss syndrome is usually located
Just below the gastroesophageal junction, lesser curvature OF THE STOMACH!!
Although commonly referred to as tears of the mucosa of the distal esophagus, the most common site is just below the gastroesophageal junction, namely the cardia of the stomach, along the lesser curvature of the stomach. Cameron p 78
Mallory-Weiss management of bleeding
endoscopic treatment such as clip application, epinephrine injection, or endoscopic banding.
Surgery is rarely required,
done via a proximal anterior gastrotomy with suturing of the tear.
most accurate in detecting the depth of invasion of gastric cancer.
EUS
CT is used to check for distant metastases, and peritoneal washings when positive predict a short mean survival time
D2 dissection refers to removal of the lymph nodes along the main trunks of the
celiac artery
indications for D2
live in Japan
D1 lymphadenectomy
periGastric nodes
Neoadjuvant therapy used for what kind of gastric cancer findings
T2 or higher tumors (those invading the lamina propria or submucosa). Cameron pp 82-33
Adjuvant imatinib as recommended for what gastrointestinal stromal tumors
3 or greater centimeters
Continued but diminished benefit at 3 years
Anastomotic obstructions after Roux-en-y gastric bypass can usually be managed by:
endoscopic balloon dilatation!
Strictures can occur in the first few months of the surgery and do usually respond to dilation
what percentage of small bowel obstructions resolve spontaneously
75% all comers
careful, high-grade obstructions will require operation 80% of the time and should receive it within 24 hours of not improving
how long to use it on a high-grade partial small bowel obstruction
24 hours!
CT protocol ordered for small bowel obstruction
IV contrast only
incidence of cancer causing intussusception an adult
50%
95% of time it is some kind of mass at only 50% of those will be a cancer
Crohn disease has 3 major phenotypes. These are:
inflammatory, stricture, fistula
Which of the following treatments for Crohn disease is associated with an increased risk of infection
Infliximab
The anti-TNF alpha class of drugs is associated with an increase in infection and reactivation of latent infection
early postoperative medical therapies to suppress recurrence of Crohn disease after surgical treatment
A. Mesalamine, sulfasalazine
B. Azothioprine, 6-mercaptopurine
C. Infliximab
metronidazole for 3 months postoperatively has been shown to reduce endoscopic recurrences, and long- term smoking cessation
reduces recurrences by about 50%.
Why aren’t stricture plasties performed:
Risk of cancer
best test for carcinoid tumors
chromogranin A
now the preferred test
also useful in postoperative surveillance
highly sensitive, it is not very specific for carcinoid tumors.
Extensive fibrosis is characteristic of which of the following small bowel tumors
carcinoids
neuroendocrine secretion
The fibrosis may cause mesenteric shortening, vascular obstructions, and bowel obstructions.
utility of imatinib in GIST of small bowel
yes indeterminate and higher risk
In younger patients, adenocarcinoma of the small bowel most commonly is found in
the jejunum
Adenocarcinoma of the small bowel in patients over 50 years of age is found most frequently in the:
duodenum
Lymphomas of the small intestine appear most frequently in the:
Most small bowel lymphomas are diffuse, large B-cell lymphomas. Patients with HIV and low CD4 counts also develop B-cell lymphomas of the small intestine. Additionally, patients with celiac disease are at very high risk for the development of small bowel lymphoma, typically non-Hodgkin T-cell lymphoma
length of bowel surface increased with STEP and percent weaned from TPN
50%
50% - this is improved for subsequent STEPs
Bianchi procedure percent weaned from TPN
80%
treatment of Hinchy III and IV
Hartmann procedure or a diversion
with coverage with an omental patch and drainage is appropriate.
NOT with primary resection and anastomosis, even with proximal fecal diversion unless contamination was limited, which generally is not true with Hinchey III and IV cases. Cameron
procedures is appropriate for a patient undergoing emergent surgical treatment of ulcerative colitis
Subtotal colectomy and ileostom
Don’t take the rectum increase operative time
lab marker finding with ulcerative colitis
p-ANCA
Anchor at the bottom UC is rectal
most likely region to perforated colon with toxic megacolon
splenic flexure is a “watershed” region, and this may account for the perforations at this site of ischemia
not the cecum with as an endoscopy
Which region of the colon is least likely to develop ischemic colitis?
rectum
The gold standard confirmatory study in cases of suspected ischemic colitis
colonoscopy
The most sensitive test for detecting C. difficile
Toxin B-detecting tissue culture method CULTURE BUT... the tissue culture method requires 24-48 hours whereas the immunoassays require only a few hours: Rapid enzyme immunoassay
he most common cause of large bowel obstruction in the United States is:
90% of colon obstructions are the result of cancer. Adhesions from prior surgery almost never cause colonic obstructions.
incarcerated inguinal hernias relatively rare
The most common complication of colonic stenting is
Stent migration occurs in 12%-15%, reobstruction in 4%-6%, and perforation in 2%-4%.
contraindications of using neostigmine
pregnancy,
hypotensive patients,
bronchospasm.
The underlying problem in patients with the solitary rectal ulcer syndrome - and what is treatment
absence of the normal mesorectal fixation in these patients.
tx:
ranges from
rectopexy with sigmoid resection to
stapled transanal rectal resection.
Which of the following is/are useful for the treatment of radiation-induced proctitis
A. Nd:YAG laser
B. Argon beam coagulation
C. Topical formalin
These are not as effective:
sucralfate, steroids, and short chain fatty acids.
The preferred treatment for radiation enteritis complicated by obstruction is:
resection of the involved bowel WITH ANASTOMOSIS
morbidity is about the same for bypass and resection, the long-term results are better in patients who undergo resection.
APC gene is what type,
tumor suppressor gene
Familial adenomatous polyposis In addition to the near certain development of colon cancer, affected patients may develop
desmoid tumors, hypertrophy of retinal pigment, osteomas, fibromas, epidermoid cysts.
in FAP benefit of an ileal-anal pouch anastomosis (IPAA) over performing an ileorectostomy (IRA)
decrease in duodenal adenoma formation after ileal-anal pouch anastomosis
thought to be due to decreased secondary bile production and reduced exposure of the duodenum to potential carcinogens as a result
Dreyfus model of performance first begin to demonstrate ability to apply knowledge of the known to new or unknown situations and is the surgeon able to successfully have experience supplant rules?
The novice and the advanced beginner basically function by following rules. Once the learner is competent, he begins to have experience supplant rules.
What hormone stimulates glycogenesis and glycolysis?
Insulin stimulates glycogenesis, the formation of glycogen from glucose
conversion of glucose to pyruvate or lactate.
Glucagon stimulates
glycogenolysis converting glycogen into glucose,
and
gluconeogenesis from amino acids, glycerol, or lactate.
Thus, glucagon raises blood suga
bile acid excreted in the feces with small amount is reabsorbed
Lithocholic acid via sulfiation
Secondary bile acids,
deoxycholic acid lithocholic acid ( excreted and feces)
are formed in the colon by bacteria degrading the primary bile acids.
primary bile acids
cholic acid
chenodeoxycholic acid.
They are formed from cholesterol in the liver
passively reabsorbed in:
the small intestine and liver,
actively absorbed in the ileum.
lean body mass and changes of cellular make up in elderly
net decrease of lean body mass.
extracellular mass stays about the same,
body cell mass decreases,
fat mass increases
In surgical patients with inflammatory states, white is seen regarding glucose used to amino acids, ketone production, responsiveness and dextrose
production of glucose from amino acids is increased
production of ketones is less robust
less response to dextrose infusion than in simple starvation
convert nitrogen to protein
protein divided by 6.25
The earliest IL response is
IL-1.
Another early response is TNF.
TNF and IL-1 peak early and they both stimulate the release of IL-6.
In severe injury, which of the following factors is/are increased greatly compared to those responses in simple starvation?
A. Hepatic ureagenesis
B. Nitrogen loss
C. Gluconeogenesis
D. Muscle proteolysis and hepatic protein synthesis
There is utilization of fat in simple starvation, but not so in patients with severe injury in which there is protein breakdown and decreased ketogenesis from fat.
counter-regulatory hormones in response to injury/trauma?
INCREASE:
ACTH ADH GH Glucagon Catecholamine release, Cortisol release, Aldosterone release,
mobilization of amino acids from skeletal muscle
“regulatory” hormone in response to injury/trauma?
Insulin
For patients in hepatic failure with encephalopathy, if total parenteral nutrition is required, it should have what proteins
Contain branched chain amino acids
CONTRAINDICATED:
aromatic amino acids - already have ketone breath and are goofy
needle catheter jejunostomy and the Witzel jejunostomy in trauma patients, which has a higher complication rate?
Witzel technique was reported to be 10% vs 2% with the needle catheter technique
Glutamine has been demonstrated As added TPN
improve villous atrophy
safe to administer
diminishes complications
shortens length of stay.
However, it is relatively unstable in solution and has a short half-life
he energy source for colonocytes
short chain fatty acids are produced in the colon by bacterial fermentation of ingested fiber
rate of thrombosis when studied by phlebography with central venous line
30%
3% clinial
The intrinsic pathway of activation of clotting is initiated by:
Conversion of XI to XIa
If D-dimer is still elevated 30 days after discontinuation of therapy,
then further treatment is indicated as there is an increased risk of DVT recurrence.
hypercoagulable states associated with artial thrombus
hyperhomocysteinemia
protein C and protein S deficiency onset of sympts
15-30 yrs
homozygous, there is usually fetal death
In the evaluation of a patient suspected of having a hypercoagulable state (such as a young patient with an unproved major DVT or arterial thrombosis), which of the following tests is/are appropriate?
A. Protein C
B. Protein S
C. Factor V Leiden
D. Factor VIII, IX, XI
The most common inherited bleeding disorder is
vonWillebrand disease
