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Surgery Rotation > EOR GI part 3- PUD > Flashcards

EOR GI part 3- PUD Flashcards

1
Q

What is peptic ulcer disease?

A

Gastric and duodenal ulcers

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2
Q

What are the possible consequences of PUD?

A

Pain
Hemorrhage
Perforation
Obstruction

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3
Q

What percentage of pts with PUD develops bleeding from the ulcer?

A

~20%

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4
Q

Which bacteria are associated with PUD?

A

Helicobacter pylori

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5
Q

What is the tx for H. pylori?

A

Clarithromycin
Ampicillin
PPI

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6
Q

What is the name of the sign with RLQ pain/peritonitis as a result of succus collection from a perforating peptic ulcer?

A

Valentino’s sign

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7
Q

In what age group are duodenal ulcers most common?

A

40-65 yoa

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8
Q

What is the ratio of male to female pts with duodenal ulcers?

A

Men >women (3:1)

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9
Q

What is the MC location of duodenal ulcers?

A

Most are within 2 cm of the pylorus in the duodenal bulb

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10
Q

What is the classic pain response to food intake in a duodenal ulcer?

A

Food classically relieves duodenal ulcer pain

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11
Q

What is the cause of a duodenal ulcer?

A

Increased production of gastric acid

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12
Q

What syndrome must you always think of with a duodenal ulcer?

A

Zollinger-Ellison syndrome

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13
Q

What are the major sx of a duodenal ulcer?

A

Epigastric pain

Bleeding

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14
Q

What are the signs of a duodenal ulcer?

A 
Tenderness in epigastric area
Guaiac-pos stool
Melena
Hematochezia
Hematemesis
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15
Q

What is the DDx of duodenal ulcer?

A 
Acute abdomen
Pancreatitis
Cholecystitis
All causes of UGI bleeding
Zollinger-Ellison syndrome
Gastritis
MI
Gastric ulcer
Reflux
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16
Q

How is the dx made of duodenal ulcer?

A

Hx
PE
EGD
UGI series (if pt is not actively bleeding)

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17
Q

When is surgery indicated with a bleeding duodenal ulcer?

A

Most surgeons use: >6 units PRBC transfusions
>3 units PRBCs needed to stabilize
OR
for significant need

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18
Q

What is the medical tx for duodenal ulcer?

A

PPIs or H2 receptor antagonists- heals ulcers in 4-6 wks in most cases
Tx for H. pylori

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19
Q

When is surgery indicated for duodenal ulcers that are not bleeding?

A

Intractability
Hemorrhage
Obstruction (gastric outlet obstruction)
Perforation

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20
Q

How is a bleeding duodenal ulcer surgically corrected?

A

Opening of the duodenum through the pylorus

Oversewing of the bleeding vessel

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21
Q

What artery is involved with bleeding duodenal ulcers?

A

Gastroduodenal artery

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22
Q

What are the common surgical options for truncal vagotomy?

A

Pyloroplasty

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23
Q

What are the common surgical options for duodenal perforation

A 
Graham patch (poor candidates, shock, prolonged perforation)
Truncal vagotomy and pyloroplasty incorporating ulcer
Graham patch and highly selective vagotomy
Truncal vagotomy and antrectomy (higher mortality rate, but lowest recurrence rate)
24
Q

What are the common surgical options for duodenal ulcer intractability?

A

PGV (highly selective vagotomy)

Vagotomy and pyloroplasty

25
Q

In what age are gastric ulcers most common?

A

40-70 yoa

26
Q

How does the incidence of gastric ulcers in men compare with that of women?

A

Men > women

27
Q

Which is more common overall: gastric or duodenal ulcers?

A

Duodenal ulcers are more than twice as common as gastric ulcers

28
Q

What is the classic pain response to food with gastric ulcers?

A

Food classically increases gastric ulcer pain

29
Q

What is the cause of gastric ulcers?

A

Decreased cytoprotection or gastric protection

30
Q

What are the associated RFs with gastric ulcers?

A 
Smoking
EtOH
Burns
Trauma
CNS tumor/trauma
NSAIDs
Steroids
Shock
Severe illness
Male gender
Advanced age
31
Q

Is gastric acid production high or low with gastric ulcers?

A

Normal or low

32
Q

What are the sx of gastric ulcers?

A

Epigastric pain

+/- vomiting, anorexia, nausea

33
Q

How is the dx of gastric ulcer made?

A

Hx
PE
EGD with multiple bx (looking for gastric CA)

34
Q

What is the most common location of gastric ulcers?

A

~70% are on the lesser curvature

~5% are on the greater curvature

35
Q

When and why should bx be performed for gastric ulcers?

A

With all gastric ulcers, to r/o gastric CA

If the ulcer does not heal in 6 wks after medical tx, rebiopsy (always bx in OR) must be performed

36
Q

What is the medical tx for gastric ulcers?

A

Similar to that of duodenal ulcer- PPIs or H2 blockers, H. pylori tx

37
Q

When do pts with gastric ulcers need to have an EGD?

A

For dx with bxs

6 wks postdiagnosis to confirm healing and r/o gastric CA

38
Q

What are the indications for surgery with gastric ulcers?

A 
Intractability
CA (r/o)
Hemorrhage
Obstruction
Perforation
39
Q

What is the common operation for hemorrhage, obstruction, and perforation in a gastric ulcer?

A

Distal gastrectomy with excision of the ulcer without vagotomy unless there is duodenal dz

40
Q

What is a common option for a poor operative candidate with a perforated gastric ulcer?

A

Graham patch

41
Q

What must be performed in every operation for gastric ulcers?

A

Bx looking for gastric CA

42
Q

What are the sx of a perforated peptic ulcer?

A

Acute onset of upper abdominal pain

43
Q

What is the DDx of a perforated peptic ulcer?

A 
Acute pancreatitis
Acute cholecystitis
Perforated acute appendicitis
Colonic diverticulitis
MI
Any perforated viscus
44
Q

Which diagnostic tests are indicated for a perforated peptic ulcer?

A

X-ray: free air under diaphragm or in lesser sac in an upright CXR

45
Q

What is the initial tx for a perforated peptic ulcer?

A

NPO: NGT (decreased contamination of the peritoneal cavity)
IVF/Foley cath
Abx/PPIs
Surgery

46
Q

What is a Graham patch?

A

Piece of omentum incorporated into the suture closure of perforation

47
Q

What type of perforated ulcer may present just like acute pancreatitis?

A

Posterior perforated duodenal ulcer into the pancreas

48
Q

Truncal vagotomy

A

Resection of a 1- to 2-cm segment of each vagal trunk as it enters the abdomen on the distal esophagus, decreasing gastric acid secretion

49
Q

What other procedure must be performed along with a truncal vagotomy?

A

“Drainage procedure” (pyloroplasty, antrectomy, or gastrojejunostomy) because vagal fibers provide relaxation of the pylorus, and, if you cut them, the pylorus will not open

50
Q

Vagotomy and pyloroplasty

A

Pyloroplasty performed with vagotomy to compensate for decreased gastric emptying

51
Q

Vagotomy and antrectomy

A

Remove antrum and pylorus in addition to vagotomy; reconstruct as a Billroth I or II

52
Q

What is the advantage of proximal gastric vagotomy (highly selective vagotomy)?

A

No drainage procedure is needed
Vagal fibers to the pylorus are preserved
Rate of dumping syndrome is low

53
Q

What is a Billroth I?

A

Truncal vagotomy, antrectomy, and gastroduodenostomy

54
Q

What are the contraindications for a Billroth i?

A

Gastric CA or suspicion of gastric CA

55
Q

What is a Billroth II?

A

Truncal vagotomy, antrectomy, and gastrojejunostomy

Surgery Rotation (19 decks)

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