Esophagus/Stomach/Duo Flashcards
How to GISTS spread?
Hematogenous–therefore don’t need lymph node dissection with resection
What is the tumor marker on path for GISTs?
c-Kit, can determine response to imatinib
What is an adequate surgical resection of a GIST?
grossly normal margins
‘scalloping’ of organs, peritoneal calcifications, ascites = ?
pseudomyxoma peritonei
How to treat proximal (in fundus or cardia) gastric adenocarcinoma?
Neoadjuvant therapy for tumors T2 or greater (locally advanced) or positive nodes then total gastrectomy (bc need 5 cm margins and are close to GE jxn)
How many nodes do you need for LND for gastric adenocarcinoma?
D1 or D2 resection of 15 nodes
What is blood supply to gastric sleeve?
Right and left gastric arteries, right gastroepiploic
What is a D1 vs a D2 resection for gastric cancer?
D1: greater and lesser omental LN
D2: = D1 + omental bursa, anterior leaf of transverse mesocolon, splenectomy
What cells secrete somatostatin? What stimulates somatostatin release?
D cells in stomach, duodenum, and pancreatic islets. Stimulated by acid in duodenum
What does somatostatin do?
“great inhibitor” - Inhibits release of insulin, glucagon, and secretin, and motilin. Decreases pancreatic and biliary output
Name a somatostatin analogue
Octreatide –> used to decreased panc fistula output
What are the two types of esophageal cancer and their risk factors?
#1 most common in Western countries = adenocarcinoma. Risk factors are GERD + Barrett's esophagus, maybe tobacco. Very common in Japan because of NITRATES. Also hx of prior gastric surgery, H pylori, EBV. SCC is the second kind, risk factors are tobacco and ETOH.
What esophageal tumors can be resected endoscopically?
T1a (flat, small, restricted to mucosa)
Most common cause of dysphagia after Nissen?
In first 8 weeks it’s perioperative edema; after 8 weeks it’s the wrap being too tight
What is higher risk for ulcer bleeding–visible vessel or adherent clot?
visible vessel is high risk, adherent clot is indermediate
What is the most common cause of chylous ascites in Western world?
Malignancy, specifically lymphoma
What are manometry findings for scleroderma?
Low amplitude simultaneous contractions with normal or low LES pressure
How does erythromycin act as a prokinetic?
binds and activates motilin receptors which augments gastric motility
What is a Billroth I?
Preserves duodenojejunal continuity by primary anastomosis between stomach and duodenal stump. Usually used after antrectomy. Alkaline reflux gastritis is common 2/2 reflux of bile into stomach.
What is Billroth II?
End to side anastomosis of jejunum to remnant stomach. Can get malabsorbtion (fat soluble vitamins) 2/2 loss of duodenal continuity.
BMI req for bariatric surgery?
> 40 or >35 with comorbidity
Where is iron absorbed?
Duodenum
What is the afferent vs the efferent limb in RYGB? What is the ideal length of the afferent limb?
Afferent limb is the remnant stomach and biliary system–length should be ~ 40 cm. Efferent limb is the pouch and jejunal attachement
What is blind loop syndrome? What are sxs and tx?
It is small intestinal bacterial overgrowth caused by stasis/poor motility in the afferent limb, Sxs are bloating, diarrhea, steatorrhea, B12 deficiency (bacteria bind with B12). Tx- tetracycline and flagyl and metclopromide for motility.
What is Barretts esophagus?
Squamous epithelium of lower esophagus changes to columnar epithelium via metaplasia
What is the tx for Barretts esophagus?
Once daily PPI, surveillance EGD q3-5 years with 4 quadrant bx every 2 cm
How to dx alkaline reflux gastritis?
EGD showing bile stained gastric pouch + HIDA/bile scintigraphy showing reflux
What is a traction diverticula?
It is a true diverticula (all 3 layers) usually occurring in lateral mid esophagus 2/2 inflamed lymph nodes that pull on esophagus.
What are the two types of ‘pulsion’ (false) esophageal diverticulae?
Zenkers and epiphrenic
How to diagnose H pylori?
Serology or rapid urease assay if patient is getting EGD
How to confirm eradication of H pylori?
Urea breath test
How to diagnose MALT?
endoscopy with bx
How to tx MALT?
It is assoc with H pylori so for low grade just treat the H pylori with abx (clarithromycin + amox). For high grade need chemo XRT. NO surgery.
Treatment algorithm for bleeding duodenal ulcer?
If patient is HDS then endoscopy. If rebleeds, repeat endoscopy. If rebleeds third time and still stable do angio with attempted embo. If unstable, needs surgery
What is the surgical tx for bleeding duodenal ulcer?
Duodenostomy (6 cm) with 3 point ligation of GDA (superior, inferior, and medial)
What is the reflex arc for hiccoughs?
Vagus–>phrenic–>sympathetic chain (T6-12)
What is dx and tx of esophageal leiomyoma?
It is benign tumor of muscle–dx with CT or EUS. DO NOT biopsy because this makes tx with enucleation more difficult.
What is tx of perforation 2/2 caustic esophageal injury?
Esophagectomy + diversion (can’t repair 2/2 caustic nature of the injury)
Types of necrosis from alkaline vs acidic esophageal injury?
Alkaline causes liquifactive necrosis.
Acid causes coagulation necrosis. Alkaline is worse
Describe findings of primary, secondary, and tertiary esophageal burn
Primary- hyperemia
Secondary- sloughing, ulceration
Tertiary- deep ulceration, lumenal narrowing
Most common site of EGD perforation?
Cricopharyngeus
What is Boerhaaves syndrome?
Esophageal perf after prolonged forceful vomiting–usually left lateral 3-5 cm above GE jxn
What is a Mallory Weiss tear?
partial thickness tear at the GE jxn after vomiting–often results in bleeding
Where in stomach does peristalsis occur?
Antrum
What type of epithelium does the stomach have?
simple columnar
What does intrinsic factor do and where does it come from>
Comes from parietal cells in the fundus and body of the stomach. It binds B12 and then is absorbed in TI.
How do PPIs work?
block H/ATPase in parietal cell membrane which prevents H+ release
What is Dieulafoy lesion?
vascular malformation with is an abnormally large submucosal artery that can bleed
What is the most common problem following vagotomy?
Diarrhea (40%)
What is the difference between truncal and proximal (highly selective) vagotomy?
Truncal divides vagal trunks at level of esophagus–causes increased liquid but decreased solid emptying.
Selective divides individual fibers which preserves both solid and liquid emptying.
Tx for H pylori?
Triple therapy: PPI + clarithromycin + amox or PPI + flagyl + tetracyclin
what causes duodenal ulcers?
too much acid, in contrast to gastric ulcers which are mostly caused by H pylori, NSAIDs, smoking etc
When is a GIST considered malignant?
> 5 cm in size or >5 mitoses per HPF
Tx of malignant GIST?
Resection with 1 cm margins, chemo with imatinib (Gleevec–tyrosine kinase inhibitor)
Average excess weight lost for each type of bariatric surgery?
Band: 40%
Sleeve: 60%
RYGB: 75%
What is reglan mechanism of action?
Dopamine agonist
What is a marginal ulcer?
Occurs at GJ after RYGB
What is a cameron ulcer?
ulcer assoc with hiatal hernia, usually on lesser curvature.
What is the most common gastric polyp?
Hyperplastic (benign)
Tx of Zenker diverticulum?
cricopharyngeal myotomy for all of them, diverticular resection for those > 2 cm. Endoscopic and surgical approaches are equal for those > 3 cm, but surgery is superior for < 3 cm.
Where does a replaced left hepatic artery come from and where does it run?
Comes from left gastric, runs in gastrohepatic ligament
Initial management of a marginal ulcer?
smoking cessation and PPI
polyps found in where in the stomach have no malignant potential?
fundus
How does esophageal adenocarcinoma spread?
Via submucosal lymph channels
Describe tumor staging of esophageal adencarcinoma? Tx based on tumor?
T1a: tumor confined to the mucosa, can consider endoscopic removal T1b: tumor invades submucosa T2: invades muscularis propria T3: invades adventitia T4: invades surrounding structures
T1 and T2 should get up front esophagectomy. Neoadjuvant chemo should be considered in node + disease and T3/4 tumors.
What is afferent loop syndrome and what is the tx?
Afferent loop syndrome is obstruction of the afferent loop. Happens with afferent loop > 30-40 cm constructed antecolic. Sx are relieved with bilious vomiting. HIDA can aid dx. Tx is conversion to Billroth I or RYGB or Braun enteroenterostomy
When is Belsey Mark IV the appropriate operation to perform?
In a redo fundoplication in an obese patient with shortened esophagus (enter through the left chest and allows for freeing up the esophagus all the way to the aortic arch).
Soap bubble or paintbrush sign
Villous adenoma, most common in the duo
What is the most common appendiceal tumor? Malignant appendiceal tumor?
Most common overall is carcinoid. Most common malignant is adenocarcinoma.
