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Absite 2019 > Esophagus/Stomach/Duo > Flashcards

Esophagus/Stomach/Duo Flashcards

1
Q

How to GISTS spread?

A

Hematogenous–therefore don’t need lymph node dissection with resection

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2
Q

What is the tumor marker on path for GISTs?

A

c-Kit, can determine response to imatinib

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3
Q

What is an adequate surgical resection of a GIST?

A

grossly normal margins

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4
Q

‘scalloping’ of organs, peritoneal calcifications, ascites = ?

A

pseudomyxoma peritonei

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5
Q

How to treat proximal (in fundus or cardia) gastric adenocarcinoma?

A

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)

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6
Q

How many nodes do you need for LND for gastric adenocarcinoma?

A

D1 or D2 resection of 15 nodes

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7
Q

What is blood supply to gastric sleeve?

A

Right and left gastric arteries, right gastroepiploic

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8
Q

What is a D1 vs a D2 resection for gastric cancer?

A

D1: greater and lesser omental LN
D2: = D1 + omental bursa, anterior leaf of transverse mesocolon, splenectomy

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9
Q

What cells secrete somatostatin? What stimulates somatostatin release?

A

D cells in stomach, duodenum, and pancreatic islets. Stimulated by acid in duodenum

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10
Q

What does somatostatin do?

A

“great inhibitor” - Inhibits release of insulin, glucagon, and secretin, and motilin. Decreases pancreatic and biliary output

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11
Q

Name a somatostatin analogue

A

Octreatide –> used to decreased panc fistula output

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12
Q

What are the two types of esophageal cancer and their risk factors?

A 
#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.
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13
Q

What esophageal tumors can be resected endoscopically?

A

T1a (flat, small, restricted to mucosa)

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14
Q

Most common cause of dysphagia after Nissen?

A

In first 8 weeks it’s perioperative edema; after 8 weeks it’s the wrap being too tight

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15
Q

What is higher risk for ulcer bleeding–visible vessel or adherent clot?

A

visible vessel is high risk, adherent clot is indermediate

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16
Q

What is the most common cause of chylous ascites in Western world?

A

Malignancy, specifically lymphoma

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17
Q

What are manometry findings for scleroderma?

A

Low amplitude simultaneous contractions with normal or low LES pressure

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18
Q

How does erythromycin act as a prokinetic?

A

binds and activates motilin receptors which augments gastric motility

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19
Q

What is a Billroth I?

A

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.

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20
Q

What is Billroth II?

A

End to side anastomosis of jejunum to remnant stomach. Can get malabsorbtion (fat soluble vitamins) 2/2 loss of duodenal continuity.

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21
Q

BMI req for bariatric surgery?

A

> 40 or >35 with comorbidity

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22
Q

Where is iron absorbed?

A

Duodenum

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23
Q

What is the afferent vs the efferent limb in RYGB? What is the ideal length of the afferent limb?

A

Afferent limb is the remnant stomach and biliary system–length should be ~ 40 cm. Efferent limb is the pouch and jejunal attachement

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24
Q

What is blind loop syndrome? What are sxs and tx?

A

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.

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25
Q

What is Barretts esophagus?

A

Squamous epithelium of lower esophagus changes to columnar epithelium via metaplasia

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26
Q

What is the tx for Barretts esophagus?

A

Once daily PPI, surveillance EGD q3-5 years with 4 quadrant bx every 2 cm

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27
Q

How to dx alkaline reflux gastritis?

A

EGD showing bile stained gastric pouch + HIDA/bile scintigraphy showing reflux

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28
Q

What is a traction diverticula?

A

It is a true diverticula (all 3 layers) usually occurring in lateral mid esophagus 2/2 inflamed lymph nodes that pull on esophagus.

29
Q

What are the two types of ‘pulsion’ (false) esophageal diverticulae?

A

Zenkers and epiphrenic

30
Q

How to diagnose H pylori?

A

Serology or rapid urease assay if patient is getting EGD

31
Q

How to confirm eradication of H pylori?

A

Urea breath test

32
Q

How to diagnose MALT?

A

endoscopy with bx

33
Q

How to tx MALT?

A

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.

34
Q

Treatment algorithm for bleeding duodenal ulcer?

A

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

35
Q

What is the surgical tx for bleeding duodenal ulcer?

A

Duodenostomy (6 cm) with 3 point ligation of GDA (superior, inferior, and medial)

36
Q

What is the reflex arc for hiccoughs?

A

Vagus–>phrenic–>sympathetic chain (T6-12)

37
Q

What is dx and tx of esophageal leiomyoma?

A

It is benign tumor of muscle–dx with CT or EUS. DO NOT biopsy because this makes tx with enucleation more difficult.

38
Q

What is tx of perforation 2/2 caustic esophageal injury?

A

Esophagectomy + diversion (can’t repair 2/2 caustic nature of the injury)

39
Q

Types of necrosis from alkaline vs acidic esophageal injury?

A

Alkaline causes liquifactive necrosis.

Acid causes coagulation necrosis. Alkaline is worse

40
Q

Describe findings of primary, secondary, and tertiary esophageal burn

A

Primary- hyperemia
Secondary- sloughing, ulceration
Tertiary- deep ulceration, lumenal narrowing

41
Q

Most common site of EGD perforation?

A

Cricopharyngeus

42
Q

What is Boerhaaves syndrome?

A

Esophageal perf after prolonged forceful vomiting–usually left lateral 3-5 cm above GE jxn

43
Q

What is a Mallory Weiss tear?

A

partial thickness tear at the GE jxn after vomiting–often results in bleeding

44
Q

Where in stomach does peristalsis occur?

A

Antrum

45
Q

What type of epithelium does the stomach have?

A

simple columnar

46
Q

What does intrinsic factor do and where does it come from>

A

Comes from parietal cells in the fundus and body of the stomach. It binds B12 and then is absorbed in TI.

47
Q

How do PPIs work?

A

block H/ATPase in parietal cell membrane which prevents H+ release

48
Q

What is Dieulafoy lesion?

A

vascular malformation with is an abnormally large submucosal artery that can bleed

49
Q

What is the most common problem following vagotomy?

A

Diarrhea (40%)

50
Q

What is the difference between truncal and proximal (highly selective) vagotomy?

A

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.

51
Q

Tx for H pylori?

A

Triple therapy: PPI + clarithromycin + amox or PPI + flagyl + tetracyclin

52
Q

what causes duodenal ulcers?

A

too much acid, in contrast to gastric ulcers which are mostly caused by H pylori, NSAIDs, smoking etc

53
Q

When is a GIST considered malignant?

A

> 5 cm in size or >5 mitoses per HPF

54
Q

Tx of malignant GIST?

A

Resection with 1 cm margins, chemo with imatinib (Gleevec–tyrosine kinase inhibitor)

55
Q

Average excess weight lost for each type of bariatric surgery?

A

Band: 40%
Sleeve: 60%
RYGB: 75%

56
Q

What is reglan mechanism of action?

A

Dopamine agonist

57
Q

What is a marginal ulcer?

A

Occurs at GJ after RYGB

58
Q

What is a cameron ulcer?

A

ulcer assoc with hiatal hernia, usually on lesser curvature.

59
Q

What is the most common gastric polyp?

A

Hyperplastic (benign)

60
Q

Tx of Zenker diverticulum?

A

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.

61
Q

Where does a replaced left hepatic artery come from and where does it run?

A

Comes from left gastric, runs in gastrohepatic ligament

62
Q

Initial management of a marginal ulcer?

A

smoking cessation and PPI

63
Q

polyps found in where in the stomach have no malignant potential?

A

fundus

64
Q

How does esophageal adenocarcinoma spread?

A

Via submucosal lymph channels

65
Q

Describe tumor staging of esophageal adencarcinoma? Tx based on tumor?

A 
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.

66
Q

What is afferent loop syndrome and what is the tx?

A

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

67
Q

When is Belsey Mark IV the appropriate operation to perform?

A

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).

68
Q

Soap bubble or paintbrush sign

A

Villous adenoma, most common in the duo

69
Q

What is the most common appendiceal tumor? Malignant appendiceal tumor?

A

Most common overall is carcinoid. Most common malignant is adenocarcinoma.

Absite 2019 (18 decks)

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