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The Abdomen > Foregut > Flashcards

Foregut Flashcards

1
Q

Complications of peptic ulceration

A
  • Haemorrhage
  • Perforation
  • Gastric outlet obstruction
  • Recurrent ulceration
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2
Q

Nerves of Laterjet

A

Gastric divisions of both anterior and posterior gastric nerves

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3
Q

Role of CCK

A
  • Secretion of enzyme-rich fluid from pancreas
  • Contraction of GB
  • Relaxation of Sphincter of Oddi
  • Induces satiety
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4
Q

Gastric ulcers associated with Burns

A

Curling’s ulcers

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5
Q

Gland predominance in antrum and pylorus

A

Mucus and neuroendocrine

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6
Q

Level of oesophogastric junction

A

T11 (passes the tip of the xiphoid process)

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7
Q

Clinical features of gastric ulcers

A
  • Epigastric pain induced by eating
  • Weight loss
  • N+V
  • IDA is common
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8
Q

Incidence of Barrett’s

A

1%

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9
Q

Branches of coeliac trunk

A
  1. Right gastric
  2. Common hepatic
  3. Splenic
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10
Q

Management of Boerhaave syndrome

A

Surgical repair urgently due to extensive contamination

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11
Q

Length of oesophagus

A

25cm

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12
Q

Barium swallow appearance of achalasia

A

‘Birds-beak’ appearance

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13
Q

Describe the course of B12 absorption

A
  1. Enters stomach bound to salivary R protein
  2. In the duodenum pancreatic trypsin hydrolyses the R protein
  3. B12 then binds to intrinsic factor
  4. Complex absorbed in terminal ileum
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14
Q

Gastric ulcers associated with brain damage

A

Cushing’s ulcers

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15
Q

Three phases of gastric acid secretion

A
  1. Cephalic phase
  2. Gastric phase
  3. Duodenal phase
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16
Q

Name the two classic gastric ulcer operations

A
  1. Bilroth 1

2. Bilroth 2

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17
Q

Describe the cephalic phase of gastric secretion

A

Vagal activity caused by site and smell of food causes:

  1. Gastric glands stimulated by Ach
  2. Gastrin released by G cells
  3. Histamine released from mast cells which stimulates parietal cells
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18
Q

Describe the gastric phase of acid secretion

A
  1. Food enters stomach

2. Stretch causes Ach release from vagus

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19
Q

Age cut off for OGD in GORD

A

55

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20
Q

Laparoscopic GORD procedure

A

Nissen 360 fundoplication - fundus is wrapped around lower oesophagus

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21
Q

Outline the superior and inferior bounds of the oesophagus

A
  • Superior = lower border of cricoid cartilage

- Inferior = cardiac orifice of the stomach

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22
Q

Origin of left gastro-omental artery

A

Splenic artery

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23
Q

Where do peptic ulcers most commonly occur

A

Duodenum (80%)

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24
Q

Incisura angularis

A
  • Most inferior part of lesser curvature

- Junction between body and pyloric part

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25
Q

Complications of achalasia

A
  • Squamous cell carcinoma
  • Bronchiectasis
  • Lung abscess
  • Nocturnal aspiration
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26
Q

Describe the 4 natural oesophageal constrictions

A
  1. Cervical caused by cricopharyngeus muscle
  2. Crosses arch of aorta
  3. Crosses left main bronchus
  4. Pierces the diaphragm
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27
Q

Complication of gasrectomy

A
  • Dumping syndrome
  • Anaemia and malnutrition
  • Carcinoma of gastric remnant
  • Pancreatitis
  • TB
  • Osteomalacia
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28
Q

What is contained within the hepatogastric ligament

A

Right gastric vessels

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29
Q

Normal resting LES tone

A

> 5mmHg over a distance of >1cm

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30
Q

How does Barrett’s develop into cancer

A

Dysplasia to adenocarcinoma

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31
Q

GOLD standard investigation of oesophageal rupture

A

Contrast study

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32
Q

GIST origin

A

Intestinal pacemaker cells of Cajal

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33
Q

Pattern of stomach venous drainage

A

Run parallel to arteries

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34
Q

Most common site of spontaneous oesophageal rupture

A

Left aspect just above the cardia

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35
Q

Describe the course of the abdominal oesophagus

A
  • Pierces diaphragm at T10 in the right crus
  • Attached to oesophageal hiatus by phrenico-oesophageal ligament
  • Lies in groove on posterior surface of left lobe of liver
  • Covered anteriorly and to the left with peritoneum
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36
Q

Gland predominance in cardia

A

Mucus cells

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37
Q

GOLD standard reflux investigation

A

pH monitoring

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38
Q

Risk factors for oesophageal adenocarcinoma

A
  • Barrett’s
  • GORD
  • Obesity
  • Smoking
  • High alcohol intake
  • High fat diet
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39
Q

Complications of GORD

A
  • Barrett’s
  • Stricture
  • Bleeding
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40
Q

Most common site of external gastric mucosa

A

Meckel’s diverticulum

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41
Q

Indication for surgical management of peptic ulcers

A
  • Failure of medical treatment
  • Complications
  • Non-healed gastric ulcer
  • Giant gastric ulcer (>3cm) that hasn’t healed in 6-8 weeks
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42
Q

How can early dumping be managed

A
  • Time and small meals

- Subcut Somatostatin injections

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43
Q

Describe the course of the left gastric artery

A
  1. Arises from coeliac axis
  2. Runs along lesser curvature
  3. Anastomoses with right gastric branch of hepatic artery
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44
Q

Role of Secretin

A
  • Increases secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells
  • Reduces gastric acid secretion
  • Inhibits antral contractions and increase pyloric sphincter tone
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45
Q

Treatment of Barett’s (metaplasia and low-grade dysplasia)

A
  • Laser/argon ablation causes squamous regeneration
  • Anti-reflux surgery normalises cancer risk
  • Long-term PPI
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46
Q

Atrophic gastritis

A

Caused by an autoimmune process attacking the parietal cells

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47
Q

Describe the effect of retrograde lymphatic spread in gastric cancer

A

Invades the hepatic nodes at the porta hepatis

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48
Q

Macroscopic appearance of linitis plastica (leather bottle stomach)

A

Marked fibrous reactions causing small, thickened, contracted stomach

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49
Q

Deficiencies resulting from gastrectomy

A
  • Iron - as wrong ionic state for absorption

- B12 - lack of intrinsic factor

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50
Q

Initial management steps of oesophageal rupture

A
  1. Resus
  2. NBM
  3. Broad spectrum abx
  4. Parenteral nutrition
  5. PPI and analgesia
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51
Q

Which vessel is divided in the McKeown oesophagectomy

A

Azygous vein

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52
Q

Describe rolling hiatus hernia (Type 2)

A
  • A.K.A. paraoesophageal
  • GOJ remains in normal position below the diaphragm
  • Stomach herniates into chest alongside oesophagus
  • Entire stomach is covered in peritoneum
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53
Q

Origin and site of short gastric arteries

A
  • Splenic artery

- Within the gastrosplenic ligament

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54
Q

How is acid secretion reduced in duodenal ulcer surgery

A

Division of the vagus nerve

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55
Q

Complications of vagus nerve division

A
  • Diarrhoea
  • Gastric atony
  • Gastric outlet obstruction
  • Gallstones (due to GB denervation)
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56
Q

Clinical features of duodenal ulcers

A
  • Epigastric pain on fasting
  • Pain at night
  • Relieved by food and antacids
  • Penetrating posterior ulcers cause pain radiating to back
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57
Q

Complications of laparoscopic oesophagectomy

A
  • Bleeding from azygous vein/intercostals/aorta
  • Injury to tracheobroncial tree
  • Injury to recurrent laryngeal nerve
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58
Q

Biochemical definition of GORD

A

Oesophageal pH of <4 for >4% of a 24-hour period

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59
Q

Angle of His

A

The oblique angle at which the oesophagus enters the stomach

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60
Q

Promotors of gastric emptying

A

Gastrin

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61
Q

Why is previous gastric surgery a cause of gastric cancer

A

Intestinal metaplasia at the anastomosis

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62
Q

Gland predominance in Fundus and body

A

Peptic and parietal

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63
Q

UGI re-bleed major stigmata

A
  1. Pulsatile or oozing haemorrhage
  2. Fresh clot on ulcer
  3. Adherent clot on ulcer
  4. Visible vessel in base of ulcer
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64
Q

Principles of gastric ulcer surgery

A
  1. Removal of the ulcer

2. Removal of the gastrin-secreting part of the antrum

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65
Q

Role of Parietal (Oxyntic) cells

A

Secrete HCL and Intrinsic factor

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66
Q

Outline treatment of sliding hiatus hernia

A
  • No surgery if asymptomatic

- Antireflux procedure is persistent symptoms

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67
Q

What is the alkaline tide

A
  • Production of HCO3 to protect the gastric mucosa

- Influenced by prostaglandin E

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68
Q

Histological change seen in Barrett’s

A

Transformation of the normal squamous lining into metaplastic columnar epithelium

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69
Q

In whom is LES pressure reduced

A
  • Smokers
  • Women on COCP
  • People on atropine
  • Pregnant women
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70
Q

Describe psuedo-achalasia

A

Carcinoma of the LES/cardia/extrinsic tumour (increased resistance to passing scope unlike true achalasia)

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71
Q

Describe Ivor-Lewis procedure

A
  1. Laparotomy with mobilisation of stomach
  2. Right thoracotomy for tumour resection
  3. Mobilised stomach brought up to anastomose with oesophagus
72
Q

Presentation of achalasia

A

Dysphagia to solids and liquids equally

73
Q

Chagas disease associations

A
  • Cardiomyopathy
  • Megacolon
  • Megaduodenum
  • Megaureter
74
Q

Role of Peptic (Chief) cells

A

Secrete pepsinogen

75
Q

Site of drainage of Left gastro-omental vein

76
Q

Metabolic picture of gastric outlet obstruction

A

Hypochloraemic hypokalaemic metabolic alkalosis

77
Q

Laser used for controlling UGI haemorrhage

A

Nd:YAG laser

78
Q

Site of drainage of right gastro-omental vein

A

Splenic vein which joins SMV

79
Q

Anterior, posterior, and lateral relations of the cervical oesophagus

A
  • Anterior = trachea, thyroid
  • Posterior = lower cervical vertebrae, prevertebral fascia
  • Left = left common carotid, left inferior thyroid artery, left subclavian, thoracic duct
  • Right = right common carotid
    (Recurrent laryngeal nerves lie on either side in the groove between trachea and oesophagus)
80
Q

Adjuvant chemotherapy for GIST

A

Imatinib (Tyrosine Kinase Inhibitor)

81
Q

Describe Zollinger-Ellison syndrome

A

Gastrin-secreting tumour (gastrinoma) of the pancreatic islet cells causing excessive acid secretion

82
Q

Relative indications for emergency surgical ulcer treatment

A
  • One re-bleed in hospital (2 if <60)
  • Transfusion requirement:
    > 4 units/24hr if >50
    > 6 units/24hr if <50
83
Q

Which MEN are gastrinomas related to

84
Q

Embryological origin of foregut

A

Cranial region of endoderm

85
Q

What comprises the foregut

A
  • Oesophagus
  • Stomach
  • Duodenum (up to ampulla of vater)
  • Liver
  • Gallbladder
  • Pancreas
  • Spleen
86
Q

Classification of Barrett’s

A
  • Short = <3cm

- Long = >3cm

87
Q

Physiology of parietal cell

A
  • Proton pump spans apical surface of cell
  • H+ from H/K ATPase system
  • CL- from Cl/K co-transporter
88
Q

Role of histamine in gastric acid secretion

A
  1. Histamine release from mast cells

2. Stimulates parietal cels vial H2 receptors

89
Q

Level of coeliac trunk

90
Q

Management of delayed presentation (>2 days) oesophageal perforation

A

Conservative as too friable to suture

91
Q

Effect of stomach acid in the duodenum

A
  • Delays gastric emptying

- Increases Secretin release

92
Q

Describe the course of the cervical oesophagus

A

Passes downwards and slightly to the left

93
Q

Risk factors for oesophageal SCC

A
  • High alcohol intake
  • Tobacco
  • Vitamin A + C deficiency
  • Coeliac disease
  • Strictures
  • Achalasia
94
Q

Anterior, posterior, and lateral relations of the thoracic oesophagus

A
  • Anterior = left common carotid, trachea, left main bronchus, pericardium
  • Posterior = thoracic vertebrae, thoracic duct, hemiazygous vein, descending aorta
  • Left = left subclavian, aortic arch, left vagus and its recurrent laryngeal branch, thoracic duct, left pleura
  • Right = right pleura, azygous vein
95
Q

List conditions causing odynophagia

A
  • Reflux
  • Peptic ulcer
  • Thrush
  • Herpes
  • Viral and bacterial pharyngitis
  • Diffuse oesophageal spasm
96
Q

Describe sliding hiatus hernia (Type 1)

A

Cephalid displacement of the GOJ and proximal stomach through the diaphragmatic hiatus into the posterior mediastinum

97
Q

Dominant phase of gastric acid secretion

A

Gastric phase - responsible for 60%

98
Q

Most common histological type of gastric cancer

A

Adenocarcinoma

99
Q

Chemical inhibitors of Gastrin

A
  • Somatostatin
  • Secretin
  • CCK
  • GIP
100
Q

Posterior relations of stomach

A
  • Lesser sac
  • Pancreas
  • Left kidney
  • Left adrenal
  • Spleen
  • Splenic artery
  • Transverse mesocolon
101
Q

Presentation of GISTs

A
  • Haematemesis
  • Melaena
  • Palpable abdominal mass
102
Q

Clinical features of diffuse oesophageal spasm

A
  • Retrosternal pain

- Radiates to jaw and intrascapular region

103
Q

Anterior relations of stomach

A
  • Diaphragm
  • Greater omentum
  • Anterior abdominal wall
  • Left lobe of liver
  • GB
104
Q

Describe the lymphatic drainage of the oesophagus

A
  • Upper 1/3rd = deep cervical
  • Middle 1/3rd = mediastinal
  • Lower 1/3rd = gastric
105
Q

Definitive surgical treatment for duodenal ulcer

A

Vagotomy and pyloroplasty

106
Q

Pathology of oesophageal carcinoma

A
  1. Adenocarcinoma - 65% (occur in lower 1/3rd)
  2. SCC - appear at any level
  3. Oat cell carcinoma - rare and poor prognosis
107
Q

Oesophageal epithelium type

A

Stratified squamous

108
Q

Treatment of T1 Oesophageal disease

A

Endoscopic mucosal resection

109
Q

What part of the stomach is removed in gastric ulcer surgery

A

Antrum - most recommend removal of the distal 1/3rd of the stomach

110
Q

Site and cause of ulcer haemorrhage

A
  • Posterior wall

- Gastroduodenal artery

111
Q

CXR features of hiatus hernia

A

Lateral film shows fluid level in posterior mediastinum

112
Q

What denotes the change in mucosa from oesophageal to gastric

113
Q

When is total gastrectomy required in gastric cancer

A

Tumours within 5cm of the GOJ

114
Q

Outline sympathetic innervation of the stomach

A

T6-T9 spinal segments which pass to coeliac plexus via greater splanchnic nerve

115
Q

Describe the arterial supply of the oesophagus

A
  • Upper 1/3rd = inferior thyroid artery
  • Middle 1/3rd = aortic branches
  • Lower 1/3rd = left gastric artery
116
Q

How can late dumping be managed

A
  • Small dry meals

- Glucose sweets

117
Q

Two types of gastric adenocarcinomas and associated prognosis

A
  1. Intestinal type - poor

2. Diffuse type - better

118
Q

Inhibitors of gastric emptying

A
  • GIP
  • CCK
  • Enteroglucagon
  • Secretin
119
Q

Treatment of Barrett’s (high-grade dysplasia)

A
  • Histology should be confirmed by 2 pathologists

- Oesophagectomy

120
Q

Outline the 4 divisions of the stomach

A
  1. Cardia - surrounds cardial orifice at T1 and posterior to 6th costal cartilage
  2. Fundus - superior to cardia
  3. Body - central portion
  4. Pyloric part
121
Q

What prevents the stomach lining being eroded by stomach acid

A
  • Alkaline mucus
  • Tight epithelial junctions
  • Prostaglandin E stimulates alkaline tide
122
Q

GORD biopsy position and histology

A
  • 5cm above GOJ

- Increased eosinophils and hypoplasia

123
Q

What are the two types of Gastritis

A
  1. Type A - associated with parietal cell antibodies

2. Type B - extends from pyloric region to the lesser curve and associated with gastric surgery

124
Q

What type of bacteria is H. pylori

A

Gram negative bacillus specific for gastric mucosa

125
Q

When does osteomalacia occur after partial gastrectomy

A

10-20 years

126
Q

Outline treatment of rolling hiatus hernias

A
  • All should be repaired

- Hernia reduced, sac excised, fundoplication

127
Q

Describe the course of the thoracic oesophagus

A
  • Passes through superior and posterior mediastinum
  • Reaches midline at T5
  • Passes down, forward, and left to pierce diaphragm at T10
128
Q

Role of gastric acid

A
  • Convert pepsinogen to pepsin
  • Tissue breakdown
  • Forms soluble salts with calcium and iron
  • Immune defence
129
Q

Describe late dumping syndrome

A

Due to rapid swing in insulin production due to presence of glucose in small bowel - causes reflex hypoglycaemia

130
Q

What is the endoscopic procedure for peptic ulcer diagnosis

A
  • OGD
  • At least 6 biopsies must be taken
  • CLO test
131
Q

Macroscopic appearance of malignant ulcer

A

Raised, everted edges

132
Q

Describe the course of the right gastro-omental (epiploic) artery

A
  1. Arises from gastroduodenal branch of hepatic artery
  2. Supplies greater curvature
  3. Anastomoses with left gastro-omental artery
133
Q

GOLD standard investigation for hiatus hernia

A

Barium swallow

134
Q

Site of drainage of right and left gastric veins

A

Hepatic portal vein

135
Q

Why is gastrectomy a risk for TB

A
  • Malnutrition

- Decreased immunity

136
Q

Management of benign pyloric strictures

A
  • Rare
  • Malignancy is a risk
  • Resection and reconstruction is recommended
137
Q

Surgical implication of prepyloric vein

A

Indicator of pylorus position (drains into right gastric vein)

138
Q

Volume of gastric acid secretion per day

139
Q

Describe Chagas disease

A

Chronic infection with Trypansoma cruzi

140
Q

Describe early dumping syndrome

A
  • Occurs 30-45 mins after eating
  • Due to rapid gastric emptying of hyperosmolar meal into small bowel
  • Dizziness, weakness, palpitation
  • Fluid moves into small bowel by osmosis
141
Q

Outline the lymphatic drainage of the stomach

A
  • Superior 2/3rd = gastric nodes
  • Right 2/3rd = pyloric nodes
  • Left 1/3rd = pancreaticoduodenal nodes
142
Q

Describe McKeown Stage 3 oesophagectomy

A
  1. Ivor-Lewis procedure plus a neck incision

2. Stomach is brought up to the cervical oesophagus

143
Q

Treatment of GIST

A

Local excision without lymphadenectomy

144
Q

Treatment of achalasia

A
  1. Conservative
  2. Balloon dilatation
  3. Heller’s cardiomyotomy
  4. Botulinum toxin
145
Q

Role of Gastrin

A

Stimulates:

  • HCL, pepsinogen and IF release
  • Gastric emptying
146
Q

Role and site of stomach mucus cells

A
  • Secrete mucus

- Opening of the gastric glands

147
Q

Management of small contained oesophageal perforation

A
  1. Conservative

2. Repeat contrast study after 5 days

148
Q

Management of large oesophageal perforation

A
  1. Conservative for 12 hours

2. Surgical repair

149
Q

Treatment of diffuse oesophageal spasm

A

Nifedipine

150
Q

Macroscopic appearance of Colloid tumour

A

Massive gelatinous growth

151
Q

Outline the follow-up of Barrett’s

A
  • No dysplastic cells = 2-yearly OGD
  • Low-grade dysplasia = repeat (Quadran) biopsy after 8-12 weeks acid suppression
  • High-grade dysplasia = esophagectomy if changes persist after acid suppression
152
Q

Origin of right gastric artery

A

Hepatic artery

153
Q

Mainstays of non-surgical management of ulcer perforation

A
  1. NBM and NG
  2. IVF and broad-spectrum abx
  3. Continued assessment
154
Q

Level of transpyloric plane

155
Q

Role of pepsin

A

Hydrolyses peptide bonds in proteins

156
Q

Structure of the oesophagus

A
  • Inner circular muscle
  • Outer longitudinal muscle
  • Submucosal layer with sparse mucous glands
157
Q

Barrett’s histological diagnosis

A
  • Intestinal metaplasia

- Presence of Goblet cells

158
Q

Describe the intestinal phase of acid secretion

A

Presence of food in the duodenum stimulates gastrin release from G cells

159
Q

Pathophysiology of achalasia

A

High LES pressure and failure of relaxation of the sphincter

160
Q

Key vertebral levels associated with the oesophagus

A
  • C6 = start
  • T10 = pierces diaphragm
  • T11 = end
161
Q

Outline parasympathetic innervation of the stomach

A
  • Anterior vagal trunk - hepatic branch and pyloric branch

- Posterior vagal trunk - coeliac branch

162
Q

Most common type of hiatus hernia

A

Sliding (Type 1)

163
Q

What connects the liver to the stomach

A

Hepatogastric ligament (membranous portion of lesser omentum)

164
Q

Absolute indications for emergency surgical ulcer treatment

A
  • Continue bleeding at endoscopy

- Lesions that invariably re-bleed

165
Q

How is the gastric mucosa divided

A
  • Columnar epithelium (secretes protective mucus layer)

- Gastric glands (contain variety of secretory cells)

166
Q

Role of Somatostatin (Ocreotide)

A
  • Decreases acid and pepsinogen secretion
  • Decreases gastrin secretion
  • Decreases pancreatic enzyme secretion
  • Decreases insulin and glucagon secretion
  • Inhibits growth hormone production
  • Stimulates gastric mucous production
167
Q

Origin of the cystic artery

A

Right hepatic artery

168
Q

Relation of the SMA to the uncinate process

A

Posterior to neck of pancreas but crosses anterior to uncinate process

169
Q

Origin of the right gastro-epiploic artery

A

Gastroduodenal artery

170
Q

Origin of the pancreas

A

Ventral and dorsal endodermal outgrowth of the duodenum

171
Q

Origin of the spleen

A

Mesenchymal tissue

172
Q

Borders of Hesselbachs triangle

A

Rectus, inguinal ligament and inferior epigastric vessels

173
Q

Origin of pancreatic carcinoma

A

Ductular epithelium

174
Q

Incision for Whipple’s

175
Q

How is splenic vein thrombosis managed following pancreatitis

A

Splenectomy

176
Q

Management of pancreatic pseudocyst

A

Elective cystogastrostomy after 12 weeks as most regress

The Abdomen (8 decks)

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