Gastric Surgery Review

Question 1

Patient is post-op from total gastrectomy, presents with malaise and megaloblastic anemia on smear…whats the issue?

Answer 1

• loss of parietal cells -> loss of intrinsic factor -> cannot absorb vitamin B12

Question 2

what is the most common site of leak for a biliopancreatic diversion with duodenal switch?

Answer 2

• the gastric sleeve

Question 3

first sign of a potential leak from a gastric surgery?

Answer 3

• tachycardia

Question 4

history of bill roth II reconstruction, complains of eipgastric pain relieved by bilious emesis…whats going on?

Answer 4

• efferent loop obstruction

Question 5

how does chronic efferent loop obstruction cause megaloblastic anemia

Answer 5

bacterial overgrowth in duodenal stump binds to B12 causing malabsorption of the vitamin downstream

Question 6

how do you treat efferent loop obstruction from a Billroth II reconstruction?

Answer 6

covert to a Roux-en-y configuration

Question 7

What is the Roux limb in a roux-en-y gastric bypass?

Answer 7

Roux limb = alimentary limb/efferent limb…the one attached to gastric pouch

Question 8

how do you treat patient with chocledocholithiasis and roux-en-y gastric bypass?

Answer 8

• ideally you do a laparoscopic assisted ERCP

Question 9

How does a PPI work?

Answer 9

inhibits H+/K+ pump on parietal cells

Question 10

give examples of H2 blockers

Answer 10

Cimetidine
Ranitidine
famotidine

Question 11

how do you manage post-vagotomy dysphagia

Answer 11

exclude solid foods temporarily

Question 12

bariatric surgery most likely to cure metabolic disorders

Answer 12

Biliopancreatic diversion with a duodenal switch

Question 13

patient with 2 week history of epigastric pain 2-3 hours after eating, with high stress job

Answer 13

• likely peptic ulcer in the duodenum (pain 3 hours after eating gives away the location)

Question 14

patient with 2 week history of epigastric pain immediately after eating, with high stress job

Answer 14

• peptic ulcer disease, ulcer in the stomach (pain right after eating gives away the location)

Question 15

treatment for H. Pylori?

Answer 15

7-10 day course of:

• PPI
• amoxicillin
• clarithromycin

Question 16

why have we abandoned vertical gastric banding for weight loss?

Answer 16

• not as effective as roux-en-y and gastric sleeve for sustained weight loss

Question 17

how low can you take a low anterior resection for rectal cancer?

Answer 17

as long as tumor is 2 cm above the puborectal sling you can do an LAR…and its preferred over anal excision because of the occult spread of tumor to lymph nodes in mesorectum (taken during LAR)

Question 18

How do you treat a Phytobezoar?

Answer 18

chemical dissolution and endoscopic fragmentation as first line

Question 19

How do you treat a Trichobezoar?

Answer 19

Surgical intervention…hair gets tangled

Question 20

Which weight loss surgery has been abandoned because it causes end-stage liver disease?

Answer 20

Jejunal bypass

Question 21

Which weight loss surgery has been abandoned because of malnutrition and high rate of marginal ulcers?

Answer 21

Biliopancreatic diversion

• there is a duodenal switch which can be added on to this procedure to improve complication rate

Question 22

how do you treat a low grade mucosa-associated lymphoma?

Answer 22

Clarithromycin and Amoxicillin

Question 23

how do you treat high grade mucosa-associated lymphoma?

Answer 23

chemotherapy and radiation

Question 24

When would surgery be indicated for MALT?

Answer 24

perforation or uncontrolled bleeding

Question 25

sub epithelial mass in stomach biopsy shows CD117 expression

Answer 25

GIST

Question 26

what genetic mutation are GISTs associated with?

Answer 26

mutation in the KIT proto-oncogene

Question 27

Treatment for locally advanced GIST

Answer 27

Imatinib - a tyrosine kinase inhibitor used to shrink tumor to allow for resection

Question 28

expected weight loss after sleeve gastrectomy

Answer 28

50-60% of EXCESS body weight

Question 29

expected weight loss from roux-en-y gastric by pass

Answer 29

80% of EXCESS body weight

Question 30

patient 1 year out form Roux-en-y gastric bypass, complaining of bloating steatorrhea fatigue with positive fecal fat study and microcytic anemia...what is going on

Answer 30

- blind loop syndrome

Question 31

confirmatory test for blind loop syndrome

Answer 31

carbohydrate breath test

Question 32

patient post-op from roux-en-y gastric bypass has diaphoresis after meals, whats going on?

Answer 32

gastric dumping syndrome

Question 33

test to perform when suspecting gastric dumping syndrome

Answer 33

monitored glucose test

Question 34

ladder of care for upper GI bleed, in stable patient

Answer 34

- endoscopy x2 - IR embo - surgery

Question 35

etiology of type II ulcer

Answer 35

hyperacid secretion

Question 36

location of type II ulcer

Answer 36

- antrum | - first part of the duodenum

Question 37

location of type III ulcer

Answer 37

pre-pyloric

Question 38

etiology of type III ulcer

Answer 38

acid hyper secretion

Question 39

Radiologic evidence suggests diagnosis of a GIST 1.5 cm in size located along greater curvature. What is the next best step?

Answer 39

resect as this surgery would not cause too much morbidity, this will be a diagnostic and potentially therapeutic resection

Question 40

Radiologic evidence shows a 2.1 cm potential GIST at the GEJ, next step?

Answer 40

- Biopsy for 2 reasons 1) size is greater than 2 cm, 2) location would necessitate an aggressive surgery - goal is to assess for genetic mutations which potentially can be treated with neoadjuvant therapy to reduce size of tumor

Question 41

pathophysiology of early dumping syndrome

Answer 41

- 30 minutes after a meal - epigastric pain, fullness, diarrhea - result of large food bolus into duodenum causing large fluid shift into the GI tract

Question 42

pathophysiology of late dumping syndrome

Answer 42

- large food bolus into duodenum, causes large release of insulin - 2-3 hours later patient feels palpitations, weakness, diaphoresis - the hypoglycemia from the insulin release causes catecholamine release from the adrenals

Question 43

how do you test for eradication of H. pylori

Answer 43

- breath test, fecal test, or repeat EGD - 4 weeks after completing treatment - hold PPI for 2 weeks prior

Question 44

Greatest stimulator of gastrin release

Answer 44

Amino acids

Question 45

underlying pathophysiology of dysphagia after antrectomy and vagotomy

Answer 45

peri-esophageal fibrosis and denervation but its usually only temporary