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Surgery > GI system > Flashcards

GI system Flashcards

1
Q

What is achalasia?

A

Derangement of the myenteric motor plexus (coordinates motility)

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2
Q

S/s of achalasia

A
  • Dysphagia for BOTH solids and liquids
  • Regurgitation of food
  • Severe halitosis

-WEIGHT LOSS, cough

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3
Q

Similar between achalasia and GERD and different?

A

BOTH have regurgitation

GERD produces a sour taste but not achalasia

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4
Q

Tests for diagnosing achalasia

A
  • CXR lateral upright: absence of gastric bubble, bird beak sign and air-fluid levels in posterior mediastinum
  • Barium swallow- distal bird’s beak sign
  • Esophageal motility (aka manometry) study- nonperistaltic contractions, incomplete LES relaxation after swallowing, inc LES resting tone
  • SCOPE to rule out mass lesions or strictures, biopsy
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5
Q

Treatment

A
  • Nitrates or CCBs- relax the LES
  • Local botox
  • Surgery: esophagomyotomy with incision of the DISTAL tunica muscularis (DON’T completely divide the LES)
  • Endoscopic dilatation an option but less success and more complications (perf)
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6
Q

Complications of achalasia?

A

Risk of SCC is up to 10% in ppl w/ long-standing achalasia

-Reflux/aspiration can cause PNA, bronchiectasis, asthma

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7
Q

Diffuse esophageal spasm?

A

Myenteric plexus dysfunction.

Distal 2/3 of esophagus and is caused by uncoordinated large-amplitude contractions of smooth muscle

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8
Q

Secondary causes of DES?

A

Diabetes neuropathy, collagen vascular dz, reflux esophagitis, obstruction

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9
Q

S/s of esophageal spasm? Associated illnesses?

A
  • Dysphagia for both solids/liquids (like achalasia)
  • CHEST PAIN similar to MI! Acute onset, retrosternal, may be radiating to arms/jaw/back

INTESTINAL DISORDERS like IBS and spastic colon

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10
Q

Key about esophageal spasm vs. achalasia?

A

NO REGURGITATION IN DES.

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11
Q

Diagnosing DES?

A

Barium swallow- corkscrew appearance; may be TOTALLY NORMAL if it’s not catching the spasm at the time. LES normal diameter
-Esophageal manometry- swallow-induced LARGE uncoordinated contractions

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12
Q

DES treatment?

A

Nitrates or CCBs

NOT usually esophagomyotomy

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13
Q

Esophageal varicies s/s?

A
  • Bleeding stops spontaneously in 50% of cases

- Rebleeding risk is high

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14
Q

Treatment of unruptured esoph varicies?

A

Medical: drugs that decrease portal blood flow- vasopressin, octreotide, somatostatin.
Beta-blockers decrease portal pressure

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15
Q

Rx for ruptured esoph varicies?

A 
pRBCs, NS
NG suction
Endoscopic sclerotherapy
Endoscopic band ligation 
(these have 90% success)

Balloon tamponade can cause perf

TIPS/portocaval shunt, liver transplant

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16
Q

Ddx of esoph rupture?

A

Aortic dissection/MI
Spontaneous pneumothorax
Pancreatitis
Perforated peptic ulcer

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17
Q

How to diagnose esophageal rupture?

A

CXR: L-sided pleural effusion, mediastinal or subcutaneous emphysema

Esophagogram w/ water-soluble contrast (shows extravasation of contrast)

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18
Q

S/s esophageal cancer

A

GRADUAL dysphagia first solids then liquids (it takes 60% occlusion to have sx)
Wt loss, fatigability, weakness

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19
Q

Diagnosis?

A
  • Barium swallow showing mass
  • CXR w/ hilar LAD
  • EGD to look at mass/biopsy it
  • CT scan of thorax for spread
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20
Q

Treatment?

A

Usually caught after widespread/metastasis so <40% candidates for surgery; many post-op complications

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21
Q

Epiphrenic/pharyngoesophageal (Zenker’s) cause?

A

Elevated pressure
Both are FALSE

Zenker’s is the one most likely to be symptomatic

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22
Q

Treatment of Zenker’s?

A

Cervical esophagomyotomy with resection of diverticulum

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23
Q

Esophageal stricture s/s?

A

Small may be asx, otherwise progressive dysphagia

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24
Q

Esophageal stricture dx?

A

SCOPE bc it MUST BE EVALUATED for malignancy

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25
Q

Stricture rx?

A

Dilators passed thru stricture

26
Q

What drugs can cause PUD? Why?

A

NSAIDs, acetazolamide, alpha blockers, alcohol

They inhibit bicarb secretion into the mucous gel

27
Q

Which drugs reduce gel thickness?

A

NSAIDs, steroids

PGE increases it

28
Q

Complications of PUD?

A

Bleeding 20%
Perforation 7%
Gastric outlet obstruction from scarring and edema

29
Q

52 yo lady pw 3 months of early satiety, wt loss, and non-bilious vomiting

A

Gastric outlet obstruction

30
Q

What does an anterior perforation of duodenal ulcer look like?

A

Free air under the diaphragm 70%

31
Q

Posterior perf od duodenal ulcer?

A

Pain radiating to back
Pancreatitis
GI bleed

32
Q

Duodenal ulcer causes

A
  • H pylori (being colonized doesn’t mean you’ll get an ulcer…only 10-20% of ppl do)
  • NSAIDs/steroids
  • Zollinger-Ellison (2/3 are malignant ulcers; diarrhea common)
33
Q

Duodenal ulcer sx?

A

Burning epigastic pain when stomach empty; food relieves within 30min
N/V
Nighttime awakening
(Weirdly assoc with blood type O)

34
Q

Dx duodenal ulcer?

A

Give treatment and see if it resolves; no need for biopsy

H. pylori- endsocopy w/ bx, serology H. pylori IgG, urease breath test

Zollinger-Ellison-
Serum gastrin level >1000pg/mL
SECRETIN STIM TEST–> paradoxical rise in serum gastrin

35
Q

Rx of duodenal ulcers?

A

DC NSAIDS, steroids, smoking cessation

PPIs better than H2 blockers

H PYLORI ERADICATION: PPI, clarithromycin, amoxicillin/mtz for 14 days

36
Q

Surgical rx of duodenal ulcers?

A

HIGHLY SELECTIVE VAGOTOMY
Cut middle of nn, spare the most distal branches; lowest rate of dumping after but highest recurrence which depends on the site of the ulcer. PREPYLORIC ulcers highest recurrence.

Rarely needed!

Only if refractory to 12 wks medical rx, or hemorrhage, obstruction, perf

37
Q

Surgical complications for rx of PUD?

A
  • Dumping syndrome
  • Afferent loop syndrome
  • Postvagotomy diarrhea
  • Duodenal stump leak
  • Efferent loop obstruction
  • Marginal ulcer (ulcers that develop at the margins of a gastrojejunostomy)
  • Chronic gastroparesis
  • Postgastrectomy stump cancer
38
Q

Gastric ulcer? RFs?

A

Decreased protection against acid

Smoking

39
Q

What do they all need?

A

Biopsy bc 3% are malignant

Dx with endoscopy

40
Q

Types for gastric ulcers and their treatments?

A

I- Lesser curvature
II- Gastic and duodenal ulcer
These get antrectomy
III- Prepyloric ulcer= highly selective vagotomy

IV- ULCER IN CARDIA
Subtotal gastrectomy then Roux-en-Y esophagogastrojejunostomy

41
Q

Dumping syndrome

A

From unregulated movement of gastric contents from stomach to intestine

Rx: avoid excessive water intake or high sugar food. Severe- octreotide

42
Q

What is Billroth II used for? What is it?

A

Refractory PUD and gastric adenocarcionma

CBD gets sewn to duodenum then gastrojejunostomy

BILLROTH II=GASTROJEJUNOSTOMY

43
Q

What is afferent loop syndrome? Rx?

A

Obstruction of afferent limb (the duodenum pouch to the stomach) of Billroth II
Mostly present within 1st wk post-op

Vomiting relieves postprandial RUQ pain/nausea
Steatorrhea

Rx: surgical revision
Endoscopic balloon dilatation

44
Q

Gastritis s/s?

A

Burning/gnawing pain

Pain worse w/ food and relieved by antacids

45
Q

Gastritis dx?

A

Endoscopy

46
Q

Gastritis rx?

A

Stop NSAIDs, triple therapy, stop smoking/EtOH, H2 blockers

47
Q

Gastric outlet obstruction causes? Dx? Rx?

A

Obstructing duodenal or gastric ulcers!
Tumor in head of pancreas or stomach

Endoscopy or barium swallow x-ray

Endoscopic balloon dilatation
Surgical resection: 7 days NG decompression and antisecretory rx then truncal vagotomy+pyloroplasty

48
Q

What’s a good drug for upper GI hemorrhage?

A

Somatostatin- inhibits gastric, intestinal, and biliary motility and dec visceral blood flow

49
Q

How often is a laparotomy needed for a UGI bleed?

A

5%

Undersew the vessel on either side of the bleeding vessel

Gastric ulcers are 3x more likely to rebleed than duodenal

50
Q

Types of gastric bypass?

A

Vertical banded gastroplasty

Signal to hypothalamus that you’re full when proximal pouch is distended

Roux-en-Y gastric bypass-

More complications but greater weight loss

51
Q

Best diagnostic test for gastric cancer?

A

Upper GI endoscopy (bc you biopsy duh)

52
Q

S/s of gastric cancer?

A

Adenocarcinoma is 95%
Krukenberg’s tumor- mets to ovaries
Blumer’s shelf- mets to pelvic cul-de-sac felt on DRE
Virchow’s node- L supraclavicular
Sister mary joseph’s- mets to umbilical LNs

53
Q

Gastric lymphoma

A

Men more, 5% of gastric cancers

HIV 5x risk

54
Q

Treatment of low vs high grade MALT? Poor prognosis?

A

Men more, low grade- H pylori rx

High grade- Radiation/chemo

Lesser curvature involvement bad

55
Q

Why do you need to do a biopsy to definitively diagnose MALT?

A

Bc you can’t distinguish from adenocarcinoma by simple inspection

56
Q

Carney triad?

A

Gastric leiomyosarcoma
Pulm chondromas
Extra-adrenal paraganglioma

Seen in women <40

57
Q

How many neoplasms of stomach are malignant? benign?

A

90% malignant

10% benign

58
Q

MC benign tumors of stomach? When do you NEED to biopsy them

A

Adenomatous polyps

Biopsy >5mm to check for cancer

59
Q

Menetrier’s disease

A

BENIGN! Can look like cancer on barium study but do monitor closely bc increased risk of cancer

Autoimmune w/ hypertrophic gastritis that causes PROTEIN-LOSING ENTEROPATHY

Definitive dx: Endoscopy w/ DEEP MUCOSAL BIOPSY (barium swallow shows thickened rugae)

Rx: Anticholinergics, H2 blockers, HIGH PROTEIN DIET, severe may need gastrectomy

60
Q

Dieulafoy’s lesion?

A

Mucosal end artery that doesn’t branch like it should. Causes pressure necrosis, erodes into stomach, and ruptures

Massive/recurrent painless hematemesis

Dx: Upper GI endoscopy

Rx: Endoscopic sclerosing therapy or electrocoag
Wedge resection

61
Q

Gastric volvulus cause?

A

Paraesophageal hernia usually

Can’t vomit, NG tube can’t pass, intermittent severe epigastric pain/distention

Dx: Upper GI contrast study

Rx: Gastropexy (tack stomach to anterior abdominal wall), fix the hernia

Surgery (5 decks)

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