GI Tract Misc Flashcards
Risk of overwhelming postsplenectomy sepsis after splenectomy in childhood is highest when the spleen is removed for what reason?
Best prognosis for splenectomy if after what indication?
Malignancy: more than 4 times the risk compared to trauma
Best prognosis: splenectomy for trauna
mesh significantly reduces the risk of hernia recurrence for hernias larger than how many cm?
In 2 recent meta-analyses, what kind of mesh placement had the highest probability of being the best treatment to prevent recurrenc? Onlay, inlay, sublay, underlay?
Which has lower rate of recurrence? Biologic or synthetic?
> 4cm
Sublay has the best result.
Onlay: on top of the anterior rectus sheath
Inlay: under the anterior rectus sheath, connecting the rectus muscles
Sublay: right under the rectus muscles
Underlay: under the posterior sheath
Synthetic has lower recurrence rate
For what size hepatic adenoma is it reasonable to first stop OCP and watch? Over what size should you just cut it out?
What’s about hepatic adenoma in males?
<5cm reasonable to stop OCP and watch. > 5cm just cut it out.
Hepatic adenoma of any size in males -> cut it out because of higher chance of malignancy
acellular dermal matrix is best for what scenario?
Entral hernia repair with ECF takedown
Young-ish pt. 30’s, rlq pain. CT shows a mass in the rlq. Bx shows spindle cell. What’s the diagnosis?
What is the recurrence rate at 5 vs 10 yrs?
Does frozen section matter?
Sarcoma.
At 5 yrs: 25-30%
At 10 yrs: 35-60%
Histologic grade and size matters a lot. Frozen little value in determining margins
Difference in recurrence rates between laparoscopic ventral hernia repairs (LVHR) and open ventral hernia repair?
There is no difference according to 4 meta-analysis
Difference in complication rate between open hasson vs varess needle?
No difference
Can you still place a synthetic mesh after inadvertant enterotomy? What about enterocutaneius fistula?
You can actually.
Not in enterocutaneius fistula
What’s the difference in infection rate in laparoscopic vs. open ventral hernia repair?
Lap repair actually has lower infection rate
but the recurrence rate is the same. go figure
For GB cancer after CCY
[T/F] staging laparoscopy is recommended before laparotomy for a potentially curative resection
Lymphadenectomy should include nodes where?
What’s the deal with interaortocaval nodes?
Resection of common bile duct is recommended if cancer is found where?
True. Laparoscopy is recommended.
Nodes should include: portahepatis, gastrohepatic ligament, retrodiodenal
Interaortocaval nodes -> metastatic if positive. Unresectable.
If cancer is found at the cystic duct margin
What are the mortality rates for child A vs B vs C
A: 10%
B: 30%
C: 80%
Who should get liver cancer screening?
Modality of choice?
What to do when you find a lesion based on size?
Hep c with compensated cirrhosis.
Hep b even without evidence of cirrhosis
Ultrasound
<1 cm: repeat US ~4mo. To see if it’s growing
>1 cm: 4-phase dynamic CT
Cirrhotic with HCC, tumor rupture.
Does rupture worsen long term survival?
How is the survival of transarterial embolization vs urgent resection?
[T/F] Once tumor ruptures, it is not amenable to curative resection
Apparently it doesn’t worse. Long term survival
TAE has lower mortality than urgent resection
Can still do curative rxn
What’s the lifetime risk of developing an umbilical hernia for cirrhotic patients who have ascites?
40% because of increased intra-abdominal pressure
3 most important factors for GIST prognosis
1) size >5 cm
2) >5 mitoses per 50 high power field
3) location outside the stomach
Hemorrhoid complication. “Mucosal eversion” what procedure causes this?
Whitehead hemorrhoidectomy
Circumferential excisional hemorrhoidectomy.
Mucosal eversion is where the rectal/anal mucosa is hanging out outside at the skin
Anal canal squamous cell cancer. When can you just cut it out and not do nigro protocol?
<1cm T1 lesion not involving the sphincters. Still do radiation
You’re in a case for an appy. Appendix is 2cm dilated, no inflammation. Swollen, well circumscribed tip that contains a focal lesion. Do you do an appy or r hemi?
Appy. Most of the time low grade mucinous neoplasm. If invasive adeno then go back and do right hemi
If >2cm or involves the base, do a right hemi right away
For PD catheters, what is the most common reason for conversion to HD?
Infection. Mechanical failure is the second most common cause
[T/F] laparoscopic PD catheters have lower exit site infection rate compared to open
What about removal rate?
False. Lap has lower catheter removal rate but infection rate is the same
For PD catheters, what can reduce the incidence of catheter mechanical dysfunction?
Rectus sheath tunneling
Quality indicator for colonoscopy:
- withdrawal time
- adenoma detection rate of at least
- incidence of perforation less than
- incidence of polypectomy bleeding less than
- rate of cecal intubation and photo documentation at least
- withdrawal time 6min
- adenoma detection rate of at least 25% (Thisrateisdefinedas thepercentageof patients age 50 and older undergoing screeningcolonoscopy, who have one or more precancerous polypsdetected) so if you scope 4 ppl you should be finding adenomas in one of the four
- incidence of perforation less than 1 in 1000
- incidence of polypectomy bleeding less than 1%
- rate of cecal intubation and photo documentation at least 90%
During your operation for a carcinoid you do a liver lesion biopsy and the pt becomes hypotensive, unresponsive to pressors. What do you do next?
Give high dose octreotide. Serotonin, histamine, bradykinin can be vasoactive
What is the expected length of survival for stage IV colon cancer with peritoneal carcinomatosis? What is it with chemo/Hipec?
6 mo. Without therapy
22 months with chemo
Paeudomyxoma peritoneii
Most common overall symptom
Second most common symptom in men vs women
MC overall: increasing abdominal girth
Second MC in men: inguinal hernia
Second MC in women: pelvic mass
What is the randomized controlled trial data on lap vs. open splenectomy?
How about case series data?
There is no randomized controlled trial data for lap vs open splenectomy
Almost all case series argue that lap spleen is better
Pt in your office with ITP. what things indicate treating with steroids vs observing?
Any pt with plt <20,000
Or, plt <30,000 with active sports or dangerous lifestyle
Or if bleeding then treat with steroids
If platelet >= 30,000
No symptoms
No active lifestyle can watch
When is splenectomy indicated for ITP?
Should you give platelets pre-op?
If platelets <30,000 after 3 months of maximal therapy
Yes, give platelets pre-op to raise count at least >50,000
What is Hill esophagogastropexy? When and how do you do it?
When someone who has had a gastric wedge and doesn’t have enough stomach to wrap around, you do this
Take the lesser curvature and plicate it around the right side of the esophagus and the median arcuate ligament
You have to do intraopetative manometry
What to do for duodenal polyps <1cm vs >1cm?
<1cm: endoscopic polypectomy
>1cm: transduodenal polypectomy or segmental resection
Truelearn says < 2cm: endoscopic
> 2cm: transduodenal polypectomy
Three types of vagotomy
For each, cuts which nerve? Effect on pylorus/drainage procedure?
Truncal: main trunks of the vagus nerve. Denervates pylorus. Needs drainage procedure
Selective: anterior and posterior latarjet nerves. Denervates pylorus. Needs drainage procedure
Highly-selective: nerve fibers innervating parietal cells. No need for drainage
For peds umbilical hernia defect greater than what cm needs mesh?
3cm
Most common location of small bowel adenoma?
Duodenum
Risk of malignancy in small bowel villous adenoma?
Up to 40%
Risk of fetal loss for perforated and non perforated appendicitis in pregnancy?
Non perforated? ~5%
Perforated? 25%
For esophageal cancer, what is the most accurate imaging tool for locoregional lymph node involvement?
PET scan (68% accuracy)
Endoscopic ultrasound (66%). It’s more SENSITIVE
Most common cause of lower gi bleed in pts under 65 vs over 65?
Under 65: diverticulosis
Over 65: angiodysplasia
How many nodes does esophageal cancer need?
Colorectal?
Stomach?
15
12
16
1, 2, 3 most common locations for accessory spleen
#1: hilum #2: tail of the pancreas #3: greater omentum
Effect of pneumoperitoneum to end tidal CO2?
Increases end tidal CO2
If varess needle is in the correct place, what should the pressure and flow be?
P <8mm
Flow 1L/min
How can pneumoperitoneum cause bradycardia?
Stretching the peritoneum too quickly can cause vagal mediated bradycardia
Gallstone ileus. Proximal enterotomy, milk the stone from distal? Or distal enterotomy, milk the stone from proximal?
Proximal enterotomy. Milk from distal to proximal
Gastric band problem. gives you an xr. Horizontal vs vertical band. Diagnosis and treatment?
Horizontal band: slipped band
Vertical band: erosion. Needs OR
Esophageal spasm after gastric band. What’s the problem?
Band too tight. Not slipped or erosion
What are the fenestrating vs reconstituting technique for subtotal ccy?
What is the leak rate/ercp rate?
What % needs additional surgery?
Fenestrating: leaving the infundibulum/cystic duct orifice open with drain in the Morrison pouch
Reconstituting: closure of a cuff of infundibulum over the top of the cystic duct orifice
Equivalent outcomes. 5-20% leak/ercp rate.
<5% need additional surgery
Laparoscopic vs open ventral hernia repair in terms of surgical site infection rate?
Laparoscopic has much lower SSI rate 5.6%)
Open: 23.3%
recurrence rate is the same
Is CD117 for GIST considered a high risk feature?
What about size/ mitosis?
No. Not a high risk.
Size > 5cm
Mitosis > 5
In pts with ITP under what plt do you start treatment with steroids?
Under 20,000
or under 30,000 with symptoms
Recurrence rate after successful endoscopic treatment of UGIB?
10-25%
Buzzword description of location for gastric ulcers
Type I:
Type III:
Type IV:
Type I: along the lessure curvature at the junction of fundal and antral mucosa near the incisura
Type III: Prepyloric region within 2-3cm of pylorus
Type IV: Higher up on the lesser curvature near the GEJ
Which gastric ulcer types are associated with acid hypersecretion?
Types II & III
Types I & IV: hyposecretion
Post splenectomy, appropriately vaccinated now with sepsis. Most likely organism?
Klebsiella pneumoniae
Laparoscopic vs open appendectomy
- wound infection?
- rate of intra-abdominal abscess?
- duration of surgery?
- negative appendectomy rate?
- hospital length of stay?
- hospital cost
- wound infection significantly lower in laparoscopic
- rate of intra-abdominal abscess higher in laparoscopic
- laparoscopic takes longer (10min)
- lower negative appy rate in laparoscopic
- shorter hospital stay for laparoscopic
- cost is lower for open
What is the average age of presentation for appendiceal carcinoid?
Is it more common in male or female?
Avg age: 65
More common in female slightly
What is the most common complication of mecekl diverticulum in adults?
Bowel obstruction due to fibrous band attached to the umbilicus
Intussusception is #2
Kids: hemorrhage
What is the most common reason for splenectomy overall?
Traumatic injury > ITP > Hypersplenism
What artery supplies the antrum of the stomach?
GDA
Left gastric supplies the upper stomach
Peutz-Jeghers with intermittent nausea and vomiting. What to do?
Push enteroscopy and endoscopic polypectomy
Likely from a polyp causing a ball-valve effect
Indication for emergent splenectomy in ITP pts?
Intracranial hemorrhage
What post-op timeframe is most common for marginal ulcer after RNYGB?
can happen at any time but most common within the first few months.
Not 1 yr after the surgery
When do you use high dose dexa suppression test?
When you see someone with Cushing features you first do low dose dexa.
If low cortisol (suppressed) -> normal
If high cortisol (not suppressed) -> measure ACTH
if low ACTH -> adrenal source -> do a CT
if high ACTH -> do high dose dexa
High dose dexa suppressed -> pituitary
High dose dexa doesn’t suppress -> ectopic source
Predictive factors for converting to open in SBO surgery?
Single band, bowel < 4cm more likely to succeed
Bowel > 4cm more likely to convert
T/F: NSAID induced ulcer disease is more prevalent in duodenum than in the stomach
T/F: the majority of ppl with H. Pylori will exhibit ulcer in their lifetime
F. NSAID ulcers are more frequent in stomach
F. Only 20% of ppl with H. Pylori will get ulcers
What are the three patterns of inflammatory response associated with h. Pylori infection?
1) mild to moderate inflammation all regions of stomach -> no ulcer
2) antral gastritis -> ulcers in the duodenum and Prepyloric areas
3) body of the stomach -> precursor for gastric cancer
Pseudomyxoma peritonei will most likely present with weight gain or weight loss?
Weight loss despite abd girth
Mortality rate of mesenteric ischemia during an admission?
Who has better prognosis? Embolic vs thrombotic?
Most common reason for mortality in pts who survive mesenteric ischemia?
> 50%
Embolic mesenteric ischemia has better prognosis.
MI is the most common cause of mortality
What size bougie do you use for sleeve gastrectomy
36-40Fr
T/F: In a pt with severe jaundice, HIDA scan is not as effective
True. DISIDA scan is better. A different technetium based thing
Criminal nerve of grassi comes from anterior or posterior vagus?
Posterior vagus
Vagus nerve fibers are mainly affarent or efferent?
How is stomach pain transmitted?
Mainly AFFERENT.
Stomach pain transferred via sympathetic nervous system
What is the pars flaccida technique?
Dissection through the fatty tissue posterior to the GEJ to create a tunnel and put in the gastric band.
Prevents slippage. <3%
Kininogr ? Kallikrein? Bradykinin? How are they related
Do they cause diarrhea?
Kallikrein is the enzyme that converts kininogen into bradykinin
No it’s the serotonin from the carcinoid that causes diarrhea
VIPoma what does it do to potassium levels? Acid base status?
Best confirmatory test?
Hypokalemia and metabolic acidosis from too much diarrhea. K and bicarb down the drain.
WDHA: watery diarrhea, hypokalemia, acidosis (van morrison syndrome)
Serum VIP levels
1) Where does the anterior gastric division of the vagus comes from?
2) Which is shorter anterior or posterior gastric division? Which one has more branches?
3) criminal nerve of grassi is from the anterior division or the posterior division?
4) What do the anterior vagal trunk and posterior vagal trunk divide into?
1) From the anterior (left) vagal trunk
2) Posterior gastric division is shorter. Anterior gastric division has more branched
3) grassi is from the posterior gastric division (latarjet is both anterior and posterior)
4) Anterior vagal trunk divides into hepatic and anterior divisions.
Posterior vagal trunk divides into posterior gastric and celiac divisions. Celiac division is the most posterior
Crypts of Lieberkuhn. What tumor?
Carcinoid
Enterochromaffin. What tumor?
Carcinoid
HIPEC is ideal at what T?
Before HIPEC you should debulk all tumors to what size?
41C
Anything more than 2mm must go
Why is a pt with long standing GERD at a risk of shortened esophagus?
Sideroblastic anemia?
GERD -> inflammation and scarring causes esoph to shorten
Pernicious anemia (vit B12), not sideroblastic (vit B6)
What does splanchnic stimulation do to bile flow?
What does vagal stimulation do to bile/gb contraction?
Splanchnic stimulation = sympathetic. Inhibitory to GI motor activity
Vagal stimulation contracts the GB, increases bile secretion
incidence of marginal ulcers after RNYGB?
incidence of anastomotic stenosis after RNYGB?
incidence of bowel obstruction after RNYGB?
up to 15% marginal ulcer
up to 20% stenosis
up to 7% obstruction
Indication for adjuvant gleevec for GIST?
Gleevec for size > 3cm, >5 mitotic figures
- What % small bowel tumors are benign. vs malignant?
- what is the most common benign tumor of SB?
- What is the #1 and 2 most common malignant tumor of SB?
- 30-50% benign
- adenomas are most common benign tumors
- adenocarcinoma (35-50%) > carcinoid (20-40%)
What is the most common cause of failure to maintain weight loss following vertical banded gastroplasty?
What % of excess body weight do they initially lose?
What % of them can maintain that weight loss?
Change in diet. Liquid carbs and junk food easier to eat than fiber and proteins due to the nature of the surgery
55-60% of excess body weight they can lose
Only 10% maintains it at 10 yrs.
For SBP, what has been shown to decrease the risk for hepatorenal syndrome?
Prophylactic administration of albumin
What is the h pylori triple therapy?
Quadruple therapy?
Treatment duration?
Triple: PPI + clarithromycin + amoxicillin
Quadruple: PPI + bismuth + metronidazole + tetracycline
Recommended rx: 10-14d
Gastric mass. polymorphous infiltrate of small cells with reactive appearing follicles. stains positive for CD19, CD20, and CD22.
What is this
MALToma. Non-hodgkin
What is the indication for surgical treatment of post-vagotomy diarrhea?
What is the procedure of choice for post-vagotomy diarrhea?
Does octreotide work?
First try medical rx. Fiber, decrease carbs, lactose, get rid of caffeine. Can try cholestyramine
If fails 1 yr of conservative management then procedure of choice is: Interposition of antiperistaltic 10cm if jejunum 100cm from ligament of treitz. Not rny
Octreotide does not work. cholestyramine does
What is the only proven treatment for alkaline gastritis?
This happens most frequently after B2.
Conversion to RNY GJ with 50-60 cm between GJ and JJ
Pain fiber for appendicitis are from what nerve roots?
T7-T12
Extent of resection for
Siewert I
Siewert II
Siewert III
Siewert I: subtotal esophagectomy, subtotal gastrectomt
Siewert II: distal esophagectomy, total gastrectomy
Siewert III: distal esophagectomy, total gastrectomy
What’s the difference between type II and III rectus sheath hematoma?
Both cross the midline but III you can have hemoperitoneum or pelvic involvement. Below the arcuate line
Gastric carcinoid/neuroendocrine tumor management for:
- multiple < 1cm lesions
- lesions > 1cm
- multiple < 1cm lesions: if fewer than 6 nodules, endoscopic polypectomy. More than 6, then can surveil every 1-2 yrs
- larger lesions: antrectomy or total gastrectomy if poorly differentiated
SESAP
GB cancer staging and 5yr survival
- invades into the muscular layer
- perimuscilar connective tissue
- directly invades the liver
What’s T4?
- muscular layer: still T1 -> this is stage I. 50%. T1b. need to go back and resect more.
- perimuscilar connective tissue: T2 -> this is stage II. 29%
- invades the liver (perforated the serosa): T3 -> Stage III. 7-8%
T4: invades main portal vein/hepatic artery -> stage IV. 2-3%
What is the most common operation performed for SMA syndrome?
Pinching of the duodenum. Between aorta and sma.
Most common- duodenojejunostomy
Short bowel syndrome
- most common cause in adults vs kids
- which medical therapy demonstrated marked mucosal growth?
- citruilline level good or bad prognosis?
- adults: Crohn’s, kids: NEC/midgut volvulus
- GLP-2 (gattex)
- high citrulline lvl = good prognosis. The levels are directly correlated to the residual functional enterocyte mass
Asymptomatic ventral hernia. You can not operate on people with these risk factors (3)
BMI > 50
Current smoker
A1c >8
Other than size > 2cm and base involvement for appendiceal carcinoid, when do you have to do right hemi
Grade II or more
Goblet cell carcinoid histology
Which of the following characteristics correctly correlates with the risk of carcinoid metastasis?
A. Tumor size B. Tumor location C. Serotonin level D. 5-HIAA level E. Patient demographics
A. Tumor size. Most <1 cm at diagnosis: no met
> 2cm at diagnosis: most have metastasized
T/F: data for anticoagulation for Splenic vein thrombosis after splenectomy is controversial
T/F: approximately 25-35% of the pts are asymptomatic
False. Treatment: anticoagulate
True. 25-35% asymptomatic
T/F: small bowel hemangiomas are a common cause of GI bleed.
T/F: when detected, small bowel hemangiomas warrant resection
T/F: CT imaging is sufficient for diagnosis
False. Because they are so rare, SB hemangiomas are not considered a common cause of GI bleed
False. Only warrant resection if symptomatic
True. CT with IV contrast is enough for dx
Gastric outlet obstruction initial treatment of choice?
Endoscopic dilation, h. Pylori eradicaiton
Lap ccy vs cholecystostomy tube:
- readmission rate
- hospital length of stay
- 30d mortality
What is the rate of recurrent cholecystitis with perc tube?
- readmission: significantly higher for cystostomy tube
- hospital length of stay: longer for cystostomy tube
- 30d mortality: higher for cystostomy tube
Recurrence: 40%
closure method after elective non-hernia abdominal operation. which is better? continuous running closure? sublay mesh? onlay mesh?
onlay mesh is the best
splenic artery anreurysm
- mortality rate upon rupture?
- risk factors for rupture?
- 25% mortality rate when it ruptures
- risk factors: diameter >2cm, pregnancy, rapid growth
what is the greatest risk factor for bleeding peptic ulcer? A. gastric adenocarcinoma B. NSAID use C. H. pylori D. tobacco and alcohol use E. consumption of food high in nitrate
NSAIDs (5x risk of bleeding) > H. pylory (2x)
Neostigmine does what to sphincter of oddi?
Contracts the sphincter. Morphine also contracts.
What is the most common complication of percutaneous cholecystostomy tube?
Bile leak. ~3%
What is the best imaging modality for gallstone ileus? CT or small bowel follow through?
CT. SBFT contrast will likely not reach the TI in the setting of obstruction
Who may benefit from prophylactic cholecystectomy for asymptomatic gallstones?
- Patients with hemolytic anemias, such as sickle cell
- Patients with a calcified gallbladder wall
- Those with large (> 2.5 cm) gallstones.
- long common channel of bile and pancreatic ducts.
- about to undergo bariatric surgery
- before organ txp
What is the risk of bile duct injury during lap ccy vs open?
Lap: 0.3-0.7%
Open: 0.1-0.2%
What are the relative contraindications to laparoscopic transcystic common bile duct exploration? (4)
- gallstones in the common hepatic duct (above the junction of the cystic and common bile ducts)
- a small (< 3 mm) or friable cystic duct
- gallstones greater than 6 to 8 mm
- more than eight common bile duct stones
Burn ICU pt with acalculus cholecystitis. Had perc tube placed 2 days ago. Now persistent fevers and white count but tube check shows free flow of contrast. What to do next?
Not okay to wait. Perc tube usually relieves symptoms within 1 day.
Needs surgery. Gangrene or perforation is likely.
