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1
Q

What is the lymph node metastasis rate for T1b Oesophageal cancer?

A 
Through muscularis mucosae:
SCC
SM1 (superficial 1/3)   8-33%
SM2 (middle 1/3)        17-30%
SM3 (Deep 1/3)          36-69%

Overall 26-50%

AC

SM1 (superficial 1/3) 0-22%
SM2 (middle 1/3) 0-35%
SM3 (Deep 1/3) 26-78%

Overall 22-41%

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2
Q

What is the investigation of choice for Achalsia?

A

High resolution manometry (>normal resolution)

Intraluminal circumferential pressures at 1cm over 26cm

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3
Q

What late complications are typically associated with a sleeve gastrectomy?

A

Reflux oesophagitis-OGD- PPI +/- convert to Roux en Y
Stricture- Endoscopic dilatation
Twist/ kink- convert to Roux en Y

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4
Q

Where do oesophageal leiomyomas most frequently occur?

A

Distal 2/3 of oesophagus, 5% multiple

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5
Q

In early GORD, which is the most common pathological mechanism of reflux?

A

Increased transient post prandial LOS relaxations (rather than fall in LOS pressure).

In late GORD, the LOS pressure reduces (?repeated acid exposure), exacerbated by decreased intra-abdominal sphincter length (obesity) and crural weakness and HH

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6
Q

In early oesophageal cancers, is SCC or Adenocarcinoma more likely to have lymph node metastases?

A

SCC

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7
Q

What are the grades of varices?

A

Grade 1 - varices the collapse to air insufflation
Grade 2 - varices between 1 and 3
Grade 3 - varices large enough to occlude lumen

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8
Q

What is the characteristic finding in achalasia

A

Loss of ganglion cells in Auerbachs plexus

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9
Q

Which lymph node stations were removed between TNM7 and TNM 8 esophagus

A

5 and 6

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10
Q

Which hormones increase (1) and decrease (3) gastric emptying?

A

Increase - gastrin

Decrase - GIP, CCK, Enteroglucagon

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11
Q

What is the most common origin cell of a gastric lymphoma?

A

Metastatic non gastric primary

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12
Q

Where is secretin released?

A

S cells in SI

in response to acidic chyme and FAs

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13
Q

What is the most common cause of oesophageal perforation?

A

Iatrogenic - diltation, VBL, sclerotherapy - mostly in hypopharynx (60%)
Boerhaave (15%) lower 1/3 usually on Left border, large defect
Rare - trauma, malignancy, FB, caustics

10-20% mortality

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14
Q

What lymph nodes are removed at a D2 gastric resection?

A

D1 stations (1-7) + 8-12

8 - Common hepatic
9 - Coeliac
10 - Splenic hilum
11 - Spenlic artery
12 - Hepatoduodenal ligament
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15
Q

Where is gastric inhibitory peptide secreted?

A

K cells of duodenum an jejunum

in response to FAs and glucose

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16
Q

Where is Somatostatin produced?

A

D cells in pancreas and stomach

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17
Q

What is the risk of peptic ulcer in patient with H.pylori?

A

10-20% (1-2% risk of gastric cancer , <1% MALT lymphoma)

Decreased risk of Oesophageal adenocarcinoma

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18
Q

What is the risk of lymph node positivity according to T stage in oesophageal cancer?

A 
T1a - 0-3%
T1b - 25%
T2 - 50%
T3 - 80%
T4 - 100%
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19
Q

What is the treatment failure rate of LHM in different types of Achalasia?

A

Type 1 14.6%
Type 2 4.7%
Type 3 30.4%

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20
Q

What length of myotomy should be performed for a LHM

A

8cm - 6cm proximal to GOJ and 2-3cm distal

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21
Q

In what proportion of patients with impacted oesophageal foreign bodies it there an underlying structural abnormality?

A

25% - stricture, HH, web, Schatzki ring, eosinophilic oesophagitis, achalasia, tumours

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22
Q

Where is the pH electrode placed?

A

5cm above manometrically determined upper border of LOS

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23
Q

What are the 4 types of hiatus hernia?

A

1 sliding (95%)
2 paraoesophageal
3 mixed
4 giant

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24
Q

Which radioactive material is typically used for brachytherapy of the oesophagus?

A

Iridium -192

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25
Q

What Types of achalsia are there?

A

Chicago Classification
Type 1 - Abnormal median IRP, 100% failed peristalsis
Type 2 - Abnormal median IRP, 100% failed peristalsis, ≥20% swallows with pan oesophageal peristalsis
Type 3 - Abnormal median IRP ≥20% swallows with presmature/spastic contraction + no evidence of peristalsis

Type 1 Classic
Type 2 Achalasia with oesophageal compression
Type 3 Spastic

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26
Q

In what circumstances can a T1b AC of the esophagus be managed by ESD?

A

ESMO guidelines 2016

SM1 - <500um invasion, L0,V0, G1/2, <20mm diameter)

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27
Q

Dilation of oesophageal cancer carries what risk of perforation?

A

4-6%

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28
Q

In which cells are the problem in Pernicious anaemia?

A

The parietal cells failing to produce sufficient IF (gastric antrum)

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29
Q

What factors increase gastric acid secretion (3)?

A

Vagal nerve stimulation
Gastrin release
Histamine release from enterochromaffin like cells

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30
Q

What is the lymph node metastasis rate for T1b oesophageal tumours?

A 
sm1 = 6% AC 27% SCC
sm2 = 23% AC 36% SCC
sm3 = 58% AC 55% SCC
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31
Q

What are the effects of GIP?

A

Mostly increased insulin release

Small decrease in gastric acid release

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32
Q

How wide is stomach typically left behind after a sleeve gastrectomy?

A

About 4cm

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33
Q

What are the characteristics of Gastric lymphoma?

A

5% of gastric malignancies - mostly B cell lymphomas
May regress with H Pylori eradication
More commonly are metastatic

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34
Q

What is the evidence for LARS?

A

LOTUS trial 2011 JAMA - less reflux symptoms but more dysphagia, bloating flatulence
REFLUX trial 2013 BMJ - Better QoL, less anti reflux meds,

Rickenbacker Meta-analysis - less symptoms, better QoL, but significant still on antacids

Watson 20 year follow up - no benefit to short gastric division

Nissen probably has less reflux but more side effects than anterior wraps (Rudolph Stringer 2020)

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35
Q

What is are the points of FB impaction in the oesophagus

A

1) Hypopharynx (cricopharynxgeus)

2) Upper thoracic oesophagus (Aortic arch, low pressure zone at transition between striated and smooth muscle fibres)

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36
Q

How do oesophageal leiomyomas tend to present?

A

Incidental finding on OGD. Tend to have more symptoms >5cm, dysphagia and reflux

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37
Q

What proportion of patients with systemic sclerosis have oesophageal involvement?

A

Systemic sclerosis - skin thickening, skin oedema, with 80% oesophageal involvement
Smooth muscle atrophy at LOS

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38
Q

What is the characteristic change seen with Barrett’s oesophagus?

A

Metaplastic change from stratified squamous to columnar gastric epithelium.

Three types - intestinal (high risk), cardiac and funds

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39
Q

What are the characteristic physiological findings of Achalasia?

A

1) Absence of swallow-induced relaxation of the LOS

2) Absence of peristalsis along oesophageal body

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40
Q

What are the characteristic histological findings of Schatzki rings?

A

They are typically found at the OG junction, with oesophageal mucosa above and columns epithelium below

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41
Q

What is the most common site of benign gastric ulcer?

A

Lesser curve (50%)

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42
Q

What is the best diagnostic test for transmural necrosis after caustic ingestion?

A

Contrast CT at 3-6 hours > OGD - WSES guidelines

Looking for absence of post-contrast wall enhancement

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43
Q

What effect dose vagal stimulation have on gastric emptying?

A

Increases it (nb vagotomy –> pyloroplasty)

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44
Q

In what percentage of patients with gastric ulceration is H.pylori implicated?

A

60%

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45
Q

What is the lifetime risk of oesophageal Adenocarcinoma after caustic ingestion?

A

7%

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46
Q

What are the effects of secretin?

A

Counteracts acidity

  • Increases exocrine pancreatic secretion
  • inhibits acid/pepsinogen secretion
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47
Q

What are the manometric findings of Nutcracker Oesophagus?

A

High amplitude contractions with normal peristalsis

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48
Q

What is the histological findings of a leiomyoma?

A

Bundles of interlacing smooth muscle cells,

well-demarcated by adjacent tissue or by a definitive capsule

Tumour cells have blunt ended elongated nuclei with minimal atypic and few mitotic figures

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49
Q

What is the normal stomach pH?

A

About 2

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50
Q

What is the risk of SCC in patients with Achalsia?

A

Increased 10-50 times

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51
Q

What are the NICE criteria for bariatric surgery?

A

1) BMI≥40 or 35-40 with significant disease (T2DM/HTN)
2) All appropriate measures undertaken and failed
3) Intensive Tier 3 management available (completed with weight loss ≥5%)
4) Patient generally fit for anaesthesia
5) Person commits for need to follow up

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52
Q

What are the effects of somatostatin?

A

Decreases acid/pepsin/gastrin
Decreases pancreatic enzyme secretion
Decreases insulin and glucagon
Inhibits trophic effects of gastrin

STIMULATES gastric mucous production

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53
Q

What advice is given re pregnancy after bariatric surgery?

A

Avoid for 12 months due to risk of foetal malnutrition

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54
Q

Which trials are investigating the treatment of presurgery complete responders to CRT in AC oesophagus?

A

ESOstrate and SANO

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55
Q

What primary prophylaxis for bleeding is required for Grade 2 varices

A

Non-selective beta blocker - e.g. Propranolol or nadolol.

Band ligation only for rebreeding. Repeat 7-14days until gone

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56
Q

What is the probability of stricture formation when EMR >50% circumference

A

2/3

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57
Q

What are proven prognostic factors for GISTs?

A

Mitotic rate
Tumour size
Tumour site (Gastric>Rectal/SB)
Presence/absence of rupture

Combined in modified NIH classification - v.low, low, intermediate, high risk

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58
Q

What are the effects of CCK?

A

Promotes digestion

  • Pancreatic enzyme release (exocrine/endocrine)
  • Contraction of GB and SOD relaxation
  • DECREASED gastric emptying
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59
Q

What percentage of GOJ cancer have peritoneal metastases?

A

Up to 15%

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60
Q

What is the optimum treatment of oesophageal leiomyomas?

A

<5cm surveillance

>5cm or symptomatic - can be approach left or right thorax, muscle layer split and lesion enucleated

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61
Q

What scoring system is used for Achalasia symptoms?

A

Eckardt score

Good outcome if ≤3, poor ≥3.
Composite of dysphagia, regurgitation, chest pain and weight loss

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62
Q

Where are lymph node metastases most frequently seen in oesophageal adenocarcinomas?

A

Left gastric (17) - 24% and paraesophaeal stations (8M/8L) - 18%

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63
Q

Which type of achalsia has the most favourable prognosis?

A

Type 2 >Type 1 >Type 3

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64
Q

In what proportion of cases of mid 1/3 SCC will cervical lymph nodes be positive?

A

17%

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65
Q

What is the RCT evidence for a minimally invasive approach to oesophagectomy?

A

TIME Trial (2012 Lancet) – open vs MIO (56 vs 59) – Pulmonary infection RR 0.30

MIRO Trial (2019 NEJM) – open vs hybrid (104 vs 103) – major complications OR 0.31, pulmonary 18 vs 30%. Survival not different QOL better up to 2 years post-surgery (when most patients die)

ROMIO trial awaited

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66
Q

What percentage of primary gastric tumours are lymphomas?

A

about 5%, typically present with vague symptoms with vague endoscopic findings.

complete regression with H.Pylori eradication may be seen

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67
Q

What medical treatment should patients with Barrett’s oesophagus receive?

A

High dose PPI (80mg esomeprazole)
?Aspirin

ASPECT trial 2018 says better for high dose PPI than low dose in preventing composite of HGD, OAC and death.

?Aspirin

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68
Q

How frequently is Barretts seen on OGD for reflux symptoms?

A

15-20%

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69
Q

Where are pulsion diverticulae most common in the oesophagus?

A

distal oesophagus, right posterolateral wall

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70
Q

What are the Lauren types of gastric adenocarcinoma and which has the best prognosis?

A

Intestinal and Diffuse - Intestinal better prognosis (20% vs 10% at 5 years)

Intestinal has M:F of 2:1 (Diffuse equal) and higher age of detection (55 vs 45)

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71
Q

What lymph nodes are removed at a D3 gastric resection?

A

D1 (1-7) + D2 (8-12) + 14-15

14 -root of SMA
15 - middle colic

(nb - not 13, posterior to pancreatic head)

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72
Q

What is the standard management of GISTs <2cm

A

Serial imaging - without biopsy

For larger tumours an EUS guided biopsy for diagnosis is helpful, small risk of seeding

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73
Q

For primary gastric lymphoma, which is the most common cell type?

A

B cell lymphomas

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74
Q

How is a thoracic oesophageal perforation repaired?

A

Thoracotomy
Two layer repair with suturing of mucosa and muscularis (25-50% failure rate)
Buttress if possible +/- T-tube
Need to extend muscular incision as mucosal injury will be greater

Feeding jejunostomy + gastric decompression

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75
Q

How long after PPIs will a h.pylori stool or breath test be accurate?

A

2 weeks

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76
Q

What are the testing strategies for H.pylori (5)?

A

1) C13/C14 breath tests - diagnosis/confirmation of eradication (cannot be used if Abx <4 weeks)
2) Blood IgG - initial diagnosis only
3) Rapid urease testing (Clo) diagnosis and confirm eradication - 80-95% sens, 90-100% spec
4) Histology (gold standard, resource intensive)
5) Culture (gold standard, resource intensive, difficult)
6) Stool antigen test

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77
Q

Which bariatric surgery procedure has the greatest long term weight loss?

A

Total At 10 years:

Bypass 25%
Sleeve 17%
Band 14%

Excess body weight loss At 5 years:

Bypass 63%
Sleeve 53%
Band 48%

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78
Q

What is the most useful investigation for Leiomyoma of the oeosophagus?

A

EUS - typical appearance with no invasion of muscularis layer. Biopsies are often non-diagnostic and can disrupt tissue planes prior to resection

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79
Q

What are the weight loss service tiers in the NHS?

A

Tier 1 - community based
Tier 2 - Advice from GP and medication (Orlistat, Mysimba [naltrexone/burprenorphine], Saxenda [liraglutide]
Tier 3 - Specialist weight management (MDT)
Tier 4 - Bariatric surgery

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80
Q

What scoring systems can be used to help predict success of NOM in oesophageal perforation

A

Altorjay criteria

Early, well, contained, no esophageal disease, close observation possible

Pittsburgh classification

Well, young patients, with contained leak, early presentation and no cancer

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81
Q

What is the lymph node metastasis rate for T1a oesophageal cancer?

A

M1 - epithelial layer 0%
M2 - invasion of lamina propria 0%

M3 SCC - Invasion of muscularis mucosae 0-8%
M3 AC - Invasion of muscularis mucosae 1.8-4.5%

Overall SCC 0-3%
Overall AC 1.3-2%

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82
Q

What interventional procedure at OGD has the highest risk of perforation?

A

Stent placement 5-25%

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83
Q

What hormones decrease gastric acid production? (3)

A

Somatostatin (via decreased histamine)
Cholecystokinin
Secretin

84
Q

What proportion of patients with CREST syndrome develop reflux?

85
Q

What are the differences between Idiopathic achalasia and Chagas disease?

A

In Chagas disease both excitatory and inhibitory neurones are lost (cf IA - inhibitory only) and the LES pressure is variable

86
Q

What comprises a D4 gastric resection?

A

D1 (1-7) + D2 (8-12) + D3 (14-15) + 16

16- Para-aortic nodes

87
Q

What is the Los Angeles Classification for oesophagitis? (4)

A

A - one fold <5mm
B - one fold >5mm
C - multiple folds <75% circumference
D - multiple folds >75% circumference

88
Q

What are the characteristics of H.pylori organism?

A

Gram negative helical rod
Microaerophillic
Produces urease enzyme (hydrolyses urea –> NH3)
NH3 affects astral G cells –> release of gastrin

Cannot colonise native duodenal mucosa, but can induce metaplasia then colonise and inflame.

89
Q

What factors may relax the LOS

A

Alcohol, smoking and caffeine

90
Q

What types of wrap are used with a fundoplication?

A

Nissen - posterior 360
Toupet - posterior 270
Dor - anterior 180
Watson - anterior 120

91
Q

What factors are measured in pH monitoring (6)?

A

Number of reflux episodes (pH<4) - Normal <50
%total time<4 (<5%)
%upright time<4 (<8%)
%supine time<4 (<3%)

Number episodes >5 minutes (<3)
Longest reflux time

Demeester score >14.7 considered pathological

Most useful is total reflux time and symptom correlation

92
Q

What are the characteristics of a normal lower oesophageal sphincter?

A

3-4cm with pressure of 10-25mmHg

93
Q

What is the most diagnostic measurement for Achalasia?

A

HRM - Supine integrated relaxation pressure (IRP) >15mmHg

SIRP - mean of 4s of maximal relaxation at beginning of UES relaxation, referenced to gastric pressure

94
Q

What surveillance should patients with Barrett’s oesophagus undergo?

A

BSG guidelines

Non-dysplastic
<3cm - 3-5 years
≥3cm 2-3years

Quadrantic biopsies every 2cm (Seattle protocol every 1cm is no better)

Dysplastic (2 GI Pathologists)
Indefinite - repeat 6 months with maximal acid suppression
LGD - repeat 6 months, if confirmed probably should have RFA (42% HGD at 4 years)
HGD - ESD>EMR/RFA (40% risk of adenocarcinoma)

EUS often unhelpful

95
Q

How long are the biliarypancreatico and ailmentary limbs typically made in a gastric bypass (for weight loss)?

A

BP 50cm

Ailmentary 100cm

96
Q

What is the 5 year success rate of Pneumatic Dilatation for achalasia?

A

90% 1 year, 86% 2 years, 82% 5 years, 50% 10 years

25-33% need repeat within 5 years

Graded PD using 30–>35–>40 balloons

Risk of perforation of about 5%

97
Q

Which lymph node station contains subcarinal lymph nodes in an oesophagectomy?

A

Station 7

picture is TNM7

98
Q

What is the recommended initial treatment of oeosophagitis (if severe)?

A

Full dose (e.g. 40mg oemp/esomep) for 8 weeks - if fails switch or go high dose

99
Q

What drug characteristically enhances contraction of the LOS?

A

Metoclopramide vagally mediated

100
Q

What is the most common soft tissue sarcoma?

101
Q

What diagnostic stains are useful for GISTs?

A

only 1% are immunonegative for CD117 and DOG1

If doubt, molecular analysis for KIT1/PDGFRA

102
Q

What late complications are typically associated with a gastric bypass?

A

Marginal ulcer-Smoking cessation, avoid NSAIDS, PPI, consider anastomosis revision
Anastomotic stricture-Endoscopic dilatation
Internal hernia-Laparoscopy and reduction of hernia, closure of spaces

103
Q

Where is CCK produced?

A

I cells in upper SI, released in response to partially digested proteins and TGs

104
Q

How frequent is reflux disease in Western populations?

105
Q

What evidence for POEM vs Heller vs PD

A

Ponds 2019 JAMA - 2 year treatment success 92% POEM 54% PD

Werner 2019 NEJM - 2 year treatment success equivalent POEM/Heller+Dor
Higher reflux POEM, Higher complications Heller

106
Q

What are the most common mutations associated with GISTs?

A

KIT or PDGFRA,

More rarely NF1 and BRAF

NB
Carney Triad syndrome (gastric GIST, paraganlgioma, pulmonary chondroma)
Carney-Stratakis syndrome
Type 1 NF
Familial GIST
107
Q

What tests should be sent if a chylothorax is suspected?

A

Presence of chylomicrons
TG>110mg/dL
Cholesterol<200mg/dL

Fluid to serum cholesterol ratio <1 and TG ratio>1

108
Q

What is the Paris Criteria for oesophageal lesions?

A

Descriptive of anatomical appearance I-III
I raised
2 flat
3 excavated

109
Q

How can Barrett’s be subdivided?

A

Long >3cm and short segment <3cm

110
Q

How is a reflux episode defined during pH monitoring?

111
Q

What classification systems for caustic ingestion exist?

A

CT
Grade 1 - homogenous enhancement of wall without oedema/fat stranding
Grade 2a - enhancement of oesophageal mucosa with oedema and enhancement of outer wall –> target
Grade 2b - no enhancement of mucosa (necrotic)
Grade 3 - no post contrast wall enhancement

Zargar’s Endoscopic
Grade 0 - normal
Grade 1 - superficial mucosal oedema and erythema
Grade 2 - mucosal ulceration (2a superficial, 2b deep)
Grade 3 - transmural ulceration with necrosis (3a Focal, 3b Extensive)
Grade 4 - perforation

112
Q

Where is gastric acid produced?

A

Oxyntic glands of Parietal cells of stomach, maintained by H/K ATPase

113
Q

Which type of gastrojejunostomy empties most effectively?

A

Posterior retrocolic

114
Q

What are the effects of VIP?

A

Digestion

  • Stimulates secretion by pancreas/intestines
  • inhibits acid/pepsinogen
115
Q

How are BMI categories altered in asian patients?

A

reduced by 2.5

116
Q

When might an endoscopic approach be appropriate for gastric cancers?

A

JGCA

  • T1a non ulcerated, differentiated <2cm - EMR/ESD
  • T1a with ulceration <3cm - ESD
117
Q

For localised GIST, when should Imatinib be given?

A

Neoadjuvant If immediate primary resection is difficult or morbid
Adjuvant for 3 years if high risk

118
Q

How many biopsies for suspicious mucosal lesions at OGD?

119
Q

What percentage of oeosophageal tumours are benign?

120
Q

What is the characteristic finding seen after ingestion of Ammonia?

A

Superficial haemorrhagic gastritis evolving over 24-48 hours

NB airway burns from vapour

121
Q

What follow up do patients undergoing bariatric surgery require?

A

For all - nutrition and CNS for 1 year
For bands - inflation increments
For sleeves and bypass - micronutrients, with regular monitoring of FBC, U&E, LFT, Folic acid, Ca, PTH, Vitamin D, Lipids, B1, B12, Vitamin A,EK

122
Q

What is the Siewert staging system for GOJ tumours?

A

Siewert 1 - Tumour epicentre 1-5cm above anatomic GOJ
Siewert 2 - Tumour epicentre 1cm above to 2cm below anatomic GOJ
Siewert 3 - Tumour epicentre 2-5cm below GOJ - treat as gastric

123
Q

What is the most common type of gastric polyp?

A

Fundic gastric polyps

Usually <0.5cm, commonly associated with HP
Small malignancy risk, polypectomy if >1cm
Can be associated with polyposis syndromes if multiple

124
Q

What is the treatment of metastatic/recurrent GIST?

A

Imatinib –> Sunitinib –> Regorafenib

125
Q

What is the increased risk of OAC in patients with Barretts?

A

OR of 11.3, 0.33% annual incidence in non-dysplastic

126
Q

What treatment is required for pancreatic heterotypia

A

These are gastric nodules of pancreatic tissue and require no treatment (although pancreatic pathology can occur in them)

127
Q

In which Lauren type of Gastric Adenocarcinoma are signet cells seen?

A

Diffuse type

Due to prominent mucin production within storm and outside glands.

128
Q

What is the most frequently occurring benign oesophageal tumour?

A

Leiomyoma (75%)

Others such as fibromas, neuromuscular tumour and NETS are very rare

129
Q

What are the BSG guidelines for gastric polyps?

A
  • All types of gastric polyp detected at endoscopy need to be sampled for which forceps biopsy usually suffices
  • Biopsy of intervening non-polypoid gastric mucosa is recommended for all hyperplastic and adenomatous polyps
  • If Helicobacter pylori is detected in patients with hyperplastic and adenomatous polyps, it should be eradicated
  • All gastric polyps with dysplastic foci and symptomatic polyps should be completely removed
  • All gastric adenomatous polyps should be removed when safe to do so
  • If adenomatous polyps are detected, an examination of the whole stomach should be made for mucosal abnormalities and any such abnormalities should be biopsied
  • Repeat gastroscopy should be performed at 1 year for all polyps with dysplasia that have not been removed
  • Repeat gastroscopy should be performed at 1 year following complete polypectomy for high risk polyps
130
Q

What are the types of gastritis (5)?

A

Type A - autoimmune (antral sparing, parietal cell antibodies, hypochlorhydria, loss of IF and B12, elevated gastrin levels)

Type B - antral (H.pylori)

Reflux - bile reflux (chronic inflammation, foveolar hyperplasia –> Prokinetics)

Erosive - NSAIDS(/etoh, COX1)

Stress - diffuse ulceration following hypotension (most sensitive GIT)

Menetriers disease - gross hypertrophy, premalignant

131
Q

What is Plummer Vinson syndrome?

A

Oesophageal web with Iron deficiency –> dysphagia

132
Q

What is the upper oesophageal sphincter comprised of?

A

Cricopharyngeus and proximal oesophageal musculature

133
Q

Where is gastrin produced?

A

G cells in antrum of stomach

134
Q

What is the eponymous disease presenting similarly to Achalasia?

A

Chagas disease - caused by Trypanosoma Cruzi.

135
Q

What is chronic afferent loop syndrome?

A

Abdominal pain after eating where an afferent (BP) loop is compressed for mechanical reasons and progressively enlarges causing pain.

Relieved by vomiting, which will be bile

136
Q

What is the Prague Criteria for Barrett’s oesophagus?

A

C/M extent + Islands

137
Q

What is the risk of malignancy in 1 2cm gastric adenomatous polyp?

A

50%

Often associated with chronic gastric metaplasia

138
Q

What are the effects of gastrin release?

A

Increase HCl, pepsinogen and IF secretion

Increases gastric motility

139
Q

What late complications are typically associated with a gastric band (5)?

A

1) Port / tubing issues-Port replacement or shortening of tube
2) Oesophagitis-OGD +/-deflation or removal
3) Slippage-AXR +/-water soluble contrast- repositioning or removal
4) Gastric pouch-Water soluble contrast swallow/ OGD-Deflation +/-gradual refilling or removal
5) Erosion-Removal

140
Q

What is the optimum management of Caustic ingestion?

A 
Type 1 -2 (CT) --> NOM
If deterioration, repeat CT
Grade 1 - discharge 24-48 hours no follow up
Grade 2a - <20% risk of strictures
Grade 2b - >80% risk of strictures
141
Q

What lymph nodes are removed in a D1 gastric resection?

A

Stations 1-7

Lesser/Greater curve + Left gastric

142
Q

In which phase is most gastric acid secreted?

A

Cephalic phase (smell/taste) –> vagal stimulation of gastrin and acid (30%)

Gastric phase (distension) –> low H+/peptides and gastrin release (60%)

Intestinal phase (food in duodenum) –> high acid/distension/hypertonic in duodenum inhibits gastric acid secretion (10%)

143
Q

What is the classification of Peptic Ulcers

A

Modified Johnson

  1. body of stomach (not associated with acid hyper secretion) (50%)
  2. Body in combination with duodenal ulcers (acid ++) (25%)
  3. Pyloric channel within 3cm of pylorus (acid ++) (20%)
  4. Proximal GOJ <10%)
  5. Chronic NSAID use
144
Q

When is surgery ideally performed for oesophageal perforation (if necessary)

A

within 24 hours - mortality 10% vs 30% after

145
Q

What is Menetriers disease?

A

Rare form of acquired gastropathy
Characteristic - foveolar hyperplasia + absent oxyntic glands
Giant rugal folds >1cm persisting after insufflation
Antral sparing
Diagnosed on deep biopsies (pit to gland ratios)
Risk of malignancy of 10% at 1 year

146
Q

What is Hereditary Diffuse gastric cancer?

A

CDH 1 mutation
Average age diagnosis of 38
Associated with lobular Brest cancers and cleft lip
60-70% risk of cancer

147
Q

What bacteria are involved in cholecystitis?

A

Primarily chemical, but secondary infections from gut

  • E.Coli, Kelbsiella and Step Faecalis (aerobic)
  • Bacteroides fragilis, clostridia (anaerobic)

Often mixed

148
Q

What is the muscular composition of the oesophagus?

A

Overall - external longitudinal, inner circular

For external
Top 1/3 - voluntary striated
Middle 1/3 - striated and smooth
Bottom 1/3 - smooth muscle

149
Q

How many sequential oesophageal dilatation should be attempted in 1 sitting?

A

No more than 3

150
Q

When should fluoroscopic guidance be used for oesophageal stricture dilatation?

A

High risk

  • post radiation/caustic
  • impassable endoscopically
  • long, angulated or multiple
151
Q

When should contrast studies be performed after oesophageal dilatation?

A

Not routinely, only if chest pain, fever, breathlessness or tachycardia

152
Q

How frequently should dilatation be performed for stricture?

A

Weekly or bi-weekly until ≥15mm dilator placed

153
Q

What size of pneumatic balloon should be used in achalasia?

A

30mm, with build up to 35 and 40mm

154
Q

What are typical indications for oesophageal dilatation?

A 
Achalsia
Post-radiation
Caustic ingestion
Post-operative/post-endoscopic
Eosinophilic oesophagitis
Schatzki's ring (if symptomatic)
Peptic strictures
155
Q

Where do Dieulafoy’s lesions most commonly occur?

A

In the stomach submucosa - large tortuous arteriole

156
Q

When should the urea 13c breath test and helicobacter stools antigen tests not be performed?

A

Within 2 weeks of PPI

Within 4 weeks of antibacterial treatment

157
Q

What is the triple therapy for H.Pylori?

A

No allergy:
1st line PPI + Amox + Clari or metronidazole (7/7)
2nd linePPI + Amox + metronidazole or Clari (other choice) (7/7)

3rd line - PPI + Bismuth subsalicylate + 2 x antibiotics or rifabutin

Pen allergy:
1st PPI + Clari + Metro (7/7)
2nd PPI + Metro + levo

158
Q

In which patients should an open approach to repair of peptic ulcer be adopted?

A

Unstable, severe CV comorbidity, especially if old

159
Q

What factors contribute to the prevention of GORD (6)?

A

1) Crura
2) Oblique Angle of GOJ
3) Apposition of mucosal folds
4) Phreno-oesophageal ligament
5) Intra-abdominal pressure compressing intra-abdominal oesophagus
6) High pressure zone of LOS

160
Q

Where is gastric cancer most common in the West?

A

Proximally (distally in East)

161
Q

Which blood group has an increased incidence of gastric cancer?

162
Q

What influence do KIT and DOG positivity have on prognosis for GIST?

163
Q

When is a PET CT not useful for OG cancers?

A
  • Obvious metastatic disease
  • T1a Oesophageal cancer
  • Gastric cancer unless suspecting occult metastatic disease
164
Q

When should patients with a BMI of 30-35 be referred for consideration for bariatric surgery?

A

Recent diagnosis of T2DM

165
Q

What length of Roux Limbs should be used for a cancer reconstruction?

A

50cm BP

50cm Alimentary

166
Q

What conditions produce foveolar hyperplasia?

A

Reflux gastritis (resection or cholecystectomy)
NSAIDS
Alcohol

167
Q

What is Gurvits syndrome?

A

Acute oesophageal necrosis.

M:F in 6th decade, DKA

168
Q

What is the most common type of gastric polyp?

A

Fundic (75%) - may be more common in patients on acid suppression

169
Q

What are some risk factors for gastric cancer?

A 
STK11 (Peutz Jaegers)
Helicobacter
EBV
Smoking
Low fibre  diet
CDH-1 (1-3% of cancers,  60-70% risk)
170
Q

What is Jackhammer oesophagus?

A

A specific type of Nutcracker oesophagus (hyper contractile) - with a distal contractile interval of >8000

171
Q

What conditions are associated with eosinophilic oesophagitis?

A

Asthma, coeliac disease

Get trachealisation or concentric rings with white plaques in oesophagus

172
Q

How should post ERCP bleeding be treated?

A

Re-ERCP and treatment

173
Q

What is the most common site of a peptic ulcer?

A

Duodenum 2 -3x more than stomach

174
Q

Where is the primary site of intestinal sodium reabsorption?

175
Q

What are the regions of the mediastinum?

A

Superior

Inferior - posterior/anterior/middle

176
Q

What are the contents of the superior mediastinum?

A 
Arteries (4)
-Arch of aorta
-right brachiochephalic
-left subclavian
-left common carotid arteries
Veins (3)
-SVC
-right brachiocephalic
-left braciocephalic
Organs (3)
-Oesophagus
-Trachea
-Thymus
Nerves (3)
-Left recurrent laryngeal
-Phrenic
-Vagus

Other
-Thoracic duct

177
Q

What are the contents of the anterior mediastinum?

A

Fat + LN + thymus

178
Q

What are the contents of the middle mediastinum?

A
  • Pericardium
  • Heart
  • Aortic root
  • Arch of azygos vein
  • Main bronchi
179
Q

What are the contents of the posterior mediastinum

A 
Oesophagus
Aorta
Azygos vein
Thoracic duct
Vagus nerve
Sympathetic nerve trunks
Splanchnic nerves
180
Q

How is the thoracic duct related to the oeosphagus?

A

Mostly posterior - passes to left at T5

181
Q

What is a specific contraindication for sleeve gastrectomy?

182
Q

What vitamin deficiencies can be seen post bypass?

A

Vitamin B3/12/1

Vitamin D

183
Q

What is Wernickes triad?

A

Thiamine

Ophthalmoplegia, cerebellar dysfunction, confusion

184
Q

What is the most important vitamin deficiency post bariatric surgery?

A

Thiamine - short half life of body stores 9-18 days

185
Q

Which nerves are divided in a highly selective vagotomy?

A

Nerves of Laterjet

186
Q

How many segments does each lung contain?

187
Q

How many lobes are in each lung?

A

Right - 3 (oblique/transverse fissures)

Left - 2 (lingual)

188
Q

At what surface landmarks is the inferior borders of the lung?

A

MC line - 6th rib
MA line - 8th rib
Posteriorly - 10th rib

Pleura two ribs lower

189
Q

How should patients with small GISTS be treated?

A

If <2cm, surveillance with annual EUS (BSG 2017)

190
Q

How should patients with NSAID associated ulcers and H.pylori be treated?

A

2 months of PPI, stop NSAID, then first line eradication regime

191
Q

How long after decontamination should gastroscopes be used?

A

Within 3 hours

192
Q

What factor would suggest that GISTS are completely insensitive to TKIs?

A

c-KIT wild type

193
Q

What treatment is given for KIT exon 17 GISTS?

A

Regorafenib

194
Q

What treatment is given for KIT exon 9 GISTS?

A

Imatinib - may benefit given dose escalation as well

195
Q

What is the minimum examination time for Barretts screening?

196
Q

How long should patients be observed post dilatation?

197
Q

What medication can reduce the risk of stricturing after large EMRs?

A

Oral prednisone

198
Q

what is the optimum management of a Type 3 Todani Choledochal cyst?

A

Spincteroplasty +/- excision (low risk malignant transformation)

199
Q

What staging investigations after CT are required for cholangiocarcinoma?

A

Staging lap

200
Q

What is the incidence of H.Pylori in perforated duodenal ulcer?

A

90-95% so treat empirically

201
Q

What histo stain would be more consistent with carcinoma than lymphoma?

A

Pancytokeratin

202
Q

from where does the right gastric artery arise?

A

Proper hepatic

203
Q

What is the size of the gastric pouch in bariatric procedures?

A

Band/Bypass - 20ml

Sleeve 150-200ml

204
Q

What are the diagnostic criteria for chylothorax?

A

Triglyceride >110mg/dl
Cholesterol <200mg/dL
Presence of chylomicrons

Use medium chain fatty acids

205
Q

What is the lifetime risk of Oesophageal and Gastric Cancers?

A

2% M 1% F Oesophageal

1% Gastric

FRCS (13 decks)

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