OG Flashcards
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%
2
Q
What is the investigation of choice for Achalsia?
A
High resolution manometry (>normal resolution)
Intraluminal circumferential pressures at 1cm over 26cm
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
4
Q
Where do oesophageal leiomyomas most frequently occur?
A
Distal 2/3 of oesophagus, 5% multiple
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
6
Q
In early oesophageal cancers, is SCC or Adenocarcinoma more likely to have lymph node metastases?
A
SCC
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
8
Q
What is the characteristic finding in achalasia
A
Loss of ganglion cells in Auerbachs plexus
9
Q
Which lymph node stations were removed between TNM7 and TNM 8 esophagus
A
5 and 6
10
Q
Which hormones increase (1) and decrease (3) gastric emptying?
A
Increase - gastrin
Decrase - GIP, CCK, Enteroglucagon
11
Q
What is the most common origin cell of a gastric lymphoma?
A
Metastatic non gastric primary
12
Q
Where is secretin released?
A
S cells in SI
in response to acidic chyme and FAs
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
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
15
Q
Where is gastric inhibitory peptide secreted?
A
K cells of duodenum an jejunum
in response to FAs and glucose
16
Q
Where is Somatostatin produced?
A
D cells in pancreas and stomach
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
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%
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%
20
Q
What length of myotomy should be performed for a LHM
A
8cm - 6cm proximal to GOJ and 2-3cm distal
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
22
Q
Where is the pH electrode placed?
A
5cm above manometrically determined upper border of LOS
23
Q
What are the 4 types of hiatus hernia?
A
1 sliding (95%)
2 paraoesophageal
3 mixed
4 giant
24
Q
Which radioactive material is typically used for brachytherapy of the oesophagus?
A
Iridium -192
25
What Types of achalsia are there?
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
26
In what circumstances can a T1b AC of the esophagus be managed by ESD?
ESMO guidelines 2016
| SM1 - <500um invasion, L0,V0, G1/2, <20mm diameter)
27
Dilation of oesophageal cancer carries what risk of perforation?
4-6%
28
In which cells are the problem in Pernicious anaemia?
The parietal cells failing to produce sufficient IF (gastric antrum)
29
What factors increase gastric acid secretion (3)?
Vagal nerve stimulation
Gastrin release
Histamine release from enterochromaffin like cells
30
What is the lymph node metastasis rate for T1b oesophageal tumours?
```
sm1 = 6% AC 27% SCC
sm2 = 23% AC 36% SCC
sm3 = 58% AC 55% SCC
```
31
What are the effects of GIP?
Mostly increased insulin release
| Small decrease in gastric acid release
32
How wide is stomach typically left behind after a sleeve gastrectomy?
About 4cm
33
What are the characteristics of Gastric lymphoma?
5% of gastric malignancies - mostly B cell lymphomas
May regress with H Pylori eradication
More commonly are metastatic
34
What is the evidence for LARS?
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)
35
What is are the points of FB impaction in the oesophagus
1) Hypopharynx (cricopharynxgeus)
| 2) Upper thoracic oesophagus (Aortic arch, low pressure zone at transition between striated and smooth muscle fibres)
36
How do oesophageal leiomyomas tend to present?
Incidental finding on OGD. Tend to have more symptoms >5cm, dysphagia and reflux
37
What proportion of patients with systemic sclerosis have oesophageal involvement?
Systemic sclerosis - skin thickening, skin oedema, with 80% oesophageal involvement
Smooth muscle atrophy at LOS
38
What is the characteristic change seen with Barrett's oesophagus?
Metaplastic change from stratified squamous to columnar gastric epithelium.
Three types - intestinal (high risk), cardiac and funds
39
What are the characteristic physiological findings of Achalasia?
1) Absence of swallow-induced relaxation of the LOS
| 2) Absence of peristalsis along oesophageal body
40
What are the characteristic histological findings of Schatzki rings?
They are typically found at the OG junction, with oesophageal mucosa above and columns epithelium below
41
What is the most common site of benign gastric ulcer?
Lesser curve (50%)
42
What is the best diagnostic test for transmural necrosis after caustic ingestion?
Contrast CT at 3-6 hours > OGD - WSES guidelines
| Looking for absence of post-contrast wall enhancement
43
What effect dose vagal stimulation have on gastric emptying?
Increases it (nb vagotomy --> pyloroplasty)
44
In what percentage of patients with gastric ulceration is H.pylori implicated?
60%
45
What is the lifetime risk of oesophageal Adenocarcinoma after caustic ingestion?
7%
46
What are the effects of secretin?
Counteracts acidity
- Increases exocrine pancreatic secretion
- inhibits acid/pepsinogen secretion
47
What are the manometric findings of Nutcracker Oesophagus?
High amplitude contractions with normal peristalsis
48
What is the histological findings of a leiomyoma?
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
49
What is the normal stomach pH?
About 2
50
What is the risk of SCC in patients with Achalsia?
Increased 10-50 times
51
What are the NICE criteria for bariatric surgery?
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
52
What are the effects of somatostatin?
Decreases acid/pepsin/gastrin
Decreases pancreatic enzyme secretion
Decreases insulin and glucagon
Inhibits trophic effects of gastrin
STIMULATES gastric mucous production
53
What advice is given re pregnancy after bariatric surgery?
Avoid for 12 months due to risk of foetal malnutrition
54
Which trials are investigating the treatment of presurgery complete responders to CRT in AC oesophagus?
ESOstrate and SANO
55
What primary prophylaxis for bleeding is required for Grade 2 varices
Non-selective beta blocker - e.g. Propranolol or nadolol.
| Band ligation only for rebreeding. Repeat 7-14days until gone
56
What is the probability of stricture formation when EMR >50% circumference
2/3
57
What are proven prognostic factors for GISTs?
Mitotic rate
Tumour size
Tumour site (Gastric>Rectal/SB)
Presence/absence of rupture
Combined in modified NIH classification - v.low, low, intermediate, high risk
58
What are the effects of CCK?
Promotes digestion
- Pancreatic enzyme release (exocrine/endocrine)
- Contraction of GB and SOD relaxation
- DECREASED gastric emptying
59
What percentage of GOJ cancer have peritoneal metastases?
Up to 15%
60
What is the optimum treatment of oesophageal leiomyomas?
<5cm surveillance
| >5cm or symptomatic - can be approach left or right thorax, muscle layer split and lesion enucleated
61
What scoring system is used for Achalasia symptoms?
Eckardt score
Good outcome if ≤3, poor ≥3.
Composite of dysphagia, regurgitation, chest pain and weight loss
62
Where are lymph node metastases most frequently seen in oesophageal adenocarcinomas?
Left gastric (17) - 24% and paraesophaeal stations (8M/8L) - 18%
63
Which type of achalsia has the most favourable prognosis?
Type 2 >Type 1 >Type 3
64
In what proportion of cases of mid 1/3 SCC will cervical lymph nodes be positive?
17%
65
What is the RCT evidence for a minimally invasive approach to oesophagectomy?
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
66
What percentage of primary gastric tumours are lymphomas?
about 5%, typically present with vague symptoms with vague endoscopic findings.
complete regression with H.Pylori eradication may be seen
67
What medical treatment should patients with Barrett's oesophagus receive?
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
68
How frequently is Barretts seen on OGD for reflux symptoms?
15-20%
69
Where are pulsion diverticulae most common in the oesophagus?
distal oesophagus, right posterolateral wall
70
What are the Lauren types of gastric adenocarcinoma and which has the best prognosis?
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)
71
What lymph nodes are removed at a D3 gastric resection?
D1 (1-7) + D2 (8-12) + 14-15
14 -root of SMA
15 - middle colic
(nb - not 13, posterior to pancreatic head)
72
What is the standard management of GISTs <2cm
Serial imaging - without biopsy
For larger tumours an EUS guided biopsy for diagnosis is helpful, small risk of seeding
73
For primary gastric lymphoma, which is the most common cell type?
B cell lymphomas
74
How is a thoracic oesophageal perforation repaired?
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
75
How long after PPIs will a h.pylori stool or breath test be accurate?
2 weeks
76
What are the testing strategies for H.pylori (5)?
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
77
Which bariatric surgery procedure has the greatest long term weight loss?
Total At 10 years:
Bypass 25%
Sleeve 17%
Band 14%
Excess body weight loss At 5 years:
Bypass 63%
Sleeve 53%
Band 48%
78
What is the most useful investigation for Leiomyoma of the oeosophagus?
EUS - typical appearance with no invasion of muscularis layer. Biopsies are often non-diagnostic and can disrupt tissue planes prior to resection
79
What are the weight loss service tiers in the NHS?
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
80
What scoring systems can be used to help predict success of NOM in oesophageal perforation
Altorjay criteria
Early, well, contained, no esophageal disease, close observation possible
Pittsburgh classification
Well, young patients, with contained leak, early presentation and no cancer
81
What is the lymph node metastasis rate for T1a oesophageal cancer?
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%
82
What interventional procedure at OGD has the highest risk of perforation?
Stent placement 5-25%
83
What hormones decrease gastric acid production? (3)
Somatostatin (via decreased histamine)
Cholecystokinin
Secretin
84
What proportion of patients with CREST syndrome develop reflux?
70%
85
What are the differences between Idiopathic achalasia and Chagas disease?
In Chagas disease both excitatory and inhibitory neurones are lost (cf IA - inhibitory only) and the LES pressure is variable
86
What comprises a D4 gastric resection?
D1 (1-7) + D2 (8-12) + D3 (14-15) + 16
16- Para-aortic nodes
87
What is the Los Angeles Classification for oesophagitis? (4)
A - one fold <5mm
B - one fold >5mm
C - multiple folds <75% circumference
D - multiple folds >75% circumference
88
What are the characteristics of H.pylori organism?
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
What factors may relax the LOS
Alcohol, smoking and caffeine
90
What types of wrap are used with a fundoplication?
Nissen - posterior 360
Toupet - posterior 270
Dor - anterior 180
Watson - anterior 120
91
What factors are measured in pH monitoring (6)?
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
What are the characteristics of a normal lower oesophageal sphincter?
3-4cm with pressure of 10-25mmHg
93
What is the most diagnostic measurement for Achalasia?
HRM - Supine integrated relaxation pressure (IRP) >15mmHg
SIRP - mean of 4s of maximal relaxation at beginning of UES relaxation, referenced to gastric pressure
94
What surveillance should patients with Barrett's oesophagus undergo?
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
How long are the biliarypancreatico and ailmentary limbs typically made in a gastric bypass (for weight loss)?
BP 50cm
| Ailmentary 100cm
96
What is the 5 year success rate of Pneumatic Dilatation for achalasia?
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
Which lymph node station contains subcarinal lymph nodes in an oesophagectomy?
Station 7
| picture is TNM7
98
What is the recommended initial treatment of oeosophagitis (if severe)?
Full dose (e.g. 40mg oemp/esomep) for 8 weeks - if fails switch or go high dose
99
What drug characteristically enhances contraction of the LOS?
Metoclopramide vagally mediated
100
What is the most common soft tissue sarcoma?
A GIST
101
What diagnostic stains are useful for GISTs?
only 1% are immunonegative for CD117 and DOG1
If doubt, molecular analysis for KIT1/PDGFRA
102
What late complications are typically associated with a gastric bypass?
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
Where is CCK produced?
I cells in upper SI, released in response to partially digested proteins and TGs
104
How frequent is reflux disease in Western populations?
20%
105
What evidence for POEM vs Heller vs PD
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
What are the most common mutations associated with GISTs?
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
What tests should be sent if a chylothorax is suspected?
Presence of chylomicrons
TG>110mg/dL
Cholesterol<200mg/dL
Fluid to serum cholesterol ratio <1 and TG ratio>1
108
What is the Paris Criteria for oesophageal lesions?
Descriptive of anatomical appearance I-III
I raised
2 flat
3 excavated
109
How can Barrett's be subdivided?
Long >3cm and short segment <3cm
110
How is a reflux episode defined during pH monitoring?
When pH<4
111
What classification systems for caustic ingestion exist?
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
Where is gastric acid produced?
Oxyntic glands of Parietal cells of stomach, maintained by H/K ATPase
113
Which type of gastrojejunostomy empties most effectively?
Posterior retrocolic
114
What are the effects of VIP?
Digestion
- Stimulates secretion by pancreas/intestines
- inhibits acid/pepsinogen
115
How are BMI categories altered in asian patients?
reduced by 2.5
116
When might an endoscopic approach be appropriate for gastric cancers?
JGCA
- T1a non ulcerated, differentiated <2cm - EMR/ESD
- T1a with ulceration <3cm - ESD
117
For localised GIST, when should Imatinib be given?
Neoadjuvant If immediate primary resection is difficult or morbid
Adjuvant for 3 years if high risk
118
How many biopsies for suspicious mucosal lesions at OGD?
6-8
119
What percentage of oeosophageal tumours are benign?
1%
120
What is the characteristic finding seen after ingestion of Ammonia?
Superficial haemorrhagic gastritis evolving over 24-48 hours
NB airway burns from vapour
121
What follow up do patients undergoing bariatric surgery require?
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
What is the Siewert staging system for GOJ tumours?
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
What is the most common type of gastric polyp?
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
What is the treatment of metastatic/recurrent GIST?
Imatinib --> Sunitinib --> Regorafenib
125
What is the increased risk of OAC in patients with Barretts?
OR of 11.3, 0.33% annual incidence in non-dysplastic
126
What treatment is required for pancreatic heterotypia
These are gastric nodules of pancreatic tissue and require no treatment (although pancreatic pathology can occur in them)
127
In which Lauren type of Gastric Adenocarcinoma are signet cells seen?
Diffuse type
Due to prominent mucin production within storm and outside glands.
128
What is the most frequently occurring benign oesophageal tumour?
Leiomyoma (75%)
Others such as fibromas, neuromuscular tumour and NETS are very rare
129
What are the BSG guidelines for gastric polyps?
* 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
What are the types of gastritis (5)?
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
What is Plummer Vinson syndrome?
Oesophageal web with Iron deficiency --> dysphagia
132
What is the upper oesophageal sphincter comprised of?
Cricopharyngeus and proximal oesophageal musculature
133
Where is gastrin produced?
G cells in antrum of stomach
134
What is the eponymous disease presenting similarly to Achalasia?
Chagas disease - caused by Trypanosoma Cruzi.
135
What is chronic afferent loop syndrome?
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
What is the Prague Criteria for Barrett's oesophagus?
C/M extent + Islands
137
What is the risk of malignancy in 1 2cm gastric adenomatous polyp?
50%
Often associated with chronic gastric metaplasia
138
What are the effects of gastrin release?
Increase HCl, pepsinogen and IF secretion
| Increases gastric motility
139
What late complications are typically associated with a gastric band (5)?
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
What is the optimum management of Caustic ingestion?
```
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
What lymph nodes are removed in a D1 gastric resection?
Stations 1-7
Lesser/Greater curve + Left gastric
142
In which phase is most gastric acid secreted?
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
What is the classification of Peptic Ulcers
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
When is surgery ideally performed for oesophageal perforation (if necessary)
within 24 hours - mortality 10% vs 30% after
145
What is Menetriers disease?
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
What is Hereditary Diffuse gastric cancer?
CDH 1 mutation
Average age diagnosis of 38
Associated with lobular Brest cancers and cleft lip
60-70% risk of cancer
147
What bacteria are involved in cholecystitis?
Primarily chemical, but secondary infections from gut
- E.Coli, Kelbsiella and Step Faecalis (aerobic)
- Bacteroides fragilis, clostridia (anaerobic)
Often mixed
148
What is the muscular composition of the oesophagus?
Overall - external longitudinal, inner circular
For external
Top 1/3 - voluntary striated
Middle 1/3 - striated and smooth
Bottom 1/3 - smooth muscle
149
How many sequential oesophageal dilatation should be attempted in 1 sitting?
No more than 3
150
When should fluoroscopic guidance be used for oesophageal stricture dilatation?
High risk
- post radiation/caustic
- impassable endoscopically
- long, angulated or multiple
151
When should contrast studies be performed after oesophageal dilatation?
Not routinely, only if chest pain, fever, breathlessness or tachycardia
152
How frequently should dilatation be performed for stricture?
Weekly or bi-weekly until ≥15mm dilator placed
153
What size of pneumatic balloon should be used in achalasia?
30mm, with build up to 35 and 40mm
154
What are typical indications for oesophageal dilatation?
```
Achalsia
Post-radiation
Caustic ingestion
Post-operative/post-endoscopic
Eosinophilic oesophagitis
Schatzki's ring (if symptomatic)
Peptic strictures
```
155
Where do Dieulafoy's lesions most commonly occur?
In the stomach submucosa - large tortuous arteriole
156
When should the urea 13c breath test and helicobacter stools antigen tests not be performed?
Within 2 weeks of PPI
| Within 4 weeks of antibacterial treatment
157
What is the triple therapy for H.Pylori?
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
In which patients should an open approach to repair of peptic ulcer be adopted?
Unstable, severe CV comorbidity, especially if old
159
What factors contribute to the prevention of GORD (6)?
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
Where is gastric cancer most common in the West?
Proximally (distally in East)
161
Which blood group has an increased incidence of gastric cancer?
A
162
What influence do KIT and DOG positivity have on prognosis for GIST?
None
163
When is a PET CT not useful for OG cancers?
- Obvious metastatic disease
- T1a Oesophageal cancer
- Gastric cancer unless suspecting occult metastatic disease
164
When should patients with a BMI of 30-35 be referred for consideration for bariatric surgery?
Recent diagnosis of T2DM
165
What length of Roux Limbs should be used for a cancer reconstruction?
50cm BP
| 50cm Alimentary
166
What conditions produce foveolar hyperplasia?
Reflux gastritis (resection or cholecystectomy)
NSAIDS
Alcohol
167
What is Gurvits syndrome?
Acute oesophageal necrosis.
M:F in 6th decade, DKA
168
What is the most common type of gastric polyp?
Fundic (75%) - may be more common in patients on acid suppression
169
What are some risk factors for gastric cancer?
```
STK11 (Peutz Jaegers)
Helicobacter
EBV
Smoking
Low fibre diet
CDH-1 (1-3% of cancers, 60-70% risk)
```
170
What is Jackhammer oesophagus?
A specific type of Nutcracker oesophagus (hyper contractile) - with a distal contractile interval of >8000
171
What conditions are associated with eosinophilic oesophagitis?
Asthma, coeliac disease
Get trachealisation or concentric rings with white plaques in oesophagus
172
How should post ERCP bleeding be treated?
Re-ERCP and treatment
173
What is the most common site of a peptic ulcer?
Duodenum 2 -3x more than stomach
174
Where is the primary site of intestinal sodium reabsorption?
Jejunum
175
What are the regions of the mediastinum?
Superior
| Inferior - posterior/anterior/middle
176
What are the contents of the superior mediastinum?
```
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
What are the contents of the anterior mediastinum?
Fat + LN + thymus
178
What are the contents of the middle mediastinum?
- Pericardium
- Heart
- Aortic root
- Arch of azygos vein
- Main bronchi
179
What are the contents of the posterior mediastinum
```
Oesophagus
Aorta
Azygos vein
Thoracic duct
Vagus nerve
Sympathetic nerve trunks
Splanchnic nerves
```
180
How is the thoracic duct related to the oeosphagus?
Mostly posterior - passes to left at T5
181
What is a specific contraindication for sleeve gastrectomy?
Barretts
182
What vitamin deficiencies can be seen post bypass?
Vitamin B3/12/1
| Vitamin D
183
What is Wernickes triad?
Thiamine
Ophthalmoplegia, cerebellar dysfunction, confusion
184
What is the most important vitamin deficiency post bariatric surgery?
Thiamine - short half life of body stores 9-18 days
185
Which nerves are divided in a highly selective vagotomy?
Nerves of Laterjet
186
How many segments does each lung contain?
10
187
How many lobes are in each lung?
Right - 3 (oblique/transverse fissures)
| Left - 2 (lingual)
188
At what surface landmarks is the inferior borders of the lung?
MC line - 6th rib
MA line - 8th rib
Posteriorly - 10th rib
Pleura two ribs lower
189
How should patients with small GISTS be treated?
If <2cm, surveillance with annual EUS (BSG 2017)
190
How should patients with NSAID associated ulcers and H.pylori be treated?
2 months of PPI, stop NSAID, then first line eradication regime
191
How long after decontamination should gastroscopes be used?
Within 3 hours
192
What factor would suggest that GISTS are completely insensitive to TKIs?
c-KIT wild type
193
What treatment is given for KIT exon 17 GISTS?
Regorafenib
194
What treatment is given for KIT exon 9 GISTS?
Imatinib - may benefit given dose escalation as well
195
What is the minimum examination time for Barretts screening?
7 minutes
196
How long should patients be observed post dilatation?
2 hours
197
What medication can reduce the risk of stricturing after large EMRs?
Oral prednisone
198
what is the optimum management of a Type 3 Todani Choledochal cyst?
Spincteroplasty +/- excision (low risk malignant transformation)
199
What staging investigations after CT are required for cholangiocarcinoma?
Staging lap
200
What is the incidence of H.Pylori in perforated duodenal ulcer?
90-95% so treat empirically
201
What histo stain would be more consistent with carcinoma than lymphoma?
Pancytokeratin
202
from where does the right gastric artery arise?
Proper hepatic
203
What is the size of the gastric pouch in bariatric procedures?
Band/Bypass - 20ml
| Sleeve 150-200ml
204
What are the diagnostic criteria for chylothorax?
Triglyceride >110mg/dl
Cholesterol <200mg/dL
Presence of chylomicrons
Use medium chain fatty acids
205
What is the lifetime risk of Oesophageal and Gastric Cancers?
2% M 1% F Oesophageal
| 1% Gastric
