Sabiston Stomach Flashcards

Question

Maintenance PPI therapy is considered in

Answer 1

-patients with large (>2 cm) ulcers -refractory or frequent PUD -those with failed H. pylori eradication -or patients requiring continued NSAID use

Answer 2

Active spurting IA Risk of reBleed > 90% Active oozing IB Risk of reBleed > 10%–20% Nonbleeding, visible vessel IIA Risk of rebleed > 50%

Answer 3

within 24 hours.

Answer 4

H. pylori status.

Answer 5

higher rates of rebleeding with Embolization useful, especially for patients who are poor surgical candidates based on other medical comorbidities

Answer 6

failed endoscopic treatment (or recurrent hemorrhage after multiple endoscopic treatments), hemodynamic instability continued slow bleeding with transfusion requirement

Answer 7

three-point U stitch technique effectively ligates the main vessel (superior and inferior stitches) and prevents back-bleeding from any smaller branches (medial stitch), such as the transverse pancreatic artery, that head to the patient’s left toward the body of the pancreas

Answer 8

careful to avoid incorporating the common bile duct into the stitch. The course of the common bile duct > identified by inserting a probe through the ampulla of Vater transduodenally or performing an intraoperative cholangiogram

Answer 9

omentum or jejunal serosa from a Roux-en-Y type limb. a pyloric exclusion is typically performed by oversewing the pylorus using absorbable suture or stapling across it using a noncutting linear stapler. A gastrojejunostomy is created to bypass the duodenum in a Billroth II or Roux-en-Y fashion. An alternative in this difficult situation is antrectomy and a Billroth II or Roux-en-Y reconstruction.

Answer 10

elective upper endoscopy should be performed 6 to 8 weeks after surgery to assess for evidence of malignancy, ulcer healing, and to test for H. pylori if that diagnosis has not yet been established

Answer 11

- develop a hypochloremic, hypokalemic metabolic alkalosis -NG tube placement -correction of fluid and electrolyte abnormalities. -Nutritional status -Gastric outlet obstruction from PUD is not a surgical emergency -gastric cancer is the most common cause of this disorder. -Upper endoscopy should be performed for malignancy and H. pylori assesment -Endoscopic dilation (with or without stenting) and H. pylori eradication are the mainstays of initial therapy.

Answer 12

primary antrectomy and reconstruction along with vagotomy.

Answer 13

failure of an ulcer to heal after an initial trial of 8 to 12 weeks of therapy or if patients relapse after therapy has been discontinued

Answer 14

adequate duration of therapy H. pylori eradication and elimination of NSAID must be confirmed. A fasting serum gastrin level should be obtained

Answer 15

a vagotomy, with or without an antrectomy

Answer 16

division of the left and right vagus nerves above the hepatic and celiac branches, just above the GE junction. vagotomy without a drainage procedure can cause delayed gastric emptying. Truncal vagotomy in combination with a Heineke-Mikulicz pyloroplasty

Answer 17

divides the main right and left vagus nerves just distal to the celiac and hepatic branches, and a pyloric drainage procedure is also performed. However, selective vagotomy results in higher ulcer recurrence rates than truncal vagotomy,

Answer 18

AKA parietal cell vagotomy or proximal gastric vagotomy. divides only the vagus nerves supplying the acid-producing portion of the stomach within the corpus and fundus. preserves the vagal innervation of the gastric antrum and pylorus, no need for routine drainage procedures.

Answer 19

These nerves are divided up until a point approximately 7 cm proximal to the pylorus Superiorly, division of these nerves is carried to a point at least 5 cm proximal to the GE junction on the esophagus Ideally, two or three branches to the antrum and pylorus should be preserved. The criminal nerve of Grassi represents a very proximal branch of the posterior trunk of the vagus, and great attention is needed to avoid missing this branch in the division process because it is frequently cited as a ''predisposition for ulcer recurrence if left intact''

Answer 20

postvagotomy dumping syndrome and diarrhea. But higher Recurrence than Truncal

Answer 21

retained antrum syndrome duodenal stump leak and afferent loop obstruction associated with gastrojejunostomy after resection

Answer 22

of twisting or kinking that could lead to afferent loop obstruction and predispose patients to the devastating complication of a duodenal stump leak

Answer 23

reflecting the trophic effect of hypergastrinemia on the gastric fundus. > Zollinger

Answer 24

triple-phase CT or MR imaging (MRI) of the abdomen. these imaging modalities have a relatively low sensitivity in detecting tumors that are less than 1 cm in diameter as well as small liver metastases. If initial imaging is nondiagnostic, localization can sometimes be achieved using somatostatin receptor scintigraphy or endoscopic ultrasound (EUS)

Answer 25

a resection according to oncologic principles should be performed (rather than a tumor enucleation) with at least 10 lymph nodes removed.

Answer 26

coagulopathy respiratory failure requiring prolonged mechanical ventilation (>48 hours)

Answer 27

Enteral nutrition > initiated as soon as possible. PPI Prophylaxis should be limited only to high-risk patients

Answer 28

In experienced centers, vasopressin can be administered into the left gastric artery and can be embolized as well to help control bleeding

Answer 29

-lesions are in the proximal stomach or fundus, a long anterior gastrotomy should be made in this area. -The gastric lumen is cleared of blood, and the mucosal surface is inspected for bleeding points. -All bleeding areas are oversewn with figure-of-eight stitches taken deep within the gastric wall. In stable patients, the operation is completed by closing the anterior gastrotomy and performing a truncal vagotomy and pyloroplasty to reduce acid secretion.

Answer 30

-Dietary measures > avoiding large amounts of sugar, frequent feeding of small meals rich in protein, fats, and fiber, and separating liquids from solids during a meal. -imodium for diarrhea and meclizine for nausea. -Anticholinergics can slow gastric emptying and treat spasms. -Octreotide is the best studied medication for dumping syndrome and can be very effective. -Patients with severe symptoms may require a reoperation -Pyloric reconstruction -Patients with a gastrojejunostomy without a gastrectomy, takedown of the gastrojejunostomy -patients with a prior distal gastrectomy, converting a loop gastrojejunostomy to a Roux-en-Y reconstruction

Answer 31

anemia > Iron ( more common ) Or Vit b12

Answer 32

If fat malabsorption is also present, the calcium malabsorption is aggravated further because fatty acids bind calcium. usually associated with a Billroth II gastrectomy. Patients with Billroth II or Roux-en-Y reconstruction that bypasses the duodenum should also receive supplementation of the fat-soluble vitamins (vitamins A, D, E, and K).

Answer 33

-Is the duodenojejunal loop proximal to the gastrojejunal anastomosis -After obstruction pancreatic and hepatobiliary secretions accumulate -empty the contents forcefully into the stomach, resulting in projectile bilious vomiting that offers immediate relief of symptoms.

Answer 34

If the obstruction has been present for a long time bacterial overgrowth occurs in the static loop, bind with vitamin B12 and deconjugated bile acids; results in a systemic deficiency of vitamin B12 (with the development of megaloblastic anemia), fat malabsorption, and deficiency in fat-soluble vitamins.

Answer 35

Failure to visualize the afferent limb on upper endoscopy is suggestive of the diagnosis. Radionuclide studies imaging the hepatobiliary tree Normally, the radionuclides should pass into the stomach or distal small bowel after being excreted into the afferent limb. If this does not occur, the possibility of an afferent loop obstruction should be considered.

Answer 36

-Surgical correction is indicated for this mechanical problem to prevent bowel necrosis or duodenal stump blowout. -A long afferent limb is usually the underlying problem, so treatment involves the elimination of this loop. -conversion of the Billroth II construction into a Billroth I anastomosis, enteroenterostomy below the afferent and efferent loops, and conversion to a Roux-en-Y reconstruction.

Answer 37

diagnosis > upper GI series or CT with oral contrast, with failure of contrast to enter the efferent limb. Operative intervention > reducing the retroanastomotic hernia if this is the cause of the obstruction and closing the retroanastomotic space to prevent recurrence

Answer 38

MC with Billroth II anastomosis. The diagnosis > careful history. A technetium biliary scan Upper endoscopy demonstrates friable, beefy red mucosa.

Answer 39

For patients with intractable symptoms, the surgical procedure of choice is conversion of the Billroth II anastomosis into a Roux-en-Y gastrojejunostomy, in which the Roux limb has been lengthened to more than 40 cm

Answer 40

Gastric emptying is delayed after truncal and selective vagotomies but not after a highly selective vagotomy reduction in the ability to empty solids

Answer 41

Increase levels of interleukin-1β and tumor necrosis factor-α expression

Answer 42

Prophylactic total gastrectomy should be considered for patients with this mutation prior to age 30

Answer 43

isolated polyp greater than 1 cm in size should have a complete polypectomy. For those with multiple polyps, the largest should be removed endoscopically remaining polyps should be biopsied. Biopsies of normal mucosa should be performed as well to assess for underlying dysplasia and H. pylori infection.

Answer 44

If the polyp is larger than 2 cm is sessile proven focus of invasive carcinoma

Answer 45

benign lesions , strongly associated with PPI

Answer 46

associated with H. pylori infection and chronic gastritis,

Answer 47

patients with H. pylori taking long-term PPIs, the low-acid environment allows the bacteria to colonize the gastric body, leading to corpus gastritis. One third of these patients develop atrophic gastritis, which is significantly more common in patients with H. pylori who are taking PPIs. atrophic gastritis is considered a major risk factor for the development of gastric cancer.

Answer 48

increased risk for developing gastric cancer. Achlorhydria is the defining feature of this condition; it occurs when chief and parietal cells are destroyed by an autoimmune reaction

Answer 49

harvesting six to eight biopsy specimens from different areas of the lesion in order to maximize the diagnostic yield

Answer 50

Small lesions (≤2 cm in diameter) can be resected at the time of initial diagnostic endoscopy

Answer 51

detects a nontrivial amount of occult metastatic disease and should be strongly considered prior to undergoing a laparotomy for curative intent.

Answer 52

distal gastrectomy the proximal stomach > at the level of the incisura at a margin of at least 2 to 3 cm for early cancers and at least 4 to 6 cm for advanced cancers. The distal margin is the proximal duodenum just distal to the pylorus. Frozen section analysis should be performed before reconstruction

Answer 53

total gastrectomy with a Roux-en-Y esophagojejunostomy and proximal gastrectomy are equivalent from an oncologic perspective. However, rates of anastomotic stenosis and reflux esophagitis are much higher after proximal gastrectomy and the lymph node harvest may be inadequate.

Answer 54

* Intestinal-type adenocarcinoma * Tumor confined to the mucosa * Absence of lymphovascular invasion * Nonulcerated tumor * Less than 2 cm in diameter

Answer 55

Patients with positive vertical margins lymphovascular invasion submucosal invasion

Answer 56

usually occur in the gastric antrum associated with gastric lymphoma > H. pylori infection, certain autoimmune diseases (i.e., rheumatoid arthritis, systemic lupus erythematous), immunosuppression, and celiac disease

Answer 57

diffuse large B cell lymphoma followed by gastric MALT lymphoma

Answer 58

Immunodeficiency and H. pylori infection

Answer 59

Endoscopy with biopsy > submucosal growth nondiagnostic. EUS Evidence of distant disease > upper airway examination to evaluate Waldeyer tonsillar ring, bone marrow biopsy, and CT of the chest and abdomen to detect lymphadenopathy. A PET/CT is often performed for patients with DLBCL as part of their initial assessment. Biopsies should be performed of enlarged lymph nodes. Histologic H. pylori testing should be performed and, if negative, confirmed by serology

Answer 60

lower grade than DLBCL preceded by H. pylori–induced gastritis four chromosomic translocations t(1;14), t(3;14), t(11;18), and t(14;18).

Answer 61

treated by H. pylori eradication alone. careful follow-up is necessary, with repeat endoscopy in 2 months to document clearance of the infection and biannual endoscopy for 3 years to document regression

Answer 62

The presence of transmural tumor extension nodal involvement, transformation into a large cell phenotype and nuclear BCL-10 expression

Answer 63

radiation therapy (if all the involved sites can be encompassed in a single field) and chemotherapy

Answer 64

-age of 70 or above -stage IV disease -elevated lactate dehydrogenase (LDH) level.

Answer 65

CD117, CD34, and PDGFRA PDGFRA mutations are restricted to the stomach.

Answer 66

Most patients who experience recurrence demonstrate metastasis to the liver, with one-third having only isolated local recurrence. Recurrence can occur over 20 years after resection; thus, long-term follow-up is warranted.

Answer 67

most common associated with chronic achlorhydria from atrophic gastritis, pernicious anemia, or possibly prolonged PPI use

Answer 68

Chromogranin A is often elevated

Answer 69

complete removal. For small pedunculated lesions that do not invade beyond the submucosa, complete removal can be accomplished endoscopically. Larger (>1 cm) lesions may require wedge resection or partial gastrectomy

Answer 70

oncologic resection with lymphadenectomy. For patients with recurrent or metastatic disease, somatostatin analogues or chemotherapy

Answer 71

-massive gastric folds in the fundus and body of the stomach, giving the mucosa a cobblestone or cerebriform appearance -associated with cytomegalovirus infection in children and H. pylori infection in adults.

Answer 72

-abnormally large (1–3 mm), tortuous artery coursing through the submucosa without a primary ulcer -The lesions generally occur near the GE junction along the lesser curvature.

Answer 73

are readily treated by splenectomy

Answer 74

occurs acutely and is associated with a diaphragmatic defect whereas mesenteroaxial volvulus is partial (<180 degrees), recurrent, and not associated with a diaphragmatic defect

Answer 75

severe upper abdominal pain, recurrent retching with production of little vomitus, and the inability to pass an NG tube

Answer 76

For KIT-mutated GISTs, these secondary mutations occur in exons 13, 14, and 17. For PDGFRA-mutated GIST, secondary mutations occur in exons 13, 14, and 15.