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BTK Review 2023 > Stomach > Flashcards

Stomach Flashcards

1
Q

What are the types of hiatal hernias?

A
  • type I: sliding
  • type II: paraesophageal
  • type III: combined
  • type IV: stomach + 1 other organ in the chest (usually colon)
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2
Q

What are the types of gastric ulcers (mechanism and location)?

A
  • I: lesser curve, decreased mucosal protection
  • II: lesser curve and duodenum, increased acid production
  • III: pre-pyloric, increased acid production
  • IV: proximal lesser curve, decreased mucosal protection
  • V: diffuse, secondary to NSAIDs
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3
Q

How are EGJ tumors classified?

A
  • type I: located between 1-5 cm above the EGJ
  • type II: cardia, within 1cm above to 2cm below the EGJ
  • type III: subcardial, 2-5cm below the EGJ
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4
Q

What single artery can the stomach survive off of?

A

the right gastroepiploic

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5
Q

Which is more common, an organoaxial or mesoaxial gastric volvulus?

A

organoaxial (along the axis from the GEJ to pylorus)

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6
Q

What are the two surgical options for treating gastric volvulus?

A
  • preferred repair is emergent hernia repair and gastropexy +/- partial gastrectomy if devitalized
  • frailer patients may be candidates for double PEG tubes
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7
Q

What are five alarm symptoms in those with GERD?

A
  • dysphagia
  • odynophagia
  • weight loss
  • anemia
  • GI bleeding
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8
Q

What are the indications for surgical management of GERD?

A
  • desire to be off lifelong medications
  • failure of medical management
  • extra-esophageal symptoms (asthma, hoarseness, cough, chest pain, aspiration)
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9
Q

How is bile reflux after a GI surgery diagnosed and managed?

A
  • diagnosed with an impedance probe
  • corrected with roux-en-y reconstruction
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10
Q

What is the pre-operative workup for GERD?

A
  • barium swallow
  • pH probe
  • EGD
  • manometry
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11
Q

What are the components of the DDemeester score? What is a positive test?

A
  • percent total time, upright time, and supine time with pH < 4
  • number of reflux episodes, number greater than 5 minutes, and longest reflux episode
  • positive if > 14.72
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12
Q

How is a diagnosis of GERD objectively made?

A

with a Demeester score > 14.72 on an ambulatory pH test

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13
Q

How long should a fundoplication be?

A
  • 2cm
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14
Q

What are the following types of fundoplication:
- Nissen
- Dor
- Toupet

A
  • Nissen: 360
  • Dor: anterior 180
  • Toupet: posterior 270
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15
Q

If anesthesia is having trouble ventilating a patient during a mediastinal dissection for fundoplication, what is occurring? How is it managed?

A
  • likely capnothorax
  • treat by enlarging the tear and placing a red rubber into the pleural tear; at the end of the case, bring one end outside the abdomen and place to water seal while a Valsalva is performed
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16
Q

What foods should patients avoid immediately after fundoplication?

A

breads, raw vegetables, meat, and carbonated beverages

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17
Q

How should dysphagia be managed after fundoplication?

A
  • get an esophogram if severe or more than 6 weeks after surgery
  • look for slipped wrap, otherwise can dilate
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18
Q

Which hiatal hernias should be repaired?

A
  • type I for the same reasons as GERD
  • all type II-IV symptomatic hernias
  • asymptomatic type II-IV hernias in good surgical candidates
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19
Q

What step in hiatal hernia repair decreases the rate of early recurrence?

A

mobilizing and excising the hernia sac

20
Q

What is the role for mesh in hiatal hernia repair?

A

likely reasonable for large defects greater than 5-8 cm; reduces early recurrence but long-term data lacking

21
Q

What procedure can be done to get extra intra-abdominal esophageal length during hiatal hernia repair?

A

a Collis gastroplasty

22
Q

Is H. pylori more commonly found in gastric or duodenal ulcers?

A

more commonly in duodenal (95%) than gastric (75%)

23
Q

What is the treatment for H. pylori?

A
  • PPI
  • clarithromycin
  • amoxicillin or flagyl
24
Q

What are the most common causes of gastric bleeding?

A

H. pylori infection or NSAID use

25
Q

What percentage of gastric ulcers contain an occult malignancy?

A

5%

26
Q

When do you operate for an UGI bleed? What do you do?

A
  • for bleeding not controlled by two endoscopic procedures and an IR procedure or for hemodynamic shock
  • midline laparotomy with anterior gastrotomy, oversew the bleeding area, biopsy, and close gastrotomy
27
Q

What is the operation for gastric bleeding?

A

1) midline laparotomy
2) anterior gastrotomy
3) oversew bleeding area
4) close gastrotomy

28
Q

What is the operation for duodenal bleeding?

A

1) laparotomy
2) longitudinal, anterior duodenotomy
3) control bleeding with sutures superior and inferior to ulcer, avoiding the CBD
4) ligate the GDA if bleeding continues
5) approximate ulcer crater
6) close duodenotomy transversely

29
Q

What procedure should be performed alongside a truncal vagotomy?

A

some sort of drainage procedure (e.g. pyloroplasty)

30
Q

What are five risk factors for gastric cancer?

A
  • H. pylori infection
  • smoking
  • heavy alcohol use
  • high salt diet
  • high nitrate diet
31
Q

How do you stage gastric cancer?

A
  • routine labs
  • CT chest/abdomen/pelvis
  • EUS with FNA
  • PET/CT
  • staging laparoscopy for cT1b or higher tumors if chemo radiation or surgery is being considered
32
Q

When is a staging laparoscopy indicated for gastric cancer?

A

cT1b disease or higher with intent to pursue chemo radiation or surgery

33
Q

How is gastric cancer staged?

A

T1a: invades mucosa
T1b: invades submucosa
T2: invades muscular propria
T3: invades subserosa
T4: invades through serosa or into adjacent structures

N1: 1-2 nodes
N2: 3-6 nodes
N3: 7 or more nodes

34
Q

What is considered unresectable gastric cancer?

A

that with peritoneal involvement, distal metastases, root of mesentery involvement, para-aortic nodal disease, and encasement of major vascular structures

35
Q

When is neoadjuvant therapy indicated for gastric cancer? What about adjuvant therapy?

A
  • neoadjuvant for cT2 or higher and for any N
  • adjuvant for T3, T4, and node positive disease
36
Q

What margins and LN harvest are required for gastric cancer resection?

A

need a 5cm margin with 15 lymph nodes

37
Q

What is a D1 node dissection for gastric cancer? What is a D2 dissection?

A
  • D1 is removal of perigastric nodes at stations 1-6
  • D2 is removal of nodes along the left gastric, common hepatic, celiac, and splenic arteries at stations 7-11
38
Q

Is a D1 or D2 dissection for gastric cancer recommended?

A
  • in Asia a D2 is standard of care
  • in western society, D2 has not been shown to have a survival benefit and may have an increased morbidity and mortality
  • standard is D1 here
39
Q

Give the following for gastric cancer:
- risk factors
- staging mechanisms
- indications for neoadjuvant therapy
- type of resection
- indications for adjuvant therapy

A
  • risk: H. pylori, smoking, alcohol, nitrates, high salt diet
  • staging: CT C/A/P, EUS with FNA, PET, diagnostic laparoscopy for cT1b or greater
  • neoadjuvant for cT2 or N positive disease
  • surgery is 5cm proximal margin with D1 dissection of stations 1-6
  • adjuvant therapy for T3, T4, or N positive disease
40
Q

What is dumping syndrome? What are the two kinds and how is it managed?

A
  • symptoms are tachycardia, diaphoresis, dizziness, and flushing
  • early occurs 20-30 minutes after a meal and is due to abrupt hyperosmolar load to small intestine
  • late occurs 1-4 hours after and is due to rapid carbohydrate load to small intestine which induces an insulin surge and rebound hypoglycemia
    -managed with small meals and avoiding sugar drinks; can try octreotide
41
Q

What is alkaline reflux gastritis? How is it diagnosed and managed?

A
  • occurs after Bilroth reconstructions
  • diagnosed via impedance studies
  • treat medically with pro-kinetic agents and bile acid binding resins
  • treat surgically with conversion to RXNY
42
Q

How long should a roux limb be to avoid bile reflux?

A

50cm

43
Q

What is a Braun enterostomy?

A

an anastomosis between an afferent and efferent limb of a bilroth II reconstruction

44
Q

What is afferent limb syndrome?

A
  • acute or chronic obstruction of afferent jejunal limb following bilroth II reconstruction which leads to increased luminal pressures
  • causes jaundice, cholangitis, pancreatitis, duodenal stump blow out, and bacterial overgrowth
  • bacterial overgrowth leads to increased beconjugation of bile acids, steatorrhea, malnutrition, B12 deficiency, and megaloblastic anemia
  • treat with conversion to RXNY
45
Q

What is the diagnosis for a gastric biopsy wooing expansion of the marginal zone compartment with development of sheets of neoplastic small lymphoid cells?

A
  • MALToma
  • treat the underlying H. pylori and most will resolve

BTK Review 2023 (18 decks)

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