Stomach Flashcards

Question

A 78-year-old female with arthritis and asthma presents to the emergency room with an acute onset of epigastric pain a couple of hours ago. Her pulse is 104, her blood pressure is unchanged trom her baseline of 110/74 mmHg, and her temperature is 98.2 Fahrenheit. Her medications include occasional naproxen and prednisone for occasional exacerbations of her asthma. On physical exam, her abdomen demonstrates significant epigastric tenderness with rebound. She has a mild leukocytosis of 12.5 cells/mcL. Her acute abdominal series demonstrates a small amount of free air. 1What is the most reasonable current treatment option for this patient as the next step? A. Laparoscopic highly selective vagotomy without resuscitation B. Nasogastric tube insertion, cessation of all oral feeds, & intravenous fluid initiation for the next 24 hours C. Open truncal vagotomy with pyloroplasty D. Open Graham patch with parietal cell vagotomy despite laparoscopic experience and resources E. Emergent anterior seromyotomy

Answer 1

B. Of all the listed options, nasogastric tube insertion with NPO status and initiation of IV fluid is a very reasonable first step in the modern era of H. pylori detection and treatment, especially in a stable patient. Graham patch with parietal cell vagotomy is also a very reasonable option but an open approach is more problematic if laparoscopic experience and resources are available. The verification of resuscitation is required prior to going to the operating room for patients. The verification in this patient can simply be assessing volume status (e.g., urine output of 0.5 cc/kg/hour or normal heart rate for a patient not on a beta-blocker. Truncal vagotomy with pyloroplasty is not a first-line treatment in the modern era of H. Pylori. Anterior seromyotomy, division of the seromuscular layer of the lesser curvature in order to achieve a highly selective vagotomy effect, is a reasonable approach but not as a first option.

Answer 2

D. Laparoscopic Graham patch with H. Pylori testing and subsequent testing is the best choice of those presented. Truncal vagotomy with antrectomy is no longer a first- line option in the modern era of H. Pylori detection and treatment. Observation is not reasonable if the patient is not improving and a more aggressive management choice is most likely necessary. Angioembolization maybe considered for bleeding peptic ulcer disease in selective cases but not for perforation of an ulcer. Parietal cell vagotomy is no longer considered one of the early line treatments but to be reserved as a treatment option for refractory peptic ulcer disease.

Answer 3

B. H. Pylori stool antigen testing is a very reasonable approach and can even be ordered semi emergently in the emergency room at some institutions to help in decisions with early treatment options. Secretin stimulation test is utilized for gastrinoma work-up, which is not yet necessary during this part of the work-up for this patient since recalcitrant peptic ulcer disease is not yet identified. Urea breath testing for H. pylori is reasonable but is not an emergent process as obtaining this test requires a clinical lab. Colonoscopy is reasonable in a patient over the age of 50 who has not had a screening process done but is not required to address the follow-up for peptic ulcer disease perforation.

Answer 4

E. Esophagogastroduodenoscopy (EGD) is necessary to rule out a gastric carcinoma that caused the perforation, especially in older patients. Pantoprazole, another proton-pump inhibitor, or H2 blockers are reasonable to start on admission for perforated peptic ulcer disease but long-term treatment is not absolutely necessary, especially after treatment for H. Pylori. Treatment of H. Pylori with a course of antibiotics but chronic suppression should not be necessary. Serum gastrin level can be checked for a patient who is suspected of gastrinoma but is not necessary if the patient’s peptic ulcer is healed.

Answer 5

B. This patient most likely has a marginal ulcer, which, at a rate of about 5% after Roux-en-Y gastric bypass, is one of the more common complications. Risk factors associated with the development of marginal (gastrojejunal/anastomotic) ulcers include environmental (smoking and alcohol), medication (NSAIDs), anatomical (gastro-gastric fistula or an enlarged gastric pouch), and technique (use of nonabsorbable sutures). There is no link associated with specific food types and ulcer formation. Other risk factors that are associated with marginal ulcer (MU) are increased acid exposure via a gastro-gastric fistula (not confirmed in this patient but more commonly seen with patients that have had an open gastric bypass versus laparoscopic), hypertension, and use of non-absorbable suture in the anastomosis and recent surgery.

Answer 6

C. Marginal ulcers are a late complication of gastric bypass surgery. Along with gastrojejunostomy (GJ) stricture they are one of the most common complications (early or late) of gastric bypass surgery. Reported rates of MU range from 1% to 25%, with most series indicating 5% incidence. GJ stricture rates are reported between 3% to 27%. The incidence of internal hernia after gastric bypass is nearly non-existent in the open gastric bypass, but after laparoscopic gastric bypass occurs in approximately 2.5% of patients. Small bowel obstruction is linked to internal hernia formation and the rates are equivalent. GJ leaks are an early complication after gastric bypass. In the laparoscopic approach, rates are reported at about 1% to 1.8%.

Answer 7

B. Of patients presenting with MU, over 30% are found to be smoking at the time of diagnosis. Most MU are symptomatic (72%). Those symptoms that are most common after surgery that lead to the diagnosis of MU are: pain (34%), dysphagia (17%), weight gain (13%), nausea and vomiting (8%), and GI bleed (3%). Active H. pylori infection has not been determined to be an independent risk factor in the development of perforated MU. There is data that suggests that in the setting of patients that must use NSAIDs following gastric bypass that proton pump inhibitors (PPIs) are protective of MU formation. While there is still debate as to whether hand-sewn gastrojejunostomy (GJ) versus stapled anastomosis is better with relationship to post operative outcomes, the data clearly relates that non-absorbable suture material at the anastomosis has a high association with MU formation. Because of this fact, the use of non-absorbable suture at the GJ anastomosis has essentially ceased.

Answer 8

A. The Ireatment of MU is largely medical. The standard of treatment is PPI therapy initiation/continuation and cytoprotective agents (i.e., sucralfate or carafate). Additionally cessation of smoking and/or NSAID use is critical, as recurrence is high in patients that continue with these high level risk factors. Studies report the incidence of surgical intervention for MU to be 4% to 10%. This usually occurs in this subset of MU for recalcitrant and/or recurrent ulcers. Continued smoking and NSAID use were found to be independent risk factors for continued non-healing ulcers. Late ulcers (those that occur after 30 days) are rarely self-limiting. In a study by Csendes they did a prospective evaluation of patients and performed endoscopy at 1 month and at 1 to 2 years. They found a 12% rate of MU at 1 month. Many authors believe this to be part of the natural progression and healing process of the anastomosis within such a short time frame. Most clinicians advocate for PPI use in the immediate postoperative period because of this. Clinically apparent MU is unlikely to heal without intervention (as mentioned above). While the data is not completely clear about the role of II. pylori infection and ulcer formation, the risk of perforation of MU is not increased by the presence of H. pylori. One study found that in patients that were H. pylori positive and eradicated prior to surgery, the rate of MU after surgery with short term PPI use was significantly reduced. Endoscopy should be part of the armamentarium of diagnosing and treating MU. Most ulcers become apparent within the first 12 months following surgery. While they can develop beyond 18 months following surgery this is not the most common time frame that they are seen. The incidence of perforation in all patients undergoing laparoscopic gastric bypass is approximately 1% and the incidence of MU on average is 5% (range l%to 16%), therefore the rate of perforation of MU is 20%. Felix et al. in 2008 found that many cases could be managed laparoscopically. In their series, over 30% were managed by oversewing of the ulcer and utilizing an omental patch. Other series have confirmed similar treatment strategies for MU perforation utilizing the omental patch. Times when it may be necessary or more appropriate to consider revising the G-J may include MU with bleeding, with or without perforation; recurrent ulceration, when a gastro-gastric fistula is present; or when the pouch is greatly enlarged.

Answer 9

D. Shortening of the afferent limb

Answer 10

B. Chronic afferent loop obstruction may lead to megaloblastic anemia

Answer 11

B. Nonbleeding visible vessel

Answer 12

C. Cameron's ulcer

Answer 13

D. Repeat endoscopy

Answer 14

D. A truncal vagotomy decreases acidic output by 50% Review Modified Johnson Classification

Answer 15

D. Gastrojejunostomy

Answer 16

B The consistently largest artery to the stomach is the left gastric artery, which usually arises directly from the celiac trunk and divides into an ascending and descending branch along the lesser gastric curvature. Approximately 20% of the time, the left gastric artery supplies an aberrant vessel that travels in the gastrohepatic ligament (lesser omentum) to the left side of the liver. Rarely, this is the only arterial blood supply to this part of the liver, and inadvertent ligation may lead to clinically significant hepatic ischemia in this unusual circumstance.

Answer 17

D Luminal peptides and amino acids are the most potent stimulants of gastrin release, and luminal acid is the most potent inhibitor of gastrin secretion. The latter effect is predominantly mediated in a paracrine fashion by somatostatin released from antral D cells. Gastrin-stimulated acid secretion is significantly blocked by H2 antagonists, suggesting that the principal mediator of gastrin-stimulated acid production is histamine from mucosal enterochromaffin-like (ECL) cells. Acetylcholine released by the vagus nerve leads to stimulation of ECL cells, which in turn produce histamine.

Answer 18

A Helicobacter pylori possess that enzyme urease, which converts urea into ammonia and bicarbonate, thus creating an environment around the bacteria that buffers the acid secreted by the stomach. H. pylori infection is associated with decreased levels of somatostatin, decreased somatostatin messenger RNA production, and fewer somatostatin-producing D cells. These effects are probably mediated by H. pylori-induced local alkalinization of the antrum (antral acidification is the most potent antagonist to antral gastrin secretion), and H. pylori-mediated increases in other local mediators and cytokines. The result is hypergastrinemia and acid hypersecretion, presumably leading to the parietal cell hyperplasia seen in many patients with duodenal ulcer. Other mechanisms whereby H. pylori can induce gastrointestinal mucosal injury include the production of toxins (vacA and cagA), local elaboration of cytokines (particularly interleukin-8) by infected mucosa, recruitment of inflammatory cells and release of inflammatory mediators, recruitment and activation of local immune factors, and increased apoptosis.

Answer 19

C Erythromycin is a common prokinetic agent used to treat delayed gastric emptying, and works as a motilin agonist. Domperidone and metoclopramide, two other commonly used medications, function as dopamine antagonists. Metoclopramide 10mg PO QID (Dopamine antagonist) Erythromycin 250mg PO QID (Motilin agonist) Domperidone 10mg PO QID (Dopamine antagonist)

Answer 20

B Activated parietal cells secrete intrinsic factor in addition to hydrochloric acid. Presumably the stimulants are similar, but acid secretion and intrinsic factor secretion may not be linked. Intrinsic factor binds to luminal vitamin B12, and the complex is absorbed in the terminal ileum via mucosal receptors. Vitamin B12 deficiency can be life-threatening, and patients with total gastrectomy or pernicious anemia require B12 supplementation by a non-enteric route.

Answer 21

D All patients with gastrinoma have an elevated gastrin level, and hypergastrinemia in the presence of elevated basal acid output (BAO) strongly suggests gastrinoma. Patients with gastrinoma usually have a BAO >15mEq/h or >5 mEq/h if they have had a previous procedure or peptic ulcer. Acid secretory medications should be held for several days before gastrin measurement, because acid suppression may falsely elevate gastrin levels. Causes of hypergastrinemia can be divided into those associated with hyperacidity and those associated with hypoacidity. The diagnosis of Zollinger-Ellison syndrome (ZES) is confirmed by the secretin stimulation test. An intravenous (IV) bolus of secretin (2 U/kg) is given and gastrin levels are checked before and after injection. An increase in serum gastrin of 200 pg/mL or greater suggests the presence of gastrinoma. Patients with gastrinoma should have serum calcium and parathyroid hormone levels determined to rule out multiple endocrine neoplasia type 1 (MEN1) and, if present, parathyroidectomy should be considered before resection of gastrinoma. See figure 26-1 (p.205, Schwartz ABSITE 10th Ed)

Answer 22

E CT will detect most lesions >1cm in size and magnetic resonance imaging (MRI) is comparable. Endoscopic ultrasound (EUS) is more sensitive than these other noninvasive imaging tests, but it still misses many of the smaller lesions, and may confuse normal lymph nodes for gastrinomas. Currently, the preoperative imaging study of choice for gastrinoma is somatostatin-receptor scintigraphy (the octreotide scan). When the pretest probability of gastrinoma is high, the sensitivity and specificity of this modality approach 100%. Gastrinoma cells contain type II somatostatin receptors that bind the indium-labeled somatostatin analogue (octreotide) with high affinity, making imaging with a gamma camera possible. Currently, angiographic localization studies are infrequently performed for gastrinoma. (See Schwartz 10th ed., pp.1072–1073.)

Answer 23

C The overall risk of significant serious adverse gastrointestinal (GI) events in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) is more than three times that of controls. This risk increases to five times in patients older than 60 years. Factors that clearly put patients at increased risk for NSAID-induced GI complications include age >60, prior GI event, high NSAID dose, concurrent steroid intake, and concurrent anticoagulant intake. Alcohol is commonly mentioned as a risk factor for peptic ulcer disease (PUD), but confirmatory data are lacking. High doses of H2 blockers have been shown to be less effective than proton pump inhibitors (PPIs) in preventing GI complications in these high risk patients on antiplatelet therapy, but clearly they are better than no acid suppression. (See Schwartz 10th ed., table26-6,p.1058.)

Answer 24

Answer: D The management of bleeding peptic ulcer is summarized in the algorithm in Fig. 26-2. All patients admitted to hospital with bleeding peptic ulcer should be adequately resuscitated and started on continuous IV PPI. Seventy-five percent of patients will stop bleeding with these measures alone, but 25% will continue to bleed or will rebleed in hospital. Among the high risk group, endoscopic hemostatic therapy is indicated and usually successful. Only then should surgical intervention be considered, with indications including massive hemorrhage unresponsive to endoscopic control and transfusion requirement of more than four to six units of blood, despite attempts at endoscopic control. Long-term maintenance PPI therapy should be considered in all patients admitted to hospital with ulcer complications. (See Schwartz 10th ed., Figure 26-42, pp. 1061, 1064–1065, and 1069.)

Answer 25

C Following antrectomy, GI continuity may be reestablished with a Billroth I gastroduodenostomy or a Billroth II loop gastrojejunostomy. Since antrectomy routinely leaves a 60 to 70% gastric remnant, routine reconstruction as a Roux-en-Y gastrojejunostomy should be avoided. Although the Roux-en-Y operation is an excellent procedure for keeping duodenal contents out of the stomach and esophagus, in the presence of a large gastric remnant, this reconstruction will predispose to marginal ulceration and/or gastric stasis. (See Schwartz 10th ed., p. 1063.)

Answer 26

A The indications for surgery in PUD are bleeding, perforation, obstruction, and intractability or nonhealing. Intractability should be an unusual indication for peptic ulcer operation nowadays. The patient referred for surgical evaluation because of intractable PUD should raise red flags for the surgeon: maybe the patient has a missed cancer, is noncompliant, or has Helicobacter despite the presence of a negative test or pre- vious treatment (differential for intractability, Table 26-3). In this setting, the patient with persistent symptoms despite appropriate treatment requires further evaluation before any consideration of operative treatment. If surgery is necessary, a lesser operation may be preferable. (See Schwartz 10th ed., Table 26-13, pp. 1059 and 1069–1071.)

Answer 27

Answer: A Gastric cancer is more common in patients with pernicious anemia, blood group A, or a family history of gastric cancer. When patients migrate from a high-incidence region to a low-incidence region, the risk of gastric cancer decreases in the subsequent generations born in the new region. This strongly suggests an environmental influence on the development of gastric cancer. Environmental factors appear to be more related etiologically to the intestinal form of gastric cancer than the more aggressive diffuse form. The commonly accepted risk factors for gastric cancer are listed in Table 26-4. (See Schwartz 10th ed., Table 26-15, pp. 1074–1075.)

Answer 28

Answer: B Surgical resection is the only curative treatment or gastric cancer and most patients with clinically resectable locoregional disease should have gastric resection. The standard operation or gastric cancer is radical subtotal gastrectomy, which entails ligation of the left and right gastric and gastroepiploic arteries at the origin, as well as the en bloc removal of the distal 75% of the stomach, including the pylorus and 2cm of duodenum, the greater and lesser omentum, and all associated lymphatic tissue. Generally, the surgeon strives for a grossly negative margin of at least 5cm. More than 15 resected lymph nodes are required or adequate staging, even in the low-risk patient. The operation is deemed an adequate cancer operation provided that tumor-free margins are obtained, >15 lymph nodes are removed, and all gross tumor is resected. In the absence of involvement by direct extension, the spleen and pancreatic tail are not removed. Reconstruction is usually by Billroth I gastrojejunostomy or Roux-en-Y reconstruction. (See Schwartz 10th ed., p. 1081.)

Answer 29

Answer: C Gastrointestinal stromal tumors (GISTs) are submucosal tumors that are slow growing, and arise from interstitial cells of Cajal (ICC). Prognosis in patients with GISTs depends mostly on tumor size and mitotic count, and metastasis, when it occurs, is typically by the hematogenous route. Any lesion >1cm can behave in a malignant fashion and may recur. Thus, all GISTs are best resected along with a margin of normal tissue—wedge resection with clear margins is adequate surgical treatment. True invasion of adjacent structures by the primary tumor is evidence of malignancy. If safe, en bloc resection of involved surrounding organs is appropriate to remove all tumor when the primary is large and invasive. Five-year survival following resection for GIST is about 50%. Most patients with low-grade lesions are cured (80% 5-year survival), but most patients with high-grade lesions are not (30% 5-year survival). Imatinib, a chemotherapeutic agent that blocks the activity of the tyrosine kinase product of c-kit, yields excellent results in many patients with metastatic or unresectable GIS, and is also recommended in high risk groups as an adjuvant therapy. Fig. 26-3 shows an algorithm for treatment of patients with GIST. (See Schwartz 10th ed., Figure 26-59, pp. 1085–1086.)

Answer 30

Answer:A Low-grade mucosa-associated lymphoid tissue (MALT) lymphoma, essentially a monoclonal proliferation of B cells, presumably arises from a background of chronic gastritis associated with H. pylori. These relatively innocuous tumors then undergo degeneration to high-grade lymphoma, which is the usual variety seen by the surgeon. Remarkably, when the H. pylori are eradicated and the gastritis improves, the low- grade MALT lymphoma often disappears. Thus, low-grade MALT lymphoma is NOT a surgical lesion. An algorithm or gastric lymphoma treatment is found in Fig. 26-4. (See Schwartz 10th ed., Figure 26-58, pp. 1084–1085.)

Answer 31

Answer: C Type III gastric carcinoids are sporadic tumors, most often solitary (usually>2cm), occur more commonly in men, and behave more aggressively than types I and II. Unlike types 1 and II, they are not associated with hypergastrinemia. Type I gastric carcinoids are the most common type of gastric carcinoid, and occur in patients with chronic hypergastrinemia secondary to pernicious anemia or chronic atrophic gastritis. Type II is rare, and is associated with MEN1 and ZES. Gastric carcinoids should all be resected, and small lesions (<2cm) conjoined to the mucosa may be treated endoscopically with endoscopic mucosal resection (EMR) if there are only a few lesions (<5) and if margins are histologically negative. Locally invasive lesions, or those >2 cm, should be removed by radical gastric resection and lymphadenectomy. Survival is excellent for node-negative patients (>90% 5-year survival); node-positive patients have a 50% 5-year survival. The 5-year survival or patients with type I gastric carcinoid is close to 100%; for patients with type III lesions, the 5-year survival is less than 50%. Most type III patients have nodal or distant metastases at the time of diagnosis, and some present with symptoms of carcinoid syndrome. (See Schwartz 10th ed., p. 1086.)

Answer 32

Answer: C The parallel red stripes atop the mucosal folds of the distal stomach give this rare entity its name. Histologically, gastric antral vascular ectasia (GAVE) is characterized by dilated mucosal blood vessels that often contain thrombi, in the lamina propria. Mucosal fibromuscular hyperplasia and hyalinization often are present (Fig. 26-5). The histologic appearance can resemble portal hypertensive gastropathy, but the latter usually affects the proximal stomach, whereas watermelon stomach predominantly affects the distal stomach. Beta blockers and nitrates, useful in the treatment of portal hypertensive gastropathy, are ineffective in patients with gastric antral vascular ectasia. Patients with GAVE are usually elderly women with chronic GI blood loss requiring transfusion. Most have an associated autoimmune connective tissue disorder, and at least 25% have chronic liver disease. Nonsurgical treatment options include estrogen and progesterone, and endoscopic treatment with the neodymium yttrium- aluminum garnet (Nd:YAG) laser or argon plasma coagulator. Antrectomy may be required to control blood loss, and this operation is quite effective but carries increased morbidity in this elderly patient group. Patients with portal hypertension and antral vascular ectasia should be considered for transjugular intrahepatic portosystemic shunt (TIPSS). (See Schwartz 10th ed., Figure 26-61, pp. 1088–1089.)

Answer 33

Dumping is a phenomenon consisting of a constellation of postprandial symptoms thought to be the result o the abrupt delivery of a hyperosmolar load into the small bowel due to ablation of the pylorus or decreased gastric compliance. Early dumping occurs 15 to 30 minutes after a meal, with patients becoming diaphoretic, weak, light-headed, and tachycardic. Late dumping occurs hours later, and is due to a reactive hypoglycemia. Late dumping is relieved by the administration of sugar. The medical therapy for the dumping syndrome consists of dietary management and somatostatin analogue (octreotide). Often, symptoms improve if the patient avoids liquids during meals. Hyperosmolar liquids (eg, milk shakes) may be particularly troublesome. There is some evidence that adding dietary fiber compounds at mealtime may improve the syndrome. If dietary manipulation fails, the patient is started on octreotide, 100 μg subcutaneously twice daily. This can be increased up to 500 μg twice daily if necessary. The long-acting depot octreotide preparation is useful. Octreotide not only ameliorates the abnormal hormonal pattern seen in patients with dumping symptoms, but also promotes restoration of a fasting motility pattern in the small intestine (ie, restoration o the migrating motor complex [MMC]). Only a very small percentage of patients with dumping symptoms ultimately require surgery. Therefore, the surgeon should not rush to re-operate on the patient with dumping syndromes. (See Schwartz 10th ed., p. 1091.)

Answer 34

Answer: A There are two clinical syndromes characterized by epithelial hyperplasia and giant gastric folds: ZES and Ménétrier disease. The latter is characteristically associated with protein-losing gastropathy and hypochlorhydria. A few patients with these unusual diseases have been successfully treated with the epidermal growth factor receptor blocking monoclonal antibody cetuximab. There may be an increased risk of gastric cancer with this disease, and gastric resection may be indicated for bleeding, severe hypoproteinemia, or cancer. The other options describe Dieulafoy lesions, watermelon stomach, and ZES, respectively. (See Schwartz 10th ed., p. 1088.)

Answer 35

c. Repeat endoscopy

Answer 36

c. Conversion of previous gastric surgery to Roux-en-Y reconstruction

Answer 37

a. Omental patch repair

Answer 38

b. Transfusion and treatment with H2 receptor antagonist

Answer 39

Angularis incisura

Answer 40

Angle of His

Answer 41

4 main arteries: left gastric and right gastric arteries along the lesser curvature and left and right gastroepiploic arteries along the greater curvature; blood is also supplied to the proximal stomach by the inferior phrenic arteries and short gastric arteries and to the pylorus by the gastroduodenal artery

Answer 42

15% to 20%.

Answer 43

Left gastric artery

Answer 44

3 of 4 arteries can be ligated

Answer 45

Left gastric (coronary) and right gastric veins usually drain into the portal vein; left gastroepiploic vein drains into the splenic vein; right vein drains into the superior mesenteric vein

Answer 46

Left vagus becomes anterior and the right vagus becomes posterior (LARP mnemonic)

Answer 47

Parasympathetic via the vagus and sympathetic via the celiac plexus

Answer 48

From T5 to T10 (travels in splanchnic nerve to celiac ganglion) Sensation of gastroduodenal pain via afferent sympathetic fibers

Answer 49

The left vagus

Answer 50

The right vagus

Answer 51

The criminal nerve of Grassi

Answer 52

Above the celiac and hepatic branches of the vagi

Answer 53

Below the celiac and hepatic branches of the vagi

Answer 54

At the crows feet to the proximal stomach while preserving the portion innervating the antrum and pylorus

Answer 55

Auerbach and Meissner autonomic plexuses

Answer 56

3 layers of smooth muscle

Answer 57

The middle layer of smooth muscle

Answer 58

Columnar glandular epithelium

Answer 59

Body; secretion of intrinsic factor and acid Intrinsic factor binds to B12 and is taken up in the terminal ileum Pernicious anemia etiology is frequently an autoimmune process that destroys parietal cells, leading to a deficiency in intrinsic factor; low B12 levels lead to a macrocytic anemia Parietal cells are inhibited by somatostatin, PGEl, secretin, and CCK

Answer 60

The cardia and prepyloric antrum

Answer 61

Body; pepsinogen | Converted to pepsin by gastric acid and is first enzyme of proteolysis

Answer 62

Antrum; gastrin Release stimulated by amino acids and acetylcholine; inhibited by acidification of the duodenum Why antrectomy can decrease acid secretion

Answer 63

Body and antrum; somatostatin Release stimulated by acidification of antrum and duodenum; inhibits gastrin and acid release

Answer 64

Body and antrum; gastrin-releasing peptide

Answer 65

Body; ghrelin Stimulates appetite, increases food intake, promotes fat storage; released when stomach is empty and inhibited by stomach stretch; acts on hypothalamic brain cells Stomach

Answer 66

Receptive relaxation and gastric accommodation

Answer 67

``` Antral G-cell hyperplasia or hyperfunction, gastric outlet obstruction, retained excluded antrum, short-gut syndrome, Zollinger-Ellison syndrome ```

Answer 68

``` Acid-reducing procedure (vagotomy), antisecretory agents (proton pump inhibitors [PPis] ), atrophic gastritis, chronic renal failure, Helicobacter pylori infection, pernicious anemia ```

Answer 69

Acetylcholine, gastrin, and histamine

Answer 70

1 to 5 mmol/h

Answer 71

Cephalic, gastric, and intestinal

Answer 72

Intracellular cyclic AMP

Answer 73

Calcium (phospholipase C converts membrane-bound phospholipids into inositol triphosphate [IP3], which mobilizes calcium from intracellular stores)

Answer 74

A covalent disulfate bond forms between the drug and the cysteine residues on the subunit of the H/K-ATPase leading to irreversible inhibition of the proton pump

Answer 75

The drug is covalently bonded to the H/K-ATPase leading to irreversible inhibition, so new proton pumps need to be synthesized before the recovery of acid secretion occurs

Answer 76

Gastric acid

Answer 77

By averaging the output of the last two 15-minute periods after secretagogue administration

Answer 78

10 to 15 mEq/h 190

Answer 79

It is the highest rate of secretion obtained during a 15-minute period following secretagogue administration

Answer 80

Gastric pacemaker cells of Cajal located in the midbody of the stomach along the greater curvature

Answer 81

90 to 120 minutes

Answer 82

Also known as the quiescent phase; slow waves are present without action potentials; increase in gastric tone but no gastric contraction

Answer 83

Motor spikes are associated with slow waves and occasional gastric contractions; gallbladder contraction

Answer 84

Motor spike activity is associated with each slow wave; forceful gastric contractions happen every 15 to 20 seconds; the stomach is cleared oflarge indigestible food substances

Answer 85

A brief recovery period before the next MMC cycle

Answer 86

Blood flow, bicarbonate secretion, cell renewal, endogenous prostaglandins, growth factors, mucus production

Answer 87

Duodenal reflux of bile, ethanol ingestion, H. pylori, hydrochloric acid secretion, hypoxia, ischemia, nonsteroidal antiinflammatory drugs (NSAIDs}, pepsins, smoking

Answer 88

H. pylori infection; eradication is imperative-treated with a combination of PPI and antibiotics

Answer 89

NSAID ingestion; blocks COX-1 enzyme, disrupts prostaglandin production leading to less protective mucus

Answer 90

On the lesser curve near the incisura (60%; type I)

Answer 91

Gastric ulcer occurring on the lesser curvature near the incisura

Answer 92

Gastric ulcer located in the body of the stomach in combination with a duodenal ulcer

Answer 93

Prepyloric gastric ulcer

Answer 94

Gastric ulcer that occurs high on the lesser curve near the GE junction

Answer 95

Drug-induced (NSAIDs) gastric ulcer that may occur anywhere in the stomach

Answer 96

Type I and IV

Answer 97

Type II and III

Answer 98

Cushing ulcer

Answer 99

Curling ulcer

Answer 100

ABCs; fluid resuscitation with correction of any platelet/coagulation abnormalities; blood transfusion if needed; administration of broad-spectrum IV antibiotics in patients with sepsis, saline lavage of the stomach through a nasogastric (NG) tube; administration of antisecretory agents after the NGT aspirate runs clear

Answer 101

0.2 to 0.4 IU/min as a continuous infusion for a maximum of 48 to 72 hours

Answer 102

Recurrent or persistent bleeding requiring >6 units of blood (3000 mL)

Answer 103

Make a long anterior gastrotomy along the proximal stomach/fundus; clear the gastric lumen of blood; inspect the mucosa! surface for bleeding points; oversew all bleeding areas with figure-of-eight stitches taken deep within the gastric wall; close the anterior gastrotomy; perform a truncal vagotomy and pyloroplasty (less commonly, a partial gastrectomy with vagotomy can be performed)

Answer 104

Gastric devascularization procedure (faster) versus total gastrectomy

Answer 105

Mallory-Weiss tear

Answer 106

Esophagogastroduodenoscopy (EGD) {band ligation, epinephrine injection, hemoclipping, multipolar electric coagulation) versus angiographic intraarterial infusion of vasopressin or transcatheter embolization (in patients with severe comorbidities)

Answer 107

>6u packed red blood cells (PRBCs) transfused; failure of EGD to stop bleeding; failure of angiographic embolization (in patients with severe comorbidities)

Answer 108

Anterior gastrotomy and oversewing ofthe bleeding site with deep 2-0 silk ligatures with reapproximation ofthe gastric mucosa

Answer 109

Rather than laparotomy and anterior gastrotomy, you may need a left thoracotomy and esophagotomy followed by suture ligation

Answer 110

Dieulafoy lesion

Answer 111

Men (M:F= 2:1)

Answer 112

Fifth decade

Answer 113

6 to 10 cm from the GE junction, generally in the fundus near the cardia

Answer 114

Sudden onset of massive, painless, recurrent hematemesis with hypotension

Answer 115

Endoscopic modalities (band ligation, heater probe, hemoclipping, injection sclerotherapy, multipolar electrocoagulation, noncontact laser photocoagulation) or angiography if endoscopy cannot identify the bleeding source

Answer 116

Gastric wedge resection to include the offending vessel (laparotomy with gastrotomy vs. laparoscopically with intraoperative endoscopy)

Answer 117

In conjunction with esophageal varices in the setting of portal hypertension (HTN); sinistral HTN from splenic vein thrombosis

Answer 118

Splenectomy

Answer 119

Volume resuscitation and correction of any coagulopathy; temporary tamponade with Sengstaken-Blakemore tube; endoscopic banding or sclerotherapy; transjugular intrahepatic portosystemic shunt (with possible balloon-occluded retrograde transvenous obliteration of a gastrorenal shunt with ethanolamine oleate)

Answer 120

Abdominal ultrasound to document splenic vein thrombosis (portal HTN often accompanies gastric varices)

Answer 121

Organoaxial

Answer 122

Mesenteroaxial

Answer 123

Organoaxial (two-thirds of cases)

Answer 124

Sudden onset of constant, severe upper abdominal pain; recurrent retching with inability to vomit; inability to pass an NG tube

Answer 125

Organoaxial gastric volvulus | mesenteroaxial volvulus usually recurrent and not associated with a diaphragmatic defect

Answer 126

A gas-filled viscus in the chest or upper abdomen

Answer 127

Detorsion and fixation of the stomach by gastropexy or tube gastrostomy through a transabdominal approach

Answer 128

Reduction and uncoiling of the stomachthrough a transabdominal approach; repair of the diaphragmatic defect; resection of compromised stomach if necessary; consideration to perform fundoplication; fixation of stomach with gastropexy versus tube gastrostomy

Answer 129

Phytobezoar

Answer 130

Trichobezoar

Answer 131

Patients with impaired gastric emptying after gastric surgery; diabetics with autonomic neuropathy

Answer 132

1 teaspoon of papain (found in Adolph Meat Tenderizer) in 150 to 300 mL of water is given several times daily

Answer 133

Enzymatic debridement followed by endoscopic fragmentation versus aggressive Ewald tube lavage; surgical removal if these methods fail

Answer 134

Long-haired females who often deny eating their own hair

Answer 135

Surgical removal; may attempt enzymatic therapy, endoscopic fragmentation, or vigorous lavage for small trichobezoars; psychiatric evaluation (recurrent bezoar formation common)

Answer 136

BMI = weight (kg) I height (m); obese: BMI 30 or greater; morbidly obese: BMI 40 or greater or BMI 35 or greater with a significant obesity-related comorbidity, or 100 lb over ideal body weight-these are the same indications to be evaluated for bariatric surgery

Answer 137

hypertension, diabetes, obstructive sleep apnea, heart disease, GERD, osteoarthritis, liver disease, increased risk of CVA

Answer 138

Laparoscopic Roux-en-Y gastric bypass-restrictive and malabsorptive Early complications: bleeding, anastomotic leak with or without sepsis, DVT/PE Later complications: vitamin B12, calcium, iron, vitamin D, and protein deficiencies; anastomotic stenosis with obstruction at the gastrojejunostomy, internal hernia, and marginal ulcer

Answer 139

Endoscopic polypectomy for histologic examination

Answer 140

Endoscopic polypectomy, as long as the entire polyp can be removed and no invasive cancer is in the specimen, with close follow-up with serial endoscopies because of the increased risk for coincident gastric carcinoma

Answer 141

Salted meat or fish, high complex-carbohydrate consumption, high nitrate consumption, low fat or protein consumption

Answer 142

Adenomatous polyps, gastric atrophy and gastritis, H. pylori infection, male gender, prior gastric surgery

Answer 143

Lack of refrigeration, low socioeconomic status, poor drinking water (well water), poor food preparation (salted, smoked), smoking

Answer 144

Linitis plastica

Answer 145

Tumor invades lamina propria or submucosa

Answer 146

Tumor invades muscularis propria or subserosa

Answer 147

Tumor invades muscularis propria

Answer 148

Tumor invades subserosa

Answer 149

Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures

Answer 150

Tumor invades adjacent structures

Answer 151

Metastasis in 1 to 6 regional lymph nodes

Answer 152

Metastasis in 7 to 15 regional lymph nodes

Answer 153

Metastasis in more than 15 regional lymph nodes

Answer 154

Microscopically margin-negative resection with no gross or microscopic tumor remaining in the tumor bed

Answer 155

Removal of all macroscopic disease with positive microscopic margins for tumor

Answer 156

Gross residual disease

Answer 157

Removal of group I lymph nodes (right paracardial, left paracardial, lesser curvature, short gastric, right gastroepiploic, left gastroepiploic, suprapyloric, infrapyloric)

Answer 158

Removal of group 1 and 2 lymph nodes (right paracardial, left paracardial, lesser curvature, short gastric, right gastroepiploic, left gastroepiploic, suprapyloric, infrapyloric + left gastric, anterior common hepatic, celiac artery, splenic hilum, proximal splenic, distal splenic, left hepatoduodenal, superior mesenteric vein)

Answer 159

D2 resection with removal of paraaortic nodes

Answer 160

Flexible upper endoscopy

Answer 161

Splenectomy (station 10 nodes are parasplenic)

Answer 162

Partial pancreatectomy (station 11 nodes are parapancreatic}

Answer 163

Patients with T3/T4 lesion, node-positive cancers, or microscopically positive resection margins

Answer 164

Within the first 3 years after gastrectomy

Answer 165

Gastric remnant at the anastomosis, gastric bed, regional nodes

Answer 166

Liver, lung, bone

Answer 167

Complete history and physical examination every 3 to 4 months for 1 year; Every 6 months for 2 years Yearly thereafter Labs (CBC and LFTs} obtained as clinically indicated CXR/CT A/P where indicated If a subtotal gastrectomy was performed yearly, endoscopy may be necessary

Answer 168

Diffused large B-cell lymphoma (55%)

Answer 169

Extranodal marginal cell lymphoma (mucosa-associated lymphoid tissue [MALT])

Answer 170

Chemoradiation (cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone [CHOP] regimen usually employed) versus multimodal therapy (resection for gastric lymphoma controversial)

Answer 171

H. pylori eradication alone with repeat endoscopy in 2 months to document clearance of infection and biannual endoscopy for 3 years to document regression

Answer 172

Nodal involvement, nuclear Bcl-10 expression, transformation into a large-cell phenotype t(11;18), transmural tumor extension

Answer 173

A margin-negative resection with en bloc resection of adjacent organs if involved by direct extension

Answer 174

Imatinib mesylate (Gleevec)

Answer 175

Menetrier disease

Answer 176

Expansion of surface mucous cells (foveolar hyperplasia); absent parietal cells

Answer 177

Total gastrectomy

Answer 178

Answer: D. This is a classic presentation of gastric volvulus with the Borchardt triad. Two-thirds of the gastric volvulus are organoaxial with the rest being mesenteroaxial.

Answer 179

Answer: A. With prolonged vomiting and loss of hydrochloric acid and potassium, a hypochloremic, hypokalemic metabolic alkalosis is encountered. Primary treatment is replacement of lost volume with normal saline.

Answer 180

Answer: D. The patient is hemodynamically labile and has already received 8U of PRBC. He needs to go to the operating room for operative intervention, which would include exploratory laparotomy, gastrotomy, and oversewing of bleeding areas. If the patient is stable preoperatively, a highly selective vagotomy or a pyloroplasty and truncal vagotomy can be performed.

Answer 181

Answer: C. A type III ulcer is located in the prepyloric area. Management includes antrectomy with incorporation of the ulcer and vagotomy.

Answer 182

Answer: B. The chief cells are found in the body and secrete pepsinogen.

Answer 183

Answer: C. The Curling ulcer is typically seen in burn patients and is a type of stress ulcer. Prophylaxis is with H2 blockers.

Answer 184

Answer: A. A coagulopathic state and intubation for more than 48 hours is the classic indication for stress ulcer prophylaxis.

Answer 185

Answer: D. The most common site to develop a lymphoma in the GI tract is the stomach.

Answer 186

Answer: D. The treatment of choice for early-stage gastric MALT lymphoma is eradication of H. pylori and EGD follow-up in regular intervals.

Answer 187

Answer: B. An aberrant left hepatic artery originates from the left gastric artery, and an aberrant right hepatic artery originates from the SMA 15% of the time.

Answer 188

Answer: A. The right gastric artery is divided during an antrectomy. Three of the 4 main arteries that supply blood to the stomach can safely be ligated.

Answer 189

Answer: D. Pulmonary embolism, bleeding, and anastomotic leak are the 3 most common life-threatening post-op complications associated with bariatric surgery. The mortality rate is less than 1% for this procedure, but these must be taken seriously.

Answer 190

Answer: B. The antrum is the most common location for H. pylori infection.

Answer 191

Answer: D. ``` PPI-related adverse effects include C. difficile; microscopic colitis; malabsorption of magnesium, calcium, B12, and iron; hypergastrinemia; atrophic gastritis; CKD; drug-induced lupus; dementia; pneumonia; and mortality ```

Answer 192

Answer: C. The preferred reconstruction is Billroth I. Anatomy does not always allow for this, as the anastomosis might be under too much tension despite maximal mobilization. An afferent limb less than 20 cm decreases the incidence of afferent loop syndrome. The Roux limb in a Roux-en-Y gastric bypass should be greater than 40 cm to prevent bile reflux.

Answer 193

ANSWER: A COMMENTS: Postgastrectomy complications range from nutritional deficiencies to mechanical malfunctions requiring surgical intervention. The most common metabolic disturbance is anemia, either iron deficiency or megaloblastic secondary to B12 deficiency. Loss of a significant portion of the stomach reduces the amount of intrinsic factor that is required to absorb vitamin B12. Calcium deficiencies are also observed, leading to osteoporosis and osteomalacia, as calcium is primarily absorbed in the duodenum. All of these conditions are treated with supplementation. Afferent loop syndrome occurs as a result of a partial or complete obstruction in the afferent limb. It can be acute or chronic and progress to blind loop syndrome in which bacterial overgrowth occurs. In the case of blind loop syndrome, megaloblastic anemia can develop due to bacterial consumption of vitamin B12. The presentation of afferent loop syndrome includes postprandial pain and fullness with eventual purely bilious emesis, which relieves the pain. Diagnosis is made with a CT scan. Treatment consists of antibiotics for bacterial overgrowth and conversion to a Roux-en-Y with a short afferent limb. Efferent loop obstruction presents the same as a small bowel obstruction. Diagnosis can be established by demonstrating a lack of filling of the efferent limb on barium swallow or by CT scan. Operative management consists of correction of the cause for the obstruction be it adhesions, internal herniation, etc. Finally, alkaline reflux gastritis most commonly plagues patients who have undergone a Billroth II reconstruction and consists of bile refluxing into the stomach remnant. Patients present with bilious emesis that does not tend to relieve their pain. Diagnosis can be made with a HIDA scan, demonstrating biliary secretion into the stomach. The surgical management of this condition involves conversion to a Roux-en-Y with a Roux limb that is greater than 40 cm in length.

Answer 194

ANSWER: B COMMENTS: The workup of a patient with gastric cancer begins with a thorough physical examination in which care is taken to identify signs of advanced disease. Prominent supraclavicular or periumbilical nodes, hepatomegaly, ascites, palpable ovaries on pelvic examination, or a firm Blumer’s shelf on rectal examination all represent possible metastasis. After an initial examination, patients should undergo an EGD with EUS for locoregional staging purposes and a CT scan for the detection of intraabdominal metastatic spread. PET scans do not have a reliable role in the staging workup of a patient; however, they have been used to track response to neoadjuvant therapy. Because CT scan has an overall detection rate of 85% for intraabdominal spread and only 50% for peritoneal metastasis, diagnostic laparoscopy can be utilized to identify the occult metastatic disease. In a 2007 study that included 106 patients with gastric cancer, 33% of patients previously thought to be resection candidates based on preoperative imaging were found to have CT occult disease on laparoscopy. There is no role for the laparoscopic resection of intraabdominal metastases.

Answer 195

ANSWER: C COMMENTS: Dumping syndrome can be divided into early and late phases, with the early occurring 20 to 30 min after eating and the late 2 to 3 h after eating. Early dumping occurs when high osmolarity contents enter the intestines at a rapid rate, inducing a large shift of extracellular fluid into the lumen. Symptoms include cramping, nausea and vomiting, epigastric fullness, and diarrhea. Late dumping occurs when contents high in carbohydrates enter the intestines, stimulating an overcompensatory insulin release that, in turn, results in profound hypoglycemia. Cardiovascular effects occur with both types; however, they are more common with late dumping. Most patients find effective relief with dietary modification alone including smaller portions, slower eating, avoiding foods high in sugars, and separating liquids from solids. Octreotide agonists are reserved for the few who do not respond to these measures. Overall, dumping is more common after Billroth II reconstructions.

Answer 196

ANSWER: A COMMENTS: Both H2 blockers and PPIs work to decrease acid secretion by parietal cells. H2 blockers function as histamine receptor antagonists at the level of the parietal cell but do not influence the release of histamine from the ECL cells. PPIs more completely inhibit acid secretion by irreversibly inhibiting the final common pathway, the proton pump. For the recovery of acid secretion to occur, new proton pumps need to be synthesized, giving them a longer duration of action than H2 blockers. All antisecretory agents result in the elevation of serum gastrin levels and hyperplasia of the G cells and ECL cells.

Answer 197

ANSWER: E COMMENTS: Mallory-Weiss tears are the result of violent retching, vomiting, or coughing. They generally occur high on the lesser curvature and involve only the mucosa, not a full perforation. They comprise around 15% of upper gastrointestinal (GI) hemorrhages. The majority of patients can be effectively diagnosed and managed with endoscopy alone. In the rare case that endoscopic control is unsuccessful, operative intervention can be carried out via an anterior gastrotomy and oversewing of the injury with mucosal reapproximation. None of the other answers would accurately diagnose this condition.

Answer 198

ANSWER: B COMMENTS: Duodenal diverticula are false diverticula containing only mucosa and submucosa, as opposed to a true diverticulum, which contains all layers of the intestinal wall (e.g., Meckel’s diverticulum). Duodenal diverticula are the second most common cause of acquired diverticula after those in the colon. They are more commonly seen in women than in men (2:1) and usually occur later in life, similar to colonic diverticula. The majority of these diverticula (∼75%) are found within a 2-cm radius from the ampulla of Vater and generally protrude through the medial wall of the duodenum. These duodenal diverticula are rarely symptomatic and do not require intervention. Surgery is reserved for those that are symptomatic and in which complications develop. Symptoms are usually the result of hemorrhage, perforation, blind loop syndrome, cholangitis, or pancreatitis from the obstruction of the biliary or pancreatic ducts. Juxtapyloric diverticula have been noted to be associated with choledocholithiasis. Their presence increases the difficulty of successful completion of endoscopic retrograde cholangiopancreatography (ERCP). When treatment is required, surgical excision (diverticulectomy) is recommended.

Answer 199

ANSWER: D COMMENTS: The patient in this scenario has compression of the third portion of the duodenum by the superior mesenteric artery (SMA) as it passes over it. This rare condition is known as SMA syndrome or Wilkie syndrome. This syndrome is usually seen in young asthenic females with predisposing conditions of weight loss, scoliosis or corrective surgery for it, supine mobilization, and place- ment of a body cast. The diagnosis is usually made with either a barium upper GI series or a CT, with oral and intravenous (IV) contrast enhancement demonstrating a dilated duodenum and stomach with an abrupt or nearly complete cutoff of contrast agent at the third portion of the duodenum and minimal flow into the jejunum. Conservative management consisting of nutritional supple- mentation can be tried initially. In patients who fail medical management, the operative treatment of choice is duodenojejunostomy.

Answer 200

ANSWER: C COMMENTS: GI hormones or their analogues have been used clinically as diagnostic or therapeutic agents. CCK is used to stimulate gallbladder contraction. This is useful in identifying patients with biliary dyskinesia or acalculous cholecystitis with the help of CCK cholescintigraphy. Pentagastrin, a gastrin analogue, is used to measure gastric acid secretion. Somatostatin or its analogues are used in various conditions as a result of their universal inhibitory function. Because they inhibit the release of GI hormones, somatostatin analogues are used for various endocrine neoplasms such as Zollinger-Ellison syndrome, VIPoma, insulinoma, and carcinoid tumors. They are also useful in patients with pancreatic fistulas, pancreatic ascites, and enterocutaneous fistulas by decreasing GI secretions. Additionally, they have been used as a treatment to decrease bleeding from the GI tract. Glucagon is used by endoscopists to relax the sphincter of Oddi to facilitate ERCP. Secretin, which inhibits acid secretion, causes a paradoxical increase in serum gastrin levels in patients with gastrinoma. Pancreatic polypeptide (PP) is predomi- nantly secreted in the pancreatic head. PP serum levels drop following the Whipple procedure and may be related to the delayed gastric emptying observed after pyloric-preserving pancreatoduodenectomy. In addition, PP secretion necessitates intact vagal nerve function; thus a blunt response to stimulation by sham feedings has been used to evaluate intact vagal nerve function, particularly in patients suspected of having iatrogenic vagus nerve injury.

Answer 201

ANSWER: D COMMENTS: The most common cause of gastric outlet obstruction is malignancy. The classic metabolic abnormality resulting from gastric outlet obstruction and prolonged vomiting is hypochloremic, hypokalemic metabolic alkalosis. Initial loss of hydrochloric acid causes hypochloremia and mild alkalosis compensated for by renal excretion of bicarbonate. Therefore in the early stages, the urine is alkaline. Continued vomiting produces a severe extracellular fluid deficit and sodium deficit from both renal and gastric losses. The kidneys begin to conserve sodium and, in exchange, excrete hydrogen and potassium cations to accompany bicarbonate. The kidneys are the predominant site of potassium loss, and the urine is paradoxically acidic. Urine chloride content is reduced throughout and is eventually absent. Serum ionized calcium levels are decreased because calcium is mildly alkaline and shifts to its nonionized form to reduce alkalosis. Treatment of this metabolic situation is accomplished primarily by the administration of isotonic saline solution, which replenishes the deficits in volume, sodium, and chloride. Potassium is replaced once the renal function is optimized.

Answer 202

ANSWER: B COMMENTS: The arterial blood supply of the stomach is derived primarily from the celiac artery. The left gastric artery comes off of the celiac artery and supplies the stomach along the lesser curvature. An aberrant/replaced left hepatic artery origi- nates from the left gastric artery (15%–24%) and can represent the only arterial blood supply to the left hepatic lobe. This aber- rant/replaced left hepatic artery runs in the gastrohepatic ligament. The right gastric artery typically arises from the common hepatic artery distal to the gastroduodenal artery. The right and left gastroepiploic arteries usually originate from the gastroduodenal artery and splenic artery, respectively. It is the right estroepiploic artery that functions as the main blood supply to the gastric conduit used in esophagectomies. The short gastric arteries arising from the splenic artery and inferior phrenic arteries also contribute significant blood volume to the proximal part of the stomach. The stomach is well protected from ischemia and can easily survive with ligation of three of four arteries because of its rich collateral circulation.

Answer 203

ANSWER: D COMMENTS: In the chest, the vagal trunks are situated to the right and left of the esophagus. At the level of the cardia, the left vagal trunk is found anterior and the right vagal trunk is found posterior secondary to the embryonic gastric rotation. The anterior vagal trunk divides into hepatic and anterior gastric (anterior nerve of Latarjet) branches. The posterior vagus divides into the posterior nerve of Latarjet and celiac branches. One of the proximal posterior branches of the posterior vagal trunk is known as the criminal nerve of Grassi and is identified as a possible cause of recurrent ulcers if left undivided during selective vagotomy. Truncal vagotomy is conventionally performed at or just above or below the diaphragmatic esophageal hiatus before it gives off celiac and hepatic branches. In contrast, a selective vagotomy is performed distal to this location and spares the celiac and hepatic branches. Highly selective vagotomy (also known as proximal gastric or parietal cell vagotomy) divides individual terminal branches of the nerve of Latarjet in the fundus and corpus of the stomach but spares the vagal branches to the antrum and pylorus, which control gastric motility and emptying— thus obviating the need for a drainage procedure.

Answer 204

ANSWER: A COMMENTS: Treatment of Zollinger-Ellison syndrome is two pronged and aimed at both resecting the tumor when possible and protecting the gastric end organ. Therapy must be individualized. Patients with known endocrine tumors should undergo careful evaluation for other potential endocrine tumors. In patients with gastrinoma and hyperparathyroidism, parathyroidectomy should be performed first to eliminate hypercalcemia. Abdominal surgery is not urgent with the current antisecretory medications. Although gastrinomas are often multiple and are usually metastatic, long-term survival is possible. Aggressive attempts to localize and resect tumors can provide a cure in 5%–20% of patients and can diminish gastrin secretion in others. Digital palpation through a duodenotomy and intraoperative ultrasound are useful operative adjuncts. Both pancreatic and duodenal gastrinomas can be resected by enucleation when appropriately located. Blind pancreatic resections are not generally indicated. When complete tumor removal is not possible, a gastric operation may be appropriate. Proximal gastric vagotomy may be useful, but total gastrectomy still provides the best long-term quality of life for some patients. Life-long pharmacologic treatment with antisecretory agents may control the ulcer diathesis in some patients, but problems with high doses, compliance, and side effects may occur. Resection or ablation of metastatic disease, although not curative, can provide important palliation and decrease the need for drug therapy.

Answer 205

ANSWER: E COMMENTS: Disorders of gastric emptying can be divided into rapid or delayed emptying, both of which can be significantly disabling conditions. Delayed gastric emptying is the more frequently encountered problem of gastric motility. Excluding mechanical obstruction, important causes of delayed gastric emptying include metabolic derangements (e.g., myxedema and hyperglycemia), electrolyte abnormalities (e.g., hypoka- lemia and hypocalcemia), drugs (e.g., narcotics and anticho- linergics), and systemic diseases (e.g., diabetes mellitus and scleroderma). Up to 40% of postvagotomy patients experience delayed gastric emptying. Rapid gastric emptying is less commonly observed. Causes of rapid gastric emptying include previous gastric resection, conditions with impaired fat absorption resulting in the loss of the inhibition of gastric emptying (e.g., pancreatic insufficiency and short bowel syndrome), and con- ditions with hypergastrinemia such as Zollinger-Ellison syndrome.

Answer 206

ANSWER: D COMMENTS: H. pylori is a curved or S-shaped, gram-negative microaerophilic motile bacterium whose natural habitat is the human stomach. H. pylori infection has been demonstrated to be associated with 90% of duodenal ulcers and 75% of gastric ulcers. After eradication of the organism as a part of ulcer treatment, recurrence of ulcer is extremely rare. In addition, H. pylori has been associated with chronic atrophic gastritis, which in turn leads to gastric atrophy and intestinal metaplasia, a suspected precursor of gastric cancer. H. pylori infection also increases the risk for low-grade MALT lymphoma; eradication of H. pylori results in the resolution of MALT lymphomas in most cases. There appears to be a negative association between H. pylori infection and GI reflux disease.

Answer 207

ANSWER: E COMMENTS: Initial studies have demonstrated that H. pylori infection is present in more than 90% of patients with duodenal ulcers. However, more recently, it has been shown that the preva- lence of H. pylori–associated duodenal ulcers is only 75% and is found to be decreasing. Thus it is important to first make the diagnosis of an active H. pylori infection rather than initiating empirical therapy. H. pylori–negative duodenal ulcers are independently associated with NSAID use, older age, multiple medical problems, and sepsis. Use of NSAIDs is the major cause of duodenal ulcers in patients who are H. pylori negative. Bleeding is the initial manifestation in these patients, and they have large and multiple ulcers.

Answer 208

ANSWER: D COMMENTS: The preferred treatment of a perforated duodenal ulcer is resuscitation and prompt surgery. Nonoperative management is reserved for old contained perforations or for terminally ill patients who otherwise cannot undergo surgery. The diagnosis is a presumptive one based on clinical grounds and should not be excluded if pneumoperitoneum cannot be demonstrated, because about 20% of patients with perforations do not have this typical radiographic feature. Operative management requires the closure of the perforation, which is generally best accomplished with an omental (Graham) patch. Closure of the perforation is usually sufficient in patients with duodenal ulcers; however, excision of the ulcer is necessary to rule out malignancy in patients with gastric ulcers before closure. Following simple repair alone, the traditional natural history has been that about one-third of patients have no further ulcer problems, one-third have ulcer recurrence amenable to medical management, and one-third require a subsequent operation for ulcer disease. It is not clear how precisely this applies to patients with H. pylori infection or those with NSAID-induced ulcers. Definitive operations should be performed only in stable patients and in those with documented failure after appropriate H. pylori eradication. Truncal vagotomy can be performed expeditiously but has a greater incidence of side effects. Highly selective vagotomy is an excellent choice but is time consuming and requires a surgeon with the expertise to perform it. Resective procedures are generally avoided in the setting of perforation because of higher morbidity. Following surgery, ulcerogenic drugs should be withheld, and any concomitant H. pylori infection should be treated.

Answer 209

ANSWER: E COMMENTS: The goal of surgical therapy for duodenal ulcers is to reduce acid production in a manner that is safe and has the fewest possible side effects. Acid can be reduced by eliminating vagal stimulation, removing the antral source of gastrin, and removing the parietal cell mass. Traditionally, subtotal two-thirds gastrectomy has carried the highest mortality rate. Truncal vagotomy with antrectomy has the lowest recurrence rate. Procedures involving antrectomy, pyloroplasty, or truncal vagotomy may be complicated by diarrhea, postprandial dumping, or bile reflux. Selective vagotomy, which preserves the hepatic and celiac vagal branches, has been associated with a lower rate of diarrhea than truncal vagotomy. Highly selective vagotomy, also known as parietal cell vagotomy, aims to denervate the parietal cell–bearing portion of the stomach but preserves innervations to the pyloroantral region and thus maintains more normal gastric emptying. This operation carries the lowest mortality rate and the lowest incidence of side effects, but the highest recurrence rate, which ranges from 5% to 15%.

Answer 210

ANSWER: B COMMENTS: Massive bleeding is usually the result of posterior erosion of a duodenal ulcer into the gastroduodenal artery. Emergency surgical intervention is indicated when bleeding is refractory to endoscopic therapy or in the presence of hemorrhagic shock. After expeditious preoperative resuscitation, the abdomen is entered and a longitudinal pyloroduodenotomy is performed. Digital pressure is applied over the ulcer base to temporize the bleeding and allow resuscitation before suture control is obtained. Proper control of bleeding requires three-point suture ligation of the duodenal ulcer. These “U” stitches are placed superior and inferior to the site of penetration to ligate the proximal and distal gastroduodenal artery. A third suture is placed on the medial aspect of the ulcer to control the transverse pancreatic branch coming off the gastroduodenal artery. After the bleeding is controlled, biopsy of gastric mucosa should be performed for histo- logic analysis of H. pylori. The longitudinal pyloroduodenotomy is then closed transversely (Heineke-Mikulicz or Weinberg pyloroplasty).

Answer 211

ANSWER: A COMMENTS: Benign gastric ulcers have been classified in terms of their anatomic location. Type I ulcers are the most common (50%) and occur in the body of the stomach along the lesser curvature. These ulcers are associated with low to normal acid secretion. Type II gastric ulcers (25%) also occur in the body of the stomach but have associated duodenal ulcers. Type III gastric ulcers (20%) are located in the prepyloric region. Both type II and type III ulcers are associated with excessive acid secretion. Type IV ulcers are the least common (<10%) and occur near the GE junction along the lesser curve. Like type I ulcers, they are associated with low or normal acid secretion. Surgical intervention is indicated for patients who have failed maximal medical therapy (12 weeks), for those in whom complications develop, or for those in whom malignancy cannot be ruled out. Surgical therapy for benign gastric ulcers depends on the type of ulcer and its associated acid secretion. Type I ulcers are usually well treated with antrectomy or hemigastrectomy (including removal of the ulcer) without vagotomy. Type IV ulcers do not require vagotomy either. Type IV ulcers near the GE junction can be treated by modifications of distal gastrectomy that include ulcer excision. Distal gastrectomy with extension along the lesser curvature to include the ulcer (Pauchet procedure) and Billroth I reconstruction can be performed for ulcers that are 2 to 5 cm from the GE junction. For type IV ulcers at the GE junction, subtotal gastrectomy with Roux-en-Y jejunal reconstruction (Csendes procedure), a rotational Tanner gastrectomy, or a Kahler-Muhlenberg procedure should be performed. Because type II and type III ulcers are associated with acid hypersecretion, they are treated as duodenal ulcers. Truncal vagotomy with Bill- roth I or II reconstruction is the preferred surgical therapy because it accomplishes both goals of a decrease in acid secretion and excision of the ulcer.

Answer 212

ANSWER: A COMMENTS: It is important to document the presence or absence of H. pylori to adequately treat patients with PUD. Both invasive and noninvasive tests are available for the diagnosis of H. pylori infection. Invasive tests require endoscopic mucosal biopsy and include histologic examination, rapid urease test, and culture. Noninvasive tests include the urea breath test and serology. Histologic examination can accurately diagnose H. pylori with two biopsy specimens with high sensitivity and specificity (90%). The rapid urease test on a mucosal biopsy specimen uses a change in pH resulting from the breakdown of urea by a urease enzyme produced by H. pylori. This test is considered the initial test of choice because of its simplicity, accuracy, and rapid results. Culture of H. pylori has the most specificity (100%) but is difficult to perform and is currently not widely available. Cultures should usually be reserved for research purposes or for patients with suspected antibiotic resistance. The urea breath test is a noninvasive test that analyzes breath for labeled carbon dioxide produced by bacterial urease from the conversion of ingested labeled urea. Because of its noninvasiveness plus high sensitivity and specificity (95%), the urea breath test is considered the test of choice for documentation of H. pylori eradication. Serologic tests are quick and inexpensive but cannot differentiate between active infection and previous exposure. Serology is useful for the initial diagnosis of H. pylori infection in patients in whom endoscopy is not indicated.

Answer 213

ANSWER: E COMMENTS: Certain gastric lesions have a significant associa- tion with gastric adenocarcinoma and can be considered precursors to malignancy. Chronic atrophic gastritis, of which several forms are recognized, underlies most gastric cancers. The epithelial changes of intestinal metaplasia and dysplasia are premalignant. Autoimmune chronic gastritis involves the body and fundus of the stomach. It is associated with pernicious anemia, achlorhydria, very high gastrin levels, and a high risk for cancer. Hypersecretory chronic gastritis involves the gastric antrum and is associated with PUD but not malignancy. H. pylori infection may be the most important risk factor for gastric adenocarcinoma worldwide. The immunoglobulin (Ig)G antibody positivity in various populations correlates with the local incidence of gastric cancer. Hereditary nonpolyposis colorectal cancer is an inheritable risk factor for gastric cancer. Adenomatous gastric polyps have malignant potential similar to colonic adenomatous polyps. The risk increases with increasing size of the polyp. Fundic gland polyps are benign and have no malignant potential.

Answer 214

ANSWER: B COMMENTS: Gastric adenocarcinoma is preferably treated by resection, although resection usually proves to be palliative. The general strategy for curative resection is to remove as much of the stomach as necessary to obtain free margins and to perform limited node dissection. Although data from Japan support the benefit of extended nodal dissection (celiac, mesenteric, hepatic, and paraaortic), studies in the United States have not generally confirmed this benefit. Furthermore, these extended dissections can be associated with substantial morbidity. Most resections entail distal subtotal gastrectomy. Total gastrectomy is appropriate for locally extensive tumors, proximal tumors (to avoid esophageal anastomosis to the distal stomach remnant), and even palliation if necessary. Extending clear margins on a distal tumor by total rather than subtotal gastrectomy is of no benefit. Resections for linitis plastica are palliative, usually necessitate total gastrectomy, and are carried out to grossly negative margins only. Splenectomy is performed according to the location of gastric resection, but its routine performance does not improve the survival rate. The number of lymph nodes resected, the number of positive nodes, and the ratio of positive to the total number of lymph nodes have important staging implications. Furthermore, a minimum number of 15 lymph nodes should routinely be examined.

Answer 215

ANSWER: B COMMENTS: GI stromal tumors are the most common mes- enchymal neoplasms of the GI tract. The majority of these GISTs occur in the stomach (60%), followed by the small bowel (30%), esophagus (1%–5%), and colon and rectum (5%). The diagnosis of GIST is based on the presence of characteristic pathologic findings on hematoxylin–eosin staining and expres- sion of the KIT receptor on immunohistochemistry. Rarely, KIT might not be overexpressed, and in such cases molecular evaluation may be necessary. These tumors do not usually metastasize to lymph nodes. Complete surgical resection is the standard of treatment of primary, localized GISTs. The majority of GISTs have an activating mutation in the KIT protooncogene that can be effectively inhibited by tyrosine kinase inhibitors such as imatinib mesylate (Gleevec). GISTs are resistant to conventional chemoradiation therapy. Laparoscopic resection is increasingly being used, provided that a negative margin can be obtained. Both the size and number of mitoses per 50 high- power field have been used to categorize tumor aggressiveness. Tumor location may have prognostic implications in that extra- gastric tumors may carry a worse prognosis. Large or unresectable tumors that show KIT overexpression may initially be treated with Gleevec.

Answer 216

ANSWER: B COMMENTS: Crohn’s disease of the duodenum is not common and is seen in only 2%–4% of patients with Crohn’s disease. Medical therapy remains the mainstay of treatment of duodenal Crohn’s disease, with surgical intervention being reserved for patients who do not respond to medical therapy or in whom a complication such as obstruction or perforation develops. In patients who do need a surgical procedure, bypass is preferred over duodenal resection. In a few select patients, their anatomy might be amenable to strictureplasty. Irrespective of the location of Crohn’s disease, GI cancer remains the leading cause of death in patients with Crohn’s disease.

Answer 217

ANSWER: A COMMENTS: Gastric volvulus is a serious complication of paraesophageal hernia. Two types of gastric volvulus may occur, depending on the axis of rotation. Organoaxial volvulus, the more common type, involves rotation around the axis of a line connecting the cardia and pylorus. Mesenteroaxial volvulus is not associated with a diaphragmatic defect and involves rotation around the line that bisects the greater and lesser curvatures. Combined types have also been described. Patients classically present with Borchardt’s triad, which includes acute epigastric pain, violent retching without vomiting, and the inability to pass an NG tube. Acute gastric volvulus is a surgical emergency and requires prompt reduction via a transabdominal approach. Repair of the diaphragmatic defect should follow with possible fundoplication. In the setting of volvulus without an associated diaphragmatic defect, detorsion of the stomach and either gastropexy or tube gastrostomy is performed to reduce the risk for recurrence.

Answer 218

ANSWER: D COMMENTS: Intractable ulcer disease is defined as that occurring after an adequate duration of antacid therapy, documentation of eradication of H. pylori infection, and elimination of NSAID use. In these patients, malignancy must be ruled out and a serum gastrin level should be drawn to evaluate for a gastrinoma. Zollinger-Ellison syndrome is the triad of gastric acid hypersecretion, severe PUD, and non–beta islet cell tumors of the pancreas. Gastrinomas occur most commonly within the gastrinoma triangle as defined by the confluence of the cystic and common bile duct, the junction of the second and third portions of the duodenum, and the junction of the neck and body of the pancreas. They are found almost equally within the wall of the duodenum as the head of the pancreas but not in the tail of the pancreas. Endoscopy often reveals prominent rugal folds, which result from the trophic effect of the hypergastrinemia. Fasting serum gastrin levels are usually elevated above 200 pg/mL, but a value greater than 1000 pg/mL is diagnostic. In the setting of equivocal gastrin levels, the most sensitive test is the secretin stimulation test. A rise in gastrin levels of greater than 200 pg/ mL above baseline is specific for gastrinoma. Gastrinomas are associated with MEN I syndrome, not MEN II syndrome. Testing for associated endocrine tumors should be performed.

Answer 219

ANSWER: C COMMENTS: Long thought to be a rare location for carcinoid malignancies, gastric carcinoid neoplasms (or neuroendocrine tumors, NET) are increasing in incidence. Many patients are asymptomatic and diagnosed incidentally during endoscopy, though rarely they can present with abdominal pain, bleeding, and symptoms of carcinoid syndrome. The rise in the use of endoscopy has been postulated to account for some of the increase in incidence; however, the increase in the long-term use of PPIs may also play a part as it has been shown to be an independent risk factor for the development of gastric carcinoid tumors. There are three types of gastric carcinoids. The majority of these are type 1 and are associated with a low acid state (normally from atrophic gastritis), resulting in hypergastrinemia, which in turn is thought to cause ECL cell hyperplasia and eventual dysplasia. This type carries a better prognosis than sporadic types, type 3, not associated with low acid states. The final type is type 2, which is associated with Zollinger-Ellison syndrome and high gastrin levels. Treatment is based on complete resection whether accomplished via endoscopic removal, wedge resection, or total gastrectomy, depending on the extent of the disease. Somatostatin analogues can serve to decrease tumor burden and address symptoms of carcinoid syndrome in patients with recurrent or metastatic disease.

Answer 220

ANSWER: C COMMENTS: It is important to have the knowledge of the cellular basis for parietal cell acid secretion to understand the pharmacologic control of acid. The parietal cell has three specific plasma membrane receptors that stimulate acid secretion: acetylcholine, histamine, and gastrin receptors. All three receptors eventually activate the H+, K+-ATPase pump via different mechanisms, which results in the secretion of a hydrogen ion for potassium. Acetylcholine- and gastrin-stimulated secretion depends on increases in intracellular calcium levels, with subsequent phosphorylase kinase–induced phosphorylation and H+, K+-ATPase activity. Histamine activates the adenylate cyclase pathway. Somatostatin, CCK, and secretin inhibit acid secretion.

Answer 221

ANSWER: C COMMENTS: The most proximal region of the stomach is the cardia. This is dominated by mucus-secreting cells, which provide a mechanical barrier to injury. Gastric ulcers in this area are deemed type IV ulcers and are associated with a breakdown of this mucus barrier. The uppermost part of the stomach is the fundus. The junction of the fundus and the left margin of the esophagus forms the angle of His. The GE junction is normally found about 2 to 3 cm below the diaphragmatic esophageal hiatus. The extension of the esophagus into the abdominal cavity creates an anatomically important pressure differential between the distal esophagus within the positive pressure abdomen and the midesophagus within the negative pressure thoracic cavity that helps to prevent reflux. This relationship is disturbed in patients with type I hiatal hernias. The body is bound by the lesser curvature on the right and greater curvature on the left. Parietal cells exist primarily within the body, with few in the fundus and antrum and none in the cardia or pre- pyloric antrum. As the lesser curvature meets the pylorus, it angles abruptly to the right, identifying the angularis incisura.

Answer 222

ANSWER: D COMMENTS: The majority of upper GI bleeding requires no intervention and ceases spontaneously. However, if it persists, it is associated with a mortality rate of 6%–8%. Initial management should include IV access, fluid resuscitation, and blood products as indicated. Placement of an NG tube can confirm upper GI bleeding with return of bloody or coffee ground lavage; however, only return of bilious lavage can effectively rule out an upper GI source of a bleed. Regardless of the degree of severity, patients who present with upper GI bleeding should undergo endoscopy within 24h of presentation for both diagnostic and therapeutic purposes. Endoscopic control results in primary hemostasis in approximately 90% of patients. Patients should be closely monitored in an intensive care unit (ICU) setting in case of persistent bleeding, and all high-risk patients should be placed on PPI infusion. Octreotide infusions are reserved for upper GI bleeding as a result of esophageal varices.

Answer 223

ANSWER: E COMMENTS: The gastric mucosa consists of surface columnar epithelial cells and glands containing various cell types. The mucosal cells vary in their anatomic location and secretory function. Within the cardia, the glands contain primarily mucus-secreting cells and the pits are short. In the body of the stomach, the glands retain their mucus-secreting cells at their luminal end but the pits extend deeper and begin to include other secretory cells. Parietal and chief cells are located predominately in the body. Parietal cells produce hydrochloric acid and intrinsic factor, whereas chief cells secrete pepsinogen. The G cells of the antrum are the primary source of gastrin. Somatostatin is synthesized and stored in delta cells located in the gastric corpus and antrum. Ghrelin, produced by endocrine cells of the gastric body, probably plays a role in the neuroendocrine response to changes in nutritional status and has been shown to enhance appetite and increase food intake. Removal of a significant portion of the gastric body resulting in decreased ghrelin levels is thought to be the mechanism of appetite control after a sleeve gastrectomy.

Answer 224

ANSWER: C COMMENTS: Gastric MALT lymphoma is associated with chronic H. pylori infection in more than 90% of cases. Chronic infection with H. pylori results in monoclonal B-cell proliferation and development of lymphoid tissue resembling Peyer’s patches in the stomach. Treatment directed toward H. pylori eradication results in the resolution of MALT lymphomas in 75% of cases. Upper endoscopy with biopsy is the diagnostic test of choice. Gastric biopsies are used to evaluate the presence of H. pylori and the histologic type of lymphoma. The depth of gastric wall invasion and the presence of nodal involvement can be determined with the help of endoscopic ultrasonography. Histologically, H. pylori– negative MALT lymphomas should be confirmed as such with serologic testing. Staging is completed with a chest radiograph, bone marrow biopsy, and CT of the abdomen. Surveillance is achieved with repeat endoscopy in 2 months with biopsy to document clearance of infection and subsequent endoscopy every 6 months for 3 years. Certain genetic translocations, large cell phenotype, nodal involvement, or transmural tumor extension all predict failure of H. pylori eradication alone.

Answer 225

ANSWER: D COMMENTS: Diffuse large B-cell lymphoma is the most common type of gastric lymphoma, with MALT lymphoma being the second most common. High-grade gastric lymphoma is gener- ally treated with chemotherapy or chemoradiation. Compared with surgical treatment, patient survival has been shown to be equivalent or better with nonsurgical treatment in several prospective clinical trials (randomized and nonrandomized). It was previously believed that surgery was superior to chemotherapy due to the risk for complications such as perforation and hemorrhage with chemotherapy. However, these risks have been found to be only approximately 5%. It is postulated that these risks may be increased with full- thickness involvement of the gastric wall. EUS can be used to determine the depth of invasion, and this information can be offered to the patient when discussing risks and benefits of treatment options. Operative intervention is therefore largely reserved for limited gastric disease in which R0 resection is a reasonable goal, patients undergoing chemoradiation with treatment failure, or for the management of rare complications of nonsurgical treatment including perforation, hemorrhage, and obstruction.

Answer 226

ANSWER: D COMMENTS: There are two types of gastric varices: those that occur in the setting of portal hypertension and those that are secondary to splenic vein thrombosis (isolated gastric varices). To establish the diagnosis of isolated gastric varices, there must be no evidence of portal hypertension, cirrhosis, or esophageal varices on endoscopy. In either type, an increased flow and pressure is trans- mitted via the short and posterior gastric veins. For isolated gastric varices, splenectomy is curative. Splenectomy is neither curative nor indicated when the varices are associated with portal hypertension. Rather, this type is best managed similarly to esopha- geal varices with endoscopy, banding, and sclerotherapy.

Answer 227

ANSWER: A COMMENTS: The duodenum is the first portion of the small intestine and the most distal foregut-derived structure. It is approximately 20 cm in length and is divided into four portions, of which the second and third are found retroperitoneally. Although the minor papilla is found superiorly to the major, they are both located within the second portion. The acute angle between the aorta and the SMA marks the transition point between the third and fourth portions. The blood supply to the duodenum is via the superior and inferior pancreaticoduodenal arteries, both of which have posterior and anterior divisions and constitute a rich bed of vascular collaterals. The anastomosis of these two vessels also represents the only connection between celiac and SMA blood supply.

Answer 228

ANSWER: A COMMENTS: Small bowel adenocarcinoma accounts for the majority (35%–50%) of small bowel malignant neoplasms, followed by carcinoid tumors, lymphomas, and sarcomas. Adenocarcinoma of the small bowel is more common in the duodenum, whereas carcinoid tumors and lymphoma are more frequently seen in the ileum. Small bowel adenocarcinoma is found in decreasing order of frequency in the duodenum, jejunum, and ileum. Most patients have nonspecific symptoms initially; however, adenocarcinoma of the duodenum is manifested earlier with signs and symptoms of obstruc- tive jaundice, gastric outlet obstruction, and abdominal pain. Operative resection (pancreaticoduodenectomy and local excision) is the treatment of choice, depending on the size and location of the adenocarcinoma, the patient’s health, and the surgeon’s expertise. Although rare in the small bowel, villous adenomas are frequently found in the duodenum and are associated with FAP syndrome (31%–92%). These villous adenomas have high malignant potential, especially if they are larger than 5 cm or are accompanied by bleeding or obstruction. The Spigelman criteria are used to grade duodenal polyposis seen in FAP. They consist of five incremental stages of severity (0 to IV). Points are earned for the number of polyps, size of polyps, histology, and grade of dysplasia. This classification also correlates with the risk for malignancy as follows: stage II, 2.3% risk; stage III, 2.4% risk; and stage IV, 36% risk. Pancreaticoduodenectomy is recommended for stage IV.

Answer 229

C. Evaluation for Helicobacter pylori

Answer 230

E. Steatorrhea

Answer 231

C. Bronchoscopy should be performed in all patients with carcinoma of the upper and middle thirds of the esophagus

Answer 232

C. Trials would suggest improved survival compared to patients receiving surgery alone

Answer 233

C. Extended lymphadenectomy including nodes along the aorta and esophagus may improve survival

Answer 234

1) Bismuth triple therapy - Bismuth 2 tabs QID - Metronidazole 250mg TID - Tetracycline 500ng QID 2) Quadruple therapy - PPI BID - Bismuth 2 tabs QID - Metronidazole 250mg TID - Tetracycline 500mg QID 3) PPI triple therapy - PPI BID - Amoxicillin 1g BID - Clarithromycin 500mg BID 10-14 days treatment is recommended

Answer 235

1. (E) Duodenal ulcer is best diagnosed by upper endoscopy and biopsy. Findings of gastritis and the presence of H.pylori are indications to prescribe appropriate therapy. This typically includes a PPI and two antibiotics (one regimen includes amoxicillin and clarithromycin). Although the urea breath test is the most sensitive and specific test used to detect H. pylori, it is not readily available in all settings.

Answer 236

2. (C) The pylorus is palpable but it is not a true physiologic sphincter. It does not demonstrate reciprocal contraction when the stomach relaxes, nor does it relax when the stomach contracts. The pylorus is normally in tonic contraction. It is partially covered by omentum and cancer is commonly found there.

Answer 237

3. (C) Surgical intervention for peptic ulcer disease is uncommon. It is indicated by four clinical situations—intractable pain, hemorrhage, perforation, and obstruction. Noncompliance with medication is often the cause of recurrence. Patients with gastric decompression need a nasogastric tube and fluid and electrolyte correction prior to surgery.

Answer 238

4. (D) If vagotomy alone is performed, gastric stasis occurs in more than 40% of cases. Branches of the vagus nerve innervate the pylorus. A drainage procedure is necessary; a pyloroplasty or a gastroenterostomy should be performed and both of these require a laparotomy. Truncal vagotomy can also be done through a thoracic approach. Transection of the vagus nerve in the neck results in paralysis of the recurrent laryngeal nerve.

Answer 239

5. (D) In highly selective vagotomy (Fig. 5–6), the nerve supply to the pylorus is left intact (and therefore no drainage procedure is necessary). During this operation, the branches of the vagus nerve that supply the parietal cell mass are meticulously divided, leaving the main anterior and posterior nerves of Latarjet intact. The main vagal trunks are also left intact, thus sparing the nerve supply to the liver, gallbladder, pancreas, and intestines. To ensure completeness of the procedure, great care is taken to divide the proximal (criminal) nerve of Grassi. Although the complication rate is lower, the recurrence rate is higher than that of an antrectomy and truncal vagotomy.

Answer 240

6. (B) An upright chest x-ray will demonstrate free air below the diaphragm in about 70–75% of patients presenting with a perforated duodenal ulcer. An abdominal sonogram may demonstrate free fluid, but not free air. Although a CAT scan will show both free fluid and free air, it will take longer to perform and may delay the definitive treatment. The combination of an acute abdomen and an upright chest x-ray with free air under the diaphragm provides enough information to take the patient to the operating room for exploration.

Answer 241

7. (B) Although surgery is generally recommended for perforation, conservative measures can be considered in select cases. A patient who has a benign clinical presentation or one who is improving, might be considered for treatment with antibiotics and nasogastric decompression. Patients who have an acute abdomen and are hemodynamically unstable should not be observed. Board-like rigidity of the abdomen occur as a result of chemical peritonitis. These patients should have fluid and electrolyte repletion, and antibiotics followed by surgery. Choice of the operative procedure should be guided by the information obtained during the history, the presence of comorbid disease, and hemodynamic stability during the operation. A omental (Graham) patch will seal the ulcer, but it will not prevent recurrence.

Answer 242

8. (D) Following truncal land selective vagotomy, gastric empyting is delayed. If a vagotomy (truncal or selective) is performed, a drainage procedure is necessary (e.g., pyloroplasty). A disturbance is gastric motility with a delay in gastric emptying may occur with a mechanical gastric outlet obstruction, diabetes, myxedema, hypokalemia, or the administration of anticholinergic or opiate drugs. Rapid gastric emptying may be seen with ZES, retained gastric antrum syndrome, steatorrhea, or massive small bowel resection where there is impaired ability to reduce gastric acid secretion. Failure of switch-off mechanism to inhibit acid secretion also results in increased motility and emptying of the stomach.

Answer 243

9. (C) Although a milder type of diarrhea is not uncommon after gastrectomy, fulminant diarrhea may be a problem after vagotomy (it is one of the many complications collectively referred to as post vagotomy syndromes). The exact mechanism is not known. It occurs in 1-2% of patients following truncal vagotomy and is less likely to be found after selective or highly selective vagotomy.

Answer 244

10. (C) H. pylori (previously called Campylobacter pylori) is associated with chronic gastritis, duodenal ulcers, gastric ulcers, and gastric cancer. Serology can accurately detect H. pylori but remains positive for up to 1 year post treatment. The urea breath test is highly sensitive (96%) and specific (94%). In 2005, Barry Marshall and J. Robbin Warren won the Nobel Prize in medicine for their work on H. pylori and its role in gastritis and peptic ulcer disease.

Answer 245

11. (C) Postgastrectomy syndromes collectively refer to complications that can occur after gastric surgery. This constellation of syndromes includes delayed gastric emptying, recurrent ulcers, diarrhea, anemia, jejunogastric intussusception, afferent loop syndrome, alkaline reflux gastritis, and dumping syndrome. There are two types of dumping syndrome, early and late. Early dumping occurs within 30 minutes and is caused by rapid gastric emptying of a hyperosmolar load into the small bowel. Late (hypoglycemic) dumping occurs 1–3 hours after eating. Symptoms are mostly vasomotor. They are related to the excessive release of insulin in response to the rapid rise in postprandial glucose.

Answer 246

12. (D) Prolapse of gastric mucosa into the duodenum may be difficult to distinguish from a polyp in the antrum. It may be detected in a patient who is asymptomatic. Surgical correction should be reserved for patients with obstructive symptoms (e.g., vomiting). Sleeping with they head elevated, H2 antagonist, and laser treatment have no role.

Answer 247

13. (D) Dumping syndrome is a symptom complex occurring after gastric surgery. It is characterized by fatigue, abdominal distention, pain, and vasomotor symptoms caused by the rapid entry of food into the small intestine. Tachycardia, sweating, and feeling lightheaded after eating are symptoms patients may feel. There are two types of dumping syndrome, early and late.

Answer 248

14. (B) Bilious vomiting is usually spontaneous and should be differentiated from vomiting that occurs after eating. The most likely cause of this complication is reflux of bile into the stomach. Bile gastritis with intestinalization of the gastric mucosa is a likely cause.

Answer 249

15. (D) Group O is the most common blood type in patients with duodenal ulcer disease. In patients who have bled from a duodenal ulcer, this observation is even more striking. Secretors have an excess of blood group antigen that is absent in nonsecretors. The secretor antigen on the red blood cell appears in body fluids also. Nonsecretors are more prone to develop dueodenal ulcers than secretors.

Answer 250

16. (E) There is a varying degree of impairment in carbohydrate, fat, protein, and mineral absorption after gastrectomy. These changes are most severe after a subtotal gastrectomy and gastrojejunostomy (Billroth II) (Fig. 5–7), in most patients these changes are mild. An acid environment is necessary to release ferric ion from food and make it available for absorption in the small intestine.

Answer 251

17. (D) In general, vagotomy with a gastric drainage procedure is less satisfactory in the treatment of primary gastric ulcer. Treatment of a gastric ulcer may include partial gastrectomy with a gastroduodenal anastomosis (Billroth I). Vagotomy is not necessary because gastric ulcers are usually not associated with acid hypersecretion. A gastric ulcer that fails to heal despite medical therapy should be excised.

Answer 252

18. (C) In ZES gastrin levels may be only mildly elevated but can be increased with provocation with intravenous calcium or secretin. Most patients with gastrinoma have serum gastrin levels that exceed 500 pg/mL. When the range is lower than 200–500 pg/mL, a stimulation test is performed to confirm the diagnosis. A rise of 200 pg/mL after 15 minutes, or a doubling of the fasting level is diagnostic. ZES can occur sporadically or as part of multiple endocrine neoplasia (MEN) I.

Answer 253

19. (C) Chronic duodenal ulcer, with recurrent episode of healing and repair, may lead to pyloric obstruction due to scarring and stenosis of the duodenum. Painless vomiting of undigested food may occur once or twice a day. Surgical intervention should be carried out after correction of fluid and electrolyte imbalances. Preoperative antibiotics should be used due to bacterial overgrowth secondary to gastric stasis.

Answer 254

20. (D) ZES is characterized by duodenal ulcer disease, high basal acid secretory output, and a pancreatic tumor. Stimulated serum gastrin levels may be in excess of 1000 pg/mL or as high as 10,000 pg/mL. ZES is due to a true pancreatic tumor in adults, but may be secondary to hyperplasia in children. Growth of the tumor is usually slow and survival is often prolonged. If an isolated tumor is found on CAT scan, surgical resection is indicated. About two-thirds of these tumors are malignant. About one-fourth of patients have MEN I syndrome tumors of parathyroid pituitary and pancreas.

Answer 255

21. (C) Gastrin is produced in the antrum, duodenum, and small intestine. It is not present in the fundus of the stomach. When the distal stomach is removed gastrin levels decrease significantly. Gastrin stimulates parietal cells to secrete acid and it stimulates chief cells to secrete pepsinogen.

Answer 256

22. (D) Hypertrophic gastritis is characterized by massive loss of plasma protein through the affected gastric mucosa. Most cases can be managed medically by maintenance of adequate nutrition. An increased incidence of gastric cancer has been reported in some series.

Answer 257

23. (E) The distinction between a benign and malignant ulcer can be difficult. The presence of achlorhydria rules out peptic ulceration. Endoscopy is indicated so that biopsy can be performed.

Answer 258

24. (D) A gastric ulcer that does not respond to medical therapy requires surgical intervention. An appropriate operation for an antral ulcer is an antrectomy with a gastroduodenal anastomosis (Billroth I). Vagotomy is not nearly as effective in preventing recurrences in gastric ulcers. It is important to realize that the management of gastric and duodenal ulcers is not identical because the etiologies are different. Duodenal ulcers are associated with acid hypersecretion while gastric ulcers are associated with impaired mucosal defense mechanisms. Both are associated with H. pylori (duodenal ulcers 90% and gastric ulcers 75%). A gastric ulcer is much more likely to harbor a malignancy as compared to a duodenal ulcer. A gastric ulcer should always be biopsied. If a gastric ulcer fails to heal after appropriate medical management, it should be excised.

Answer 259

25. (A) EGC is found only in the mucosa and submucosa. Regional lymph nodes may or may not be involved. EGC can be missed on a UGI series (low sensitivity). Treatment is gastric resection with care to ensure that the resection margins and the anastomosis are tumor free. Selected cases may be treated by endoscopic mucosal resection. In the United States, EGC is found in only 15% of patients diagnosed with gastric cancer. In Japan the incidence is up to 40%. Up to 14% of patients will have synchronous cancers. Five-year survival is 85–90%.

Answer 260

26. (E) The treatment of an antral gastric cancer is distal subtotal gastrectomy with lymph node dissection (provided there is no metastatic disease). Surgical resection is the only potential curative therapy. Proximal margins should be 5–6 cm. Total gastrectomy does not improve 5-year survival. Postoperative chemoradiation may increase 5-year survival (limited studies).

Answer 261

27. (D) The incisura is located at the distal portion of the lesser curvature. It is the point at which the body of the stomach ends and the antrum begins.

Answer 262

28. (B) GISTs were previously called leiomyosarcomas. They are rare (4% of all gastrointestinal tumors). They can cause confusion because the overlying mucosa may remain intact. They grow slowly, invade locally, and are not responsive to radiation or chemotherapy. Eosinophilic gastroenteritis is an infiltrative lesion that usually involves the gastric antrum. It is of unknown origin and differs from Menetrier’s disease, where the mucosal folds of the proximal stomach are intially involved.

Answer 263

29. (C) The stomach is the most common site of involvement in extranodal non-Hodgkin’s lymphoma (NHL). Lymphoma is the second most common malignancy of the stomach. Surgery was previously the treatment of choice for gastric lymphoma. More recent studies show that nonoperative treatment with chemotherapy and radiation therapy results in similar 5-year survival and is currently first-line therapy. Surgery is used mainly to treat complications of gastric lymphoma (e.g., perforation, bleeding). Mucosa associated lymphoid tissue (MALT) lymphoma is a type of NHL. It is associated with H. pylori. Treatment with a PPl and antibiotics will cure up to 75% of low-grade MALTomas.

Answer 264

30. (D) A GIST (previously called leiomyoma or leiomyosarcoma) can occur in any part of the stomach. Most commonly they are found in the submucosa and grow towards the lumen. Ulceration may occur and give rise to the characteristic “doughnut sign” on barium studies. Hematemesis and/or melena may sometimes be massive. Local resection is curative.

Answer 265

31. (C) Hyperplastic polyps are unlikely to harbor carcinoma. Multiplicity of hyperplastic polyps does not seem to predispose to the development of cancer. Adenomatous polyps occur more commonly in the antrum. Hyperplastic polyps are distributed more evenly throughout the stomach. For this reason, antral polyps should be removed first. (Adenomatous polyps may have a focus of cancer within them.)

Answer 266

32. (C) Adenomatous polyps of the stomach resemble colon polyps. Coexisting carcinoma may be present in up to 20% of cases. The incidence of carcinoma is increased if lesions are larger than 2 cm. Both hyperplastic and adenomatous polyps are more common in long-term follow-up of patients treated successfully for familial polyposis. All adenomatous polyps should be removed.

Answer 267

33. (E) Gastric volvulus is often associated with a large paraesophageal hiatal hernia. The twist causes a cut-off at the cardia above and at the pylorus below leading to distension and ischemia, which may progress to gangrene. Organoaxial volvulus is more common and rotation occurs along the axis between the cardia and the pylorus. In the less common type of gastric volvulus, rotation occurs through an axis that is at the right angle to the organoaxial axis described.

Answer 268

34. (C) Acute gastric distension can lead to a vasovagal reaction. Treatment consists of nasogastric decompression for 24–48 hours to allow normal gastric tone to return. Appropriate parenteral fluids should also be administered.

Answer 269

35. (B) Autoimmune metaplastic atrophic gastritis is associated with hypochlorhydia parietal cell antibodies, and high gastrin levels. There is an increased risk for developing gastric carcinoid tumors or adenocarcinomas. Other premalignant conditions include adenomatous polyps, gastric ulcer, previous gastric resection (>15 years), chronic atrophic gastritis, and histologic changes showing intestinal metaplasia and dysplasia.

Answer 270

36. (A) In 1948, Dragstedt introduced a gastric drainage procedure to overcome stasis that occurred in over 30–40% of cases following vagotomy. Pyloroplasty, gastrojejunostomy, and antrectomy are the three recognized drainage procedures performed in conjunction with vagotomy. The decision on which one to perform is based on the overall condition of the patient and the severity of the ulcer, amongst other things. A drainage procedure is not necessary with a highly selective vagotomy because the innervation to the pylorus is left intact.

Answer 271

37. (D) In general, surgery for peptic ulcer bleeding is indicated at an earlier stage in an older patient because vessels are atherosclerotic and less likely to stop bleeding spontaneously. In addition, diminished perfusion of the heart, brain, and kidneys is less well tolerated in elderly patients. At surgery, the gastroduodenal artery is oversewn, and a vagotomy and drainage procedure is performed.

Answer 272

38. (B) The scan will fail to visualize the gallbladder if acute cholecystitis is present. In a patient with cholelithiasis, the incidence of cholecystitis and associated biliary complications is increased following truncal vagotomy. A sonogram will show gallstones but may not distinguish acute cholecystitis.

Answer 273

39. (B) GIST is the most common sarcoma of the gastrointestinal tract. It is most commonly found in the stomach (60–70%). Other sites include small intestine (25%), rectum (5%), esophagus (2%), and other less frequent locations. It may be difficult to distinguish between malignant and benign GISTs. Factors that are correlated with improved prognosis include gastric location, low mitotic index <2 cm diameter, and absence of tumor rupture and spillage during resection.

Answer 274

40. (B) If the mass is deemed resectable, the goal of surgery is resection with grossly negative margins. Precautions should be taken to prevent rupture of the mass. Radiation and chemotherapy have traditionally been ineffective. Clinical trials with the drug imatinib mesylate (Gleevec) are promising.

Answer 275

41. (C) Patients with pernicious anemia have achlorhydria and an increased risk (about 5%) of developing gastric carcinoma. There is a deficiency in vitamin B12 that leads to megaloblastic anemia and neurologic involvement (subacute degeneration of the dorsal and lateral spinal columns).

Answer 276

66. (B) The hepatic artery is medial to the common bile duct and anterior to the portal vein. The inferior vena cava passes posterior to the (epiploic) foramen of Winslow, where it lies behind the portal vein. The foramen represents the only natural communication between the lesser and greater peritoneal bursa (sac).

Answer 277

67. (E) This test is a useful method of determining if a mass is due to an abdominal wall lesion or an intra-abdominal lesion. Attempts by the patient to sit up will make the anterior abdominal wall muscles taut and thus reduce the palpability definition of an intra-abdominal mass. An abdominal wall mass will still be palpable after this maneuver. This is called Fothergill’s sign.

Answer 278

68. (D) H. Pylori infection, smoking, and a high salt intake are all risk factors for gastric cancer. A diet high in fruits, vegetables, and fiber may lower the risk for gastric cancer. The incidence of gastric cancer is low in North America. Gastric cancer is one of the most common cancers in Japanese men.

Answer 279

69. (E) Acute gastric dilatation may result in a vasovagal response. This response is characterized by typical signs and symptoms of marked gastric and abdominal distension. These are clearly demonstrable in an awake patient. Unfortunately, this condition may occur after anesthesia is administered and thus go unrecognized. Vomiting, aspiration, hypoxia, or bleeding from erosive stress gastritis may occur. Gastritis, gastric volvulus, and pernicious anemia do not cause a vasovagal response.

Answer 280

70. (E) GISTs are the most common mesenchymal tumors of the gastrointestinal tract. They may be benign, malignant, or intermediate grade. They demonstrate a mutation of the c-kit oncogene. Distant metastases occur late. Prolonged survival follows resection, including adjucent organs if necessary (e.g., colon, pancreas). Hemorrhage can result if the tumor erodes through the gastric mucosa. Malnutrition results from compromise of the capacity of the stomach.

Answer 281

71. (E) Patients with familial adenomatous polyposis are at risk for developing carcinoma in adenomatous polyps arising in the stomach and duodenum. Ampullary and bile duct cancers will result in jaundice.

Answer 282

``` 72. (D) Conservative treatment of GERD includes lifestyle modifications (e.g., smoking cessation, decreased caffeine intake, avoidance of large meals before lying down, elevation of the head of the bed, and avoidance of constrictive clothing). ``` PPl’s are very effective. If nonoperative management fails, surgical intervention should be considered. Preoperative evaluation includes manometry, 24-hour pH test and esophagogram, in addition to endoscopy. Manometry evaluates the LES resting pressure and effectiveness of peristalsis. The 24-hour pH test is the gold standard for diagnosing and quantifying acid reflux. Esophagogram shows the external anatomy of the esophagus and proximal stomach, as well as demonstrating the presence of a hiatal hernia. Nissen fundoplication is a 360° gastric wrap. It can be performed as an open or laparoscopic procedure. It is the most common operation performed for GERD. Partial fundoplications (e.g., Thal, Dor, Toupet) are done if esophageal motility is poor.

Answer 283

73. (E) Critically ill patients who have multiple organ involvement, from trauma or other diseases, are at risk for developing bleeding from erosive gastritis. Risk factors include multiorgan dysfunction, sepsis, trauma, and respiratory failure requiring mechanical ventilation. The pathogenesis of acute stress gastritis is multifactorial. One factor is thought to involve hypoperfusion of the gastric mucosa and ischemia.

Answer 284

74. (E) Endoscopic findings range from petechiae to multiple ulcers in the body of the stomach and duodenum. Endoscopy can safely be performed at the bedside in the intensive care unit. Because bleeding may be secondary to shallow mucosal erosions, a CAT scan, UGI series, and angiogram will not be diagnostic. Capsule endoscopy is sometimes used in the diagnosis of occult gastrointestinal bleeding when other methods have not been helpful.

Answer 285

75. (A) Peptic ulcer disease is the most common cause of UGI bleeding in patients presenting to the emergency department. Most bleeding ulcers (80%) will stop with conservative measures. A visible vessel seen during endoscopy can have up to a 55% chance of rebleeding. Other causes of bleeding include gastritis, gastric cancer, esophagitis, Mallory-Weiss tear, Dieulafoy’s lesion, and esophageal varices, but these occur less commonly than peptic ulcer as a likely cause of bleeding.

Answer 286

76. (E) Prostaglandin E (misoprostol) has not been useful in the management of erosive gastritis because diarrhea has been a troublesome side effect. At lower doses it can be used as prophylaxis against NSAID associated gastropathy.

Answer 287

77. (B) Gastrinoma (ZES) should always be excluded in patients presenting with severe peptic ulcer disease that fails to respond to therapy. It accounts for 0.1–1% of peptic ulcers. It is usually caused by a gastrinoma (a non b-cell tumor found in the pancreas or duodenum). The diagnosis is based partly on an elevated fasting serum gastrin level (normal 60 pg/mL; in ZES >150 pg/mL and can be over 1000 pg/mL). Basal acid secretion is increased above 15 mEq/h. Duodenal ulcers are the most common ulcers, but ulcers in unusual locations (e.g., jejunum) may also be seen.

Answer 288

78. (C) Since the patient is stable, she does not require any therapeutic endoscopic or surgical procedures. Triple therapy (a PPI and two antibiotics) should be initiated to eradicate the H. pylori organism. She should also be educated about the association of aspirin and NSAIDs with peptic ulcer disease.

Answer 289

79. (D) Duodenal ulcers are associated with acid hypersecretion and impaired neutralization of aid in the duodenum. The other choices are not associated with duodenal ulcers.

Answer 290

80. (E) If all nonoperative measures have failed to control bleeding from an ulcer, the next definitive step is surgery. Although the patient may require continued resuscitation with crystalloids and blood products, the bleeding will not stop without surgical intervention. Elderly patients have poor toleration for hypotension due to comorbidities, therefore emergency surgery not elective is appropriate.

Answer 291

81. (B) There is an increased incidence of gastric cancer in patients with gastric ulcer disease. The overall 5-year survival is 12%, but it can be as high as 35% if the nodes are negative (and 7% if the nodes are involved). It is important that the cut edges are free of tumor otherwise the cancer will recur. Proximal lymph nodes should be removed from the stomach. The extent of lymph node dissection remains controversial. Extended D2 lymph nodes dissections are performed in Japan and demonstrate improved survival. These results have not been replicated in the West.

Answer 292

82. (C) Endoscopic gastrostomy by percutaneous means is rapid and safe. It should be considered in patients who are unable to maintain an appropriate caloric intake orally. The procedure is performed under local anesthesia and sedation.

Answer 293

83. (D) A patient is a candidate for bariatric surgery if he or she meets certain criteria. A patient whose weight is 100 lb greater than his ideal body weight or whose BMI is greater than 35 mg/kg is morbidly obese. Prior to surgery, a patient must have a thorough evaluation by a multidisciplinary team (e.g., internist, dietician, psychologist, surgeon, and the likes). Patients who are not morbidly obese and simply want to lose weight are not candidates for these procedures. Patients are at risk for multiple complications, including fatal pulmonary embolus.

Answer 294

84. (C) There are multiple morbid obesity operations. Jejunoileal bypass has a higher incidence of both early and late complications. Gastric restrictive procedures (e.g., vertical banded gastroplasty) are generally less effective than GBP. GBP patients can be expected to lose up to two-thirds of their weight initially. The gastric pouch capacity should be no larger than 30cc. Anastomotic leak rate should be less than 5%.

Answer 295

89. (C) The Lauren classification divides gastric adenocarcinomas into two histologic types— an intestinal type and a diffuse type. The intestinal type is more common and usually forms a discrete lesion. The diffuse infiltrating type is less common and a mass may not be seen. In the intestinal type, cells form glandular strictures. in the diffuse type, cells are poorly organized and full of mucin (signet ring cells). The diffuse type may extensively infiltrate the muscles of the stomach, thus leading to rigidity. Gross appearance may be unremarkable, but palpation aids in the diagnosis. “Leather bottle stomach” refers to a stomach that is entirely involved with diffuse type cancer. The 5-year survival is poor.

Answer 296

90. (C) Hemobilia may be secondary to instrumentation of the biliary tree, or malignancy, or trauma. It involves bleeding from the biliary tract that transits through the ampulla into the duodenum. Bleeding may be subacute or massive. Endoscopic retrograde cholangiopancreatography (ERCP) or angiogram may be diagnostic. Angioembolization may be therapeutic.

Answer 297

91. (D) “Watermelon stomach” is a term used to describe the appearance of the stomach in a condition called GAVE (gastic antral vascular ectasis) syndrome. Dilated blood vessels radiate from the pylorus to the antrum in a pattern that resembles the stripes of a watermelon. It is an uncommon cause of gastrointestinal bleeding. It has been associated with certain autoimmune diseases, however, it may also be seen in individuals not affected by these conditions. It may also be seen with portal hypertension. It is most commonly seen in elderly women. Endoscopic laser treatment is usually effective.

Answer 298

``` 93. (E) A dieulafoy lesion is an uncommon cause of UGI bleeding (0.3–7%). ``` It can occur anywherein the gastrointestinal tract, but is most commonly found in the stomach (near the GE junction). It is often difficult to visualize because of its small size. A dilated submucosal artery is the source of the bleeding. First-line management is therapeutic endoscopy. There is no association with NSAIDs or alcohol. These lesions are more common in men.

Answer 299

94. (E) Patients with impaired gastric emptying, such as those who have had previous gastric surgery or those with diabetes, can develop bezoars. Bezoars can be classified as two types—phytobezoars (undigested vegetable matter) and trichobezoars (hair). The diagnosis can be made by EGD or barium study. Nonoperative management is often successful. Patients are told to ingest meat tenderizer (which contains papain) and repeat endoscopy is performed for further fragmentation and removal of the bezoar. If the patient is obstructed and endoscopic therapy is unsuccessful, surgery is indicated. Patients who ingest their hair should be referred for psychiatric evaluation.

Answer 300

97. (C) An aortoenteric fistula should be suspected in any patient who has had previous aortic surgery and presents with massive UGI bleed. Most aortoenteric fistulas are secondary to this type of surgery. It is important to separate an aortic graft from intestine (e.g., retroperitoneal tissue). Most aortoenteric fistulas occur between the aorta and duodenum. Mortality is high, but timely surgical intervention can be successful. Surgery may involve performing an extraanatomic bypass and removing the aortic graft.

Answer 301

Resection of: 1) Distal 75% of the stomach 2) Pylorus 3) 2cm of proximal duodenum 4) Greater and lesser omentum 5) Associated lymph node Reconstruction by Billroth II gastrojejunostomy or Roux-en-Y gastrojejunostomy

Answer 302

1) Removal of stomach 2) Roux-en-y limb sewn to esophagus Indicated for: - All lesions in the midbody or fundus (proximal) of the stomach - Linitis plastica - Cancers associated with Menetrier disease, gastric remnant carcinoma, and multiple diffuse gastric polyps

Answer 303

Gastrectomy + incomplete resection of N1 nodes

Answer 304

Gastrectomy + complete dissection of N1 nodes

Answer 305

Gastrectomy + resection of N1 and N2 nodes

Answer 306

Gastrectomy + resection of N1 to N3 nodes

Answer 307

Most extensive, includes all lymph node levels

Answer 308

Perigastric nodes along greater and lesser curvatures (levels 1-6)

Answer 309

Adjacent to the celiac axis and its major branches (levels 7, 8a, 9, 10, 11p, 11d, 12a, 14v)

Answer 310

Hepatoduodenal ligament, retropancreatic region, celiac plexus, SMA

Answer 311

Paraaortic nodes

Answer 312

T1 N1 M0 | T2 N0 M0

Answer 313

T1 N2 M0 T2 N1 M0 T3 N0 M0

Answer 314

T1 N3 M0 T2 N2 M0 T3 N1 M0 T4a N0 M0

Answer 315

T2 N1 M0 T3 N2 M0 T4a N3 M0

Answer 316

T3 N3 M0 T4a N2 M0 T4b N1 M0 T4b N0 M0

Answer 317

T4a N3 M0 T4b N3 M0 T4b N2 M0

Answer 318

Any T Any N M1

Answer 319

EMR/Submucosal Resection | Tumors <2cm, limited to mucosa/submucosa

Answer 320

1: R cardiac 2: L cardiac 3: Lesser curvature 4: Greater curvature 5: Suprapyloric 6: Infrapyloric 7: L gastric artery 8: Common hepatic artery 9: Celiac artery 10: Splenic hilar 11: Splenic artery 12: Hepatic pedicle 13: Retroduodenal 14: Mesenteric root 15: Middle colic artery 16: Paraaortic 17: Around lower esophagus 18: Supradiaphragmatic

Answer 321

Type I: - Type A chronic atrophic gastritis, with/without pernicious anemia - Autoimmune (antibodies to parietal cells) - Most common - Hypergastrinemia - Women - Benign Type II: - Carcinoid-associated with Zollinger-Ellison Syndrome - MEN Type 1 Type III: - Carcinoid tumor of sporadic form or neuroendocrine carcinoma - Not associated with hypergastrinemia - More common in men - Usually solitary - Worst prognosis - Larger tumors and more advanced stage

Answer 322

Caused by: - Hormonal excess, local tumor growth, or metastases - Incidental at surgery - Only 10% present with carcinoid syndrome (usually associated with hepatic mets) Sx: - Secretory diarrhea - Flushing - Telangiectasia - Valvular heart disease - Pellagra - Cramping - Edema - Bronchial constriction Dx: - Endoscopy + biopsy - EUS - Plasma chromogranin A and NSE - 24-h urine 5-HIAA - Localizing test (somatostatin analogue like indium octreotide) Tx: - Carcinoid syndrome: Debulking surgery + Octreotide - H1 and H2 receptor antagonists, methoxamine, cyproheptadine, diphenoxylate sodium with atropine - Resistant to most chemotherapeutic agents - By type: TYPE I: Endoscopic polypectomy TYPE II: Treat gastrinoma, somatostatin analogues, local excision or antrectomy TYPE III: En-bloc resection with regional lymph nodes, chemoRT