Stomach and Bowel Flashcards
1
Q
management of large mesenteric cysts?
A
excision and resection of associated bowel , high risk of recurrence if marsupialize
2
Q
management of gastric cardia adenocarcinoma?
A
total gastrectomy
3
Q
margins for gastric adenocarcinoma?
A
resection with at least 5cm margins (subtotal gastrectomy can be done win distal tumors but proximal tumors usually require total)
4
Q
when do you give neoadjuvant chemotherapy in gastric adenocarcinoma?
A
lesions >T2 or any N
5
Q
what are the recommendations for lymph node dissections for gastric adenocarcinoma?
A
D1 or D2 resection of at least 15 lymph nodes
6
Q
what’s the difference between D1 and D2 dissection in lymph node dissection w gastric adenocarcinoma?
A
D1 = gastrectomy + the greater and lesser omental lymph nodes D2 = all that plus the omental bursa, leaf of the transverse mesocolon, and corresponding arteries
7
Q
when is a splenectomy performed during resection of gastric adenocarcinoma?
A
for a D2 dissection for proximal gastric tumors
8
Q
what is the cell of origin of a GIST?
A
interstitial cells of cajal: aka the pacemaker cells
9
Q
what is the cell of origin of a carcinoid tumor?
A
enterochromaffin cells aka Kulchitsky cells
10
Q
what is the cell origin of pheochromocytomas?
A
neuroectodermal cells of the adrenal medulla
11
Q
what are th 3 different pattens of inflammation associated with H. Pylori infection?
A
- diffuse* MC, not assoc w PUD
- antral
- stomach-body related
12
Q
how does gastrin stimulate acid secretion? (2 ways)
A
- stimulation of the synthesis and release of histamine from enterocrhomaffin-like cells which bind to H2 receptors on parietal cells
- from parietal cells via cholecystokinin B receptor
13
Q
side effect of metoclopramide?
A
tardive dyskinesia
14
Q
two different types of dumping syndrome and causes
A
- Early dumping: 30 min after eating and due to hyperosmotic load causing large fluid shift
- Late dumping: 2-3 hours after eating and due to large insulin release from large fluid bolus hitting the duo
15
Q
what is the best test to determine a) diagnosis and b) eradication of h pylori?
A
a) serology: IgG
b) urea breath test
16
Q
treatment of low versus high grade MALToma?
A
low = abx alone high = CHOP
17
Q
what is triple therapy for H pylori?
A
PPI, clarithromycin, flagyl (metronidazole)
18
Q
where is protein mostly absorbed?
A
mostly jejunum
19
Q
what does the terminal ileum absorb?
A
bile salts, vitamin B12, fat soluble vitamins (ADEK)
20
Q
where are the majority of small bowel adenocarcinomas found?
A
duodenum
21
Q
what is the most common neoplasm of small bowel?
A
metastasis: MC melanoma, lung, breast, cervix, sarcoma, colon
22
Q
most common PRIMARY small bowel neoplasm?
A
NET
23
Q
UC or Crohns: Granulomas
A
Crohns
24
Q
UC or Crohns: Rectal Involvement
A
UC
25
UC or Crohns: Cobblestone appearance
Crohns
26
UC or Crohns: Transmural involvement
Crohns
27
UC or Crohns: Patchy areas of bowel
Crohns
28
whats a finney stricturoplasty and when do you use it?
indicated for strictures 7-15cm, fold the diseased bowel on itself and create a large opening between the two loops
29
what is a Heineke-Mikulicz stricturoplasty and when is it used?
strictures <7cm, MC, make a longitudinal incision on the antimesenteric side of the bowel and close transversely
30
what are the different types of enterocutaneous fistulas?
Low output: <200mL/day
Moderate: 200-500mL/day
High output: >500mL/day
31
what are the sympathetic fibers for gastroduodenal pain?
afferent sympathetic fibers T5-10
32
cell type of mucosal lining of stomach?
simple columnar epithelium
33
where is the pacemaker (SA) node of the stomach?
Cardia
34
chief cells release what?
pepsinogen
35
Parietal cells release what?
H+ and intrinsic factor
36
what are 3 factors that stimulate H+ release from parietal cells of stomach?
1. Acetylcholine (vagus nerve)
2. Gastrin (from G cells in antrum)
3. Histamine (from mast cells)
37
mechanism of how acetylcholine and gastrin increase H+
activate phospholipase which increases Ca (PIP -> DAG + IP3 to increase Ca), Ca-Calmodulin activates phosphorylase kinase -> increases H+
38
mechanism of how histamine increases H+
histamine activates adenylate cyclase -> cAMP -> activates protein kinase A -> increase H+ release
39
MOA omeprazole
blocks the H/K ATPase in parietal cell membrane (final pathway of H+ release)
40
what are 4 major inhibitors of parietal cells?
Somatostatin, prostaglandins (PGE1), secretin, CCK
41
intrinsic factor: released from? function? reabsorbed?
Released from parietal cells in gastric antrum
binds vitamin B12
reabsorbed in terminal ileum
42
what are brunner's glands?
located in duodenum, secrete alkaline mucus
43
what is menetrier's disease?
mucous cell hyperplasia, increase in rugal folds
44
tx of gastric volvulus?
reduction and Nissen fundoplication
45
where is the tear usually in Mallory-weiss?
lesser curvature of stomach near GE junction
46
truncal vagotomy versus proximal vagotomy?
truncal: divides vagus at level of esophagus, increases emptying of solids
proximal: highly selective, divides individual fibers, normal emptying of solids
47
most common problem following vagotomy, tx
diarrhea: caused by sustained MMCs (migrating motor complex) forcing bile into the colon and leading to osmotic diarrhea
tx: cholestyramine and loperamide
48
how do you diagnose gastroparesis?
gastric emptying study- normal should have <10% in stomach at 4 hours, if more then + gastroparesis
49
what are the biggest risk factors for rebleeding at time of EGD? like what do you see and assoc risk of rebleeding
1. Spurting blood vessel (60% chance)
2. Identifiable blood vessel (40% chance)
3. Diffuse oozing (30% chance)
50
what is triple therapy for H. pylori?
bismuth salts, amoxicillin, metronidazole/tetracycline
| BAM or BAT
51
what is ZES?
gastric acid hypersecretion, peptic ulcers, gastrinoma
52
what are 3 surgical options for acid-reducing surgery? assoc recurrence rate of ulcers?
1. proximal vagotomy: 10-15% recurrence, 0.1% mortality
2. Truncal vagotomy w pyloroplasty: 5-10% recurrence, 1% mortality
3. truncal vagotomy w antrectomy: 1-2% recurrence, 2% mortality, reconstruct w RNYGB* v B1 v B2
53
how do you perform GDA ligation for bleeding duodenal artery?
3 suture ligation: proximal GDA, distal GDA and U stitch to transfix the pancreatic branch
54
best test for H pylori?
histiologic examination of biopsies from antrum
55
best test for h pylori eradication?
urea breath test
56
what are the 5 types of gastric ulcers?
type 1: lesser curvature, near antrum, nml acid
type 2: both gastric and duodenal, high acid
type 3: prepyloric, high acid
type 4: near GEjxn, nml acid
type 5: assoc w NSAIDs
57
cushing ulcer vs curling ulcer
cushing ulcer: head trauma and gastric ulcer
| curling ulcer: burn patient and duodenal ulcer
58
where does a stress gastric ulcer appear first?
fundus
59
two types of chronic gastritis
type A: fundus, assoc w pernicious anemia and autoimmune disease
type B: antral, assoc w h pylori
60
40% of gastric cancers are located where?
antrum
61
what blood type increases risk of gastric cancer?
type A
62
risk of cancer in gastric adenoamtous polyp?
15%, tx: endoscopic resection
63
two types of gastric cancer?
intestinal type: japan, rare in US, histology shows glands, need 10cm margins, attempt subtotal gastrectomy
Diffuse gastric type: linitis plastica, MC in US, no glands on histology, tx total gastrectomy
64
MC benign gastric neoplasm
GIST (but can also be malignant)
65
what does biopsy of GIST show?
C-kit positive staining
66
when do you consider a GIST malignant?
>5cm or >5 mitoses/50 HPF
67
tx of GIST
resection w 1 cm margin, no nodal dissection
| tx: imatinib if malignant
68
MOA imatinib
gleevac: tyrosine kinase inhibitor
69
tx if MALT lymphoma doesnt regress w h pylori tx?
XRT
70
MC location for extra-nodal lymphoma?
stomach!
71
stomach lymphoma is usually what type?
non-hodgkins lymphoma, B cell
72
tx for gastric lymphoma?
chemotherapy and XRT
73
what comorbidity does NOT get better after bariatric surgery?
PAD
74
where is Fe absorbed?
duodenum
75
vitamin deficiencies after RNYGB?
B12 (intrinsic factor) and Fe (bypass duo)
76
MC cause of leak in RNYGB?
ischemia
77
why does dumping syndrome occur?
rapid entering of carbohydrates into the small bowel
78
what are 2 phases of dumping syndrome?
hyperosmotic load causes fluid shift into bowel (hypotension, diarrhea, dizziness), then (rare phase) hypoglycemia from reactive increase in insulin and decrease in glucose
79
what is blind loop syndrome? dx and tx?
- seen with B2 of RNYGB, caused by poor motility and bacterial overgrowth (GNR, Ecoli) from stasis in afferent limb
dx: EGD of afferent limb
tx: tetracycline or flagyl, reglan to improve motility, or can shorten afferent limb to 40cm
80
what is afferent loop obtsruction?
w B2 or RNYGB, mechanical obstruction of afferent limb
| tx: dilation or reanastomosis w shorter afferent limb
81
what is efferent limb obstruction?
obstruction of efferent loop, can balloon dilate or reoperate
82
what is MOA of infliximab and one particular use?
TNF alpha inhibitor, shown to help close fistulas in Crohn's disease
83
what's triple therapy for H pylori?
PPI and 2abx: choose from amoxicillin, metronidazole, tetracycline, clarithromycin
84
which organ has the highest secretion of K?
colon
85
MC location of small bowel carcinoid?
ileum
86
where in the bowel are lymphoid follicles most prominent?
ileum (thats why small bowel lymphoma is most frequently there)
87
what is the Forest classification?
classification of risk for bleeding based on endoscopic findings in bleeding ulcers
High risk = active bleeding and visible vessel
medium risk = adherent clot
low risk = black spot or clean base
