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Surgery > stomach and duodenum > Flashcards

stomach and duodenum Flashcards

1
Q

esophageal motility disorder characterized by failure of the circular esophageal muscle in the distal 2cm of the esophagus to relax

A

achalasia

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2
Q

definite mucosal change from gastric epithelium to intestinal epithelium (striated columnar cells w interspersed goblet cells) and 1-3cm long smooth muscle valve known as pylorus

A

gastroduodenal junction

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3
Q

what does the pylorus do

A

prevents reflux of duodenal contents into stomach; controls gastric emptying

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4
Q

antrectomy

A

distal gastric resection that removes the gastrin producing cells of the stomach

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5
Q

basal acid secretion

A

circadian rhythm w highest levels at night and lower levels in the morning

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6
Q

what is responsible for creating the concentrated acid environment within the lumen of the stomach

A

H for K, ATPase

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7
Q

diffuse erythema and disruption of the mucosa of the stomach; assoc w ingestion of irritating agents

A

gastritis

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8
Q

Schilling test

A

used to determine cause of bit B12 def: pernicious anemia or small intestinal bacterial overgrowth

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9
Q

what two things promote ulcer formation by altering the balance between the protective and potentially harmful components of the gastric environment

A

H. pylori and NSAIDs

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10
Q

causes a chronic active gastritis w dysregulation of gastrin and acid secretions

A

h. pylori

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11
Q

inhibit cox1 which is essential for prostaglandin synthesis, thereby altering local blood flow, mucus production,and bicarb secretion in the stomach

A

nsaids

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12
Q

mc cause of benign gastric ulcer ds

A

h pylori and nsaids

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13
Q

type 1 gastric ulcers

A

most frequent, occur along lesser curvature of the stomach in the zone above the antrum; normal or low acid output

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14
Q

type 2 gastric ulcers

A

arise in combo w duodenal ulcers; acid hyper secretion

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15
Q

type 3 gastric ulcers

A

dev in prepyloric region; acid hypersecretion

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16
Q

type 4 gastric ulcers

A

least frequent, occur high on lesser curvature near GE junction; normal or low acid output

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17
Q

how is h pylori spread

A

gastrooral or fecal oral

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18
Q

s/sx of uncomplicated gastric ulcers

A

gnawing epigastric pain that can radiate to back; anorexia and wl because assoc w ingestion of food

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19
Q

s/sx complicated gastric ulcers

A

may or may not have any prior to perforation or bleeding

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20
Q

what confirms the presence of an ulcer

A

EGD; any gastric ulcer found needs to be bx for malignancy; always bx for h pylori

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21
Q

endoscopic features suggestive of malignancy

A

bunched up ulcer border or large (>3cm) ulcer size; presence of achlorhydria

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22
Q

besides EGD another dx study gastric ulcer

A

barium upper GI contrast; con is can’t bx

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23
Q

first line therapy for uncomplicated gastric ulcer disease

A

cessation of all potential ulcerogenic agents (tobacco, nsaids, aspirin, steroids, alcohol); tx h pylori w abx; acid suppression therapy; cytoprotective agents (sucralfate, misoprostol)

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24
Q

abx to tx H pylori

A

clarithromycin, amoxicillin, metronidazole, tetracycline, bismuth, omeprazole

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25
Q

what is mandatory after initiating medical tx for gastric ulcer

A

repeat endoscopy; after 6 weeks ulcer should show healing

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26
Q

surgical tx for nonhealing, obstructing or refractory gastric ulcers types 1-3

A

excision; antrectomy (50% gastrectomy, mc performed), GI continuity restored to either proximal duodenum (Billroth 1), loop of proximal jejunum (billroth 2) or transposed limb of jejunum isolated from biliopancreatic secretions (Roux en y)

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27
Q

Which gi reconstruction may be assoc w impaired gastric emptying and intestinal transit

A

roux en y

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28
Q

pts w type 2 and 3 often receive what n addition to antrectomy for further dec gastric acid secretion

A

truncal vagotomies

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29
Q

surgical tx type 4

A

may require near total gastrectomy w roux en y reconstruction

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30
Q

tx emergent operation for perforated pyloric channel ulcer prev unrecog

A

oversew and omental patch without resection

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31
Q

inflammation of the stomach mucosa that may be assoc w erosions and hemorrhage

A

acute gastritis

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32
Q

s/sx acute gastritis

A

n, v, hematemesis, melena, or hematochezia

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33
Q

causes of acute gastritis

A

h pylori, nsaid, aspirin, bile reflux, alcohol irradiation, local trauma

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34
Q

tx acute gastritis

A

acid suppression, removal of noxious agent, occasional gastric decompression, nutritional support

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35
Q

pts can develop mucosal erosions beginning in the proximal stomach and progressing rapidly throughout the rest of the organ

A

stress gastritis

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36
Q

ulcer formation in major burn victims (curling’s ulcer) and patients w cns injury (cushing’s ulcer)

A

stress gastritis

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37
Q

prophylaxis in critical ill pt since stress gastritis can dev within 48hr

A

PPI, h2 rec blockers, sucralfate, misoprostol

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38
Q

intraluminal ph should not dec below

A

4.0

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39
Q

mc complication of stress gastritis

A

hemorrhage; watch for blood per rectum, blood in ng aspirate, or drop in blood ocunt

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40
Q

what confirms the dx of stress gastritis

A

endoscopy

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41
Q

hypertrophic gastritis (menetrier’s ds)

A

rare disorder of the lining of the stomach characterized by massive hypertrophy of the gastric rugae

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42
Q

s/sx hypertrophic gastritis (menetriers)

A

epigastric pain, n, v occult hemorrhage, anorexia, wl, diarrhea; hypoproteinemia and peripheral edema

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43
Q

tx hypertrophic gastritis (menetriers)

A

acid suppression w ppi, h2 or antacids; high protein diet

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44
Q

upper GI hemorrhage secondary to linear tearing of the mucosa at the GE junction

A

mallory weiss syndrome

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45
Q

when do mallory weiss tears usually occur

A

after episodes of strong valsalva maneuver causes mechanical stress on mucosa in region; retching, heavy lifting, childbirth, vomiting, blunt abd trauma, seizures

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46
Q

eval of mallory weiss tear

A

ng tube and gastric lavage; if blood then endoscopy, nuclear scintigraphy or selective angiography

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47
Q

tx mallory weiss tear

A

fluid resuscitation, stabilization; acid suppression; if bleeding persists then electrocautery, heater probe or injection therapy

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48
Q

gastric polyp

A

hyperplastic or adenomatous in nature. Hyperplastic polyps are more common and are typically benign, although rare cancerous transformation has been reported. Adenomatous polyps have a higher risk of malignant degeneration, especially those >1.5 cm. When a gastric polyp is diagnosed, the physician should consider the possibility of other polyps within the GI tract and polyposis syndromes.

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49
Q

presence of multiple benign polyps in small intestine and sometimes portions of gi tract, melanin spots on lips and buccal mucosa

A

peutz jeghers syndrome- auto dom

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50
Q

accumulation of lg mass of indigestible fiber within the stomach

A

bezoar (vegetable=phytobezoar) (hair=trichobezoar)

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51
Q

mc stomach cancer

A

adenocarcinoma

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52
Q

risk factors for gastric adenocarcinoma

A

h pylori infx, pernicious anemia, achlorhydria, chronic gastritis; caustic injury from lye ingestion; adenomatous polyps

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53
Q

mc category of gastric adenocarcinoma

A

ulcerative carcinomas

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54
Q

two histologic types of gastric adenocarcinoma

A

intestinal (older pt and spreads hematogenously) and diffuse (signet ring cells, younger, type A blood, spreads lymphatics and local extension)

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55
Q

term used to describe complete infiltration of the stomach w carcinoma

A

linitis plastica; stomach looks like a leather bottle

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56
Q

s/sx of later stages of gastric carcinoma

A

epigastric pain, wl, dysphagia, hematemesis, melena, n, v; iron def anemia or guaiac positive stools

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57
Q

dx imaging gastric carcinoma

A

upper endoscopy, bx, endoscopic us, cxr, ct abd/pelvis;PET

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58
Q

dx lab gastric carcinoma

A

cbc, electrolytes, creatinine level, lfts

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59
Q

what do pts undergo who don’t have any evidence of metazoic ds on initial workup

A

laparoscopic staging

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60
Q

surgical tx of gastric carcinoma

A

Complete surgical resection in an attempt to cure gastric adenocarcinoma should only be undertaken in the presence of localized disease. Considerable debate exists regarding the extent of such a resection. For most distal lesions, many surgeons favor a radical subtotal gastrectomy. In this procedure, approximately 85% of the stomach is removed, including the omentum. The proximal portion of the resected specimen is then immediately examined by the pathologist (i.e., frozen section) to verify that it is free of tumor involvement. Only after such verification is GI continuity restored by means of a Roux-en-Y gastrojejunostomy. Total gastrectomy is reserved for either large distal lesions or more proximal tumors. Splenectomy or pancreatectomy may also need to be included in the operative procedure. They should, however, be avoided unless absolutely necessary.

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61
Q

NCCN guidelines of chemo w gastric carcinoma

A

perioperative chemo using epirubicin, cisplatin, and 5 fluorouracil for lesions invade beyond lamina propria or have positive nodes

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62
Q

is chemoradiotherapy necessary for less invasive lesions (only invade submucosa)

A

no can be excised without but 5 fluorouracil w or without leucovorin is recommended after

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63
Q

indications for palliative surgical intervention of gastric carcinoma

A

proximal or distal tumor obstruction and bleeding

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64
Q

gastric carcinoma stage 1

A

mucosa, muscularis mucosa, submucosa

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65
Q

gastric carcinoma stage 2

A

mucosa, muscularis mucosa, submucosa, muscularis propria

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66
Q

gastric carcinoma stage 3

A

mucosa, muscularis mucosa, submucosa, muscularis propria, lymph nodes

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67
Q

gastric carcinoma stage 4

A

mucosa, muscularis mucosa, submucosa, muscularis propria, lymph nodes, distant metastases or contiguous spread

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68
Q

primary source of almost 2/3 of all gi lymphomas

A

stomach; older and nonhodgkins predominates

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69
Q

s/sx gastric lymphoma

A

upper abd pain, lw, fatigue, bleeding

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70
Q

dx gastric lymphoma

A

tissue bx during upper endoscopy; sometimes during surgical exploration

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71
Q

if dx is made prop what workup should be done for gastric lymphoma

A

cxr, abd ct, bone marrow bx

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72
Q

tx gastric lymphoma

A

chemo but has risk of gastric perforation or hemorrhage; or resection followed w chemo or radiation

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73
Q

submucosal growths of the GI tract arising from variety of cell types

A

formerly known as leiomyomas and leiomyosarcomas but now gastrointestinal stromal tumors (GISTs)

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74
Q

what suggests malignancy with GISTs

A

large tumor size >6cm and tumor necrosis

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75
Q

s/sx GISTs

A

asyp; nonspecific abd pain, but bleeding and obstruction can manifest; may present w abdominal mass

76
Q

eval of GISTs

A

upper endoscopy, endoscopic us, abdominal ct

77
Q

most common site of GIST and mc site for disseminated disease

A

stomach; liver

78
Q

tx GIST

A

local excision w margin of 2-3cm included; if aggressive chemo using imatinib mesylate

79
Q

two ucergenic agents for duodenum

A

h pylori and nsaids; maybe tobacco

80
Q

s/sx uncomplicated duodenal ulcers

A

burning epigastric abd pain that is gnawing in character; can radiate to back; occur 1-3hrs after food and accentuated by fasting; awaken from sleep; relief w acid suppressants; food intake can also improve pain

81
Q

older dx imaging uncomplicated duodenal ulcer

A

upper gi series (not used as much), gastric acid analysis (ng tube placed in stomach for samples of gastric aspirates for 1 hr, >4 basal acid output)

82
Q

noninvasive dx testing for uncomplicated duodenal ulcer

A

quantitative and qualitative serologic antibody,urease tests, and fecal antigen test for h pylori; upper endoscopy*

83
Q

tx uncomplicated duodenal ulcer

A

stop ulcerogenic agents, acid suppression therapy, abx h pylori

84
Q

4 main manifestations of complicated PUD

A

perforation, hemorrhage, gastric outlet obstruction, intractability

85
Q

s/sx pt w perforated ulcer

A

acute onset of severe epigastric pain, tachycardia, rigid abdomen; may have rlq rebound tenderness

86
Q

eval of perforated ulcer

A

upright chest radiograph- evidence of free intraperitoneal air (pneumoperitoneum) outlining diaphragm or liver, cbc and bmp

87
Q

s/sx bleeding ulcer

A

hematemesis, melena, blood per rectum, hypotension,tachycardia, pallor, mental status changes, active bleeding

88
Q

eval bleeding ulcer

A

ng tube w gastric lavage, endoscopy, serial hematocrits and coag parameters, blood type and cross match

89
Q

s/sx gastric outlet obstruction resulting from chronic ulcer scarring

A

inability to tolerate oral intake, projectile vomiting shortly after eating, lw, dehydration, upper abd fullness, dec skin turgor, dry mucus membranes, epigastric peristaltic waves

90
Q

eval gastric outlet obstruction

A

electrolyte and creatinine levels- often have hypokalemic, hypochloremic metabolic alkalosis

91
Q

s/sx intractable ulcers

A

persistent ds after adequate nonop therapy, pe same as pt w uncomplicated PUD

92
Q

tx complicated pud

A

initial stabilization phase (resuscitation and nonop therapy) if doesn’t work then surgery

93
Q

tx perforated ulcer

A

surgical emergency; fluid resuscitation and nasogastric decompression; oversewing the ulcer w buttressing w a tag of momentum is performed followed by intensive tx w PPIs and abx

94
Q

tx hemorrhage ulcer

A

volume resuscitation then Advanced Trauma Life Support (ATLS) guidelines: 2L crystalloid followed by whole blood; stomach decompressed using NG tube; high dose PPI therapy, then coag abnorm corrected; upper endoscopy w electrocautery; surgery for refractory bleeding (>6u in first 12hr)

95
Q

tx gastric outlet obstruction

A

stomach is decompressed w an NG tube for 5-6d or until returns to normal size, NPO, nutrition/fluids through IV w normal saline crystalloid and total parenteral nutrition; surgery

96
Q

tx intractable ulcers

A

surgical intervention to dec acid secretion through interruption of the vagal neural pathway w or without removal of gastrin producing cells in antrum usually by truncal vagotomy and pyloroplasty

97
Q

proximal gastric vagotomy

A

antiulcer operations; selectively denervates vagal stimulation to the parietal cells; maintains function of the pyloric sphincter

98
Q

dumping syndrome

A

complex myriad symptoms; may include cramps abd pain and diarrhea; secondary to ablation of the pyloric sphincter mechanism

99
Q

familial adenomatous polyposis

A

auto dom dev w polyps in the colon and gastroduodenal region; possible malig so close monitoring

100
Q

Zollinger-Ellison syndrome

A

severe variant of duodenal ulcer ds; results from the independent production of gastrin by a tumor (gastrinoma) that arises in the pancreas or paraduodenal area

101
Q

ZE syndrome has strong assoc w what endocrine neoplasm

A

multiple endocrine neoplasia type 1 syndrome (MEN 1)

102
Q

characteristics of MEN 1

A

pituitary adenomas, hyperparathyroidism, pancreatic islet cell tumors

103
Q

s/sx ZE syndrome

A

ulcer like symptoms w concomitant chronic or severe diarrhea

104
Q

dx ZE syndroma

A

establishing presence of hypergastrinemia w hyper secretion of acid so a fasting serum gastrin level is necessary; make sure PPI discontinued stopped 1 week prior; >1000 is dx; secretin stimulation test inc >200; gastric ph

105
Q

tx ZE syndrome

A

total gastrectomy w esophageal anastomosis; high dose PPI or H2 rec antag; hormonal manipulation w somatostatin octreotide

106
Q

tx ZE syndrome w MEN1

A

parathyroidectomy +/- surgical exploration

107
Q

mc site for adenocarcinoma in the small bowel

A

duodenum; 2/3 in the second part in the periampullary region

108
Q

s/sx adenocarcinoma of duodenum

A

nonspecific abd pain w wl to intestinal/gastric outlet obstruction; melena or hematochezia due to ulceration of the lesion; pe unremarkable

109
Q

dx adenocarcinoma of duodenum

A

upper endoscopy w tissue bx; ct

110
Q

tx adenocarcinoma of duodenum

A

surgical excision; pancreaticoduodenectomy is in 1/2 part of duodenum; duodenojejunostomy if in 3/4 part; unresectable have diverting gastroenterostomy; postop radiation

111
Q

what happens when the stomach is denervated

A

control of gastric emptying is abolished

112
Q

if someone is having a complicated postop course what is used for eval

A

upper GI series- doc extent of gastric resection and type of reconstruction, determine cause of vomiting, asses gastric emptying and motility

113
Q

symptoms that occur after ingestion of food of high osmolarity

A

early dumping syndrome

114
Q

15m after eating pt presents w anxiety, weakness, tachycardia, diaphoresis, and palpitations; extreme weakness and wants to lie down; cramps abd pain, borborygmi heard

A

early dumping syndrome

115
Q

what is happening during early dumping syndrome

A

uncontrolled emptying of hypertonic fluid into small intestine which moves rapidly from intravascular space into intraluminal space leading to intravasc vol depletion

116
Q

tx early dumping syndrome

A

avoid hypertonic liquid meals, alter vol of each meal, ingest fat w each meal to slow gastric emptying; ingest liquids 30min before or after meal; frequent small meals; if doesn’t work roux en y gastrojejunostomy may be necessary

117
Q

late dumping syndrome

A

same symptoms of early but begin within 3 hours after meal and not assoc w borborygmi or diarrhea

118
Q

cause of late dumping syndrome

A

rapid changes in serum glucose and insulin levels leading to hypoglycemia

119
Q

tx late dumping syndrome

A

small snack 2 hr after meals (crackers/pb); acarbose; if all else fails surgery

120
Q

what do almost half the pts who undergo a truncal vagotomy experience

A

change in bowel habits (inc freq, more liquid)

121
Q

causes of postvagotomy diarrhea

A

enhanced intestinal motility (vagal denervation), rapid gastric emptying, bile malabsorption, and bacterial overgrowth

122
Q

tx postvagotomy diarrhea

A

fluid intake restricted; food w low fluid content; antidiarrheal/antimotility agents (codeine, diphenoxylate hydrochloride, loperamide); cholestyramine or somatostatin; if refractory to med man then reversed 10cm set of jejunum inserted 100cm distal to ligament of treitz

123
Q

afferent loop obstruction occurs after which reconstruction

A

gastrectomy w billroth 2

124
Q

cause of afferent loop obstruction

A

kink in afferent limb adjacent to anastomosis; pancreatic and biliary secretions are trapped in limb and cause distention

125
Q

s/sx afferent loop obstruction

A

severe abd cramping mimed after ingestion of meal; pain as crushing; within 45 min feel abd rush assoc w inc pain then n and v of dark brown bitter tasting material; symp resolve w vomiting; wl

126
Q

tx afferent loop obstruction

A

exploration of the abdomen and conversion of billroth 2 anastomosis to either a roux en u gastrojejunostomy or billroth 1 gastroduodenostomy

127
Q

blind loop syndrome is more common after what procedure

A

billroth 2; bypass of small intestine secondary to radiation injury or morbid obesity

128
Q

assoc w bacterial overgrowth in the limb of intestine that is excluded from the flow of chyme; interferes w folate and bit b12 metab

A

blind loop syndrome

129
Q

a def of vit b 12 leads to

A

megaloblastic anemia

130
Q

s/sx blind loop syndrome

A

steatorrhea, diarrhea, wl, weakness

131
Q

dx blind loop syndorme

A

schilling test using cobalamin found to IF is abnormal

132
Q

tx blind loop syndrome

A

oral broad spectrum abx cover aerobic and anaerobic bacteria (tetracycline); conversion to billroth 1 gastroduodenostomy

133
Q

alkaline reflux gastritis is seen in pts in which what contents reflux into the denervated stomach

A

duodenal, pancreatic, and biliary contents

134
Q

s/sx alkaline reflux gastritis

A

weakness, wl, persistent n, epigastric abd pain radiates to back, anemia

135
Q

what will an upper endoscopy reveal w alkaline reflux gastritis

A

edematous, bile stained gastric epithelium that is atrophic and erythematous;inflammatory changes w corkscrew appearance of submucosal blood vessels; need to take bx

136
Q

inflammatory changes w corkscrew appearance of submucosal blood vessels

A

alkaline reflux gastritis

137
Q

tx alkaline reflux gastritis

A

surgical correction consists of diverting duodenal contents away from stomach w long limb roux en y gastrojejunostomy; minimum distance between gastrojejunostomy and entry point of biliopancreatic limb draining the digestive juices into intestine is 40cm (18in)

138
Q

where do marginal ulcers develop

A

jejunal side of gastrojejunostomy anastomosis

139
Q

why do marginal ulcer develop

A

secondary to ischemia but also smoking

140
Q

s/sx marginal ulcers

A

abd pain during eating along w n/v

141
Q

what does upper endoscopy show for marginal ulcer

A

ulcer on jejunal side no more than 2cm distal to anastomosis

142
Q

conservative management of marginal ulcer

A

stop tobacco use and start PPI; severe NPO and TPN; surgery

143
Q

recurrent ulcer ds following surgical intervention in benign PUD is most commonly due to

A

incomplete vagotomy; posterior vagal trunk or branch of right posterior nerve (criminal nerve of Grassi) is left intact

144
Q

dx recurrent ulcer ds

A

upper endoscopy is used to help confirm persistent vagal innervation to the stomach. Congo red is used to demonstrate areas of pH drop in the gastric mucosa after the administration of an acid secretagogue (pentagastrin). Such regions have intact vagal innervation

145
Q

what should be eval for pts w recurrent ulceration and verified complete vagotomy

A

search for endocrine etiology; fan hx MEN1; calcium and parathyroid hormone levels for hyperparathyroidism; gastrin levels

146
Q

mc metabolic abnorm after gastric resection

A

anemias

147
Q

medication for late dumping syndrome

A

acarbose- alpha glucosidase hyrolase inhibitor

148
Q

medication for postvagotmy diarrhea and alkaline reflux gastritis

A

cholestyraime- bile salt binding agent

149
Q

medication for postvagotomy diarrhea and dumping syndrome

A

somatostatin- secretory inhibitor

150
Q

medication for gastric atony

A

metoclopramide- promotility agent

151
Q

medication for marginal ulcer and alkaline reflux gastritis

A

sucralfate- gi protectant

152
Q

medication for postvagotomy diarrhea

A

diphenoxylate hydrochloride or loperamide

153
Q

10kcal/day of extra energy can result in how much weight gain over the course of a year

A

1lb

154
Q

what 3 things play an important role in appetite regulation within the body

A

hypothalamus, stomach, adipocyte:Food intake is triggered by the release of the hormone ghrelin from gastric oxyntic cells. This compound stimulates the release of neuropeptides in the “hunger center” of the hypothalamus, increasing caloric consumption. To signal adequate caloric load, the adipocyte releases the hormone leptin, which activates the “satiety center” of the hypothalamus. In this manner, food intake is decreased.

155
Q

bmi=weight (kg)/ height (m)(squared) ranges

A

40 (severely obese)

156
Q

3 categories for tx for overweight and obese ppl

A

behavior modification (all BMIs), pharmacotherapy (all BMI except underweight), surgical intervention (obese or severely obese)

157
Q

calorie range for low calorie diet

A

500-1000kcal/day so for women this is reached at 1000-1200kcal/day and men 1200-1500kcal/day; will lose 0.45-.9kg/week

158
Q

goal of low calorie diet

A

10% weight loss over 6 months

159
Q

long term weight reduction agent that is FDA approved

A

sibutramine and orlistat

160
Q

3 different bariatric procedures that limit food intake by forcing the pt to eat smaller portions

A

adjustable gastric banding (AGB), sleeve gastrectomy (SG) and vertical banded gastroplasty (VBG)

161
Q

malabsoprtive operation that alters food processing by limiting its absorption in the intestines

A

biliopancreatic diversion (BPD) w or without duodenal switch (BPD/DS)

162
Q

combined restrictive and malabsorptive operation for bariatric procedures

A

roux en y gastric bypass

163
Q

roux en y

A

creation of small proximal gastric pouch by transecting the stomach; roux limb measures 75-150cm in length

164
Q

adjustable gastric banding (AGB)

A

creation of proximal gastric pouch using inflatable band and placement of access port;A pars flaccida technique is used to create a posterior gastric tunnel from the lesser curve to the angle of His. The band is then positioned and secured by imbricating its anterior aspect. The distal fundus is sutured to the proximal gastric pouch. The port is placed on the abdominal muscle fascia. Adjustments of the band are made by instilling sterile solution percutaneously via the access port.

165
Q

sleeve gastrectomy (SG)

A

surgeon removes approximately 85% of the stomach laparoscopically so that the stomach takes the shape of a tube or “sleeve” This procedure is not reversible. Unlike many other forms of bariatric surgery, the pylorus and stomach innervation remain intact.

166
Q

BPD and BPD/DS

A

BPD is basically a subtotal gastrectomy with a very distal Roux-en-Y reconstruction. BPD/DS involves SG, duodenal transection with duodenojejunostomy creation, and very distal jejunoileostomy

167
Q

vertical banded gastroplasty

A

reation of a proximal gastric pouch by stomach partitioning and the reinforcement of the stoma with banding. Partitioning is usually via gastric stapling, and polypropylene is a popular banding material

168
Q

early complication of bariatric procedures (periop or before pt discharged)

A

anastomotic leak (roux), dvt and pe (roux, ABG, SG), bleeding (roux, abg, sg), infection (roux,abg, sg), splenic or visceral injury (roux, abg, sg)

169
Q

late complications of bariatric procedures (after discharge)

A

nutritional disturbances (roux, abg, sg), marginal ulcers and anastomotic strictures (roux), internal hernia (roux), afferent limb syndrome (roux), cholelithiasis (roux, sg), band slippage (sg), esophageal dilation (ABG, sg), band erosion (abg)

170
Q

mc site of anastomotic leak

A

gastrojejunostomy

171
Q

s/sx of anastomotic leak

A

abd pain, unexplained tachycardia, tachypnea, hypoxia

172
Q

dx anastomotic leak

A

upper gi series or abd ct w oral contrast

173
Q

tx anastomotic leak

A

percut drainage and parenteral nutrition; if not surgery

174
Q

tx dvt or pe after bariatric surgery

A

enoxaparin or unfractionated heparin for initial tx then oral anticoag w warfarin for 6m

175
Q

bariatric surgical patients are instructed to consume extra what after surgery so don’t dev nutrition disturbance

A

protein (60-80g/d)

176
Q

mc def of gastric bypass pts

A

iron def (65mg/d plus vit c) then b12 (IM or subling)

177
Q

pt complain of progressive intolerance of solids/liquids w postprandial abd pain and vomiting

A

stricture after bariatric surgery

178
Q

pt w abd pain, n, nonbilious vomiting after bariatric surgery

A

biliopancreatic limb obstruction

179
Q

since cholelithiasis can occur due to rapid wl following gastric bypass surgery what is taken for 6m postop

A

ursodeoxycholic acid 300mg BID

180
Q

tx for pt for has roux en y done and regained weight due to pouch or pouch outlet enlargemnt

A

stomaphyx

181
Q

guidelines for adolescents to receive bariatric surgery

A

tried for 6m to lose weight w no success, vmi >40, reached adult height, serious obesity related health problems, psych eval pt and parents

182
Q

A 60-year-old man comes to the emergency room because of hematemesis and bright red blood per rectum. He reports a history of gnawing epigastric pain radiating to the back and improved with eating. His past medical history is significant only for frequent headaches and back pain, for which he takes nonsteroidal anti-inflammatory drugs (NSAIDs) and over-the-counter medications. On physical exam, he is pale, hypotensive, and tachycardic. After resuscitation, initial upper endoscopy reveals evidence of an upper gastrointestinal hemorrhage and an ulcer in the posterior duodenal bulb. Which blood vessel is the most likely source of bleeding?

A

The patient presents to the emergency room with evidence of a massive upper gastrointestinal hemorrhage (hematemesis with bright red blood with hypotension and tachycardia). His symptoms of gnawing epigastric pain radiating to the back and Improved with eating suggest a posterior bulb duodenal ulcer. Ulcers in this location can erode into the gastroduodenal artery as It passes behind the first portion of the duodenum, causing massive gastrointestinal hemorrhage. The left gastric artery arises from the celiac axis. The common hepatic artery divides Into the gastroduodenal and proper hepatic arteries. The right gastric artery arises from the proper hepatic artery. The superior mesenteric artery is a branch off the aorta.

183
Q

A 63-year-old man came to the office because of epigastric pain of 2 months’ duration not relieved with antacids. He has a history of an adenomatous gastric polyp removed 3 years ago. At upper endoscopy, he was found to a have another gastric polyp in his antrum that, on endoscopic ultrasound, appeared to be superficial and not associated with any enlarged lymph nodes. Pathological analysis of the polyp reveals evidence of adenocarcinoma invading into the submucosa. On clinical staging, there Is no evidence of distant metastasis. The next step in therapy for this patient is

A

subtotal gastrectomy

This patient has an early stage gastric cancer (i.e., no evidence of metastasis or perigastric lymph nodes) on clinical staging and is a candidate for potentially curative resection. Patients with minimal evidence of gastric wall invasion (i.e., mucosal or submucosal invasion) do not require any preoperative therapy and should proceed straight to surgical resection. In this patient with an antral lesion, a subtotal gastrectomy is Indicated with frozen section analysis of surgical margins to ensure adequate resection. Wedge resection is not recommended. In patients with evidence of greater gastric wall invasion (I.e., invasion to and beyond the lamina propria), perioperative chemotherapy with epirublcin, clsplatln, and 5-fluorouracil has been demonstrated to provide a survival benefit.

184
Q

A 34-year-old woman is being evaluated for epigastric pain and Is found to have an ulcer In the anterior duodenal bulb on upper endoscopy. Rapid urease testing of a mucosal biopsy of the antrum of the stomach is positive. In addition to omeprazole, appropriate therapy at this time would include a 2-week course of omeprazole, metronidazole, and

A

All patients presenting with duodenal ulceration should undergo testing for the presence of Helicobacter pylori Infection. The rapid urease test can be performed on antral stomach biopsies and Is Indicative of infection if positive. If H. pylori infection is present, it should be eradicated. First-line therapy includes acid suppression with clarithromycin and amoxicillin or clarithromycin and metronidazole for a minimum of 7 days. Traditional quadruple therapy Is a second-line treatment and consists of acid suppression with bismuth, metronidazole, and tetracycline for a minimum of 7 days.

185
Q

A 53-year-old woman comes to clinic for evaluation for weight loss. She has recently diagnosed diabetes, asthma, sleep apnea, and hypertension. Her BMI is 38 kg/m2. Which of the following weight loss options Is most appropriate for this patient?

A

This patient has type II obesity with the life-threatening comorbidity of sleep apnea. As such, she qualifies for surgical intervention according to 1998 NIH guidelines. Weight loss surgery is the only treatment option to demonstrate sustained, substantial weight loss. Gastric bypass, therefore, is Indicated. Very low calorie diets are not recommended for weight loss by the NIH guidelines. Although low-calorie diets, sibutramine, and orlistat are all options in treating obese patients, those individuals who qualify for surgery should undergo it if they are deemed appropriate candidates.

186
Q

A 42-year-old woman comes to the emergency room with epigastric pain radiating to right upper quadrant. She underwent a laparoscopic adjustable gastric band 6 months ago. She has lost approximately 80 lbs over the 6 months. She is afebrile with stable vital signs. A right upper quadrant ultrasound is shown below. Which of the following medications would have been most effective In preventing this complication?

A

This patient has developed symptomatic cholelithiasis following rapid weight loss after a bariatric procedure. The ultrasound shows several echogenlc stones within the gallbladder. Without pharmacotherapy, the risk of gallstone formation during this period approaches 30%. The prophylactic use of ursodeoxycholic acid decreases the risk of gallstone formation to approximately 2%. Sucralfate is used to promote healing of anastomotic ulcers. Cholestyramine Is used in the treatment of alkaline reflux gastritis to bind bile salts. Calcium citrate Is given to bariatric patients to prevent calcium deficiency and subsequent osteoporosis. Omeprazole is a proton pump Inhibitor used in the treatment of anastomotic ulcers.

Surgery (21 decks)

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