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Rosalynn's ABSITE > Stomach and duodenum > Flashcards

Stomach and duodenum Flashcards

1
Q

What are classic symptoms of afferent loop syndrome?

A

severe epigastric pain and cramps
bilious vomiting with relief of symptoms

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2
Q

why does afferent loops syndrome happen?

A

obstruction of the afferent loop resulting in accumulation of pancreatic and hepatobiliary secretions causing sever epigastric pain

resulting high intraluminal pressure forces the fluid into the stomach resulting in bilious vomiting and relief of symptoms

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3
Q

what is the treatment of afferent loop syndrome?

A

surgical correction
-conversion of billroth II to billroth I anastomosis
-enteroenterostomy below the stoma
-creation of a roux en y procedure

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4
Q

what is the length of the roux limb?

A

variable but often 100-150 cm
-100 cm in smaller patients (BMI 40-50)
-125-130 cm (BMI 50-55)
-150 in larger patients (BMI greater than 55)

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5
Q

In a patient with a recurrent duodenal ulcer bleed that is unstable, what is the next step of management?

A

duodenotomy and oversewing of the vessel

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6
Q

In a patient with a recurrent duodenal ulcer bleed that is stable, what is the next step of management?

A

repeat endoscopy

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7
Q

what is Petersen’s defect/space?

A

area between the mesentery of the roux (alimentary) limb and the transverse mesocolon

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8
Q

what two mesenteric defects can attribute to internal hernia in a roux en y bypass?

A

petersen’s defect
jejunojejunostomy

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9
Q

what test should you do to determine if h.pylori infection has been eradicated

A

urea breath test 4 weeks after completion of therapy

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10
Q

biliary reflux gastritis most commonly happens after what surgery?

A

billroth II gastrojejunostomy

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11
Q

what ulcer is associated with large hiatal hernias?

A

Cameron ulcer

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12
Q

what is the management of a duodenal perforation in an unstable patient?

A

controlled duodenal fistula, temporary pyloric exclusion, and gastrojejunostomy

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13
Q

what is the management of a duodenal perforation in a stable patient?

A

either the first portion of the duodenum is resected and reconstruct or jejunoserosal patch

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14
Q

what is the management of a duodenal perforation that is small less than 1-2 cm

A

primary repair

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15
Q

what is the management of a duodenal perforation that is 1-3 cm?

A

graham patch

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16
Q

patient’s with chronic pancreatitis may not be able to absorb what?

A

long chain fatty acids

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17
Q

what is the treatment for small bowel lymphoma

A

wide excision and lymph node dissection followed by adjuvant chemorads

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18
Q

a villous adenoma in the small bowel has what chance of cancer?

A

about 40%

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19
Q

what is the optimal way to close a loop ileostomy opening

A

circumferential subcuticular wound approximation

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20
Q

what is the most common malignant mass of the jejunum?

A

metastatic melanoma

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21
Q

what is the most common presentation of mesenteric venous thrombosis?

A

nonspecific abdominal pain, vomiting, diarrhea

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22
Q

What are the 4 types of hiatal hernias?

A

Type 1 (sliding type, mc), Type 2 (paraesophageal, need repair), type 3 (sliding and paraesophageal, need repair), type 4 (entire stomach is in the chest with a part of another organ in the chest)

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23
Q

which types of hiatal hernias need to be fixed?

A

Types 2, 3, 4
Type 1 only if symptomatic

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24
Q

Ulcer on body of stomach, incisor, and duodenal ulcer (active or healed)

A

Type II gastric ulcer

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25
Q

Medication induced gastric ulcer (can be anywhere)

A

Type V gastric ulcer

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26
Q

Prepyloric gastric ulcer

A

Type III gastric ulcer

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27
Q

Ulcer on the lesser curve, incisura

A

Type I gastric ulcer

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28
Q

Ulcer high on lesser curve, near GE junction

A

Type IV gastric ulcer

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29
Q

which gastric ulcer types are due to acid hyper secretion?

A

Types II and III (more distal ulcers)

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30
Q

which types of gastric ulcers would respond to vagotomy?

A

Types II and III

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31
Q

Which gastric ulcers are due to less protection of the gastric lining?

A

Types I and IV

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32
Q

Type I Stewart Stein EGJ tumor

A

distal part of esophagus between 1-5 cm above anatomic GEJ

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33
Q

Type II Siewart Stein EGJ tumor

A

Cardia (within 1 cm above and 2 cm below the EGJ)

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34
Q

Type III Sieward Stein EGJ tumor

A

Subcardial stomach (2-5 cm below EGJ)

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35
Q

which Stewart Stein tumors are treated more like adenocarcinoma of the esophagus?

A

Types I and II

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36
Q

How is Type III Stewart Stein tumors treated?

A

according to guidelines for gastric adenocarcinoma

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37
Q

What is the most common type of gastric volvulus?

A

organoaxial

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38
Q

what are the two types of gastric volvulus?

A

organoaxial and mesoaxial

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39
Q
A

organoaxial gastric volvulus

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40
Q
A

mesoaxial gastric volvulus

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41
Q

Gastric volvulus that rotates along the short axis of stomach bisecting the lesser and greater curvature

A

Mesoaxial volvulus

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42
Q

Gastric volvulus that rotates along the axis of the stomach from the GE junction to the pylorus

A

Organoaxial volvulus

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43
Q

How are gastric volvulus’ usually treated?

A

emergent surgery (hernia repair, gastropexy, partial gastrectomy if devitalized)

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44
Q

Can endoscopic decompression be used for gastric volvulus?

A

Yes, in frail patients with double PEG tubes (high perforation risk)

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45
Q
A

organoaxial gastric volvulus

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46
Q

what are the alarm symptoms for GERD

A

dysphagia, odynophagia, weight loss, anemia, GI bleeding

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47
Q

If a patient has atypical GERD symptoms with hx of GI surgery

A

bile reflux

get impedance probe ,usually needs RNY reconstruction

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48
Q

what work up do you need before doing any surgery for GERD?

A

barium swallow
EGD
ambulatory ph testing
esophageal manometry to r/o motility disorder (can’t do full Nissen if dysmotility)

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49
Q

What Demeester score means GERD

A

> 14.72

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50
Q

What is a Dor fundoplication

A

anterior 180-200 degree wrap

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51
Q

What is a Toupet fundoplication?

A

posterior 270 degree wrap

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52
Q

What is a Thal fundoplication

A

270 degree anterior wrap

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53
Q

What is a Belsey

A

270 degree anterior thoracic wrap

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54
Q

What is a Lind repair?

A

300 degree posterior wrap

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55
Q

During fundoplication surgery, patient is hard to ventilate, what is the problem?

A

capnothorax - enlarge tear to avoid tension capnothorax, place red rubber into the pleura and other end in the abdomen to equalize the pressure, at end of surgery bring one end outside the abdomen and place to water seal while valsalva administered (can also needle decompress intra op but need to prep lower chest)

56
Q

what do you order if patient is having dysphagia after fundoplication surgery

A

esophagram - look for recurrent hernia, slipped warp, if not present may need dilation

57
Q

when to use mesh with hiatal hernias?

A

large hiatal hernias (>5/8 cm) - decreases short term recurrence

58
Q

what is the risk of rebreeding with an actively bleeding pulsatile vessel on EGD?

A

up to 80%

59
Q

what is the risk of rebreeding on EGD with a visible vessel

A

up to 50%

60
Q

what is the risk of rebreeding with adherent clot on EGD?

A

15-25%

61
Q

what is the risk of rebreeding if an ulcer with clean base is seen on EGD?

A

<5%

62
Q

what is the most common cause of gastric bleeding?

A

H. pylori and NSAIDS

63
Q

how often is there underlying malignancy with gastric ulcers?

A

about 5%

64
Q

With gastric adenocarcinoma, which T stage do you have to do a staging laparoscopy?

A

Greater than T1b (invades submucosa, past lamina proprietor which is T1a)

Can hold off if already has mets, getting definitive chemorads, or palliation only

65
Q

what surgeries can you do for patients with perforated gastroduodenal ulcer that is refractory to medical management

A

truncal vagotomy and pyloroplasty

highly selective vagotomy

vagotomy and antrectomy (higher morbidity, needs Billroth)

66
Q

who gets neoadjuvant therapy for gastric adenoma carcinoma?

A

T2 or greater, and N stage

67
Q

what is unresectable for gastric cancer?

A

peritoneal involvement, distal mets, root of mesentery involvement or paraaortic nodal disease confirmed by bx, encasement of major vascular structure (excluding splenic vessels)

68
Q

What margins do you need for gastric adenocarcinoma and how many lymph nodes?

A

at least 4 cm and at least 15 nodes

69
Q

what is the resection for proximal (Siewart II) gastric adenocarcinoma?

A

total w/esophagojejunostomy - distal part of esophagus may need to be resected for adequate margins

70
Q

What surgery do you do for distal (Stewart III) gastric adenocarcinoma?

A

subtotal gastrectomy

71
Q

how are cancers crossing the GE junction managed?

A

like esophageal cancer

72
Q

Do you need to do a prophylactic splenectomy for gastric cancer?

A

No, only if spleen or hilum are grossly involved

73
Q

Which T stage needs en bloc resection of all involved structures?

A

T4

74
Q

What is a D1 node resection?

A

removal of N1 nodes (peri gastric nodes along greater and lesser curve)

75
Q

What stations are in a D1 node resection?

A

Stations 1-6

76
Q

What is a D2 resection?

A

removal of N1 and N2 nodes (lesser/greater curve, left gastric, common hepatic, celiac, and splenic arteries)

77
Q

What stations is a D2 resection?

A

Stations 1-6 and 7-11

78
Q

what does R0 mean

A

negative microscopic margin

79
Q

what does R1 mean

A

negative gross margin, positive microscopic margin

80
Q

what does R2 mean

A

positive gross margin

81
Q

what are the two types of gastric cancers?

A

intestinal or diffuse type

82
Q

What is the gene associated with hereditary diffuse gastric cancer?

A

AD, 2/2 germane mutation in CDH1

83
Q

what is the treatment for hereditary diffuse gastric cancer

A

prophylactic gastrectomy recommended between 18-40 years for CDH1 carriers

84
Q

women with CDH1 are at increased risk of what other cancers?

A

breast cancer similar to BRCA patients

85
Q

what are other hereditary syndromes with increased risk for gastric cancer?

A

Lynch syndrome (DNA mismatch), Juvenile polyposis syndrome (SMAD4), Peutz-Jehgers syndrome, Familial adenomatous polyposis (APC gene on 5q21)

86
Q

How do you stage gastric cancer?

A

routine labs, CT C/A/P, EUS with FNA, PET/CT

87
Q

what is the stomach transit time?

A

3-4 hours

88
Q

gastroduodenal pain is sensed through which afferent fibers?

A

sympathetic fibers of T5-10

89
Q

what are the branches of the celiac artery

A

left gastric, common hepatic, splenic artery

90
Q

the gastroepiploic and short gastric arteries are branches of which artery

A

splenic artery

91
Q

the right gastroepiploic artery is a branch of which artery

A

GDA

92
Q

The greater curvature is supplied by which arteries

A

right and left gastroepiploics, short gastrics

93
Q

the pylorus is supplied by which artery

A

GDA

94
Q

which glands are mucus producing

A

cardia glands

95
Q

chief cells

A

pepsinogen (1st enzyme of proteolysis)

96
Q

parietal cells

A

release H+ and intrinsic factor

97
Q

what increases acid production?

A

acetylcholine (vagus), gastrin (G cells antrum), histamine (mast cells)

98
Q

acetylcholine and gastrin activates what?

A

phospholipase which activates Ca calmodulin which activates phosphorylase kinase leading to acid production

99
Q

Histamine activates

A

adenylate cyclase which increase cAMP and activates protein kinase A which increases acid

100
Q

Phosphorylase kinase and protein kinase A phosphorylate

A

H+/K+ ATPase to increase acid and K absorption

101
Q

PPI block

A

H+/K+ ATPase in parietal cell membrane (final pathway for H+ release)

102
Q

what are inhibitors of parietal cells

A

somatostatin, prostaglandins (PGE1), secretin, CCK

103
Q

what does intrinsic factor do?

A

bind B12 and reabsorbed in the terminal ileum

104
Q

Types of cells in the fundus and body glands

A

chief, parietal

105
Q

types of cells in the antrum and pylorus glands

A

G cells, D cells, mucus and HCO3

106
Q

G cells release

A

Gastrin - reason why antrectomy is helpful for ulcer disease

107
Q

G cells are inhibited by

A

H+ in duodenum

108
Q

G cells are stimulated by

A

amino acids, acetylcholine

109
Q

D cells secrete

A

somatostatin which inhibit gastrin and acid release

110
Q

what glands secrete alkaline mucus in the duodenum

A

Brunner’s glands

111
Q

what is the MCC of rapid gastric emptying

A

previous surgery (#1), ulcers

112
Q

where is the tear usually for a Mallory Weiss tear?

A

lesser curve

113
Q

what is Menetrier’s disease?

A

mucus cell hyperplasia, increase in rural folds

114
Q

IF a mallory weiss tear does not resolve with EGD what is the next step?

A

gastrostomy and oversewing of the vessel

115
Q

where is a truncal vagotomy done?

A

divides vagal trunk at level of esophagus, increases emptying of solids

addition of pyloroplasty results in increase of solid emptying

116
Q

where is a highly selective vagotomy done?

A

divides individual fibers and preserves the crow’s foot - normal emptying of solids

117
Q

other alterations that happen with truncal vagotomy

A

decrease acid output by 90%, increase gastrin, gastrin cell hyperplasia, decrease exocrine pancreas fn, decrease postprandial bile flow, increase gallbladder volumes, decrease vaguely mediated hormones

118
Q

what is the mc problem following vagotomy?

A

diarrhea caused by sustained migrating motor complex (MMC) forcing bile acids into the colon

119
Q

how do you treat diarrhea after a vagotomy?

A

cholestyramine and loperamide

120
Q

anterior duodenal ulcers usually

A

perforate

121
Q

posterior duodenal ulcers usually

A

bleed from the GDA

122
Q

where does stress gastritis happen

A

in the fundus usually 3-10 days after the event (multiple trauma, burn, complicated post op)

123
Q

Type A chronic gastritis happens where?

A

fundus - associated with pernicious anemia, automimmune dz

124
Q

Type B chronic gastritis happens where?

A

Antrum - associated with H. pylori

125
Q

what is the classic symptoms of gastric adenocarcinoma

A

pain unrelieved by eating and weight loss

126
Q

what is a Krukenberg tumor

A

gastric cancer mets to the ovaries

127
Q

what are Virchow’s nodes

A

mets to supraclavicular node

128
Q

what is the MC benign neoplasm in the stomach

A

GIST, can be malignant

129
Q

biopsy of a GIST shows

A

C-KIT positive

130
Q

GISTS are malignant if

A

> 5 cm or >5 mitoses/50 HPF

131
Q

what is the treatment for GIST cancer?

A

resection with 1 cm margin, no nodal dissection

132
Q

what is the chemo for GIST

A

imatinib (Gleevac)

133
Q

Imatinib works how?

A

tyrosine kinase inhibitor

134
Q

How do you treat a MALT lymphoma?

A

treat H. pylori

135
Q

what is the most common location of a MALT lymphoma

A

stomach, lesser curve

136
Q

extra nodal lymphoma most commonly happens in the

A

stomach

137
Q

treatment for gastric lymphoma

A

primarily chemorads, surgery possible for only stage I disease (tumor confined to stomach mucosa, only partial resection is needed)

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