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ABSITE > stomach & general abdomen > Flashcards

stomach & general abdomen Flashcards

1
Q

GIST

A

most common nonepithelial tumors of the GI tract

mutations in c-KIT (CD117) or platelet-derived growth factor receptor alpha (PDGFRA) genes are commonly seen

sarcoma of the interstitial cells of cajal

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2
Q

GIST mgmt

A

5+ cm in size with more than 5 mitoses per high-power field requires preop IMATINIB tyrosine kinase inhibitor - if resistant, try sunitinib

just want R0 or 1 cm margin
adjuvant imatinib x 3 years

not nodal spread (no need for nodal dissection)

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3
Q

gist mets

A

liver and peritoneal surfaces

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4
Q

where does RIGHT gastric aa branch

A

from proper hepatic artery AFTER GDA takeoff

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5
Q

stomach cells
chief, partietal cell

A

chief: pepsinogen
parietal : release H and intrinsic factor

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6
Q

parietal cell reactio

A

ACh and gastrin cause PHOSPHOLIPASE acivation

PIP, DAG IP3 CALCIUM.***.=
Ca-calmodulin activates kinase to release H.

histamin activates adenylate cyclase.
increase CAMP, PKA to release H.

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7
Q

gastrin released from?

A

G cells (antrum).

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8
Q

gastrin regulation

A

inhibited by H in duodenum
stinulated by amino acids/ACh

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9
Q

Brunners glands where/what

A

duodenum; secrete ALKALINE MUCUS

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10
Q

inbhitors of parietal cell HKATPase

A

somatostatin, prostagland PGE1, secretin , CCK

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11
Q

hereditary diffuse gastric cancer.

A

AD… CDH1, which encodes the cell-cell adhesion protein E-cadherin

ppx gastrectomy 20-40 YO
women have increased breast ca risk

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12
Q

other syndromes ass’d gastric ca

A

Lynch, jevnile polyposis SMAD4, peutz jeghers, FAP 5q21

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13
Q

esophageal FBO removal timing

A

<24 hrs

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14
Q

stomach FBO removal timing

A

<24 hrs if sharp objects, >5cm, and magnets, and 1+day (blunt >2cm and batteries)

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15
Q

coin FBO

A

dx XR. retrieve if symptomatic or if stays (anywhere for 3-4 wks)

can leave in esophagus if asx

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16
Q

EGD tools for battery ingestion

A

A double-channel endoscope is preferred for foreign object retrieval so diagnostic and therapeutic instruments can be passed through the scope.

An esophageal overtube should be used for this patient to protect the esophageal mucosa and upper airway when pulling the object out of the alimentary tract.

Forceps are preferred when retrieving flat objects such as disk batteries or coins.

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17
Q

how to evaluate the celiac lymph node basin

A

US probe on L lobe of the liver (during dx lap for staging gastric adeno ie)

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18
Q

rectus sheath hematoma grades

A

type I hematoma is small and confined within the rectus muscle, and it does not cross the midline or dissect fascial planes

type II hematoma is confined within the rectus muscle; however, it can dissect along the transversalis fascial plane or cross the midline&raquo_space; need to trend Hemoglobins and see if unstable, then can go to embolization

type III hematoma is usually below the arcuate line, large in size, and presents with blood in the prevesical space of Retzius and/or hemoperitoneum.&raquo_space; needs angiography & embolization.

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19
Q

exit site PD catheter infection

A

obtain culture and start empiric abx

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20
Q

bacterial peritonitis 2/2 PD catheter

A

start Abx, hold off on taking catheter out until failure of ab 4-5 days, or if fungal peritonitis, or if intraabdominal pathology suspected

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21
Q

abx of choice for SBP 2/2 PD catheter

A

Intraperitoneal gentamicin and ceftriaxone

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22
Q

mesenteric simple cyst

A

Benign
F>M
Small>large bowel
full of: serous or chyle fluid

mgmt: enucleate or marsupialize (if too big)

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23
Q

harmonic scalpel works

A

minimal thermal injury; dividing tissue < 6 mm using coag; monopolar can just use the blade alone; no tissue sticking; SLOW CYCLING of active blade during coag can spread hemostasis. RAPID CYCLING of cutting allows for precision.

disrupts protein H bonds and causes coagulation

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24
Q

insulation failure on bovie

A

stray marks near operative field

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25
Q

argon beam mechanism

A

energy transferred across argon gas
2m necrosis (superficial coag)
and is NONCONTACT so hemostasis is good for liver // smokeless

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26
Q

gore tex vs dacron

A

gore text = PTFE = no fibroblast ingrowth
dacron = polypropylene =- allows fibroblast ingrowth (think mesh)

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27
Q

veress/trocar injury rate

A

0.1%

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28
Q

Nd;YAG laser

A

good for deep penetration (bronchial lesions)
1-2 mm cut
3-10mm vaporize
1-2 cm coagulates

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29
Q

capacitative and direct coupling

A

charge dispersed through other instruments which would result on burns on contacted organ

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30
Q

monopolar thermal injury

A

2-3 days after index case

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31
Q

pneumoperitoneum effects (during lap)

A

increased intrathoracic pressure
decreased functional residual capacity and Vt (resp acidosis)
atelectasis
hypercarbia (diffusion)
hypercarbia -> systemic arterial vasodilation and myocardial depression
hyeprcarbia ->increased pulmonary vascular resistance (worsens pulmHTN and RV failure)
compression of IVC causing decreased preload and increased afterload overall hypotension from liimited cardiac output and myocardial depression (bradycardia)
stretching of vagal receptrs (cardiac slowing)

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32
Q

ideal pneumoperitoneum pressures

A

12-15 mm Hg

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33
Q

fine dissection requiring very precise heat?

A

use BIPOLAR

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34
Q

co2 embolism = gas lock effect

A

embolism in RA or RV blocking outflow from RV
increased end tidal CO2, hypotension, pulmonary hypertension, CV collapse

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35
Q

mgmt co2 embolism

A

cessation insufflation, Trendelenberg and LLD to keep them in the RA. HF O2, fluids, aspiration via CVC in RIJ

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36
Q

granulation tissue painful around PEG site

A

silver nitrate; don’t put protective padding (can cause tension)

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37
Q

what nerve must be included in vagotomy for ulcer disease

A

criminal nerve of Grassi (branch of posterior vagus)

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38
Q

gastric carcinoid tumors 3 types

A
  1. atrophic gastritis or pernicious anemia
  2. Zollinger-Ellison syndrome
  3. tumors occur sporadically.
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39
Q

mgmt gastric carcinoid tumor

A

complete regression of all tumors after antrectomy alone has been documented in patients with atrophic gastritis and multiple small carcinoids

local excision of the dominant tumor with antrectomy

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40
Q

GIST spread

A

hematogenously; to liver and peritoneal surfaces > spleen

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41
Q

GIST prognosis

A

Tumors 5-10 cm and 5+ mitoses per HPF were found to have the highest malignant potential. Need imatinib.

<2 cm and <5 mitoses per HPF = benign, NTD

2-5cm and <5 mitoses per HPF
and 10+cm with <5mitoses per HPF

worst px: esophag/colorectal primary, >10cm, >10M/10 HPF, local invasion, distant mets

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42
Q

bleeding duodenal peptic ulcer mgmt after 2x egd

A

The patient is likely bleeding from the GDA due to erosion from a posterior ulcer.

anterior duodenotomy and oversewn with a three-point U stitch, ligating the main vessel (GDA) superiorly and inferiorly and preventing back-bleeding with a medial stitch (transverse pancreatic aa). If this patient is stable in the operating room, a **vagotomy and pyloroplasty would be indicated because he has known peptic ulcer disease
no need to Bx if duodenal; transverse duodenal CLOSURE

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43
Q

MC cause of gastric ulcer

A

NSAIDs and H.pylori (but higher incidence of cancer compared to duodenal ulcer)

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44
Q

surgical tx of gastric ulcer that is BLEEDING

A

make sure to Bx…..

anterior gastrotomy, oversew, BIOPSY, close

need to Bx the ulcer and antrum ( to r/o H. pylori)

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45
Q

staging gastric ca

A

Start with EGD (identify it)
PETCT CAP
then EUS (T staging) with FNA
then Staging laparoscopy is essentialIF GREATER THAN T1B in the staging of gastric cancer (N and M) - NCCN

Peritoneal lavage with cytology testing is an important component of staging laparoscopy. mean overall survival of 14 to 20 months.

T1a: invade lamina propria
T1b: submuocsa
T2: invade muscular propria
T3: invade subseerosa
T4: into adjacent strucutr
N1: 1-2
N2: 3-6
N3 7+
M1 survival is 3-6 mos

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46
Q

Bile reflux gastritis

A

after Billroth II reconstruction as a consequence of a defective pyloric channel. It results from exposure of the gastric mucosa to bile, pancreatic secretions, and duodenal contents.

(intestinalization of gastric glands with inflammation).

mgmt: Conversion to Roux-en-Y gastrojejunostomy with a Roux limb of at least 40 cm is associated with symptomatic relief in up to 85% of patients. Distal Braun enteroenterostomy has been shown to improve symptoms of bile reflux gastritis in 53% of patients.

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47
Q

surveillance after gastrectomy for gastric adeno

A

stage II disease: CT of the chest, abdomen, and pelvis is necessary every 6 to 12 months for 2 years and then annually for up to 5 years

stage I disease, CT of the chest, abdomen, and pelvis should be performed as needed

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48
Q

internal hernia diagnosis (hx of RNY)

A

PO & IV contrast-enhanced CT scan of the abdomen and pelvis
= mesenteric swirl with volvulus of the Roux limb.

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49
Q

Afferent loop syndrome

A

Aff loop in B2 becomes partially or completely obstructed… diarrhea then obstructive jaundice and pancreatitis

pain relieved with bilious emesis

CT shows dilated afferent limb

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50
Q

mgmt afferent loop syndrome

A

surgical correction; eliminate the likely LONG afferent limb via conversion to RNY or enteroenterostomy below the stoma

abx too but limited; balloon but limited

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51
Q

efferent limb syndrome like an internal hernia

A

sx: n/v, pain
dx: CT
mgmt: surgical emergency!

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52
Q

perforated G or D ulcer from ulcer disease? first occurence or patient is not stable enough at subsequent episdoes

A

omental patch repair

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53
Q

perforated G or D ulcer from ulcer disease? SECOND occurrence (failed >12 mo medical therapy) and patient is stable enough

A
  1. Highly selective vagotomy - divide the anterior and posterior nerves of Latarjet and preserving the “crow’s feet” division at the antrum. 10% recurrence.
  2. Truncal vagotomy with pyloroplasty has a 10% to 12% ulcer recurrence rate
    **3. Truncal vagotomy with antrectomy [for GASTRIC ULCERS ANTRUM] followed by Billroth I or Billroth II (TL 2 is answer if duodenal disease) reconstruction has a lower ulcer recurrence rate at 1% to 2% since both cephalic and gastric phases of acid secretion are eliminated. Fiser says RNY is BEST after truncal + antrectomy

need to Bx and get the ulcer out at time of stomach surgery

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54
Q

mgmt gastric ca, margins and nodes

A

5-6 cm proximal
2 cm distal margins
at least 16 nodes (D1)

Neoadj T2 or N.

UnresectBle: paraaortic, encasement of vessels (aside from splenics), metastatic, peritoneal involvement

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55
Q

mgmt gastric ca linitis plastica

A

total gastrectomy because very diffuse

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56
Q

dumping syndrome early

A

20-30 minutes after eating
more common
pathophys: rapid shift of intracellular fluid into the intestinal lumen is incorrect because it is an extracellular fluid shift; likewise, this is more commonly related to early dumping syndrome effects

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57
Q

dumping syndrome late

A

2-3 hrs after eating.
sx: CARDIOVASCULAR, PALPITATIONS, TACHY, DIAPHROESIS, FAINTING, FLUSHING, BLURRED VISION
esp after B2
pathophys: rapid gastric emptying, specifically carbohydrates being delivered to the small intestine. These carbohydrates are quickly absorbed, causing hyperglycemia and insulin release. Subsequent overcompensation leads to profound hypoglycemia and increased catecholamine release from the adrenal glands.

mgmt: 6 small meals, separate liquid/solid, avoid sugar, increase fiber, candy between meals

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58
Q

siewert stein classification for GEJ tumors

A

Type I: ca in distal esophagus 1-5cm above anatomic GEJ
Type II; ca 1cm above nd 2 cm below GEJ
Type III: 2-5cm below GEJ

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59
Q

siewert I - III tx

A

I and II: esophageal ca
III: gastric ca

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60
Q

gastric antral vascular ectasia GAVE disease

A

watermelon stomach; hyperemic mucosal tissue

mgmt of bleed: ablation with argon plasma coagulation

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61
Q

NSAID related ulcer pathogen

A

reduced production of mucosal prostagladnings from inhibition of COX

thus, decreased mucosal blood flow and bicarb/mucin secretion

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62
Q

duo perf <1 cm

A

primary repair

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63
Q

1-3 cm duo perf

A

graham patch as long as also included acid reducing procedure

or pylorplasty (includes duo injury obviously) with acid reducing procedure

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64
Q

> 3cm duo perf

A

jejunal serosal patch wth acid reducing procedure

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65
Q

hyperplastic polyp mgmt

A

resect completely if > 0.5 cm

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66
Q

cushing ulcer

A

single and DEEP… GASTRIC ULCER
head trauma.

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67
Q

curling ulcer

A

BURN > 30%
mostly duodenal

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68
Q

stress ulcers

A

shallow, multiple, proximal stomach (like fundus) in 3-10 days from insult

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69
Q

stress ulcer ppx

A

GCS 10 or below
traumatic spinal cord injury
INR > 1.5, PTT > 2x normal
plt < 50K
severe burn 20+ TBSA

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70
Q

types of chronic gastritis

A

A: PERNICIOUS anemia, AI disease (fundus)
B: H pylori (antral)

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71
Q

UGIB bleed post-EGD surveillance

A

after ex, 4-6 wk repeat (but not if mallory weiss)

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72
Q

mallory weiss tear in stomach

A

mostly on lesser curve hear teh GEJ…

tx with EGD and HEMOCLIP!&raquo_space;> gastrostomy & oversewing of vessel

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73
Q

D2 vs D1 dissection gastric ca

A

D2 showed superior recurrence free survival with trend toward increased survival

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74
Q

survival of R0 gastric adeno intestinal… (the good one)

A

35%

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75
Q

hormone changes after RYGB bariatric

A

ghrelin lower - decreased hunger
leptin higher - increased satiety
neuropeptide Y lower - decreased appetite

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76
Q

MC site of stricture/leak after LSG?

A

incisura angularis
dx with CT with PO & IV contrast

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77
Q

small bowel adenocarcinoma resection margin & nodes

A

10 cm proximal, 5 cm distal margin
+wedge of mesenteric nodes
OK to primary anastomse

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78
Q

2 ducts into D2?

A

duct of Wirsung (going through ampulla of Vater) and duct of Santorini (accessory)

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79
Q

arterial supply to duo

A

superior pancreaticuduodeanl artery ( Off GDA)
inferior pancreaticoduodenal artery (off SMA)
have anterior and posterior branches

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80
Q

how long jejunum

A

100cm long

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81
Q

vasa recta length jej vs ileum

A

long in jej, short in ileum

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82
Q

location of fe absorption

A

DUO

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83
Q

location B12 absorption

A

TI with intrinisic factor

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84
Q

location bile acids absorption

A

ileum

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85
Q

location folate aborption

A

TI

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86
Q

where is the most absorption in gut? (esp NaCl and water)

A

JEJUNUM

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87
Q

ileum length

A

150cm

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88
Q

enzymes of brush border

A

maltase, sucrase, dextriniase, lactase

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89
Q

goblet cell secretion

A

mucin

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90
Q

paneth cell secretion

A

secretory granules, enzymes

91
Q

enterochromaffin cells = KULCHITSKY CELLS secrete

A

APUD, 5-HT, carcinoid precursor

92
Q

Bruner’s glands

A

alkaline solution secretion

93
Q

APC of intestinal wall?

A

M cells

94
Q

IgA in gut

A

released in gut; transverses breast milk

95
Q

MMC migrating motor complex

A

phase I: rest
II: acceleration, GB contraction
III: peristalsis (*MOTILIN)
IV: deceleration

96
Q

bile aci reabsorption

A

95% are reabsorbed
50% passively via unconjugated salts into ileum
50% actively via conjugated salts into NaKATPase in TI

97
Q

short gut syndrome suspicioin

A

75cmbowel to survive off TPN
50 cm with competent ileocecal valve

98
Q

tests in short gut syndrome

A

sudan red stain: fecal fat
schilling test: radiolabeled B12 in urine

99
Q

mgmt short gut

A

restrict fat, PPI, lomotil

100
Q

MC cause of LBO

A

cancer

101
Q

MC cause of SBO

A

hernia (If no OR before), adhesions (if OR before)

102
Q

gallstone ileus location

A

stone in TI
fistula infundibulum to D2

103
Q

mgmt gallstoneileus

A

remove stone (enterotomy)
leave fistula alone if sick
or chole and close duo if not sick

104
Q

meckel’s

A

2 ft from ICV, 2% population, 2YO, TRUE DIVERTIC, 2inches

105
Q

pathophys meckel’s

A

failure of closure of OMPAHLOMESENTERIC DUCT

106
Q

presentation meckel’s

A

painless GIB < 2YO
or SBO in adult

107
Q

ectopic tissue in meckel’s

A

panreatic > gastric
panc = pain
gastric = bleeding

108
Q

mgmt incidental finding of meckel’s

A

resect if thickened (suspect gastric mucosa) or very small neck

109
Q

dx of meckel’s

A

Mekcel’s scan (technetium 99) if can’t localize

110
Q

mgmt of sx meckel’s

A

diverticulectomy with segmental resection if complicated diverticulitis or if neck > 1/3 bowel lumen, or if base inflamed

111
Q

duodenal diverticulum mgmt

A

segmental resection if sx-ic unless in D2
if in D2, justa-ampullary - HJ (biliary sx) or ERCP with stent (pancreatic sx)

112
Q

mgmt of large skin tags in Crohn’s

A

don’t touch it

113
Q

serotonin

A

made in Kulkchitsky cells (enterochromaffin /argentaffin cell)
part of AMINE PRECURSOR DECARBOXYLASE SYSTEM APUD.

breakdown into 5-HIAA (can measure this in urine)

114
Q

carcinoid syndrome

A

from bulky liver mets

115
Q

sx carcinoid syndrome

A

flushing (kallikrein), diarrhea (serotonin), ashtma (bradyinin), RHvalve lesions

116
Q

dx carcinoid syndrome

A
  1. chromogranin A level (HIGHEST SENSITIVITY for detecting tumor)
  2. localize with OCTREOTIDE SCAN (BEST for localization)
  3. add on 24hr urine 5-HIAA
117
Q

MC site of carcinoid in small bowel

A

appendix > ileumm > rectum

118
Q

mgmt carcinoid

A

< 2 cm: wide local
2+ cm: oncologic resection (SCORE: >1cm)

chemotherpay (streptozocin and 5-FU) if unresectable, octretodie for sx***, albuterol, a-blockers (for flushing)

119
Q

small bowel adenoma prsentation

A

usually DUO
bleeding/obstruction

120
Q

mgmt small bowel adenoma

A

resect (via endoscopy)

121
Q

small bowel adenocarcinoma presentation

A

usually DUO
obstruction/*jaundice

122
Q

mgmt small bowel adenocarcinoma

A

resection and adenectomy x 8 nodes at least
5mm margins, send frozen

Whipple if D2

Tis-T1 to submucosa only D1, D3, D4 can be endoscopically attempted

123
Q

assocaitions with duodenal adenocarcinoma

A

FAP, Gardner’s, von Recklinghausen’s NF1

(test for mismatch repair MMR or microsatellite instability MSI testing)

124
Q

leiomyosarcoma dx in small boewel

A

bx = >5 mitoses/50HPF and atypia or necrosis
negative for C-kit (r/o GIST)

125
Q

mgmt leiomyosarcoma

A

resetion without adenectomy

126
Q

small bowel lymphoma

A

mostly ileum, Non hodkins

127
Q

dx lymphoma small bowel

A

CT scan and node sampling

128
Q

mgmt lymphoma small bowel

A

wide en bloc resection with nodes
if in D2, chemoXRT only – no Whipple

129
Q

mgmt parastomal hernias

A

don’t fix unless symptomatic

130
Q

MC stomal infection

A

Candida

131
Q

pathophys diversion colitis

A

lack of SCFA to the diverted segment

132
Q

mgmt of diversion colitis

A

enemas of SCFA

133
Q

uric acid kidney stones after ileostomy

A

loss of bicarb – these are radioLUCENT

134
Q

mgmt of salmonella typhoid enteritis (RLQ pain, rash, large mesenteric LN)

A

bactrim

135
Q

veress injury incidence

A

0.1%

136
Q

laproscopic approach to SBO indications

A

laparoscopic approach is appropriate in patients with fewer than three previous operations, early presentation, proximal site of obstruction with mild distention, or an anticipated single adhesive band

137
Q

before DLI reversal what imaging should you get

A

rectal contrast study

138
Q

increase risk of small bowel adenocarcinoma with CROHNS

A

especially in TI

139
Q

panc polypeptide

A

causes decreased panc & gb secretion

140
Q

most release of somatostatin (D)

A

from antrum in response to acid in duodenum

141
Q

motilin acts on

A

antrum

142
Q

bombesin

A

gastrin releasing peptide; increased motor activity & panc & gastric stuff

143
Q

GLP2

A

good for short gut - increases intestinal mucosal growht & improves fluid absorption

144
Q

MALToma gastric tx

A

QUAD H pylori tx; if still there, XRT.

if 11;18 +, then XRT from the beginning too

if can’t do XRT< then do rituximab

if H. pylori negative, just do XRT (or rituximab)

145
Q

peptide YY

A

from TI;
inhibit acid secretion and stomach contraction

146
Q

small bowel MALToma tx

A

observation is ok

147
Q

blind loop syndrome

A

postgastrectomy complication esp B2 or RNY, poor motility
sx: pain, STEATORRHEA (bac deconjugate bile), B12 def(bac eat it), malabsorption

bacterial overgrowth in afferent.. inc Bacteroids, anaerobics, enterococci

dx: d-xylose test carb, EGD and aspirate bugs

tx: Abx (tetracycline flagyl, Reglan, Augmentin), and TPN-B12
or make shorter afferent limb ~ 40 cm

148
Q

amifostine

A

protects intestin from radiation damage

149
Q

dieulafoy ulcer

A

vascular malformation; can bleed

150
Q

menetriers disease

A

mucous cell hyperplasia; increase rugal folds

151
Q

highly selective vagotomy

A

PROXIMAL vagotomy at the level of the lesser sac; divides individual fibers (preserve crows foot) normal SOLID EMPTYING. divides criminal nerve of grassi

152
Q

truncal vagotomy

A

divide vagal trunks at level of esophagus
need to add empyting procedure (pyloroplasty or antrectomy with RNY GJ > B1/B2 2/2 dumping and alkaline reflux gastritis)

153
Q

gastrin cell hyperplasia

A

after truncal vagotomy

154
Q

diarrhea after vagotomy

A

MC complication
from sustained **MMCs forcing bile acids into colon

mgmt: cholestyramine and loperamide

155
Q

pyloroplasty

A

Heineke Mikulicz pyloroplasty

156
Q

quad therapy H pylori

A

PPI
clarithromycin
metronidazole vs amoxicillin
BI

157
Q

obstruction 2/2 DU

A

don’t forget bx
resect with antrectomy and truncal vagotomy (include ulcer in resection if proximal to ampulla)

158
Q

best test for H pylori eradication

A

ureas breath test

159
Q

gastric adenocarcinoma chemo

A

5FU, doxorubicin, mitomycin C

Indicated for all: clinical T2, nodal
Entire upfront prior (just like esophageal)

160
Q

stomach lymphoma

A

MC extranodal Lymphoma (mostly NHL)

161
Q

sotmach lymphoma mgmt

A

chemo and XRT
just resection for stage I

162
Q

5 yr survival for gastric lymphoma

A

50%

163
Q

bariatric surgery indications

A

BMI > 40 or 35 w/ comorbidities
no drug/EtOH
mental health
failure of lifestyle

164
Q

contraindications to elective ventral hernia repair?

A

BMI > 50
HgbA1c 8+
active smoking

165
Q

what comorbidity does not get better with bariatric surgery?

A

peripheral artery disease

166
Q

RNY GB

A

with chole if stones
UGI POD 2

167
Q

marginal ulcer RNY GB

A

10%
PPI
in jejunum

168
Q

dilated excluded stomach postop

A

G tube

169
Q

alkaline reflux gastritis

A

postprandial PAIN, VOMITING DOESN’T HELP
esp after B1 or B2

dx: impedance testing

170
Q

mgmt alkaline reflux gastritis

A

RNY conversion 50 cm afferent.

medicien: PPI, cholestyramine, Reglan

171
Q

high output fistula volume

A

> 500 cc/day

fluid resuscitation, 4-6 mo (12 wks) surgery (don’t prolong TPN), imodium vs octreotide

172
Q

low output ECF

A

<200cc/day

tx: regular diet, wound management

173
Q

increase ileostomy length if under tension, technique

A

release adhesion to mobilize mesentery
divide proximal vessels if needed (lots collaterals)

174
Q

mgmt stricture in crohns

A

conservative trial
if fail,
@ anastomosis: DILATE
@ colon: RESECT (could be ca)
@ 2+ locations: SUBTOTAL
@ small bowel LONG segment: STRICTUROPLASTY (super long: side to side isoperistaltic; not super long: Heinecke) c
@ small bowel short/isolateed: RESECT

175
Q

timing of ostomy reversal

A

at least 6 weeks; ideally 12 weeks

176
Q

papaverine utility

A

increasing mesenteric perfusion in global low flow (on pressors ie)

177
Q

chronic mesenteric ischemia vs acute

A

chronic: can consider angiography/stent
acute: needs an embolectomy

178
Q

H ppylori pathophys

A

colonization on mucosa in patches of GASTRIC METAPLASIA; make ulcer very vulnerable to acid/pepsin/urease

179
Q

Bariatric surgery postop vitamin deficiencies

A

D&raquo_space;> B12 and Fe

180
Q

can’t tolerate pneumoperit in indicated chole?

A

don’t abort; go to open.

181
Q

worried about adhesive disease and want to go lap?

A

hasson.

182
Q

best prognosis colon sessie polyp

A

MSI

183
Q

biliopancreatic diversion with duodenal switch

A

gastric pouch + pylorus to distal ileum (250cm from pylorus) + BP limb to terminal ileus (50-100cm from ICV)

not done because: osteoporosis, cirrhosis, kidney stones

184
Q

Witzel jejunostomy

A

30 cm from LoT J tube

185
Q

idiopathic retroperitoneal fibrosis RPF = Osmond’s disease

A

chronic inflammation
fibroblast proliferation
extracellular matrix deposition
maybe 2/2 hypersensitivity to methysergide

(lower back/abd/flank pain, hydronephrosis, big ole mass looking thing that attenuates like muscle and compresses the cava, medial deviation of ureters)

elevated IgG4 sometimes

dx: MOST SENSITIVE test is IV pyelogram to see trapped ureters

histo: Type I collagen around vessels, hyaline rings around vessels

tx: HD-glucocorticoids x 4-8 wks +/- rituximab/methotrexate/MM if nonresponder to steroids
+ free up ureters if renal failure and wrap ureters in omentum

don’t rly have to do a biopsy

186
Q

normal basal acid secretion

A

<5 mEq

187
Q

GLP2

A

sitmulate mucosal growth & improve absoprtion in short gut

188
Q

bowel function

A

small bowel hours
stoamch 24-48 hours
colon 48-72 hours

189
Q

short bowel

A

<100 cm
or <50cm with ICV.+ colon

190
Q

petersen space

A

defect between mesentery of ROUX and T-mesocolon (MC internal hernia)

191
Q

other spots for internal hernia in RNY

A

jejunojejunostomy defect
petersen (roux meentery & transverse mesocolon)
mesocolic (roux limb posterior to t-colon in retrocolic bypass

192
Q

bx findings in stress gastritis

A

coagulation necrosis and lymphocyte infiltration into lamina propria

193
Q

bx findings in NGT trauma

A

focal mechanical trauma

194
Q

bx findings in H pylori

A

gastric atrophy (early) - intestinal metaplasia (late)

195
Q

borchardt triad

A

gastric volvulus
retching, cannot pass NGT, epigastric pain

196
Q

worse px with volvulus? high M&M?

A

PEH

197
Q

tx gastric volvulus (ass’d with PEH 2, 3 and 4

A

emergent reduction
repair hernia
and do a ?partial Nissen to anchor the stomach
may need resection of anything devitalized

198
Q

antireflux surgery goal intraabdominal esophagus?

A

3 cm

199
Q

NGT placement in perforated ulcer

A

place it. this is what BTK says

200
Q

thal patch

A

> 3cm perforations may need JEJUNAL SEROSAL PATCH instead of omental patch

201
Q

retained antrum syndrome

A

after gastrectomy… constant G cells (ie in duodenum) within alkaline fluid leads to constant gastrin release..

tx: PPI, vagotomy, resection of retained antrum (and check for pNET gastrinoma)

202
Q

MC cause sb bleeding

A

angiodysplasia

203
Q

MC rp tumor

A

LYMPHOMA > LIPOSARCOMA

204
Q

MC mesenteric tumor

A

LIPOSARCOMA … the more central, the more malignant

205
Q

omental cyst

A

1/3 malignant (MC is a met) so just resect
no bx needed

206
Q

secretin D cells

A

increase pancreatic BICARB release, inhibit gastrin release, inhibit HCl release

207
Q

pancreatic polypeptide – END DIGESTION

A

islet in pancreas secretes….

stim by food and digestion

to decrease pancreatic and gallbladder secretions.

208
Q

motilin released in what phase of peristalsis

A

phase III (also erythromycin acts on same receptor)

209
Q

phases of peristalsis

A

resting > accelerating > peristalsis III (MOTILIN) > decelerating

210
Q

peristalsis pain from what nerves

A

sympathetic fibers T5-T10 AFFERENTS

211
Q

what size gastric ulcer may need surgical intervention

A

2 cm

212
Q

duo ulcer MC location

A

ANTERIOR wall D1

213
Q

truncal vagotomy and antrectomy (what kind of recon)

A

should do. RNY.

because less dumping syndrome + less alkaline reflux gastritis compared to BI and BII

214
Q

modified graham

A

close defect first and then place omentum

graham: just put omentum

215
Q

what is intractible ulcer disease

A

MUCOSAL findings (ulcer) (not sx) while on escalating PPI doses for 3 months**

216
Q

MC gastric ulcer location

A

lesser curve (obvi from H pylori first) > NSAID s

217
Q

gastric adenomatous polyp

A

15% risk of cancer
endoscopic resection is tx

218
Q

krukenberg tumor

A

gastric adeno ca met to ovaries

219
Q

virchows nodes

A

gastric adeno to supraclavicular node

220
Q

MC cause of leak after RNY

A

ishcemia

221
Q

tx of distended remannt stomach after RNY

A

G tube

222
Q

where is iron absorbed

A

duo

223
Q
A

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