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Cameron Stomach > Stomach_Duodenal_Ulcer > Flashcards

Stomach_Duodenal_Ulcer Flashcards

1
Q

Do PPIs have in vitro activity against H. pylori?

A

Yes.

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2
Q

What % of patients with duodenal ulcers have an H. pylori infection and/or recent NSAIDs/ASA use?

A

90%

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3
Q

The majority of duodenal ulcers are located in what segment?

A

First portion of the duodenum (90%)

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4
Q

What % of patients newly diagnosed with a duodenal ulcer will have Zollinger-Ellison syndrome?

A

1-2%

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5
Q

What recreational/illicit drug use is associated with duodenal ulcers?

A

Cocaine use.

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6
Q

What is the medical treatment for duodenal ulcers?

A

Eradication of H. pylori, abstention from NSAIDs/ASA, acid suppression (e.g. PPIs, H2 blockers)

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7
Q

If NSAIDs/ASA are stopped and H pylori is treated, when can acid suppressing agents be stopped?

A

2 months after elimination of H. pylori,with low-likelihood of recurrent ulcer

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8
Q

When should PPIs be continued indefinitely in patients treated for duodenal ulcer?

A

Those with high risk: Cannot stop NSAIDS, ASA, steroids or anticoagulants.

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9
Q

What are the indications for duodenal ulcer disease surgery?

A

Bleeding, perforation, obstruction and intractable ulcer disease.

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10
Q

What are the surgical options for duodenal ulcer disease?

A

Simple closure/oversewing, highly selective vagotomy, vagotomy + drainage (pyloroplasty/gastrojejunostomy), vagotomy + antrectomy.

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11
Q

What are the risks associated with truncal vagotomy?

A

Dumping, diarrhea and gastroparesis

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12
Q

What percentage of patients who undergo truncal vagotomy suffer from the associated complications?

A

10% will experience dumping, diarrhea and gastroparesis

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13
Q

Is a bleeding or perforated duodenal ulcer more likely to be fatal?

A

Perforation.

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14
Q

What is the definitive ulcer surgery for perforated duodenal ulcer?

A

Highly selective vagotomy or truncal vagotomy and drainage.

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15
Q

When is definitive ulcer surgery indicated for a perforated duodenal ucler?

A

Patients who have clearly failed medical management and well-documented chronic disease.

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16
Q

What is the Taylor procedure?

A

Posterior truncal vagotomy, and either anterior seromyotomy or anterior parietal cell vagotomy

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17
Q

What is an anterior parietal cell vagotomy?

A

AKA highly-selective vagotomy: denervatio of the fundus and body of the stomach only (parietal cell containing areas), sparing thevagal hepatic and celiac branches.

18
Q

What is a selective vagotomy?

A

Anterior and posterior division of the nerves of Latarjet (only after the celiac and hepatic vagal branches have come off).

19
Q

When is a diet started for patients who have undergone surgery for perforated duodenal ulcer?

A

POD2 or 3 after an water-soluble upper GI, followed by a barium study.

20
Q

What is the purpose of imaging studies prior to starting a diet after duodenal ulcer surgery?

A

Confirm no leak and adequate gatric emptying.

21
Q

Describe non-acid suppressing operations to treat duodenal ulcer perforations.

A

Serosal jejunal patching, omental patch/plug, triple intubation: gastrostomy, feeding jejunostomy and retrograde jejunostmy for duodenal decompression.

22
Q

What are the surgical options to treat bleeding duodenal ulcers?

A

Simple oversewing of ulcer, oversewing w/ vagotomy + drainage, oversewing w/ vagotomy + antrectomy

23
Q

If bleeding from a duodenal ulcer is vigorus, what maneuver may you do to manually control the bleeding?

A

Kocher maneuver

24
Q

When bleeding from a duodenal ulcer is postbulbar, what structure should be avoided when oversewing?

A

The commond bile duct.

25
Q

What is the postbulbar portion of the duodenum?

A

Distal to the duodenal bulb. Duodenal bulb: between the pylorus and ends at the neck of the gallbladder (within 5 cm distal to stomach).

26
Q

What is the duodenal bulb?

A

Duodenal bulb: between the pylorus and ends at the neck of the gallbladder (within 5 cm distal to stomach).

27
Q

Is a duodenotomy for a bleeding ulcer closed in 1 or 2 layers?

A

2

28
Q

What is the Heineke-Mikulicz pyloroplasty?

A

Reconstruction of the pyloric channel with a longitudinal incision of the pylorus, and suturing the incision transversely

29
Q

Wha is the Finney pyloroplasty?

A

Full-thickness incision from duodenum,-> pylorus, and into the gastric antrum, with a C-shaped closure to provide a wider opening between stomach and duodenum.

30
Q

Is the rebleeding rate greater for vagotomy + drainage or antrectomy for a bleeding duodenal ulcer?

A

Vagotomy + drainage. Note the in-hospital mortality is the same for both procedures.

31
Q

If a patient rebleeds after a vagotomy + drainage for a bleeding duodenal ulcer what is the next operative step?

A

Antrectomy

32
Q

What are physical exam findings for gastric outlet obstruction?

A

Succussion splash and/or distended epigastrium

33
Q

What are the three treatment options for chronic gastric outlet obstruction?

A
  1. Endoscopic balloon dilatation.
  2. Lap or open HSV and gastrojejunostomy.
  3. Vagotomy and antrectomy.
34
Q

What is the main disadvantage for using endoscopy balloon dilatation and lap HSV and gastrojejunostomy for treatment of GOO 2/2 duodenal obstruction?

A

Less of an ability to diagnose malignancy

35
Q

What is the advantage of a gastrojejunostomy over a pyloroplasty for intractable duodenal ulcer disease?

A

The former may be reversed if intolerable dumping develops.

36
Q

Define a giant duodenal ulcer

A

Duodenal ulcer > 2 cm

37
Q

What surgical approach should be taken with a giant duodenal ulcer?

A

A definitive ulcer operation in addition to repair of a perforation if present shuld be considered (vagotomy and antrectomy)

38
Q

What approach should be taken if an ulcer has destroyed the posterior duodenal wall?

A

The anterior edge of the open duodenum should be sewed to the proximal or distal lip of the ulcer with interrupted suture. Test the stump for leaks. Cover with omentum.

39
Q

How should repair of a duodenal stump be tested?

A

Retrograde placement of an NGT and inflate the stump with air.

40
Q

How should the duodenal stump be drained?

A

Via a retrograde tube through the proximal duodenum, lateral duodenostomy or end duodenostomy (the latter two not favored). Roux limb anastomosed to the end of the duodenum could be done.

41
Q

Other than ulcer repair/drainage/decompression surgery, what other procedure should be considered in pts w/ a difficult duodenal stump?

A

Gastrostomy and feeding jejunostomy.

Cameron Stomach (8 decks)

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