Upper GI Surgery

Question 1

How do you manage dysphagia?

Answer 1

Barium swallow and esophagoscopy with biopsy

DDx achalasia, Zenker diverticulum, esophageal cancers, strictures

Question 2

What are the types of esophageal cancers?

Answer 2

SCC in upper 2/3 due to cigarettes and EtOH, adenocarcinoma in the lower 1/3 due to Barrett’s
Sx: progressive dysphagia and weight loss

Question 3

How do you manage esophageal cancer?

Answer 3

Esophagoscopy and biopsy, then staging via endoscopic ultrasound and CT scan, then specific tx

Question 4

How do you treat esophageal cancer?

Answer 4

Upper 1/3: chemo and radiation only
Middle 1/3: chemo and radiation to shrink the tumor, then esophagectomy
Lower 1/3: esophagectomy and proximal gastrectomy
Never operate on stage IV cancer

Question 5

What is Zenker diverticulum?

Answer 5

Pulsion diverticulum that develops at upper esophagus due to abnormal coordination of cricopharyngeal constriction; Sx dysphagia, regurgitation, and bad breath
Manage by barium swallow, cricopharyngeus myotomy

Question 6

What is a traction diverticulum?

Answer 6

Diverticulum at the middle esophagus due to LN traction, indicates cancer

Question 7

What are the esophageal motility disorders?

Answer 7

Achalasia: hypertonic and non-relaxing LES with poorly relaxing esophagus, sx of dysphagia of lipids>solids
Nutcracker esophagus: painful swallowing due to high amplitude action potentials, tx with nifedipine
Diffuse esophageal spasms: uncoordinated third degree peristalsis, tx medically
hypertensive LES: high LES pressure at baseline but relaxes with swallow, tx medically

Question 8

How do you manage achalasia?

Answer 8

Dx bird’s beak on barium swallow and increase LES pressure on manometry, tx with Heller myotomy

Question 9

What is on the differential for acute epigastric pain?

Answer 9

DDx acute pancreatitis, GERD, PUD (gastric ulcers or duodenal ulcers), cholelithiasis, gastroenteritis
gallstones or alcoholism = acute pancreatitis
NSAIDs or steroid use = PUD

Question 10

How do you manage esophageal varices?

Answer 10

Present as UGIB due to portal HTN, often alongside coagulopathy (liver failure)
-management: band the bleeding varices, correct any coagulopathy, IV octreotide to lower portal pressure –> if bleeding continues, repeat endoscopic banding –> if bleeding continues, TIPS or gastric balloon tamponade
Follow up with beta blockers to lessen chance of rebleeding

Question 11

How does Mallory-Weiss syndrome present?

Answer 11

UGIB due to retching lacerating the lower esophagus, bleeding usually stops spontaneously

Question 12

How does Boerhaave syndrome present?

Answer 12

Presents as epigastric pain and fever due to retching perforating the esophagus
Dx contrast swallow, tx emergent surgical repair

Question 13

How do you treat GERD?

Answer 13

PPIs – if persistent after six weeks, do EGD with biopsy

Question 14

How do you treat esophagitis?

Answer 14

Multiple, nonulcerating erosions in the stomach; mild to moderate esophagitis –> PPIs for 8-12 weeks, severe esophagitis –> lap Nissen, uncontrollable esophagitis –> subtotal gastrectomy

Question 15

How do you treat Barrett esophagus?

Answer 15

intestinal metaplasia of esophageal epithelium
no dysplasia –> tx PPIs or lap Nissen
low grade dysplasia –> tx lap Nissen + annual surveillance
high grade dysplasia –> esophagectomy

Question 16

What is Lap Nissen dundoplicaiton?

Answer 16

Wraps fundus of stomach around LES to keep it in the abdominal cavity
Contraindicated in morbidly obese patients (do gastric bypass instead)

Question 17

What are the types of hiatal herias?

Answer 17

Hernia from abdominal cavity, through diaphragm, into chest cavity
Type 1: sliding hernia, risk of reflux esophagitis, Tx PPIs
Type 2: paraesophageal hernia, risk of incarceration/strangulation, surgical repair as tx
Type 3: presence of both types 1 + 2, tx surgical repair

Question 18

What are the indications for PUD surgery?

Answer 18

Intractability, perforation, obstruction, bleeding

Question 19

Duodenal ulcers

Answer 19

Caused by increased acid secretion; most commonly in 1st part of the duodenum, DU in 2nd-4th part indicates Zollinger-Ellison syndrome (gastrinoma)
types: posterior ulcers bleed due to gastroduodenal artery, anterior ulcers perforate
Tx: triple therapy– if ulcer persists, surgery is indicated, also get serum gastrin levels to rule out ZE syndrome

Question 20

What do you see on CXR if there is a DU?

Answer 20

free air under the diaphragm

Question 21

How do you treat a perforated DU?

Answer 21

Use omentum to patch the ulcer, then stop acid with PPIs or HSV
If with sepsis, also give IV abx
if bleeding due to posterior ulceration into GDA, oversew the ulcer

Question 22

Gastric ulcers

Answer 22

Caused by decreased mucosal protection
Type 1: lesser curvature at incisure
Type 2: duodenum and stomach
Type 3: pylorus
Type 4: GE junction
Tx: PPIs, if ulcer persists after six weeks, do endoscopy and multiple marginal biopsies for possibility of gastric cancer. If persists after 18 weeks, surgery is indicated
If the GU is bleeding, then tx is excision

Question 23

What is GU surgery?

Answer 23

Wedge resection or distal gastrectomy (due to possibility of cancer), TV +P for types II and III due to increased acid production

Question 24

What are the types of gastric cancers?

Answer 24

Gastric adenocarcinoma: often spreads to left supraclavicular node and ovaries
Linitis plastica: infiltrating carcinoma with desmoplastic reaction causing stomach to look fixed and rigid
Gastric lymphoma
GIST: any soft tissue tumor of stomach

Question 25

How do you treat the gastric cancers?

Answer 25

Adenocarcinoma: if proximal, total gastrectomy
if distal, distal gastrectomy with anastomosis, take out D1 LN at lesser curvature

Linitis plastica: total gastrectomy with splenectomy

Gastric lymphoma: determine cancer stage, partial thickness–> radiation, full thickness –> surgical resection

GIST: wedge resection with 1 cm negative margins

Question 26

How do gastric varices present?

Answer 26

UGIB due to portal HTN

Tx uncontrollable bleeding with TIPS or splenectomy instead of banding

Question 27

What are the four complications of gastric ulcers?

Answer 27

1) Bleeding
2) Perforation
3) Gastro-pancreatic fistula
4) Gastric dysmotility

Question 28

When do you worry about a gastric ulcer that does not go away after six weeks?

Answer 28

Gastric cancer

Question 29

What causes duodenal ulcers?

Answer 29

H. pylori

Question 30

Which ulcer type gets better with food?

Answer 30

Duodenal ulcer

Question 31

What are the types of ulcers?

Answer 31

Type II: lesser curvature of the stomach
Type IV: diffuse, due to NSAIDs
If anywhere else, then you are concerned for a malignant process

Question 32

What is a Sister Mary Joseph node?

Answer 32

Metastatic node from abdominal cancer at the umbilicus

Question 33

What is Vircov’s node?

Answer 33

Visceral cancer that has crossed the diaphragm.

Will also see acanthosis nigricans and Bloomer’s node (metastasis in the pouch of Douglas)

Question 34

What are the types of gastric cancer?

Answer 34

1) adenocarcinoma
2) intestinal type
3) superficial spreading
4) MALToma (associated with H. pylori)
5) GIST cell tumor
6) Lymphoma

Question 35

How do you treat duodenal cancer?

Answer 35

Duodenum, head of the pancreas, and extrahepatic biliary tree
Whipple procedure