Upper GI Tract Disorders

Question 0

34-year-old man presents with acute onset of sharp epigastric pain. What routine screening studies are appropriate?

Answer 0

CBC, urinalysis, amylase, lipase, liver function tests, obstructive series, chest x-ray

Question 1

Differential diagnosis for epigastric pain.

Answer 1

• pancreatitis
• PUD
• Gastric ulcer
• gastroenteritis
• GERD
• Cholelithiasis

Question 2

34-year-old man presents with acute onset sharp epigastric pain. Moderate tenderness in the epigastrium. What is the next step? What if the next step fails question

Answer 2

Abdominal ultrasound to rule out gallstones. If negative empirical treatment course with an H2 blocker or PPI treat Gerd, ulcer, gastritis

Upper G.I. endoscopy to establish a diagnosis biopsies to rule out any malignancies and to detect H. Pylori

Question 3

GERD which is symptomatic even with maximal therapy. Next step in management

Answer 3

EGD with biopsy and esophageal manometry -need to demonstrate in tact esophageal peristalsis before surgery

Question 4

What percentage of patients with GERD have a hiatal hernia?

Answer 4

80%

Question 5

How frequently does mild to moderate esophagitis resolve with maximal medical therapy?

Answer 5

Responds to 8–12 weeks of treatment with proton pump inhibitors.
Complete remission in 85% of patients

Question 6

Treatment for severe esophagitis, especially erosive esophagitis?

Answer 6

Requires an anti-reflex procedure – fundoplication

Question 7

Frequency of Barrett’s esophagitis in patients with chronic gastroesophageal reflux disease?

Answer 7

10% – 15%

Question 8

How often should you biopsy with a barrett esophagus?

Answer 8

Surveillance endoscopy and biopsies every 18–24 months to determine if a Barrett’s esophagus progresses to dysplasia

Question 9

Next step if biopsy of distal esophagus shows barrett esophagus with severe dysplasia

Answer 9

High risk of occult adenocarcinoma in the distal esophagus. Esophageal resection is necessary.

Question 10

Rx for type I hiatal hernia?

Answer 10

Sliding hiatal hernia – treatment for GERD, without surgery

Question 11

What is a type II hiatal hernia?

Answer 11

A portion of the stomach herniates into the chest, but the GE junction remains in the normal location. Extremely dangerous because entire stomach can necrose

Question 12

Treatment for a type II hernia?

Answer 12

Surgical repair

Question 13

Type I hernia

Answer 13

sliding hiatal hernia

Question 14

Type II hiatal hernia

Answer 14

Paraesophageal hiatal hernia

Question 15

Rx for uncomplicated PUD if medical therapy has failed?

Answer 15

Highly selective vagotomy (HSV) is procedure of choice but truncal vagotomy and pyloroplasty may be used.
Measure serum gastrin levels to rule out Zollinger-Ellison syndrome

Question 16

Biopsy indicating infiltrating gastric carcinoma. What is the prognosis?

Answer 16

-Intestinal types – form glands more favorable prognosis

Diffuse form – extend widely in submucosa, worse prognosis

Question 17

Biopsy indicating infiltrating gastric carcinoma and wall of stomach that appears fixed and rigid?

Answer 17

Diffusely infiltrating gastric carcinoma is termed linitis plastica - or prognosis. Involves all layers of stomach wall.

Question 18

Treatment for linitis plastica?

Answer 18

Total gastrectomy with splenectomy

Question 19

Biopsy indicating gastric carcinoma at the gastroesophageal junction. Incidence? Prognosis? What is the recommendation?

Answer 19

40% of gastric adenocarcinomas involve the proximal stomach
prognosis is less favorable than those in the antrum
Gastric resection at least 6 cm distally beyond tumor

Question 20

Free air under the diaphragm

Answer 20

Sign of perforation

Question 21

Patient treated for perforation in the OR becomes hypotensive

Answer 21

Presumably secondary to sepsis. Complete the operation as quickly as possible and stabilize in ICU – IV antibiotics and omeprazole

Question 22

Multiple non-ulcerating erosions in the stomach

Answer 22

Gastritis

Question 23

Multiple linear erosions in the gastric mucosa at the GE junction

Answer 23

Mallory-Weiss syndrome - bleeding often stops spontaneously

Question 24

Patient with cirrhosis actively bleeding esophageal varices. What measures would you take to control the bleeding?

Answer 24

INITIAL
-band the bleeding esophageal varices
-Correct the coagulopathy: high PT with FFP, thrombocytopenia with platelet transfusion
-IV OCTREOTIDE - to lower portal pressure
IV vasopressin - coronary vasoconstriction as side effect.

Repeat endoscopy

TIPS procedure

Question 25

What is the treatment for a sigmoid volvulus?

Answer 25

sigmoid colectomy with diverting colostomy or resection with primary anastomo­sis, depending on the preoperative condition of the patient

Question 26

Treatment for a Cecal volvulus?

Answer 26

Urgent surgical treatment: detorsion alone, cecopexy, or right colectomy

Question 27

Treatment for ogilvie syndrome

Answer 27

the colon diameter exceeds 11-12 cm endoscopic decompression is indicated.
Many surgeons also attempt a brief trial of neostigmine, a parasympatholytic agent, which may increase colonic tone and counteract the dilation. If the neostigmine is unsuccessful, surgical decompression of the cecum or a right colectomy is necessary.

Question 28

patient complains of pain and drainage in his sacrococcygeal area of the lower back. You examine him and find an abscess in that location. What management is appropriate?

Answer 28

This condition is a pilonidal abscess, which is an infection in a hair-containing sinus in the sacrococcygeal area. Treatment involves unroofing the abscess, removing all hair, and leaving the wound open to heal by secondary intention.