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Surgery - Upper GI Flashcards

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1
Q

Do you ppx varices w/ sclerotherapy?

A

NO!

Only do after 1st episode bleeding

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2
Q

How do we know an NG tube is in correct place to eval for UGI bleed?

A

Need to get bile back

Know is sampling stomach and duodenum

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3
Q

How long after acid ingestion does fibrosis result?

A

6-13 weeks

Commonly pyloric stricture

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4
Q

How long do you have diabetes to get diabetic gastroparesis?

A

> 10 years

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5
Q

Dx esophageal perforation

A

Contrast (usually H2O soluble) esophogram
- Gastrografin-contrast esophography

Need broad spectrum abx, TPN, and surgical repair

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6
Q

Causes pill esophagitis

A

Can cause esophageal perforation!

Tetracyclines
Aspirin
NSAIDs
Alendronate
KCl
Quinidine
Iron
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7
Q

Young pt, no smoking w/ Chronic fixed, fleshy growth on hard palate

A

Torus palatinus

  • benign bony growth on midline suture of hard palate
  • congenital, usually in younger pts, women, and Asians
  • usually < 2 cm in size and can inc in size during life
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8
Q

Acute bacterial parotitis

A

Dehydrated post op pts and elderly most prone to develop infection

Can avoid w/ fluid hydration + oral hygiene

Usually staph aureus infection

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9
Q

Dx esophageal perforation

A

water soluble contrast

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10
Q

Tx esophageal perforation

A

Surgery - closure of esophagus
Drain mediastinum

Need to do in 6 hrs to prevent development of mediastinitis

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11
Q

Best 1st diagnostic tool for GI Bleed?

A

NGT lavage

UGIB more common than lower GIB

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12
Q

Secretion contents of

  • bile
  • SI
  • saliva
  • gastric juice
  • colon
  • pancreatic
A

Bile + SI
- like LR

Saliva, gastric, colon

  • high K
  • low Na

Pancreatic
- high bicarb

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13
Q

Esophagitis

A

Assoc w/ reflex or infection or lye ingestion

HSV 1 = punched out ulcers

CMV = linear ulcers

Candida = pseudomembrane

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14
Q

Plummer Vinson syndrome

A

Due to Fe deficiency

Dysphagia
Glossitis
Iron deficiency anemia

Increases risk of SCC of esophagus

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15
Q

Barrett’s esophagus

A

Glandular metaplasia

Nonkeratinzed stratified squamous –> columnar epithelium

Due to chronic acid reflux

Assoc w/ esophagitis, esophageal ulcers, increased risk of esophageal cancer

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16
Q

Menetrier’s disease

A

Gastric hypertrophy w/ protein loss, parietal cell atrophy, and increase mucous cells

Precancerous

SUPER hypertrophy of rugae of stomach

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17
Q

Gastric vs duodenal ulcer

A

Gastric

  • GREATER pain w/ meals
  • H. pylori is majority
  • due to decreased mucosal protection against acid
  • increased risk of cancer

Duodenal ulcer

  • DECREASED pain w/ meals
  • 100% have H. pylori
  • Hypertorphy of Brunner’s glands
  • Never malignant
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18
Q

Tx peptic ulcers

A

3x therapy

PPI
Clarithromycin
Amoxicillin (metronidazole if PXN allergy)

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19
Q

Most common serious complication of peptic ulcer disease

A

Hemorrhage

Tx:

  • fluid + blood resuscitation
  • med tx
  • endoscopic intervention

Usually will stop bleeding spontaneously

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20
Q

When do surgery for GERD?

A

Nissen fundoplication for:

Long standing symptomatic disease cannot be controlled by medical means

Intolerant to PPIs

Don’t want to take long term meds

Complications - ulceration, stenosis

Resection for:
Severe Dysplasia (if only on sub-medical therapy; try optimal med therapy if not on it first)
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21
Q

Dx esophageal dysmotility

A

Manometry is definitive

Barium 1st

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22
Q

Esophageal cancer

  • signs
  • types
  • dx
A

Signs:

  • dysphagia for solids –> softs –> liquids
  • wt loss

SCC in smokers
Adenocarcinoma in GERD

High incidence in those w/ corrosive esophagitis

ALWAYS do barium before endoscopy to avoid perforation
Have to do endoscopy and bx for diagnosis

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23
Q

Tx

  • Mallory Weiss tear
  • Boerhaave syndrome
Study These Flashcards
A

MW tear
- endoscopy + photocoagulation

Boerhaave

  • dx w/ gastrografin 1st, then barium if it is negative
  • emergency surgery repair
24
Q

Tx MALToma of stomch

Study These Flashcards
A

Tx h pylori and can reverse it if it is low grade!

25
Esophageal atresia - sx - work up - tx
Sx: - excess salivation after birth - choking spells after 1st feeding - NGT coils in chest Most common type is upper esophagus is blind, fistula between lower esophagus and trachea Workup: - R/o VACTER Tx: - primary surgical repair - if delayed, put in gastrostomy to protect lungs from acid reflux
26
Green vomiting in newborn + double bubble sign What could it be?
Duodenal atresia Annular pancreas Malrotation of intestine (most dangerous and at risk for ischemia)
27
Green vomiting in newborn + multiple air fluid levels on xray - what is it?
Intestinal atresia Usually vascular event in utero
28
Indications for bariatric surgery
BMI > 40 or BMI > 35 + comorbidities
29
N/v and dilated bowel loops s/p bariatric surgery what is the dx?
these symptoms and signs along with X Rays represent bowel obstruction. In a patient with gastric bypass, this is often due to an internal hernia. Retrocolic position of the Roux limb predisposes patients to developing an internal hernia through the transverse mesocolon.
30
Vit deficiency to watch out for s/p gastric bypass
Vit B12 - b/c no stomach to make intrinsic factor to bind
31
The inability to tolerate a diet that has progressed from solids to liquids in an otherwise stable patient s/p gastric bypass is very suggestive of......
a stenosis of the gastrojejunostomy. dx w/ UGI series w/ contrast. Endoscopy can also visualize the stenosis and can also be used to treat the stenosis using balloon dilators.
32
Inability to tolerate a diet after a laparoscopic band suggests
either the band is too tight or has slipped. An UGI series or even plain X Rays can diagnose a slipped band but, if the band is too tight then an UGI series will be needed. Emergent treatment is to decompress the band by removing fluid from the port (band adjustment).
33
Billroth I
Remove pylorus (distal stomach) Proximal stomach - duodenum connectino
34
Billroth II
Connect lower stomach (greater curvature) to jejunum directly side-to-side Resect lower antrum stomach For refractory peptic ulcer disease
35
Alcoholic person + UGI bleed + evidence of cirrohosis S/p resusscuitation w/ fluids, what do you do next?
Endoscopy! Sclerotherapy can contorl hemorrhage in most cases Angiography will r/o arterial hemorrhage but will not show bleeding varices
36
When do you do surgery on sliding esophageal hernia?
Symptomatic + objectively documented esophagitis or stenosis Refulx is not an indication unless progresses to the 2 above Size of hernia is not important
37
Massive hematemesis in children - what is this due to?
Variceal bleeding (almost always) Results from extrahepatic portal V obstruction 2/2 bacterial infection from patent umbilical v during infancy Tx electively for recurrent bleeding episodes. Bleeding usually stops and is self limited
38
Tx Zolinger ellison syndrome
Most will die of mets than primiary Highly selective vagotomy + tumor resection Dx: Gastrin levels If gastrin levels not diagnostic, secretin stim test (usually will decrease gastrin) will confirm ZES
39
Most common presentation of idiopathic retroperitoneal fibrosis
Ureteral obstruction
40
Most reliable objective indicator of GERD
24 hr pH monitoring
41
Assoc sx of esophageal perforation
Chest pain (ASAP) SubQ emphysema (1 hr) Pleural effusion usually on L (immediate or > 6h later) Fever, leukocytosis 2/2 sepsis from mediastinis (>4 hr) Death
42
Dx esophageal perforation
Water-soluble contrast esophogram - Gastrographin Barium is more sensitive but it can be assoc w/ mediastinitis adn peritonitis if there is a tear
43
#1 cause esophageal perforation
Iatrogenic (endoscopy)
44
Person w/ duodenal ulcers Failed med therapy (ppi+ amoxicillin + clarithromycin) and ulcer is getting larger What do you do? How about gastric ulcer?
Surgery Highly selective vagotomy (chice procedure) - fundus and body denervated + antrum and pylorus innveration intact so gastric emptying and mixing can stll happen Truntal vagotomy Pyloroplasty Vagotomy + antrectomy Billroth I partial gastrectomy (no vagotomy)
45
When do you resect gastric ulcers?
If treated medically for 18 weeks and no healing No vagotomy performed
46
What should be done for all gastric ulcers?
biopsied to r/o malignancy
47
Types of gastric ulcers & treatments
I & 2 - low acid output 3& 4 - high acid output 1 - lesser curvature of body of stomach possibly 2/2 to NSAIDs or steroids - tx: antrectomy +/- vagotomy if intractable 2- gastric and duodenal - tx: vagotomy + pylorplasty w/ oversewing of ulcer in duodenal ulcer - tx: vagotomy + gastrojejunostomy if gastric outlet obstruction 3 - pyloric and prepyloric - tx: antrectomy + vagotomy 4 - At GE junction, - tx: partial gastrectomy but NO vagotomy
48
For perforated ulcers, you close most of them but when do you do a vagotomy?
When the person has had the ulcer for a while and managed on meds but the meds have not worked.
49
gastric pH needed to reduce risk of rebleeding
5
50
Where is an actively bleeding ulcer usually?
In posterior duodenum involving gastroduodenal A
51
Tx difference for gastric vs. duodenal ulcers
Need to bx gastric ulcers b/c may have underlying gastric cancer Will excise gastric ulcers rather than oversew Only oversew duodenal ulcers that are new - recurrent ones, will resect and do a vagotomy
52
Tx actively bleeding esophagea varices
Band bleeding esophageal varices w /EGD correct coagulopathy w/ FFP + Plt transfusion Tx w/ IV octreotide to lower portal pressure. Can also use IV vasopressin Continue to bleed... - repeat endoscopy Final steps if still bleeding... portosystemic shunt balloon tamponade Beta blockers may lessen chance of rebleeding
53
Gastric lymphoma tx
Get rid of H pylori! Surgery only if H. pylori eradication doesn't shrink tumor an tumor is stage 1 or 2
54
Dieulafoy's lesion
Often in proximal stomach Abnormally large submucosal A protruding through small solitary mucosal defect
55
#1 ongenital diaphragmatic hernia in infants
Foramen of Bochdalek Also most likely to cause ARDS in infants
56
Tx mallory weiss tear
Usually stops bleeding by itself If not.. Balloon tamponade or endoscopic control of bleeding or Gastrotomy and suture ligation
57
Dumping syndrome tx
1) Dietary modification 2) Octreotide in resistant cases 3) Reconstructive surgery for intractable cases

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