Flashcards in 28-30 GI Hormones, Esophagus, Stomach Deck (162):
What are the 2 target cells of Gastrin?
parietal cells and chief cells
What 3 things are increased as a result of Gastrin?
HCI, intrinsic factor and pepsinogen
Somatostatin is produced by what cells and where?
D cells in the antrum
What stimulates the secretion of somatostatin?
acid in duodenum
What is somatostatin also called?
the great inhibitor
What drug can be used to decrease pancreatic fistula output?
What cells produce gastric inhibitory peptide and where?
K cells in duodenum
What are the 2 target cells of gastric inhibitory peptide? and response stimulated?
parietal cells of stomach and beta cells of pancreas
decreases HCl secretion and pepsin; increases insulin release
What cells produce CCK and where?
I cells of duodenum and jejunum
What cells produce secretin and where?
S cells in duodenum
What is the response caused by secretion of secretin?
increased pancreatic HCO3-, increased bile flow, inhibits gastrin release (this is reversed in pts with gastrinoma)
What cells in the pancreas release insulin? and glucagon?
beta cells, alpha cells
What cells produce pancreatic polypeptide? and what is the response?
islet cells in pancreas
decreases pancreatic and gallbladder secretion
Released from terminal ileum following a fatty meal → inhibits acid secretion and stomach contraction; inhibits gallbladder contraction and pancreatic secretion
What is the time from for recovery of small bowel? stomach? large bowel?
Small bowel 24 hours
Stomach 48 hours
Large bowel 3–5 days
What are the layers of the esophagus?
stratified squamous epithelium (mucosa), circular inner muscle layer, outer longitudinal muscle layer; no serosa
What is the blood supply of the cervical esophagus? and abdominal esophagus?
Cervical esophagus – supplied by the inferior thyroid artery
Abdominal esophagus – supplied by the left gastric artery and inferior phrenic arteries
Which direction does the lymphatics of the esophagus drain?
upper 2/3 drains cephalad, lower 1/3 caudad
What kind of muscle is in the upper esophagus? lower esophagus?
striated muscle, smooth muscle
Right vagus nerve – travels on ____ portion of stomach as it exits chest; becomes ____ plexus; also has the criminal nerve of ___ → can cause persistently high acid levels postoperatively if left undivided
posterior, celiac, Grassi
Left vagus nerve – travels on ____ portion of stomach; goes to liver and biliary tree
The upper esophageal sphincter is how far from the incisors? and lower?
15 cm, 40 cm
What is the most common site of esophageal perforation (usually occurs with EGD)?
What muscle comprises the upper esophageal sphincter and prevents air swallowing?
What are the 3 anatomic areas of narrowing of the esophagus?
compression by the left mainstem bronchus and aortic arch,
What is the surgical approach to the cervical esophagus? upper 2/3 thoracic? Lower 1/3 thoracic?
Cervical esophagus – left
Upper ⅔ thoracic – right (avoids the aorta)
Lower ⅓ thoracic – left (left-sided course in this region)
What is the cause in primary esophageal dysfunction? secondary?
unknown in primary
secondary includes systemic disease, gastroesophageal reflux disease (GERD; most common), scleroderma, polymyositis
What is the diagnostic procedure of choice for dysphagia and odynophagia?
barium swallow (better at picking up masses)
What is the usual cause of cervical esophageal dysphagia?
What is the 3 parts of tx for plummer-vinson syndrome?
dilation, Fe, screen for oral CA
What can occur between the cripharyngeus and pharyngeal constrictors?
What is the tx for Zenker's diverticulum?
cricopharyngeal myotomy; Zenker's itself can either be resected or suspended
What do you get on POD #1 after a cricopharyngeal myotomy for Zenker's?
How is a traction diverticulum different from Zenker's?
Zenker's is a false diverticulum and lies posterior; traction is a true diverticulum is usually lateral in the mid esophagus
What is the tx for a traction diverticulum of the esophagus?
excision and primary closure; may need palliative therapy if due to invasive CA
What is caused by failure of peristalsis and lack of LES relaxation after food bolus, and is secondary to neuronal degeneration in muscle wall?
What is the medical tx for achalasia (2)? what is next step?
LES dilation (effective in 60%)
What is the next step in tx of achalasia if CCB, nitrates and LES dilation fail?
What infection can produce similar sx to achalasia?
Chest pain; other sx similar to achalasia. May have psych history, normal LES tone, strong unorganized contractions.
Diffuse esophageal spasm
What are 4 types of tx for diffuse esophageal spasm?
CCB, nitrates, antispasmotics, Heller myotomy
Causes dysphagia, loss of LES tone; most have strictures, fibrous replacement of smooth muscle ■ Tx: esophagectomy; Nissen may be effective in some
GERD sx with bloating suggests what?
aerophagia and delayed gastric emptying
What is the best test for GERD?
What is the surgical tx for GERD?
The key maneuver in Nissen is identifcation of what?
What is name of the approach through the chest in a Nissen?
During a Nissen, when not enough esophagus exists to pull down into abdomen, can staple along stomach and create a “new” esophagus. What is this called?
Name the type of hiatal hernia:
Sliding hernia from dilation of hiatus (most common); often associated with GERD
Name the type of hiatal hernia:
Paraesophageal; hole in the diaphragm alongside esophagus, normal GE junction.
What is a Type III hiatal hernia? and type IV?
Type III – combined ■ Type IV – entire stomach in the chest plus another organ (i.e., colon, spleen)
Almost all pts with Schatzki's ring have an associated ___
sliding hiatal hernia
What is the tx for Schatzki's ring?
dilatation of the ring usually sufficient; may need antireflux procedure
What is the transformation in pts with Barrett's esophagus?
squamous metaplasia to columnar epithilium
Pts with Barrett's esophagus are at 50x increased risk for what?
Severe Barrett's dysplasia is an indication for what?
Uncomplicated Barrett's can be treated like GERD with PPI or Nissen and surgery will decrease esphagitis and further metaplasia but it will not prevent what?
malignancy or cause regression of the columnar lining
Pts with Barrett's esophagus who get a Nissen still need careful lifetime follow up with what?
Esophageal tumors are almost always malignant. How does it spread?
submucosal lymphatic channels
What is the best test for unresctablity in esophageal CA?
What is the #1 esophageal CA? What type occurs most often in the upper 2/3?
Squamous cell carcinoma
Supraclavicular nodes in esophageal CA indicate what?
Distant metastases with esophageal CA is a contraindication to what? what is the survival?
esophagectomy, < 12 mos
What is the mortality from surgery in esophagectomy for CA? and what percentage is it curative?
What is the primary blood supply to stomach after replacing esophagus in esphagectomy?
right gastroepiploic artery (have to divide left gastric and short gastrics)
What is the name of the type of esophagectomy with an abdominal incision and right thoracotomy -> exposes all of the esophagus; intrathoracic anasomsis
What type of esophagectomy may be choice in young pts with benign disease when you want to preserve gastric function.
What do you need after esophagectomy on post op day 7?
contrast study to rule out leak
Name two chemo agents that can be used with esophageal CA for node positive disease or use preop to shrink tumors?
5FU and cisplatin
In esophageal CA with malignant fistulas, most die within 3 months due to what?
What is the most common benign tumor of the esophagus?
Diagnosis of Leiomyoma is esophogram, endoscopy to rule out CA. Why don't you bx?
can form scar and make subsequent resection difficult
Tx for Leiomyoma of the esophagus is excision via thoractomy. What are the 2 indications?
>5 cm or sx
Caustic esophageal injury:
no, no, no
What is first step in dx in caustic esophageal injury? then what?
CXR and AXR to look for free air,
endoscopy to assess lesion (but not with suspected perforation)
What is the most common cause of esophageal perforation?
What is the most common site of esophageal perforation?
How to dx esophageal perforation?
gastrograffin swallow followed by barium swallow
What is the tx for esophageal perforation that is contained, self-draining and no systemic effects?
Conservative: IVF, NPO, spit
What type of flap can be used with repair of esophageal perforation to help the area heal?
intercostal muscle pedicle flap
What is Hartmann's sign?
mediastinal crunching on ascultation
How to dx Boerhaave's syndrome?
What is the stomach transit time?
Where does peristalsis occur in the stomach?
only in the distal stomach
What are the branches of the Celiac trunk?
left gastric, common hepatic, splenic
Left gastroepiploic and short gastrics are branches of what artery?
What is the blood supply of the greater curvature of the stomach?
right and left gastroepiploics, short gastrics
What is the blood supply of the lesser curvature of the stomach?
right and left gastrics
The right gastric is a branch of what artery?
What is the blood supply of the pylorus?
What is the mucosa of the stomach lined with?
simple columnar epithelium
What is the first enzyme in proteolysis and what cell secretes it?
Pepsinogen, secreted by chief cells
What do the parietal cells secrete?
H+ and intrinsic factor
What 2 things do Brunner's glands in the duodenum secrete?
pepsinogen and alkaline mucus
Antrectomy with gastroduodenal anastomosis?
Antrectomy with gastrojejunal anastomosis?
____ ulcer is a vascular malformation in the stomach
____ disease is mucous cell hyperplasia, increased rugal folds of the stomach.
What is the tx for gastric volvulus?
reductiona and Nissen
Associated with type II (paraesophageal) hernia ■ Nausea without vomiting; severe pain.
Where is the tear usually located in a Mallory-Weiss tear?
near lesser curvature of the stomach near GE junction
What is the result of a vagotomy
vagal denervation all forms increase liquid emptying -> vagally mediated receptive relaxation is removed, results in increased gastric pressure that accelerates liquid emptying
In complete vagotomy (truncal or selective) there is decreased emptying of solids. In highly selective vagotomy there is normal emptying of solids. Addition of what procedure to either results in increased solid emptying?
What is the most common problem following vagotomy (30-50%)?
Upper GI bleed and having trouble localizing source with EGD. What can be done next?
tagged RBC scan
What is the biggest risk factor for rebleeding of an upper GI bleed at the time of EGD?
spurting blood vessel
In a pt with liver failure, what is the most likely source of an upper GI bleed?
What is the tx for a bleeding esophageal varices?
EGD with sclerotherapy or TIPS, not OR
What location of duodenal ulcers usually perforate? what location bleed from GDA?
anterior ulcers perforate, posterior ulcers bleed from GDA
Describe the incision and closure of a Heineke-Mikulicz pyloroplasty.
longitudunal incision of the plyloric sphincter followed by a transverse closure
What is the most frequent complication of duodenal ulcers?
The 1st surgical option for bleeding duodenal ulcer is duodenstomy and what? what if the pt has been on PPI therapy?
truncal vagotomy and pyloroplasty
With GDA ligation for bleeding duodenal ulcer, it is important to avoid hitting what structure?
common bile duct
What is the initial treatment of choice for obstruction due to duodenal ulcer?
Pt on H-pump inhibitor develops a perforated duodenal ulcer. What is the best surgical option? what if they were not on H-pump inhibitor?
Graham patch and highly selective vagotomy; just do Graham patch and place on omeprazole
What is the test for Zollinger-Ellison Syndrome?
Secretin test results in high gastrin level
In Zollinger-Ellison syndrome, what size tumors can be enucleated?
What is the most common location for gastric ulcers? and the most common cause?
lesser curvature; decreased mucosal defense (normal acid secretion)
Hemorrhage is associated with higher mortality in duodenal or gastric ulcers?
What location in the stomach is the bx for H. pylori taken?
List the locations of gastric ulcers types I-V
Type I - lesser curve along body of stomach
Type II - 2 ulcers, lesser curve and duodenal
Type III - prepyloric
Type IV - lesser curve high along cardia of stomach
Type V - associated with NSAIDs
What is the timing after event for stress gastritis?
3-10 days after event
Chronic gastritis has types A and B what is their location and what are they associated with?
Type A (fundus) – associated with pernicious anemia, autoimmune disease
Type B (antral) – associated with H. pylori
Where are 40% of gastric cancers located?
What is the difference in the pain with gastric cancer vs gastric ulcer?
gastric ulcer pain is relived by eating but recurs 30 min later.
What blood type is a risk factor for gastric cancer?
What is Krukenberg tumor?
gastric cancer with mets to ovaries
What is Virchow's nodes?
gastric cancer with metastases to supraclavicular nodes
What size margins in subtotal gastrectomy for gastric cancer?
What is diffuse gastric cancer called?
What is the surgical tx for linitis plastica?
In palliation for gastric cancer, proximal obstruction can be treated with what? and distal?
proximal can be stented, distal lesions can be bypassed with gastrojejunostomy
What is the most common benign gastric neoplasm? aka?
gastric leiomyomas, also called gist tumors
What is the chemotherapy agent and MOA for gastric leiomyomas?
Gleevec (tyrosine kinase inhibitor)
What is the proto-oncogene are most gastric leiomyomas positive for?
What route does gastric leiomyosarcoma spread?
What is the tx for mucosa associated lymphoid tissue lymphoma (MALT lymphoma)? and if it does not regress?
Triple therapy abx for H. pylori; CHOP
What are the surgical eligibility criteria for bariatric surgery?
BMI >40 kg or BMI >35 kg with coexisting comorbiditiies
What is the medical and surgical tx for dumping syndrome?
octreotide may be effective. Surgery is rarely needed but includes converting a billroth I or II to a roux-en-Y gastrojejunostomy. Or increasing the gastric reserve with a jejunal pouch or increasing emptying type with a reversed jejunal loop
What is the dietary tx for dumping syndrome?
small, low-fat, low-carb, increased-protein meals; no liquids with meals; no lying down after meals
What are two surgical options for treating dumping syndrome after gastrectomy?
conversion of billroth I or billroth II to Roux-en-Y gastrojejunostomy
Operations to increase gastric reservoir (jejunal pouch) or increase emptying time (reversed jejunal loop)
After a gastrectomy there is postprandial epigastric pain associated with N/V; pain not relived with vomiting. Evidence of bile reflux into stomach and histologic evidence of gastritis. Dx?
Alkaline reflux gastritis
What are 3 medical options for the tx of alkaline reflux gastritis after gastrectomy?
H2 blockers, cholestyramine, metoclopramide
What is the surgical option for treating alkaline reflux gastritis after gastrectomy?
Conversion of Billroth I or Billroth II to Roux-en-Y gastrojejunostomy with afferent limb 60 cm distal to original gastrojejunostomy
In roux-en-y which limb is the roux limb? Which is the afferent limb?
The roux limb goes from the gastrojejunostomy to the jejunojenuostomy. The afferent limb is the portion of duodenum and jejunum feeding the jejunojenunostomy.
What is the cause of roux stasis?
stasis of chyme in Roux limb due to loss of jejunal motility.
How do you dx Roux stasis?
EGD, emptying studies
What are 2 treatment options for Roux stasis?
shorten Roux limb to 40 cm
What is caused by delayed gastric emptying after vagotomy?
chronic gastric atony
What is the surgical treatment for chronic gastric atony after gastrecomy?
near total gastrectomy with Roux-en-Y
What is the surgical option for small gastric remnant and early satiety after gastrectomy?
jejunal pouch reconstruction
After Billroth II or Roux-en-Y, symptoms include pain, diarrhea, malabsorption, B12 deficiency, steatorrhea. Caused by bacterial overgrowth and stasis in affarent limb.
What is the medical and surgical treatment options for blind-loop syndrome?
tetracycline, Flagyl, metoclopramide
reanastomosis with shorter (40 cm) afferent limb
Whiteout on CXR:
Midline shift toward whiteout is most likely collapse. Needs what tx?
No shift - do CT to figure it out
Midline shift away from whiteout likely effusion. Needs what tx?
collapse needs bronchoscopy to remove plug
effusion needs chest tube
Bronchiectasis is acquired from infection, tumor or what other condition?
Noncaseating granulomas are seen in what lung condition?
What is the pleural fluid protein to serum ratio seen in an exudate? and the pleural fluid LDH to serum ratio seen in exudate?
Recurrent pleural effusions can be treated with what?
mechanical pleurodesis (talc pleurodesis for malignant pleural effusions)
Airway fires are usually associated with the laser. What is the tx?
stop gas flow, remove ET tube, reintubate for 24 hrs; bronchoscopy
AVMs, connections between the pulmonary arteries and pulmonary veins; usually occurs in the lower lobes and in pts with what disease?
What is the tx for AVMs in the lung?