28-30 GI Hormones, Esophagus, Stomach Flashcards Preview

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Flashcards in 28-30 GI Hormones, Esophagus, Stomach Deck (162):
1

What are the 2 target cells of Gastrin?

parietal cells and chief cells

2

What 3 things are increased as a result of Gastrin?

HCI, intrinsic factor and pepsinogen

3

Somatostatin is produced by what cells and where?

D cells in the antrum

4

What stimulates the secretion of somatostatin?

acid in duodenum

5

What is somatostatin also called?

the great inhibitor

6

What drug can be used to decrease pancreatic fistula output?

octreotide

7

What cells produce gastric inhibitory peptide and where?

K cells in duodenum

8

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

9

What cells produce CCK and where?

I cells of duodenum and jejunum

10

What cells produce secretin and where?

S cells in duodenum

11

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)

12

What cells in the pancreas release insulin? and glucagon?

beta cells, alpha cells

13

What cells produce pancreatic polypeptide? and what is the response?

islet cells in pancreas

decreases pancreatic and gallbladder secretion

14

Released from terminal ileum following a fatty meal → inhibits acid secretion and stomach contraction; inhibits gallbladder contraction and pancreatic secretion

Peptide YY

15

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

16

What are the layers of the esophagus?

stratified squamous epithelium (mucosa), circular inner muscle layer, outer longitudinal muscle layer; no serosa

17

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

18

Which direction does the lymphatics of the esophagus drain?

upper 2/3 drains cephalad, lower 1/3 caudad

19

What kind of muscle is in the upper esophagus? lower esophagus?

striated muscle, smooth muscle

20

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

21

Left vagus nerve – travels on ____ portion of stomach; goes to liver and biliary tree

anterior

22

The upper esophageal sphincter is how far from the incisors? and lower?

15 cm, 40 cm

23

What is the most common site of esophageal perforation (usually occurs with EGD)?

cricopharyngeus muscle

24

What muscle comprises the upper esophageal sphincter and prevents air swallowing?

cricopharyngeus muscle

25

What are the 3 anatomic areas of narrowing of the esophagus?

cricopharyngeus muscle,
compression by the left mainstem bronchus and aortic arch,
diaphragm

26

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)

27

What is the cause in primary esophageal dysfunction? secondary?

unknown in primary

secondary includes systemic disease, gastroesophageal reflux disease (GERD; most common), scleroderma, polymyositis

28

What is the diagnostic procedure of choice for dysphagia and odynophagia?

barium swallow (better at picking up masses)

29

What is the usual cause of cervical esophageal dysphagia?

plummer-vinson syndrome

30

What is the 3 parts of tx for plummer-vinson syndrome?

dilation, Fe, screen for oral CA

31

What can occur between the cripharyngeus and pharyngeal constrictors?

Zenker's diverticulum

32

What is the tx for Zenker's diverticulum?

cricopharyngeal myotomy; Zenker's itself can either be resected or suspended

33

What do you get on POD #1 after a cricopharyngeal myotomy for Zenker's?

esophagogram

34

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

35

What is the tx for a traction diverticulum of the esophagus?

excision and primary closure; may need palliative therapy if due to invasive CA

36

What is caused by failure of peristalsis and lack of LES relaxation after food bolus, and is secondary to neuronal degeneration in muscle wall?

Achalasia

37

What is the medical tx for achalasia (2)? what is next step?

CCB, nitrates

LES dilation (effective in 60%)

38

What is the next step in tx of achalasia if CCB, nitrates and LES dilation fail?

Heller myotomy

39

What infection can produce similar sx to achalasia?

T. cruzi

40

Chest pain; other sx similar to achalasia. May have psych history, normal LES tone, strong unorganized contractions.

Diffuse esophageal spasm

41

What are 4 types of tx for diffuse esophageal spasm?

CCB, nitrates, antispasmotics, Heller myotomy

42

Causes dysphagia, loss of LES tone; most have strictures, fibrous replacement of smooth muscle ■ Tx: esophagectomy; Nissen may be effective in some

Scleroderma

43

GERD sx with bloating suggests what?

aerophagia and delayed gastric emptying

44

What is the best test for GERD?

pH probe

45

What is the surgical tx for GERD?

Nissen

46

The key maneuver in Nissen is identifcation of what?

left crura

47

What is name of the approach through the chest in a Nissen?

Belsey

48

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?

Collis gastroplasty

49

Name the type of hiatal hernia:

Sliding hernia from dilation of hiatus (most common); often associated with GERD

Type I

50

Name the type of hiatal hernia:

Paraesophageal; hole in the diaphragm alongside esophagus, normal GE junction.

Type II

51

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)

52

Almost all pts with Schatzki's ring have an associated ___

sliding hiatal hernia

53

What is the tx for Schatzki's ring?

dilatation of the ring usually sufficient; may need antireflux procedure

54

What is the transformation in pts with Barrett's esophagus?

squamous metaplasia to columnar epithilium

55

Pts with Barrett's esophagus are at 50x increased risk for what?

adenomcarcinoma

56

Severe Barrett's dysplasia is an indication for what?

esophagectomy

57

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

58

Pts with Barrett's esophagus who get a Nissen still need careful lifetime follow up with what?

EGD

59

Esophageal tumors are almost always malignant. How does it spread?

submucosal lymphatic channels

60

What is the best test for unresctablity in esophageal CA?

Chest/abdominal CT

61

What is the #1 esophageal CA? What type occurs most often in the upper 2/3?

Adenocarcinoma

Squamous cell carcinoma

62

Supraclavicular nodes in esophageal CA indicate what?

unresectability

63

Distant metastases with esophageal CA is a contraindication to what? what is the survival?

esophagectomy, < 12 mos

64

What is the mortality from surgery in esophagectomy for CA? and what percentage is it curative?

5%, 20%

65

What is the primary blood supply to stomach after replacing esophagus in esphagectomy?

right gastroepiploic artery (have to divide left gastric and short gastrics)

66

What is the name of the type of esophagectomy with an abdominal incision and right thoracotomy -> exposes all of the esophagus; intrathoracic anasomsis

Ivor Lewis

67

What type of esophagectomy may be choice in young pts with benign disease when you want to preserve gastric function.

Colonic interposition

68

What do you need after esophagectomy on post op day 7?

contrast study to rule out leak

69

Name two chemo agents that can be used with esophageal CA for node positive disease or use preop to shrink tumors?

5FU and cisplatin

70

In esophageal CA with malignant fistulas, most die within 3 months due to what?

aspiration

71

What is the most common benign tumor of the esophagus?

Leiomyoma

72

Diagnosis of Leiomyoma is esophogram, endoscopy to rule out CA. Why don't you bx?

can form scar and make subsequent resection difficult

73

Tx for Leiomyoma of the esophagus is excision via thoractomy. What are the 2 indications?

>5 cm or sx

74

Caustic esophageal injury:
NG tube?
Induce vomiting?
Irrigation?

no, no, no

75

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)

76

What is the most common cause of esophageal perforation?

EGD

77

What is the most common site of esophageal perforation?

cricopharyngeus muscle

78

How to dx esophageal perforation?

gastrograffin swallow followed by barium swallow

79

What is the tx for esophageal perforation that is contained, self-draining and no systemic effects?

Conservative: IVF, NPO, spit

80

What type of flap can be used with repair of esophageal perforation to help the area heal?

intercostal muscle pedicle flap

81

What is Hartmann's sign?

mediastinal crunching on ascultation

82

How to dx Boerhaave's syndrome?

gastrofrafin swallow

83

What is the stomach transit time?

3-4 hours

84

Where does peristalsis occur in the stomach?

only in the distal stomach

85

What are the branches of the Celiac trunk?

left gastric, common hepatic, splenic

86

Left gastroepiploic and short gastrics are branches of what artery?

splenic

87

What is the blood supply of the greater curvature of the stomach?

right and left gastroepiploics, short gastrics

88

What is the blood supply of the lesser curvature of the stomach?

right and left gastrics

89

The right gastric is a branch of what artery?

common hepatic

90

What is the blood supply of the pylorus?

gastroduodenal artery

91

What is the mucosa of the stomach lined with?

simple columnar epithelium

92

What is the first enzyme in proteolysis and what cell secretes it?

Pepsinogen, secreted by chief cells

93

What do the parietal cells secrete?

H+ and intrinsic factor

94

What 2 things do Brunner's glands in the duodenum secrete?

pepsinogen and alkaline mucus

95

Antrectomy with gastroduodenal anastomosis?

Billroth I

96

Antrectomy with gastrojejunal anastomosis?

Billroth II

97

____ ulcer is a vascular malformation in the stomach

Dieulafoy's

98

____ disease is mucous cell hyperplasia, increased rugal folds of the stomach.

Menetrier's

99

What is the tx for gastric volvulus?

reductiona and Nissen

100

Associated with type II (paraesophageal) hernia ■ Nausea without vomiting; severe pain.

Gastric volvulus

101

Where is the tear usually located in a Mallory-Weiss tear?

near lesser curvature of the stomach near GE junction

102

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

103

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?

Pyloroplasty

104

What is the most common problem following vagotomy (30-50%)?

diarrhea

105

Upper GI bleed and having trouble localizing source with EGD. What can be done next?

tagged RBC scan

106

What is the biggest risk factor for rebleeding of an upper GI bleed at the time of EGD?

spurting blood vessel

107

In a pt with liver failure, what is the most likely source of an upper GI bleed?

esophageal varices

108

What is the tx for a bleeding esophageal varices?

EGD with sclerotherapy or TIPS, not OR

109

What location of duodenal ulcers usually perforate? what location bleed from GDA?

anterior ulcers perforate, posterior ulcers bleed from GDA

110

Describe the incision and closure of a Heineke-Mikulicz pyloroplasty.

longitudunal incision of the plyloric sphincter followed by a transverse closure

111

What is the most frequent complication of duodenal ulcers?

bleeding

112

The 1st surgical option for bleeding duodenal ulcer is duodenstomy and what? what if the pt has been on PPI therapy?

GDA ligation,

truncal vagotomy and pyloroplasty

113

With GDA ligation for bleeding duodenal ulcer, it is important to avoid hitting what structure?

common bile duct

114

What is the initial treatment of choice for obstruction due to duodenal ulcer?

serial dilation

115

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

116

What is the test for Zollinger-Ellison Syndrome?

Secretin test results in high gastrin level

117

In Zollinger-Ellison syndrome, what size tumors can be enucleated?

<2 cm

118

What is the most common location for gastric ulcers? and the most common cause?

lesser curvature; decreased mucosal defense (normal acid secretion)

119

Hemorrhage is associated with higher mortality in duodenal or gastric ulcers?

gastric

120

What location in the stomach is the bx for H. pylori taken?

antrum

121

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

122

What is the timing after event for stress gastritis?

3-10 days after event

123

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

124

Where are 40% of gastric cancers located?

antrum

125

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.

126

What blood type is a risk factor for gastric cancer?

type A

127

What is Krukenberg tumor?

gastric cancer with mets to ovaries

128

What is Virchow's nodes?

gastric cancer with metastases to supraclavicular nodes

129

What size margins in subtotal gastrectomy for gastric cancer?

5 cm

130

What is diffuse gastric cancer called?

linitis plastica

131

What is the surgical tx for linitis plastica?

total gastrectomy

132

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

133

What is the most common benign gastric neoplasm? aka?

gastric leiomyomas, also called gist tumors

134

What is the chemotherapy agent and MOA for gastric leiomyomas?

Gleevec (tyrosine kinase inhibitor)

135

What is the proto-oncogene are most gastric leiomyomas positive for?

c-kit (CD117)

136

What route does gastric leiomyosarcoma spread?

hematogenous

137

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

138

What are the surgical eligibility criteria for bariatric surgery?

BMI >40 kg or BMI >35 kg with coexisting comorbiditiies

139

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

140

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

141

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)

142

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

143

What are 3 medical options for the tx of alkaline reflux gastritis after gastrectomy?

H2 blockers, cholestyramine, metoclopramide

144

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

145

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.

146

What is the cause of roux stasis?

stasis of chyme in Roux limb due to loss of jejunal motility.

147

How do you dx Roux stasis?

EGD, emptying studies

148

What are 2 treatment options for Roux stasis?

metoclopramide/prokinetics

shorten Roux limb to 40 cm

149

What is caused by delayed gastric emptying after vagotomy?

chronic gastric atony

150

What is the surgical treatment for chronic gastric atony after gastrecomy?

near total gastrectomy with Roux-en-Y

151

What is the surgical option for small gastric remnant and early satiety after gastrectomy?

jejunal pouch reconstruction

152

After Billroth II or Roux-en-Y, symptoms include pain, diarrhea, malabsorption, B12 deficiency, steatorrhea. Caused by bacterial overgrowth and stasis in affarent limb.

Blind-loop syndrome

153

What is the medical and surgical treatment options for blind-loop syndrome?

tetracycline, Flagyl, metoclopramide

reanastomosis with shorter (40 cm) afferent limb

154

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

155

Bronchiectasis is acquired from infection, tumor or what other condition?

cystic fibrosis

156

Noncaseating granulomas are seen in what lung condition?

sarcoidosis

157

What is the pleural fluid protein to serum ratio seen in an exudate? and the pleural fluid LDH to serum ratio seen in exudate?

> 0.5

> 0.6

158

Recurrent pleural effusions can be treated with what?

mechanical pleurodesis (talc pleurodesis for malignant pleural effusions)

159

Airway fires are usually associated with the laser. What is the tx?

stop gas flow, remove ET tube, reintubate for 24 hrs; bronchoscopy

160

AVMs, connections between the pulmonary arteries and pulmonary veins; usually occurs in the lower lobes and in pts with what disease?

Osler-Weber-Rendu disease

161

What is the tx for AVMs in the lung?

embolization

162

What is the most common benign chest wall tumor? and malignant?

benign - osteochondroma
malignant - chondrosarcoma