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Surgery Clerkship - De Virgilio COPY > Summary of Essentials - Ch. 48- (GI) > Flashcards

Summary of Essentials - Ch. 48- (GI) Flashcards

1
Q

Most common cause of melena?

A

UGI bleed

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2
Q

Presentation - bloody emesis in a patient who is critically ill and in the ICU?

A

Stress ulceration

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3
Q

Presentation - bloody emesis in a patient with a history of aortic surgery?

A

Aortoenteric fistula

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4
Q

Work-up for suspected aortoenteric fistula?

A

Endoscopy and CT (gas/stranding around graft)

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5
Q

Dx cause of bloody emesis?

A

If unclear whether upper or lower GI - NG tube lavage

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6
Q

Management of UGI bleed?

A

-ABCs, 2 large-bore IVs, type and cross -If massive bleed, consider intubation -Transfuse Hgb below 7 -Start PPI early -Triple therapy for H. pylori eradication -Admit to montored setting -Upper endoscopy with 12 hours (most can be Rx with endoscopic techniques) -Calculate MELD?

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7
Q

When is surgery indicated in the setting of an UGI bleed?

A

Duodenal ulcer (open duodenum, 3-point ligation of ulcer), gastric ulcer (excise and close for acute vs. distal gastrectomy for chronic)

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8
Q

Which type of varices are more difficult to treat and do not respond well to banding or sclerotherapy?

A

Gastric (vs. esophageal)

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9
Q

In the setting of isolated gastric varices along the greater curve, consider ___ from prior pancreatitis. ___ is curative.

A

Splenic vein thrombosis; splenectomy

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10
Q

What can be used to prevent recurrent bleeding from esophageal varices?

A

Propranolol

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11
Q

Presentation - sudden onset severe epigastric pain that becomes diffuse, history of PUD/H. pylori/smoking/chronic NSAIDs, evidence of SIRS, lying motionless in bed, peritoneal signs

A

Perforated peptic ulcer

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12
Q

What are the 5 types of gastric ulcers?

A

I - lesser curve of stomach II - in stomach and duodenum III - pre-pyloric IV- proximal by the cardia V - 2/2 NSAID use

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13
Q

Work-up of suspected perforated peptic ulcer?

A

Upright CXR - free air under diaphragm CT with oral gastrografin

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14
Q

Management of perforated duodenal ulcer?

A

Primary closure with omental patch

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15
Q

Management of perforated gastric ulcer?

A

Primary closure, biopsy, omental patch vs. wedge resection (must rule out malignancy)

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16
Q

Rx H. pylori?

A

Triple therapy - clarithromycin, amoxicillin, PPI for 14 days

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17
Q

Most common type of stomach cancer?

A

Adenocarcinoma (2 types - intestinal and diffuse)

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18
Q

Most common cause of stomach cancer?

A

H. pylori infection

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19
Q

This type of gastric cancer is poorly differentiated, occurs most often in the proximal stomach, and is often related to congenital disorders

A

Diffuse type

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20
Q

This type of gastric cancer occurs in the distal stomach and is associated with environmental factors

A

Intestinal-type

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21
Q

What is infiltration oft he entire gastric wall with cancer?

A

Linitis plastica

22
Q

What are GIST tumors?

A

Smooth, submucosal tumors that express c-KIT and CD117

23
Q

Study of choice to dx gastric cancer?

A

Endoscopy Further staging with CT chest, A/P, and/or PET

24
Q

Management of gastric cancer?

A

Stage IB or higher - pre-operative chemo Surgery: tumor distal to stomach - subtotal gastrectomy vs. in proximal stomach: proximal gastrectomy or total gastrectomy Post-operative chemo and radiation

25
Q

Rx low grade MALT lymphoma? High-grade?

A

Low grade - H. pylori eradication High grade - chemo

26
Q

Presentation - thoracic pain radiating to the lower back and aggravated by swallowing, chest pain/vomiting/subQ emphysema

A

Boerhaave’s syndrome

27
Q

Work-up of chest pain after vomiting?

A

Initial study - CXR (look for L pleural effusion and atelectasis, pneumomediastinum is pathognomonic) Gastrografin esophogram or CT chest with water-soluble oral contrast to confirm

28
Q

Management of Boerhaave’s syndrome?

A

Conservative (consider in healthy patients with mild sepsis and a contained rupture within the mediastinum) - continuous NG suction, IV broad-spectrum ABX, parenteral nutrition Surgery within 24 hours - debride necrotic tissue, primary suture closure, coverage with pedicle flap

29
Q

Location of femoral hernia?

A

Posterior and inferior to the inguinal ligament and medial to the femoral vein

30
Q

Cause of indirect vs. direct inguinal hernia?

A

Indirect - congenital (patent processus vaginalis) outside go hasselbach’s triangle Direct - acquired weakness transversalis fascia located within Hesselbach’s triangle

31
Q

Location of indirect inguinal hernia?

A

Lateral to inferior epigastric vessels, through the deep and superficial ring

32
Q

Location of direct inguinal hernia?

A

Medial to inferior epigastric vessels, through the superficial ring only

33
Q

Diagnosis for Inguinal Hernia

A

-Visible, palpable groin protrusion or bulge -Inguinal pain -Increase of symptoms during physical activity Palpation of the inguinal canal 1. With the patient standing, palpate from the scrotal skin towards the superficial (external) inguinal ring. 2. Ask the patient to cough or strain and bear down (Valsalva maneuver). Bulging can be felt with a fingertip. Testing: Ultrasound: Imaging test of choice Visualization of the hernial orifice and hernial contents may be possible. CT/MRT: to distinguish from differential diagnoses in ambiguous cases

34
Q

Inguinal Hernia Complications

A

Incarcerated hernia: inability to reduce the hernia back into abdominal cavity; fixation of contents in the hernial sac (Surgical emergency in case of concurrent bowel obstruction) Strangulated hernia: tight constriction of hernial contents leading to constriction of blood vessels, bowel ischemia, and necrosis Patients must undergo surgery within 4–6 hours to avoid possible bowel loss. Symptoms of bowel obstruction

35
Q

Indications for surgery for Inguinal hernia

A
  • Complicated hernia
  • Uncomplicated hernia + moderate symptoms:
    • Inguinal pain associated with exertion
    • Daily activities are limited due to pain
    • Manual reduction is not possible
  • Uncomplicated hernia + mild symptoms:
    • elective hernia repair
    • Observation
36
Q

Risks of surgery for Inguinal Hernia Repair

A
  1. Vas deferens injury
  2. Spermatic vessels injury, dissection, or constriction, which may lead to testicular necrosis
  3. Injury to femoral nerve, artery, or vein
  4. Chronic inguinal pain
  5. Bladder injury
  6. General risks of surgery
37
Q

Inguinal Hernia In Infants- Risk factors

A
  1. Incidence: ∼ 1–5% of all children (11% in premature children)
  2. ♂ > ♀ (∼ 4:1)
  3. Occurs more often on the right side
  4. Premature birth
  5. Urogenital dysplasia syndromes
  6. Increased intraabdominal pressure (e.g., gastroschisis, ascites, omphalocele)
  7. Weakness of the connective tissue (e.g., Ehlers-Danlos syndrome)
38
Q

Rx umbilical hernia in children?

A

Repair if persistent >age 4, if defect >2 cm, if progressive enlargement after age 2

39
Q

Hiatal Hernia- Epidimiology & Risk

A

Age: affects ∼ 70% of people > 70 years

↑ BMI

Prevalence

More prevalent in females and Western populations

Most commonly occur on the left side, as the liver protects the right diaphragm.

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

NOTES

FEEDBACK

Etiology

The etiology is multifactorial. Lax diaphragmatic esophageal hiatus

Advanced age

Smoking

Obesity

Genetic predisposition (rare)

Prolonged periods of increased intra-abdominal pressure

Pregnancy

Ascites

Chronic cough

Chronic constipation

Defects of the pleuroperitoneal membrane

40
Q

Sliding Hiatal Hernia

A
  • Most common type (95% of cases)
  • The Gastroesophageal junction and the gastric cardia slide up into the posterior mediastinum.
  • The gastric fundus remains below the diaphragm (hourglass stomach)
41
Q

Paraesophageal Hiatal Hernia (type2)

A
  • Part of the gastric fundus herniates into the thorax.
  • The GEJ remains in its anatomical position below the diaphragm.
  • Upside-down stomach (extreme type): a rare type of paraesophageal hernia in which the entire stomachherniates into the thoracic cavity and rotates on its organoaxial axis. It is associated with a high mortality and morbidity rate due to strangulation of the stomach.
42
Q

Mixed Hiatal Hernia (type 3)

A
43
Q

Complex Hiatal Hernia (type 4)

A
44
Q

Complications type 1 haital hernia

A
45
Q

Complications of type 2,3,4 haital hernia

A

Often Medial Emergency

  • Occur mainly due to vascular compromise of the herniated portion of the stomach, which leads to mucosal ischemia

They include:

  • Upper gastrointestinal bleeding (occult/massive)
  • Gastric ulcers
  • Gastric perforation
  • Gastric volvulus
  • Total gastric obstruction
46
Q

Borchardt’s triad

A
  1. severe epigastric pain
  2. unproductive retching
  3. inability to pass a nasogastric tube
47
Q

Clinical Features Type 1 Hiatal Hernia

A

Symptoms of GERD

48
Q

CLinical Features type 2,3,4 Hiatal Hernia

A
49
Q

Saint Trias

A
  • Cholelithiasis
  • Diverticulosis
  • Hiatal Hernia
50
Q

Hiatal Hernia Diagnosis

A
  • Barium swallow: most sensitive test
    • Assesses type and size of a hernia (including location of the stomachand the GEJ)
  • Endoscopy: used to diagnose hiatal hernia and evaluate for possible complications
    • Z-line: squamocolumnar junction, corresponds to the GEJ
      • Types I and III: Z-line lies above the diaphragmatic hiatus

Types II and IV: Z-line remains undisplaced (below the diaphragmatic hiatus)

51
Q

Hiatal Hernia Treatment

A

Non OP

  • Lifestyle Modifications
  • PPI

Surgery

  • Fundoplication + hiatoplasty
    • indications: peristence of symptoms, severe complications of GERD
52
Q

Hiatal Hernia Treatment (type 2,3,4)

A

Non OP

  • older patient or multiple comorbitites

Surgery

  • herniotomy + fundoplication, hiatoplasty, and gastropexy/fundopexy
  • Indications
    • Asymptomatic, small hernias in patients < 50 years of age
    • Symptomatic type II, III, IV hernias

Surgery Clerkship - De Virgilio COPY (9 decks)

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