EOR GI part 4- gastric CA, bariatric surgery, SBO

Question 1

What are the associated RFs of gastric CA- diet?

Answer 1

Smoked meats
High nitrates
Low fruits and veggies
EtOH 
Tobacco

Question 2

RFs of gastric CA- environmental

Answer 2

Raised in high-risk area
Poor SES
Atrophic gastritis
Male gender
Blood type A
Previous partial gastrectomy
Pernicious anemia
Polyps
H. pylori

Question 3

Which blood type is associated with gastric CA?

Answer 3

Blood type A

Question 4

What are the sx of gastric CA?

Answer 4

Weight loss
Emesis
Anorexia
Pain/epigastric discomfort
Obstruction
Nausea

Question 5

What is a Blumer’s shelf?

Answer 5

Solid peritoneal deposit anterior to rectum, forming a “shelf”, palpated on rectal exam

Question 6

What is a Virchow’s node?

Answer 6

Metastatic gastric CA to the nodes in the left supraclavicular fossa

Question 7

What is a surveillance lab finding in gastric CA?

Answer 7

CEA elevated in 30% of cases (if pos, useful for post-op surveillance)

Question 8

What is the initial workup for gastric CA?

Answer 8

EGD with bx
Endoscopic u/s to evaluate the level of invasion
CT abdomen/pelvis for metastasis
CXR
Labs

Question 9

What is the histology of gastric CA?

Answer 9

Adenocarcinoma

Question 10

What is the DDx for gastric tumors?

Answer 10

Adenocarcinoma
Leiomyoma
Leiomyosarcoma
Lymphoma
Carcinoid
Ectopic pancreatic tissue
Gastrinoma
Benign gastric ulcer
Polyp

Question 11

Which morphologic type of gastric CA is named after a “leather bottle”?

Answer 11

Linitis plastica- the entire stomach is involved and looks thickened (10% of cancers)

Question 12

Which pts with gastric CA are non-operative?

Answer 12

Distant metastasis

Peritoneal implants

Question 13

What is the role of laparoscopy in gastric CA?

Answer 13

To r/o peritoneal implants and to evaluate for liver metastasis

Question 14

What is the genetic alteration seen in >50% of pts with gastric CA?

Answer 14

P53

Question 15

What is the tx for gastric CA?

Answer 15

Surgical resection with wide (>5 cm checked for frozen section) margins and lymph node dissection

Question 16

What operation is performed for a tumor in the antrum?

Answer 16

Distal subtotal gastrectomy

Question 17

What operation is performed for a tumor in the midbody?

Answer 17

Total gastrectomy

Question 18

What operation is performed for a tumor in the proximal?

Answer 18

Total gastrectomy

Question 19

What is a subtotal gastrectomy?

Answer 19

75% of the stomach removed

Question 20

What is a total gastrectomy?

Answer 20

Stomach is removed and a Roux-en-Y limb is sewn to the esophagus

Question 21

When should splenectomy be performed in gastric CA?

Answer 21

When the tumor directly invades the spleen/splenic hilum or with splenic hilar adenopathy

Question 22

What is the adjuvant tx for gastric CA?

Answer 22

Stages II and III: post-op chemo and radiation

Question 23

Define morbid obesity

Answer 23

BMI >40
OR
BMI >35 with a medical problem related to morbid obesity

Question 24

What medical conditions are associated with morbid obesity?

Answer 24

Sleep apnea
Coronary artery dz
Pulm dz
DM
Venous stasis ulcers
Arthritis
Infections
Sex-hormone abnormalities
HTN
Breast CA
Colon CA

Question 25

What are the current best options for bariatric surgery?

Answer 25

Sleeve gastrectomy Gastric bypass (malabsorptive) Vertical-banded gastroplasty

Question 26

Gastric bypass

Answer 26

Stapling off of small gastric pouch (restrictive) | Roux-en-Y limb to gastric pouch (bypass)

Question 27

How does gastric bypass work?

Answer 27

Creates a small gastric reservoir Causes dumping sx when a pt eats too much food or high-calorie foods; the food is "dumped" into the Roux-en-Y limb Bypass of small bowel by Roux-en-Y limb

Question 28

What is the MC sign of an anastomotic leak after a gastric bypass?

Answer 28

Tachycardia

Question 29

What is a LAP-BAND?

Answer 29

Laparoscopically placed band around stomach with a subcutaneous port to adjust constriction; results in smaller gastric reservoir

Question 30

What is a Petersen's hernia?

Answer 30

Seen after bariatric gastric bypass- internal herniation of small bowel through the mesenteric defect from the Roux-en-Y limb

Question 31

What is small bowel obstruction?

Answer 31

Mechanical obstruction to the passage of intraluminal contents

Question 32

What are the S/sx of SBO?

Answer 32

``` Abdominal discomfort Cramping Nausea Abdominal distention Emesis High-pitched bowel signs ```

Question 33

What lab tests are performed with SBO?

Answer 33

Electrolytes CBC Type and screen UA

Question 34

What are classic electrolyte/acid-base findings with proximal SBO?

Answer 34

Hypovolemic, hypochloremic, hypokalemia, alkalosis

Question 35

What must be r/o on PE in pts with SBO?

Answer 35

Incarcerated hernia (also look for surgical scars)

Question 36

What major AXR findings are associated with SBO?

Answer 36

Distended loops of small bowel air-fluid levels on upright film

Question 37

Define complete SBO

Answer 37

Complete obstruction of the lumen

Question 38

What is the danger of complete SBO?

Answer 38

Closed loop strangulation of the bowel leading to bowel necrosis

Question 39

Define partial SBO

Answer 39

Incomplete SBO

Question 40

What is initial management of all pts with SBO?

Answer 40

NPO NGT IVF Foley

Question 41

What tests can differentiate partial from complete SBO?

Answer 41

CT with PO contrast

Question 42

What are the ABCs of SBO?

Answer 42

Causes: Adhesions Bulge (hernias) CA and tumors

Question 43

What is SMA syndrome?

Answer 43

Seen with wt loss- SMA compresses duodenum, causing obstruction

Question 44

What is the tx of complete SBO?

Answer 44

Laparotomy and lysis of adhesions (LOA)

Question 45

What is the tx of incomplete SBO?

Answer 45

Initially, conservative tx with close observation plus NGT decompression

Question 46

Intraoperatively, how can the level of obstruction be determined in pts with SBO?

Answer 46

Transition from dilated bowel proximal to the decompressed bowel distal to the obstruction

Question 47

Can a pt have complete SBO and bowel movements and flatus?

Answer 47

Yes; the bowel distal to the obstruction can clear out gas and stool

Question 48

After a small bowel resection, why should the mesenteric defect always be closed?

Answer 48

To prevent an internal hernia

Question 49

What may cause SBO if pt is on Coumadin?

Answer 49

Bowel wall hematoma

Question 50

What is the #1 cause of SBO in adults (industrialized nations)

Answer 50

Postop adhesions