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Surgery > Gastrointestinal Surgery: Part 2 > Flashcards

Gastrointestinal Surgery: Part 2 Flashcards

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1
Q

Indications of Bariatric surgery

A
  1. BMI >40 kg/m2
  2. BMI >35 kg/m2 with obesity complications
  3. Asian population: Lower cutoff for Sx
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2
Q

Types of Bariatric surgery

A
  1. Sleeve gastrectomy
  2. Roux-en-Y gastrojejunostomy
  3. Duodenal switch/Biliopancreatic diversion
  4. Gastric banding and intragastric balloon placement
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3
Q

Irreversible Bariatric procedures

A
  1. Biliopancreatic diversion and Duodenal switch
  2. Roux-en-Y gastrojejunostomy
  3. Lap sleeve gastrectomy
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4
Q

Reversible Bariatric procedures

A
  1. Gastric banding
  2. Intragastric balloon placement
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5
Q

Common channels thru which BPD and DS can be done

A

Biliopancreatic switch: 50 cm
Duodenal switch: 100 cm

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6
Q

Disadvantages of BPD and DS

A

Max surgical complications
Max weight loss (D/t malabsorption)

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7
Q

Roux limb length in Roux-en-Y gastrojejunostomy

A

100 cm

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8
Q

Nutritional deficiencies seen in Roux-en-Y gastrojejunostomy

A

Iron (M/C)
Vit D3/Ca 2+
Vit B12

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9
Q

Limbs in Roux-en-Y gastrojejunostomy

A

Biliary limb: Bypassed duodenum
Roux limb: Jejunum

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10
Q

M/C Bariatric procedure done

A

Lap sleeve gastrectomy

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11
Q

What is Lap sleeve gastrectomy?

A

Restrictive surgery:
Greater curvature of stomach is removed

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12
Q

Complications of Lap sleeve gastrectomy

A
  1. M/C: Bleeding from staple line
  2. Nutritional deficiencies
  3. Leak from angle of His (Most distressing: Peritonitis)
  4. Redistension of sleeve (Mx: Transoral gastroplasty)
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13
Q

What is Gastric banding?

A

Band placed 6 cm from GE junction
Reversible pressure adjustable balloon -> Weight loss can be titrated

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14
Q

Complications of Gastric banding

A
  1. Prolapse (M/C)
  2. Nutritional complications
  3. Erodes into stomach
  4. Rupture
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15
Q

What is Intragastric balloon placement?

A

Balloon is distended in the stomach
Removed after weight loss is achieved
Self dissolvable balloon: Dissolves after 3 months

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16
Q

Features of Bariatric Sx
Just study

A
  1. M/C cause of death: DVT -> Pulmonary embolism
  2. AKA metabolic surgery: Weight loss + Improvement in DM/HTN/Hyperlipidemia
  3. Nutrient replacement:
    > Iron
    > Vit B12
    > Vit D3 and Ca 2+
    > Fat soluble vitamins: In sleeve gastrectomy and Roux-en-Y bypass
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17
Q

IOC for Mesenteric cyst

A

CECT

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18
Q

Tillaux triad for Mesenteric cyst

A
  1. Periumbilical swelling
  2. Tillaux sign: Swelling moves at right angle to attachment of mesentery
  3. Transverse band of resonance
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19
Q

Types of Mesenteric cyst

A
  1. Chylolymphatic cyst (M/C)
  2. Enterogenous cyst
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20
Q

Tissue seen in Chylolymphatic cyst

A

Sequestered lymphatic tissue

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21
Q

Tissue seen in Enterogenous cyst

A

Sequestered bowel tissue

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22
Q

Diff b/w Chylolymphatic and Endogenous cyst

A

Chylolymphatic cyst. Enterogenous cyst
Cyst wall Thin Thick
Fluid Clear. Turbid
Blood supply Independent. Shared with bowel
Rx Enucleation. Resection and anastomosis

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23
Q

What is upper GI hemorrhage?

A

Bleeding proximal to ligament of Treitz

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24
Q

Causes of Non-varicella bleeding

A
  1. Peptic ulcer: Duodenal > Gastric
  2. Mallory Weiss tear
  3. Gastritis
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25
Types of Gastritis
1. Type A 2. Type B 3. Stress induced 4. NSAIDS induced 5. AIDS induced
26
What is Type A Gastritis?
Autoimmune gastritis (AutoAb against parietal cells) Natural sparing, pernicious anemia, achlorhydria
27
What is Type B Gastritis?
H. Pylori induced (Affects antrum)
28
Types of Stress induced Gastritis
1. Cushing’s ulcer 2. Curling ulcer
29
What is Cushing’s ulcer?
In head injury, involves the stomach
30
What is Curling ulcer?
In burns, involves first part of duodenum
31
Vessel involved in Mallory Weiss tear
Left gastric artery
32
What is GAVE?
Gastric Antral Vascular Ectasia Seen at antrum Autoimmune
33
Endoscopy of GAVE shows
Watermelon stomach (D/t dilated venules)
34
Management of GAVE
Argon photocoagulation
35
Portal gastroplasty is seen in
Portal hypertension
36
Endoscopy of Portal gastroplasty shows
Strawberry stomach (Reddish nodules)
37
What is Menetrier’s disease?
Hypertrophy of gastric mucosal folds d/t over expression of TGF ALPHA Inc risk of cancer
38
C/F of Menetrier’s disease?
1. Protein losing enteropathy (Earliest) 2. Upper GI hemorrhage
39
Management of Menetrier’s disease
Fails Cetuximab (Monoclonal Ab against EGFR) ———-> Gastrectomy (Severe cases)
40
Varicella cause of upper GI bleeding
Portal hypertension
41
Hepatic Venous Pressure Gradient (HVPG)
Doppler (Diagnosis) 1-5 mmHg: Normal 6-10 mmHg: Preclinical sinusoidal portal HTN >=10 mmHg: Clinically significant portal HTN -> Variceal formation >= 12 mmHg: Inc risk for rupture of varices
42
Porto-systemic shunts seen in portal HTN
1. Left gastric + short gastric veins -> Distal Esophageal veins 2. Left gastric/gastroepiploic vein -> Esophageal/paraesophageal veins 3. Caput medusae: Periumbilical 4. Rectum 5. Bare area of liver (Segment 7)
43
C/F of Portal HTN
1. Upper GI hemorrhage 2. Splenomegaly 3. Ascites 4. Signs of liver failure
44
Management of Portal HTN
Bleeding | V ABC management | V IV drugs: 1. Best: IV terlipressin 2. M/C used: IV octreotide 3. Not used: IV propranolol | Patient stabilised V Upper GI endoscopy: Banding (M/C) > Sclerotherapy (Sodium tetradecyl sulphate) | Assess bleeding | | V V Controlled 2nd attempt at UGI-scopy |. | Fails V V 24 hour observation Sengstaken blakemore tube | | V V Discharge on oral propanolol Prepare for TIPSS
45
What is TIPSS?
Transjugular Intra-hepatic Portosystemic Shunt Shunt b/w Portal vein and hepatic vein
46
Complications of TIPSS
1. Rupture of capsule: Earliest 2. Blocked -> Rebleeding (M/C) 3. Encephalopathy: D/t non selective shunt
47
Scoring systems for Portal HTN
1. Rockall’s score 2. BLEED score 3. Child Pugh Turcotte score
48
Cardinal features of Bowel obstruction
1. Non passage of flats and faeces (Obstipation) 2. Vomiting 3. Distension 4. Abdominal pain
49
Investigations for Bowel obstruction
1. X ray abdomen erect and supine: Initial Ix 2. CECT: IOC in adults 3. USG: IOC in children
50
X ray features in Bowel obstruction
1. Erect X ray: >3 air fluid levels 2. Supine X ray: > Jejunum: Feathery appearance, Valvulae conniventes (Concertina effect) > Ileum: Featureless (Loops of wangensteen) > Large bowel: Incomplete haustrations
51
Management of Bowel obstruction
1. NPO 2. IV fluids 3. IV antibiotics and painkillers 4. Ryle’s tube insertion 5. Sx: Emergency laparoscopy
52
Caecum is visualised 1st before surgery. Why? Just study
Distended: Large bowel obstruction Collapsed: Small bowel obstruction
53
What is Intussception?
Telescoping of one bowel loop into another Intussuscipiens: Receiving loop Intussusceptum: Loop going inside
54
Types of Intussception
Primary: 6 months-2 years age group Secondary: Adults
55
Triggers of each type of Intussception
Primary: Hypertrophy of Peyer’s patches Secondary: Secondary of pathological lead point: Polyp, diverticulum, cancer
56
Features of Primary Intussception
Ileocolic (M/C) Red currant jelly stools Sign of dance: Empty RIF (Lump is in lumbar region)
57
Investigations for Intussception
1. X ray abdomen: Erect and supine (Initial) 2. USG: Target/Donut/Pseudokidney sign 3. Contrast enema: Pincer/claw sign > Diagnostic and therapeutic > C/I: Perforation, recurrence or secondary to pathological lead point
58
Pre-disposing factors for Sigmoid volvulus
1. Long and narrow mesentery 2. Redundant sigmoid 3. Loaded sigmoid
59
Sigmoid volvulus commonly seen in
On antipsychotic meds With constipation
60
D/D coffee bean sign
1. Sigmoid volvulus (Apex points towards RT shoulder, large bowel dilated) 2. Caecal volvulus (Apex points towards Lt shoulder, large bowel collapsed)
61
Management of Sigmoid volvulus
Stable, no peritonitis: Sigmoidoscopic decompression (Flatus tube) -> Definitive Sx: Sigmoidectomy Unstable, peritonitis: Hartmann’s procedure
62
What is Hartmann’s procedure?
1. Resect perforated segment 2. Proximal colostomy 3. Distal end closed and kept inside
63
Causes of Intestinal stricture
1. Cancer 2. Post radiotherapy 3. TB 4. Crohn’s disease
64
Management of Intestinal stricture
1. Strictures are close: Resection and anastomosis 2. Strictures are far apart: Heineken Mikulicz stricturoplasty
65
What is Meckel’s diverticulum?
Remnant of vitellointestinal duct Present along antimesenteric border True diverticulum: All layers + Independent blood supply: Safe resection possible
66
Rule of 2 in Meckel’s diverticulum
2% of population 2 inches long 2 feet from ileocolic junction
67
Vitellointestinal duct abnormalities
1. Completely patent: Fecal discharge 2. Fibrous band formation: Leads to volvulus 3. Patent umbilical end: Umbilical cyst/polyp -> Purulent discharge +/- 4. Ideal end patent: Meckel’s diverticulum
68
What is Duodenal atresia?
Duodenum not continuous Common in Down’s syndrome C/F: Bilious vomiting since brith
69
D/D of Duodenal atresia
CHPS
70
X ray of Duodenal atresia
Double bubble sign
71
Management of Duodenal atresia
Duodenoduodenostomy
72
X ray feature of Jejunal atresia
Triple bubble sign

Surgery (11 decks)

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