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Flashcards in GI Surgery Deck (131):
1

FIRST diagnostic test in patients with suspected esophageal disease

Barium swallow

2

Can be used when patient complains of dysphagia and no obstruction is seen on barium swallow

Barium-impregnated marshmallow, bread, hamburger

3

Diagnostic test for patients complaining of dysphagia with normal radiographic study

Endoscopy

4

Diagnostic test for patients when a motor abnormality is considered and barium swallow and endoscopy are normal

Manometry

5

Essential tool in preoperative evaluation of patients before antireflux surgery

Manometry

6

MOST DIRECT method of measuring increased esophageal exposure to gastric juice (NOT REFLUX)

24-hour ambulatory pH monitoring

7

GOLD STANDARD for diagnosis of GERD

24-hour ambulatory pH monitoring

8

MOST SPECIFIC symptom of foregut disease

Dysphagia

9

Primary cause of GERD

Permanent attenuation of collar sling musculature, with resultant opening of gastric cardia and loss of high-pressure zone measured in manometry

10

3 characteristics of defective LES

1) Mean resting pressure less than 6 mmHg
2) Overall sphincter length less than 2 cm
3) Intraabdominal sphincter length less than 1 cm

11

MOST IMPORTANT consideration affecting competence of GEJ

Intraabdominal sphincter length less than 1 cm

12

Grading of esophagitis: Small, circular, non confluent erosions

Grade I

13

Grading of esophagitis: Linear erosions lined with granulation tissue that bleeds easily when touched

Grade II

14

Grading of esophagitis: Linear erosions coalesce into circumferential loss of epithelium

Grade III

15

Grading of esophagitis: Cobblestone mucosa

Grade III

16

Grading of esophagitis: Stricture

Grade IV

17

Incidence of esophagitis in patients with GERD

10-15%

18

End stage of natural history of GERD

Barrett esophagus

19

HALLMARK of Barrett esophagus

Intestinal metaplasia

20

Earliest sign for malignant degeneration of Barrett esophagus

Severe dysplasia or intramucosal adenoCA

21

Fraction of patients with BE that present with malignancy

1/3

22

Barrett esophagus surveillance frequency

1) Every 2 years
2) Every 6 months if with low-grade dysplasia

23

Most important etiologic factor for the development of esophageal adenoCA

Barrett esophagus

24

Management for uncomplicated GERD

12-week empiric treatment with antacid

25

Most important factor predicting failure of medical therapy for GERD

Structurally defective LES

26

GERD surgery: Abdominal or thoracic 360-degree circumferential wrap of gastric fundus

Nissen fundoplication

27

GERD surgery: Chest approach; 280 degree anterior wrap

Belsey operation

28

GERD surgery: Abdominal approach; 180 degree wrap

Hill

29

GERD surgery: Esophageal lengthening

Collis gastroplasty

30

GERD surgery: Horseshoe-shaped silastic device placed around distal esophagus, keeping it in the abdomen

Angelchik prosthesis

31

GERD surgery: Pressure of distal esophageal sphincter should be restored to a level ___x the resting gastric pressure

2

32

Diaphragmatic hernia: Structure that herniates into thorax in sliding hernia

Cardia

33

Diaphragmatic hernia: Structure that herniates into thorax in paraesophageal hernia

Fundus

34

Sliding vs rolling diaphragmatic hernia: Phrenoesophageal ligament stretched but intact

Sliding

35

Weak in a Zenker diverticulum

Cricopharyngeus muscle (Killian area/triangle)

36

Sliding vs rolling diaphragmatic hernia: Most common

Sliding

37

Sliding vs rolling diaphragmatic hernia: Can evolve into a type III hernia

Sliding

38

Men vs women: Rolling esophageal hernia

Women

39

Type of diaphragmatic hernia: GEJ in the mediastinum

Type 3

40

Type of diaphragmatic hernia: Whole stomach migrates up into the chest by rotating 180 degrees around its longitudinal axis

Type 4

41

Acquired diaphragmatic hernia: Most common complications (3)

1) Occult GI bleeding from gastritis
2) Ulceration in herniated portion
3) Gastric volvulus

42

Triad of gastric volvulus

Borchardt's triad
1) Pain
2) Nausea with inability to vomit
3) Inability to pass NGT

43

Diagnostic procedure that detects paraesophageal hernia

Barium esophagogram

44

Diagnostic procedure that detects pouch lined with gastric rugal folds lying 2 cm or more above margins of diaphragmatic crura

Fiber-optic esophagoscopy

45

Surgical management for esophageal hernia that can reduce recurrence rates if the hernia is > 8cm

Use of mesh

46

Diagnostic procedure for Boerhaave syndrome

Water-soluble (gastrografin) contrast esophagogram

47

Most common esophageal diverticulum

Zenker's diverticulum

48

True vs false diverticulum: Zenker diverticulum

False

49

Achalasia: Classic triad

1) Dysphagia
2) Regurgitation
3) Weight loss

50

Infection that can cause achalasia

T. cruzi infection

51

Destroyed by T. cruzi, causing achalasia

Auerbach's plexus

52

Chance of developing CA in achalasia

10%

53

Surgical management of achalasia

Heller myotomy

54

Most common primary esophageal motility disorder

Nutcracker esophagus

55

Characterized by peristaltic esophageal contractions with peak amplitudes >2 SD above normal value

Nutcracker esophagus

56

T/F Achalasia = hypertensive LES

F

57

Diverticula formed due to increase in pressure

Pulsion

58

Diverticula formed due to inflammatory disorder, not associated with increase in pressure

Traction

59

Key to optimum management of Boerhaave

Early diagnosis

60

Most favorable outcome of Boerhaave is obtained if primary closure is done within

24 hours

61

Cervical vs thoracic vs distal esophageal CA: Frequently unresectable because of early invasion

Cervical

62

Alkali vs acid: More severe injury to esophagus

Alkali

63

Strength of esophageal contractions is weakest at

Striated-smooth muscle junction

64

Striated-smooth muscle junction vs lower portions: More severely affected by caustic ingestion

Striated-smooth muscle junction

65

Phases of caustic injury (3)

1) Acute necrotic phase
2) Ulceration and granulation phase
3) Cicatrization and scarring phase

66

Removed in Ivor-Lewis procedure

(Radical) All LN with lesser curvature

67

Phases of caustic injury: Ulceration and granulation begins

3-5 days after injury

68

Phases of caustic injury: Quiescent period

Ulceration and granulation phase

69

Phases of caustic injury: Period that the esophagus is weakest

Ulceration and granulation

70

Phases of caustic injury: Ulceration and granulation lasts

10-12 days

71

Phases of caustic injury: Cicatrization and scarring begins

3rd week following injury

72

Phases of caustic injury: Characterized by dysphagia

Cicatrization and scarring

73

Esophageal Ca: Most common presenting symptom

Dysphagia

74

T/F Dysphagia is an EARLY symptom of esophageal CA

F, late

75

Management of esophageal CA: Cervical esophagus

Radiation + chemo

76

Management of esophageal CA: Thoracic esophagus

VATS +- thoracotomy

77

Management of esophageal CA: Distal esophagus

Curative resection

78

Surgery primarily for middle esophageal lesion

Ivor-Lewis

79

Largest artery to the stomach

Left gastric

80

Vagus nerve forms ___ branches at the esophageal hiatus as it descends from the mediastinum

LARP
1) Left anterior
2) Right posterior

81

Standard test to confirm eradication of H. pylori post-treatment

Urease breath test

82

Nerves of Laterjet: Branches to the

Body of stomach

83

Nerves of Laterjet: Terminate near the

Incisura angularis

84

Nerves of Laterjet: Terminates as the

Crow foot

85

Posterior branch of the vagus (stomach)

Criminal nerve of Grassi

86

Laterjet vs Grassi: Easily missed during truncal or highly selective vagotomy

Criminal nerve of Grassi

87

Gastric contraction is due to

Vagal stimulation

88

Gastric relaxation is due to (3)

1) CCK
2) Distention of duodenum
3) Glucose in duodenum

89

Alarm symptoms that indicate need for upper endoscopy (5)

1) Recurrent vomiting
2) Dysphagia
3) Weight loss
4) Bleeding
5) Anemia

90

Length of fasting before EGD

8 hours

91

EGD vs double contrast upper GI series: More sensitive

EGD

92

Most serious complication of EGD

Esophageal perforation

93

Double contrast upper GI series is better than EGD in detecting

1) Diverticula
2) Fistula
3) Tortuosity or stricture location
4) Size of hiatal hernia

94

Gold standard for H. pylori diagnosis

Antral mucosal biopsy

95

Urease secreted by H. pylori converts urea to

Ammonia + bicarbonate

96

Tests that can be used to confirm cure from H. pylori

1) Urease breath test
2) Fecal antigen test

97

H. pylori: Gastric vs duodenal

Duodenal > gastric

98

Largest predictor of PUD risk

Smoking

99

Males vs females: Duodenal ulcer

Males

100

Peptic ulcer formed after severe brain damage

Cushing ulcer

101

Associated blood type: Duodenal ulcer

O

102

Associated blood type: Gastric ulcer

A

103

Classification of gastric ulcer

Modified Johnson

104

Modified Johnson classification of gastric ulcer

Type I-V

105

Modified Johnson classification of gastric ulcer: Located near incisura angularis on lesser curvature; normal or decreased acid secretion

Type I

106

Modified Johnson classification of gastric ulcer: Located near incisura angularis on lesser curvature; associated active or quiescent duodenal ulcer

Type II

107

Modified Johnson classification of gastric ulcer: Located near incisura angularis on lesser curvature; normal or increased acid secretion

Type II

108

Modified Johnson classification of gastric ulcer: Prepyloric

Type III

109

Modified Johnson classification of gastric ulcer: Increased vs decreased gastric acid secretion, type III

Normal or increased

110

Modified Johnson classification of gastric ulcer: Near GEJ

Type IV

111

Modified Johnson classification of gastric ulcer: Increased vs decreased gastric acid secretion, Type IV

Normal or decreased

112

Modified Johnson classification of gastric ulcer: NSAID induced anywhere in stomach

Type V

113

Peptic ulcer formed after severe burn injury

Curling ulcer

114

Gastric vs duodenal ulcer: H. pylori

Both

115

Gastric vs duodenal ulcer: NSAID overuse

Gastric

116

Gastric vs duodenal ulcer: Increased acid production

Duodenal

117

Gastric vs duodenal ulcer: Steroid overuse

Gastric

118

2nd most common complication of PUD

Perforation

119

Why all gastric ulcers must undergo endoscopy and biopsy

To rule out cancer and test for H. pylori

120

Management for gastric ulcer

Triple therapy, antacids

121

Management for duodenal ulcer

Triple therapy, stop smoking and alcohol consumption

122

Most common symptom of PUD

Abdominal pain

123

Indications for endoscopy in PUD

1) Symptomatic >= 45 y/o
2) Symptomatic any age if with alarm symptoms

124

Mainstay of therapy for PUD

PPI

125

PUD: Indications for surgery

1) Bleeding
2) Perforation
3) Obstruction
4) Intractability

126

T/F Best/First-line management for non healing ulcer is surgery

F, consider other differentials for non healing PUD first

127

Surgery for nonhealing PUD is only considered if

1) Multiple recurrences
2) >2 cm
3) (+) complications
4) Suspected malignancy

128

Most common gastric ulcer type

Type I

129

Gastric ulcer types associated with acid hypersecretion

II and III

130

PUD: Most common cause of ulcer related death

Bleeding

131

Most common cause of UGIB in admitted patients

PUD