Stomach Flashcards

1
Q

A 68-year-old male with a history of hypertension and hypercholesterolemia presents to his primary care physician’s office with a chief complaint of worsening epigastric pain and weakness. The pain is improved with oral intake, especially milk-based products. The patient has been treating his pain with naproxen.

In the office, the patient is non-toxic with normal vital signs. His physical examination reveals mild epigastric tenderness with deep palpation. Serum hemoglobin was 8.3 g/dL. Fecal occult blood testing was positive. The patient underwent colonoscopy, which was normal.

Esophagogastroduodenoscopy (EGD) revealed a 2.5 cm ulcerated lesion with elevated, irregular borders 5 cm distal to thegastroesophageal junction.

Appropriate management of the ulcer includes?

A. Observation

B. Cessation of naproxen and begin sucralfate and a proton-pump inhibitor with repeat EGD in 3 months

C. Biopsy the ulcer

D. Proximal gastrectomy

E. Total gastrectomy

A

C.

Historically, biopsy of gastric ulcers was uniform practice throughout medical and surgical disciplines since there was a 5% to 11% attendant risk of malignancy. However, data now suggest that the incidence of gastric cancer is decreasing, thereby rendering mandatory biopsy of all gastric ulcers unnecessary.

When gastric ulcers have features suggestive of malignancy such as elevated irregular folds, association with a polypoid or fungated mass, and abnormal adjacent mucosal folds, then biopsy is warranted. Several biopsies, typically 6 or more, are necessary to minimize the false negative risk. If benign ulcers are diagnosed, then EGD is repeated in 6 weeks to ensure resolution. All ulcers should be followed and biopsied until complete resolution occurs.

If malignancy is detected, then further work-up with potential operative intervention is pursued.

Ulcers with a diameter of 3 cm or greater are termed giant gastric ulcers (Fig. 23-2). These large ulcers harbor an underlying malignancy in 30% of lesions.

Given the higher incidence of malignancy, perforation, and bleeding, surgical treatment is warranted.

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2
Q

A 68-year-old male with a history of hypertension and hypercholesterolemia presents to his primary care physician’s office with a chief complaint of worsening epigastric pain and weakness. The pain is improved with oral intake, especially milk-based products. The patient has been treating his pain with naproxen. In the office, the patient is non-toxic with normal vital signs. His physical examination reveals mild epigastric tenderness with deep palpation. Serum hemoglobin was 8.3 g/dL. Fecal occult blood testing was positive. The patient
underwent colonoscopy, which was normal. Esophagogastroduodenoscopy (EGD) revealed a 2.5 cm ulcerated lesion with elevated, irregular borders 5 cm distal to the gastroesophageal junction.

Final pathology reveals a poorly differentiated adenocarcinoma. The most sensitive preoperative examination to determine and N stage is:

A. Positron emission tomography (PE) scan

B. Endoscopic ultrasound (EUS)

C. Magnetic resonance imaging (MRI) with gadolinium

D. Diagnostic laparoscopy

E. Triple-phase helical computed tomography (CT) scan

A

B.

EUS is important in preoperative locorégional staging for gastric cancer. It is currently the best imaging modality for assessing both tumor depth and nodal invasion. Spatial resolution of 0.1 mm can be achieved with EUS. T staging accuracy ranges from 60% to 90%, whereas N staging accuracy ranges from 50% to 80% EUS is better at identifying T1 (80%) and T3 (90%) lesions as opposed to T2 (38.5%).

EUS is not reliable at delineating between individual benign and malignant lymph nodes. Increasing T stage directly correlates with increased risk of nodal and distant metastasis (> 80% likelihood of nodal metastasis in T3 disease versus < 5% in stage T1 m).

CT remains an important preoperative tool to evaluate for metastatic disease. If metastatic disease is present, an unnecessary operation can be avoided.

T staging accuracy with CT approaches 80% (66% to 77%). N stage determination is variable with a wide range of 25% to 86%.

Small gastric tumors and metastases less than 5 mm can be missed on CT.

CT, MRI, and PET scanning show promise for preoperative staging, but have yet to become standard of care.

Routine diagnostic laparoscopy to minimize unnecessary operations has become a less popular pre-resection strategy.

However, diagnostic laparoscopy still has a role in advanced gastric cancer. Power et al., in 2009, evaluated patients with known gastric cancer without obvious metastatic disease and stratified them into low-risk (Tl-2, NO) and high-risk (T3-4, N+ , or both) groups based on EUS. Both
groups underwent diagnostic laparoscopy, which identified Ml disease in 20.5% of the high-risk patients and 4% of the low-risk patients.

The study concluded that laparoscopy can be avoided in patients with EUS early stage cancer, whereas more advanced
gastric cancers would benefit from diagnostic laparoscopy to rule out occult metastatic disease.

When diagnostic laparoscopy is performed, peritoneal lavage cytology should be obtained as positive results
can alter further therapy. Diagnostic laparoscopy, however, does not address the N stage.

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3
Q

A 68-year-old male with a history of hypertension and hypercholesterolemia presents to his primary care physician’s office with a chief complaint of worsening epigastric pain and weakness. The pain is improved with oral intake, especially milk-based products.

The patient has been treating his pain with naproxen. In the office, the patient is non-toxic with normal vital signs. His physical examination reveals mild epigastric tenderness with deep palpation. Serum hemoglobin was 8.3 g/dL. Fecal occult blood testing was positive. The patient underwent colonoscopy, which was normal.

Esophagogastroduodenoscopy (EGD) revealed a 2.5 cm ulcerated lesion with elevated, irregular borders 5 cm distal to the gastroesophageal junction.

The EUS suggests a T3N0 lesion. The most appropriate next step would be:

A. Neoadjuvant therapy

B. Proximal gastrectomy with negative margins (RO) only

C. Total gastrectomy

D. Total gastrectomy with splenectomy and distal pancreatectomy

E. Esophagogastrectomy with colonic interposition graft

A

A.

Although the patient will ultimately need an operation, the MAGIC trail demonstrates that the patient will benefit from neoadjuvant therapy instead of proceeding straight to the operating room, unless the patient is hemorrhaging from the mass resulting in hemodynamic instability.

Neoadjuvant therapy consisting of epirubicin, cisplatin, and fluorouracil is recommended for patients with T2 lesions or higher.

The benefits from the preoperative therapy are to reduce tumor size and stage, eliminate micrometastases, improve tumor-related symptoms, and determine whether tumors are sensitive to chemotherapy.

Gastric adenocarcinoma exists as two distinct entities: diffuse and intestinal type:

INTESTINAL
Age: Older
Gender: M>F
Mets: Hematologic
Site of mets: Liver
Risk factors: Atrophic gastritis, intestinal metaplasia, H. pylori, diet high in salt, smoked and preserved food
Cellular etiology: Glandular gastric mucosa
Prognosis: Better
DIFFUSE
Age: Younger
Gender: M=F
Mets: Lymphatic, submucosal spread which can result in a thickened, non-distensible stomach (linitis plastica)
Site of mets: Peritoneum
Risk factors: CHD-1 mutation, obesity
Cellular etiology: Lamina propria
Prognosis: Poor

Controversies surrounding the surgical management of gastric adenocarcinoma include: adequacy of surgical margins, need for resection of adjacent structures (i.e. spleen and distal pancreas), and extent of lymphadenectomy.

Diffuse type gastric adenocarcinoma spreads in the submucosa, thereby increasing the risk of microscopic residual positive margin (R1 resection).

In order to minimize the risk of leaving microscopic disease or recurrence, a 5 to 6 cm margin is considered acceptable for an R0 resection.

Newer studies emerging from Japan suggest that smaller proximal resection margins of 2 to 3 cm are adequate for T1 lesions.

If the patient went straight to surgery, total gastrectomy is preferred as the tumor is within 5 cm of the gastroesophageal junction.

Esophagogastrectomy is unnecessary when the gastroesophageal junction has no direct tumor involvement and surgical margins exceed 5 cm.

Assessing nodal disease at the time of operation can be difficult. A minimum of 15 lymph nodes is recommended for staging. Most surgeons tend to remove the perigastric lymph nodes (DI resection).

In countries like Japan where gastric cancer has a higher prevalence, a more aggressive D2 lymphadenectomy is frequently employed harvesting lymph nodes along the celiac trunk and its named branches, the middle colic artery, the superior mesenteric artery, and the periaortic area.

Several studies have demonstrated prolonged survival with the more aggressive (D2) lymphadenectomy. This is thought to be related to better locorégional disease control.

A recent randomized trial comparing DI versus D2 lymphadenectomy did not reveal a significant difference in long-term survival. Accordingly, more studies regarding the extent of lymphadenectomy
are required before a long-term endorsement of this more aggressive strategy can be made.

Removal of adjacent structures (ie., distal pancreas and spleen) confer no survival benefit and actually increase morbidity and mortality. Resection of these adjacent structures should be reserved for primary tumor invasion.

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4
Q

A 68-year-old male with a history of hypertension and hypercholesterolemia presents to his primary care physician’s office with a chief complaint of worsening epigastric pain and weakness. The pain is improved with oral intake, especially milk-based products.

The patient has been treating his pain with naproxen. In the office, the patient is non-toxic with normal vital signs. His physical examination reveals mild epigastric tenderness with deep palpation. Serum hemoglobin was 8.3 g/dL. Fecal occult blood testing was positive. The patient underwent colonoscopy, which was normal.

Esophagogastroduodenoscopy (EGD) revealed a 2.5 cm ulcerated lesion with elevated, irregular borders 5 cm distal to the
gastroesophageal junction.

The final pathology revealed a T4N1 lesion with negative margins. The patient should next receive:

A. No additional therapy

B. Imatinib

C. External-beam radiation only

D. Fluorouracil-based chemotherapy only

E. External-beam radiation and fluorouracil-based chemotherapy

A

E.

The final pathology revealed Stage III gastric cancer. Given the high rate of locorégional failure (40% to 70%) and a 5-year survival rate of 20% to 28%, adjuvant therapy is recommended. This recommendation originates from the Intergroup Trial 0116, which demonstrated a benefit for those patients with advanced
gastric cancer undergoing curative resection combined with postoperative fluorouracil-based chemotherapy and radiation.

The CLASSIC trial demonstrated survival advantages using an adjuvant chemotherapy therapy regimen of capecitabine and oxaliplatin.

Resection without adjuvant therapy resulted in decreased survival when compared with those who received postoperative chemoradiation.

Palliation can be achieved with either external-beam radiation or chemotherapy, but local control and long-term survival are poor. Imatinib is a tyrosine-kinase
inhibitor currently used for gastrointestinal stromal tumors and other malignancies.

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5
Q

Which of the following describes the association between Irish’s node and gastric cancer?

A. An anterior mass palpable on digital rectal examination

B. A metastatic left supraclavicular lymph node

C. An ovarian mass from metastatic tumor

D. Metastatic left axillary lymph node

E. Umbilical mass suggestive of metastatic gastric cancer

A

D.

In general, physical findings portend advanced disease. Patients are typically cachectic and jaundiced when nodal metastatic disease obstructs the common bile duct.

Irish’s node is an enlarged lymph node within the left axilla.

A prerectal mass palpable on digital rectal examination is a Blumer shelf suggestive of a drop metastasis.

Virchow’s node, also known as Troisier’s sign, refers to carcinomatous involvement of the left supraclavicular lymph nodes at the junction of the thoracic duct with the subclavian vein.

Krukenberg tumors are ovarian masses from metastatic gastric cancer.

The Sister Mary Joseph node is a periumbilical nodule suggestive of carcinomatosis. It reflects tumor extension from the falciform ligament.

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6
Q

A 62-year-old man with hypertension was referred to the general surgery clinic for further evaluation of chronic abdominal pain, bloating, and early satiety, which had been worsening over several months. He was previously healthy except for hypertension controlled with metoprolol and a history of inguinal hernia repair.

His last screening colonoscopy performed 2 years ago was negative. On review of systems, he endorses significant fatigue. Laboratory results are consistent with mild anemia. An abdominal CT scan was obtained for
further evaluation and revealed a large tumor of gastric origin (pictured below).

The best next step to definitively diagnose this lesion is:

A. Abdominal MRI

B. Endoscopic ultrasound with FNA

C. Percutaneous image-guided biopsy

D. Diagnostic laparoscopy with biopsy and peritoneal washings

A

B.

The CT slice shown demonstrates a large, well-demarcated, heterogeneously enhancing mass that appears to grow outward from the wall of the stomach.

These findings are characteristic of gastric GIST, although the differential diagnosis includes gastric adenocarcinoma, carcinoid, lymphoma,or leiomyosarcoma, as well as tumors of pancreatic, renal, or adrenal
origin.

GIST is a relatively uncommon neoplasm, with an incidence of about 7 per million population in the United States and Europe. The benefits of EUS include defining the layer of stomach wall from which the tumor originates, delineating its relationship to surrounding structures, and obtaining a tissue diagnosis transluminally, which avoids the risk of seeding a percutaneous biopsy tract.

Percutaneous image-guided biopsy may result in intraperitoneal tumor spillage or
hemorrhage as a result of the friable, vascular nature of these tumors and is therefore less desirable.

MRI offers no additional benefit over CT diagnostically, though it may provide more information regarding the tumors relationship to surrounding tissues. Diagnostic laparoscopy with peritoneal washings for cytology has a prognostic role in gastric adenocarcinoma, but a similar role has not been established in GIST.

Laparoscopic excision of the lesion may be performed without a tissue diagnosis for a small tumor, but the goal in this case is resection to clear margins, rather than simply to obtain tissue for diagnostic purposes and therefore, endoscopic ultrasound is the best choice.

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7
Q

Biopsied tissue is positive for KIT (CD 117) upon immunochemical staining. Which of the following is true of this type of tumor?

A. Gastrointestinal stromal tumor (GIST) most commonly arises from the stomach.

B. The most common subtype is epithelioid.

C. A positive stain tor KIT (CD 117) is required to make the diagnosis of GIST.

D. The most common site of metastatic spread is the peritoneum.

E. All tumors >1 cm should be considered potentially malignant.

A

A.

The presence of the c-kit receptor tyrosine kinase on tumor cells, as in this case, is diagnostic of GIST.

However, it is noteworthy that about 5% of gastrointestinal stromal cells tumors are KIT-negative and only about 80% have a KIT mutation.

Other useful histologic markers include CD34 and smooth-muscle actin, if KIT negative GIST is suspected. The most common histologic subtype is the spindle-cell variety (70%), followed by epithelioid (20%) and mixed subtypes (10%).

All tumors greater than 2 cm in size should be considered malignant, even in the absence of metastases on initial work-up. The most common site of metastatic spread of GIST is the liver, followed by the omentum
and peritoneum. If present, these metastases are often identified by contrast enhanced CT scanning.

Metastasis to the lymph nodes, lung, or other distant sites may occur, but this is quite rare. Thus, extended surgical lymphadenectomy is not indicated for these tumors.

Over half of all GISTs arise from the stomach, making it the most common primary site.

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8
Q

Further review of the CT scan raises concerns that this 6-cm tumor may involve the neck of the pancreas. There is no evidence of distant metastatic disease. Further therapy in this case should include:

A. Surgical resection with en-bloc removal of the involved pancreas to achieve 1 cm negative margins.

B. Neoadjuvant imatinib prior to surgical therapy.

C. Avoidance of pancreatectomy by enucleation of the tumor.

D. An open rather than laparoscopic approach should be used.

E. An extended lymphadenectomy should be performed.

A

B.

When surgical morbidity can be reduced by its use, preoperative therapy with imatinib, a receptor tyrosine kinase inhibitor, should be strongly considered.

In this case, tumor down-staging could potentially eliminate involvement with the pancreas and obviate the need for pancreatectomy.

For localized GIST, surgical resection is indicated and is curative for low risk lesions. If necessary to achieve an R0 resection, en-bloc removal of involved organs outside the primary site is indicated. However, there is no additional survival benefit to resection beyond microscopically negative margins.

An extended lymphadenectomy also offers no benefit to the patient, as nodal metastasizes are uncommon with GIST occurring about 1% of the time.

Enucleation of the tumor risks violating its pseudocapsule which may result in intraoperative tumor spillage, resulting in recurrence rates approaching 100%. Though laparoscopic surgery for GIST has not been prospectively evaluated, there is good retrospective evidence to show adequate oncologic outcomes with this approach.

Rates of R0 resection between 97% and 100% and disease free survival and overall survival rates of over 90%.

In the past, an open approach for tumors larger than 5 cm has been recommended.

Current guidelines indicate that laparoscopy is appropriate for larger tumors, providing
sound oncologic principles are maintained.

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9
Q

Af er appropriate therapy, final pathology returns with a GIST of gastric origin, 6 cm in greatest dimension with 15 mitoses per high-power field.

Which of the following is true regarding this patient?

A. Adjuvant therapy with imatinib will increase his chance of recurrence-free and overall survival at 5 years.

B. If this lesion were in the small bowel, the prognosis would be better.

C. This patient is at low risk of tumor recurrence.

D. Five year overall survival for all GIST patients is about 50%.

A

A.

Tumor size, mitotic rate, and location are important prognostic factors in GIST. Tumors with a size < 5 cm have a 5-year overall survival of about 70%.

This drops to about 45% when tumor size is > 10 cm.

Similarly, about 75% of patients with < 5 per
high-power field will survive 5 years, only 20% of those with more than 5 per high-powered field are alive at 5 years. Tumors of gastric origin are more favorable than those originating in the small bowel, with survival rates of approximately 75% and 50%, respectively, after 5 years.

Tumor rupture before or during surgery also portends a poor prognosis, as discussed above. Given the mitotic rate of the tumor in
this case, the patient has a relatively poor prognosis.

Adjuvant therapy with imatinib for 1 year has been shown to increase recurrence free survival by 15% and, if continued for 3 years, improve 5-year overall survival by 10%. However, about half of all patients will develop resistance to the drug within 2 years of its initiation. For these patients, other tyrosine kinase inhibitors (i.e. sunitinib) remain effective second line therapy.

Historically, the overall survival for all patients with GIST at 5 years has been about 50%. However, in the era of imatinib, the 5-year OS has improved to 84%, though survival varies markedly between patients with Stage 1 tumors (nearly 100%) versus more Stage 3 and higher tumors (22%).

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10
Q

Which of the following is true of gastrointestinal stromal tumors?

A. Because they arise from the mucosa, GISTs are easily identified at endoscopy.

B. Surgical resection is often appropriate for patients with recurrent or metastatic GIST.

C. These tumors arise from the smooth-muscle cells of the intestinal wall.

D. GIST tends to arise as a solitary lesion.

E. Abdominal pain is the most common clinical manifestation of GIST.

A

D.

Gastrointestinal stromal tumors are more likely to be solitary than multiple. This stands in contrast to carcinoid tumors, which often occur multiply. They arise from the muscular layer of the intestinal wall, but
from the interstitial cells of Cajal, not the smooth muscle cells.

Their location in the muscular layer can make small GISTs somewhat difficult to detect and lead to underestimation of tumor extent by endoscopy.

At presentation, GIST is frequently found to be metastatic, most commonly to the liver or peritoneum. Presenting symptoms may include abdominal pain, dyspepsia, or early satiety, but gastrointestinal bleeding is the most common occurrence, leading to the eventual diagnosis of a GIST. Life-threatening hemorrhage from intraperitoneal rupture of these highly vascular tumors may also occur.

Generally speaking, imatinib chemotherapy is considered first line therapy for metastatic or recurrent GIST and surgical resection is often inappropriate due to high rates of recurrence.

However, some patients with tumors response to imatinib and lesions that are felt
to be completely resectable may benefit. I

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11
Q

A 56-year-old man with a 4-month history of vague epigastric abdominal pain, decreased appetite and weight loss presents to his local gastroenterologist for evaluation. An esophagogastroduodenoscopy (EGD) reveals
non-specific gastritis and a polypoid lesion in the region of the antrum. Laboratory findings note mild anemia, elevated LDH, and H. pylori positive samples from the EGD.

Follow-up endoscopic ultrasound (EUS) notes a thickened antral wall, and multiple biopsies obtained reveal an extra-nodal marginal zone B cell lymphoma of mucosa (gut)-associated lymphoid tissue (MALT) type (MALT lymphoma). Computed tomography of the
chest, abdomen, and pelvis reveals thickening of the distal half of the stomach with no evidence of adenopathy. Bone marrow biopsy reveals no evidence of disease dissemination.

After the patient has undergone a complete staging work-up as noted above, what stage low-grade gastric MALT lymphoma does this patient have?

A. Stage I

B. Stage II

C. Stage III

D. Stage IV

E. Unknown

A

A.

The staging of gastric lymphoma is paramount in the proper management of the disease. Although often indolent, approximately 10% of patients with gastric lymphoma will present with advanced disease.

EGD allows for visualization of the lesion and often tissue sampling as well as H. pylori diagnosis. Endoscopic ultrasound is also an important diagnostic procedure that can determine extent of disease, depth of invasion, and often allows more complete tissue sampling.

EUS also allows for accurate estimates of
depth of invasion, which is an important prognostic marker for disease recurrence. CT of the chest, abdomen, and pelvis is important to assess for disseminated disease while a bone marrow biopsy will detect evidence of distant disease in up to 15% of patients.

Standard laboratory testing includes complete blood count and LDH, as well as other standard chemistries.

Based on the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines, the Lugano Staging System for Gastrointestinal Lymphoma is adequate. This modification of the Ann
Arbor Staging System is noted below, directly compared with the Ann Arbor Staging System.

Utilizing either staging system is appropriate. Based these staging systems, the above patient has Stage I disease.

Lugano Staging System
Stage I - The tumor is confined to the gastrointestinal tract. It can be a single primary lesion or multiple, noncontiguous lesions.

Stage II - The tumor extends into the abdomen. This is further subdivided based upon the location of nodal involvement:

• Stage II1 - Involvement of local nodes (paragastric nodes for gastric lymphoma or para-intestinal nodes for intestinal lymphoma)

• Stage II2: Involvement of distant nodes (paraaortic, para-caval, pelvic, or inguinal nodes for most tumors; mesenteric nodes in the case of
intestinal lymphoma)

• Stage IIE: The tumor penetrates the serosa to involve adjacent organs or tissues

Stage III - There is no stage III disease in this system.

Stage IV - There is disseminated extranodal involvement or concomitant supra-diaphragmatic nodal involvement.

Ann Arbor Staging System
Stage I - Involvement of a single lymph node region (I) or of a single extralymphatic organ or site (IE)*

Stage II - Involvement of two or more lymph node regions or lymphatic structures on the same side of the diaphragm alone (II) or with involvement of limited, contiguous extralymphatic
organ or tissue (IIE)

Stage III - Involvement of lymph node regions on both sides of the diaphragm (ID), which may include the spleen (HIS) or limited, contiguous extralymphatic organ or site (HIE) or both (IIIES)

Stage IV - Diffuse or disseminated foci of involvement of one or more extralymphatic organs or tissues, with or without associated lymphatic involvement

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12
Q

A 56-year-old man with a 4-month history of vague epigastric abdominal pain, decreased appetite and weight loss presents to his local gastroenterologist for evaluation. An esophagogastroduodenoscopy (EGD) reveals
non-specific gastritis and a polypoid lesion in the region of the antrum. Laboratory findings note mild anemia, elevated LDH, and H. pylori positive samples from the EGD.

Follow-up endoscopic ultrasound (EUS) notes a thickened antral wall, and multiple biopsies obtained reveal an extra-nodal marginal zone B cell lymphoma of mucosa (gut)-associated lymphoid tissue (MALT) type (MALT lymphoma). Computed tomography of the
chest, abdomen, and pelvis reveals thickening of the distal half of the stomach with no evidence of adenopathy. Bone marrow biopsy reveals no evidence of disease dissemination.

The proper surgical management of this patient with gastric lymphoma is:

A. Total gastrectomy with D2 lymph node dissection

B. Total gastrectomy with D1 lymph node dissection

C. Partial gastrectomy with D1 lymph node dissection

D. Partial/total gastrectomy with no lymph node dissection

E. Surgical resection is not warranted in most cases

A

E. Gastric lymphoma is the second most common gastric malignancy (behind gastric adenocarcinoma) and the most frequent cite of extra-nodal non-Hodgkin’s Lymphoma. For decades, surgical resection was considered appropriate therapy for all stages of “resectable” gastric lymphomas.

Although surgical resection has provided outstanding results and excellent long-term survival, stomach preserving methods have provided equivalent results without the morbidity associated with gastrectomy (partial or total) for both low-grade and high-grade B-cell lymphomas.

A prospective trial by the German Multicenter Trial group in 2005 examined 185 patients with Stage I and II low-grade gastric lymphoma and noted no difference in survival between those patients treated surgically and those receiving no surgical intervention.

A follow-up study by the same group examined an additional 393 patients and provided similar results. The results are similar for high-grade gastric lymphomas, where survival rates between primary
surgery and primary chemotherapy and radiation therapy groups is equivalent.

Surgical intervention for gastric lymphoma is largely reserved for rare cases of perforation, or hemorrhage that cannot be
controlled endoscopically.

Stomach preserving treatment strategies are now the standard of care in the management of gastric lymphoma.

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13
Q

A 56-year-old man with a 4-month history of vague epigastric abdominal pain, decreased appetite and weight loss presents to his local gastroenterologist for evaluation. An esophagogastroduodenoscopy (EGD) reveals non-specific gastritis and a polypoid lesion in the region of the antrum. Laboratory findings note mild anemia, elevated LDH, and H. pylori positive samples from the EGD.

Follow-up endoscopic ultrasound (EUS) notes a thickened antral wall, and multiple biopsies obtained reveal an extra-nodal marginal zone B cell lymphoma of mucosa (gut)-associated lymphoid tissue (MALT) type (MALT lymphoma).

Computed tomography of the chest, abdomen, and pelvis reveals thickening of the distal half of the stomach with no evidence of adenopathy. Bone marrow biopsy reveals no evidence of disease dissemination.

First line therapy for a MALT lymphoma as noted in the patient above would consist of which of the following?

A. Surgical resection

B. Radiation therapy

C. Chemotherapy

D. H. pylori eradication

E. Watchful waiting

A

D.

Gastric MALT lymphomas arise from B-cells and constitute approximately 50% of gastric lymphomas, with the diffuse large B-cell lymphoma making up the other large proportion of gastric lymphomas.

Although surgical therapy was considered the mainstay of therapy for decades, in the late 1980s, a connection between Campylobacter (later Helicobacter) pylori, chronic gastritis and mucosal associated lymphoid tissue (MALT) was suspected.

By the early 1990s, the connection between the two was firmly established and the treatment of gastric MALT lymphoma with H. pylori eradication was
instituted. A meta-analysis of 34 studies with 1271 patients noted an overall H. pylori eradication rate of 98.3%, associated with a complete remission of
gastric lymphoma in 77.8% of patients.

The relapse rate for patients was 2.2% per year, and only 0.05% of patients had transformation of low-grade lymphoma into an aggressive, high-grade lymphoma.

Frequent endoscopic monitoring (3 month intervals initially) is paramount to assess for treatment response. Patients with pathology revealing clearance of H. pylori and resolution of lymphoma will require continued surveillance. Those patients with persistent H. pylori should receive additional eradication therapy. If gastric lymphoma persists despite multiple rounds of anti-H. pylori therapy, the
addition of external beam radiation and/or chemotherapy is warranted.

Patients with H. pylori negative gastric MALT lymphoma often have a documented translocation t(ll;18), and thus eradication therapy is often not effective. These patients are treated with radiation
therapy as first-line therapy. Rituximab has shown some effectiveness in these patients as well, and is currently considered in those patients with persistent localized disease and a contraindication to radiotherapy.

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14
Q

What is the management for persistent, localized, MALT lymphoma following repeatedly failed efforts at H. pylori eradication therapy?

A. Radiation therapy

B. Surgical resection

C. Chemotherapy

D. Rituximab

E. Bevacicumab

A

A.

The management of persistent, localized, early stage gastric MALT lymphoma is radiation therapy. Although there are various approaches taken in the management of these patients, radiation therapy (external beam, 30-40 cGy) has shown excellent
results and is the recommended treatment by NCCN guidelines.

In general, first-line salvage therapy provides remission rates of 90.1%. Radiation therapy was superior to chemotherapy or surgery, with a 97.3% remission rate versus 92.5% for surgery, and 85.3% for chemotherapy.

In fact, radiation therapy as a sole therapy was found to be superior to even combined
modality approaches.

Further support for radiation therapy is provided by Goda, et al. who noted an overall remission rate of 92% with excellent long-term (10-year) survival data.

Additional studies show long-term remission rates of 88% to 97% (5 to 7.8 years).

For some patients with Stage I disease, chemotherapy may be added to radiotherapy, but this is not considered the standard approach.

Chemotherapy for low-grade gastric MALT lymphoma is typically reserved for persistent Stage II disease or patient presenting with more advanced disease (Stage IIE or IV).

The exact chemotherapeutic regimen for advanced stage gastric MALT lymphoma is not well established, but is often treated with agents utilized against follicular lymphomas.

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15
Q

How does the treatment strategy change in patients with high-grade gastric lymphoma (advanced MALT lymphoma or diffuse large B-cell lymphoma)?

A. Surgical resection

B. Radiation therapy alone

C. Chemotherapy alone

D. H. pylori eradication

E. Combined chemotherapy with or without radiation therapy

A

E.

As addressed earlier, surgical therapy has been largely abandoned as the primary treatment of gastric lymphoma, including patients with advanced gastric MALT lymphoma and gastric diffuse large B-cell lymphoma (DLBCL).

A study examining the long-term outcomes in patients treated with surgery alone, surgery followed by radiation therapy, surgery followed by chemotherapy and chemotherapy alone noted that complete response rates were similar in
the 4 arms.

But, survival was significantly improved in patients receiving chemotherapy, with no clear benefit to combined modality therapy with surgery and chemotherapy.

In fact, late toxicity was more frequent and severe in patients who had surgery.

In terms of H. pylori eradication, studies are ongoing. It was once thought that there was little benefit in treating H. pylori in these patients, since there was no MALT component in most patients.

Although there are cases exhibiting both gastric MALT lymphoma and DLBCL, first-line therapy was typically targeted at the more aggressive entity.

Recently, there has been some success noted with H. pylori eradication in early stage DLBCL patients that are H. pylori positive.

In comparing patients with pure gastric DLBCL and mixed (MALT and DLBCL), H. pylori eradication rates were 100% and 94.1%, respectively.

Remission rates were 68.8% for pure DLBCL and 56.3% for the mixed gastric DLBCL. Prospective studies are ongoing.

Currently, chemotherapy, with or without biologic therapy, is considered first-line therapy for gastric DLBCL, which is considered the more aggressive of the two most common gastric lymphomas.

NCCN clinical practice guidelines note that Stage I and II disease are treated with chemotherapy with localized radiation therapy added in certain cases.

The chemotherapeutic regimens utilized vary, but the most common regimen combines cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) and often the addition of a biologic agent (riuximab) (R-CHOP).

The CHOP regimen shows complete remission (CR) rates of 87% to 100% with good long-term survival.

An examination of the R-CHOP regimen reveals similar statistics with a CR rate of 87%, with the remaining 13%exhibiting a partial remission.

The addition of radiation therapy for early stage disease has been examined and there was a notable decrease in local recurrences in those patients treated with radiation therapy.

But, radiation therapy did not add to overall survival when compared with chemotherapy alone. Overall, radiation therapy is selectively added to chemotherapy in patients with gastric DLBCL, specifically for local control.

For patients with more advanced disease (specifically Lugano Stage IV), chemotherapy alone is utilized with radiation therapy reserved as needed for local control of symptoms.

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16
Q

A 58-year-old male presents to your clinic with upper abdominal pain and heartburn alter meals. He occasionally relieves symptoms with chewable antacids (calcium carbonate). He denies other problems except for gaining 5 lbs over the last year with decreased exercise. He has no surgical history, takes no medications, and has no significant family history. He used to smoke, but quit 15 years ago and drinks 2 glasses of red wine each night.

Other than improving his diet and decreasing his alcohol intake, what medication would you prescribe to best limit his esophageal acid exposure?

A. Proton pump inhibitor (PPI)

B. H2 receptor antagonist (H2RA)

C. Calcium carbonate

D. Sucralfate as needed

A

A.

The mainstay of medical treatment of GERD is acid suppression. Patients with persistent symptoms should be given PPIs, such as omeprazole. In doses as high as 40 mg/d, they can effect an 80% to 90% reduction in gastric acidity.

In patients with reflux disease, esophageal acid exposure is reduced by up to 80% with H,RAs and up to 95% with PPIs. Despite
the superiority of the latter class of drug over the former, periods of acid breakthrough still occur.
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17
Q

A 58-year-old male presents to your clinic with upper abdominal pain and heartburn alter meals. He occasionally relieves symptoms with chewable antacids (calcium carbonate). He denies other problems except for gaining 5 lbs over the last year with decreased exercise. He has no surgical history, takes no medications, and has no significant family history. He used to smoke, but quit 15 years ago and drinks 2 glasses of red wine each night.

He is started on the medication and experiences relief. He returns to your clinic 1 year later, but now the medication is no longer relieving his symptoms. He also reports occasional cough and the sensation that he has to clear his throat. What should be your next step?

A. Esophagogastroduodenoscopy (EGD)

B. Perform barium swallow

C. Perform 24 hr ambulatory pH monitoring

D. Perform pulmonary function tests

A

A.

If after a year of successful symptom relief, the symptoms are no longer controlled by a single medication and he has developed extraesophageal symptoms (cough and sensation of postnasal drip) of GERD, then consideration should be given to prescribing another PPI.

It is important, though, to rule out ulcers, malignancy, a hiatal hernia, esophagitis or other esophageal, gastric, or duodenal erosive pathology. Therefore, EGD is the best option for direct mucosal visualization.

If no other pathology can account for the symptoms, a 24-hour pH monitoring would be the next step in diagnosis. This would determine if acid reflux is the cause of the patient’s symptoms.

A barium swallow could add some more information but is not diagnostic.

Halitosis would be an indicator of a diverticulum (Zenker’s) or possibly achalasia in which food is retained within the esophagus.

A better study to evaluate these pathologies is barium swallow esophagram. Pulmonary function tests are not indicated for evaluation of the patients cough.

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18
Q

A 58-year-old male presents to your clinic with upper abdominal pain and heartburn after meals. He occasionally relieves symptoms with chewable antacids (calcium carbonate). He denies other problems except for gaining 5 lbs over the last year with decreased exercise. He has no surgical history, takes no medications, and has no significant family history. He used to smoke, but quit 15 years ago and drinks 2 glasses of red wine each night.

He follows up in 3 weeks with a barium swallow, pH monitoring, and an EGD from an outside provider. He provides a copy of the 24 hr ambulatory pH monitoring report to you, which can be viewed below. He has a sliding (Type I) hiatal hernia, and
no evidence of intestinal metaplasia or ulcers.

ACID REFLUX COMPOSITE SCORE ANALYSIS (JOHNSON/DEMEESTER) (pH)

Upright time in reflux: 10.4% (5.1) (NV: <6.3)

Recumbent time in reflux: 10.0% (21.9) (NV: <1.2)

Total time in reflux: 10.2% (7.3) (NV: <4.2)

Episodes over 5 min: 5.4 (4.9) (NV: <3.1)

Longest episode: 41.7min (15.1) (NV: <9.2)

Total episodes: 48.6 (2.9) (NV: <50.1)

Composite score: 57.1 (NV: <22)

What is the intervention would you offer him at this time?

A. Esophagectomy

B. Nissen fundoplication

C. Heller myotomy with Dor fundoplication

D. Botulinum toxin injection

A

B.

The acid reflux composite score analysis shown is consistent with the diagnosis of GERD. Therefore, a Nissen fundoplication is an appropriate surgical choice for this patient with refractory GERD and a sliding hiatal hernia.

Since the patient does not have high-grade dysplasia or evidence of esophageal cancer, esophagectomy would not be the correct choice.

The patient has a type I sliding hiatal hernia, not a paraesophageal hernia (Types II, III, and IV), therefore answer C would not be correct (see diagram).

Botulinum toxin and Heller myotomy with Dor fundoplication are used in the treatment of achalasia, but would not be indicated in a patient with GERD.

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19
Q

What is the most common long-term complication of a Nissen fundoplication?

A. Stricture

B. Gastroesophageal leak

C. Gas bloat syndrome

D. Dysphagia

E. Slipped Nissen

A

D. Early complications of Nissen fundoplication: gastroesophageal leak, pneumothorax, abscess, and hematoma.

Of these, the most common is dysphagia.

Late complications of Nissan fundoplication: stricture, gas bloat syndrome, wrap disruption, wrap herniation, and dysphagia.

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20
Q

A 58-year-old male presents to your clinic with upper abdominal pain and heartburn alter meals. He occasionally relieves symptoms with chewable antacids (calcium carbonate). He denies other problems except for gaining 5 lbs over the last year with decreased exercise. He has no surgical history, takes no medications, and has no significant family history. He used to smoke, but quit 15 years ago and drinks 2 glasses of red wine each night.

He undergoes a Nissen fundoplication without complication and is discharged the following day. Five days after surgery, he returns for follow up appointment reporting left upper quadrant pain. He is hemodynamically normal and has a hemoglobin one point lower than his preoperative values. CT scan of the chest, abdomen, and pelvis shows a heterogeneous left upper quadrant fluid collection without rim enhancement and an associated small left pleural effusion.

What is the most appropriate initial management for this patient?

A. Admit for fluids and observation

B. Admit for antibiotics and total parenteral nutrition

C. Return to the operating room

D. Percutaneous drainage

A

A.

Development of fluid collection postoperatively without instability in vital signs, fever, WBC or other evidence of infection is most suspicious for hematoma.

The development of the collection of five days postoperatively would indicate a slow bleed, not requiring urgent reoperation.

Percutaneous drainage would increase the risk of introducing bacteria and infecting the fluid collection. Conservative management including hydration and observation is recommended for a small, stable hematoma. Antibiotics are not indicated without evidence of infection.

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21
Q

A 63-year-old female with a long history of gastroesophageal reflux disease presents to your clinic after a gastroenterologist performs an EGD. She is diagnosed with Barretts esophagus without evidence of dysplasia based upon the results of several biopsies.

When should her next EGD with biopsy be performed for appropriate surveillance?

A. 3 months

B. 6 months

C. 1 year

D. 3 years

A

C. Barrett’s esophagus without dysplasia has a risk of 0.1% to l%rate of progression to adenocarcinoma and initial surveillance should be with annual EGD with biopsy. Low grade dysplasia requires surveillance every 6 months until no dysplasia is found.

If no more dysplasia is found, surveillance can be extended to once every 3 years. High-grade dysplasia has a 5-year risk of adenocarcinoma of 30% and must be intervened upon with excision or ablation or
undergo endoscopic surveillance every 3 months.

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22
Q

A 63-year-old female with a long history of gastroesophageal reflux disease presents to your clinic after a gastroenterologist performs an EGD. She is diagnosed with Barretts esophagus without evidence of dysplasia based upon the results of several biopsies.

Her follow-up EGD demonstrates Barrett esophagus with low-grade dysplasia on multiple biopsies, so she is scheduled for follow up EGD in 6 months. She presents to the ER 12 hours later with rapid respirations, tachycardia, fever, and elevated WBC. Based upon your clinical suspicions, what is the best initial diagnostic test?

A. Gastrografin esophagography

B. Thin barium esophagography

C. CT with IV contrast for PE/DVT protocol

D. EGD

A

A. The patient has suffered an iatrogenic esophageal perforation.

The best initial test for diagnosis of this is esophagram with water-soluble contrast such as gastrografin.

If this does not demonstrate leak, thin barium should be used next.

The WBC elevation and acute nature of the presentation in relationship to the EGD procedure makes PE less likely than esophageal perforation.

EGD would not be recommended in this scenario as it could enlarge the perforation.

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23
Q

A 63-year-old female with a long history of gastroesophageal reflux disease presents to your clinic after a gastroenterologist performs an EGD. She is diagnosed with Barretts esophagus without evidence of dysplasia based upon the results of several biopsies.

A small intrathoracic perforation is confirmed. In your determination of a management plan, which of the following is an absolute contraindication to non-operative management?

A. Time of perforation >72 hrs

B. A history of Barrett’s esophagus with low grade dysplasia

C. Perforation contained in the mediastinum

D. Evidence of SIRS (systemic inflammatory response syndrome)

A

D.

Operative management is imperative in the
patient who is becoming unstable (developing a SIRS response) as it may become life-threatening. It should be considered if the perforation is not well-contained, in the acute time period after the procedure, or there is associated malignancy. In contrast, non-operative
management should be considered if the time of perforation > 72 hrs, there is no evidence of associated malignancy, or the perforation is well-contained.

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24
Q

A 63-year-old female with a long history of gastroesophageal reflux disease presents to your clinic after a gastroenterologist performs an EGD. She is diagnosed with Barretts esophagus without evidence of dysplasia based upon the results of several biopsies.

The patient has a small thoracic esophageal perforation with a left sided effusion and is
developing low blood pressure. After beginning resuscitation, you determine she needs to go to surgery for repair of the leak. Based upon the most likely location of these types of injuries, which incision would you use to expose the esophagus for repair?

A. Right postcriolatcral thoracotomy

B. Left postcriolatcral thoracotomy

C. Median sternotomy

D. Laparotomy

A

B. The surgical approach to the distal esophagus is a left posteriolateral thoracotomy. Any esophageal injury should be buttressed with other tissue like nearby pleura, a pericardial at pad, pedicled intercostal muscle, or the diaphragm.

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25
Q

A 78-year-old female with arthritis and asthma presents to the emergency room with an acute onset of epigastric pain a couple of hours ago. Her pulse is 104, her blood pressure is unchanged trom her baseline of 110/74 mmHg, and her temperature is 98.2 Fahrenheit. Her medications include occasional naproxen and prednisone for occasional exacerbations of her asthma. On physical exam, her abdomen demonstrates significant epigastric tenderness with rebound. She has a mild leukocytosis of 12.5 cells/mcL. Her acute abdominal series demonstrates a small amount of free air.

1What is the most reasonable current treatment option for this patient as the next step?

A. Laparoscopic highly selective vagotomy without resuscitation

B. Nasogastric tube insertion, cessation of all oral feeds, & intravenous fluid initiation for the next 24 hours

C. Open truncal vagotomy with pyloroplasty

D. Open Graham patch with parietal cell vagotomy despite laparoscopic experience and resources

E. Emergent anterior seromyotomy

A

B. Of all the listed options, nasogastric tube insertion with NPO status and initiation of IV fluid is a very reasonable first step in the modern era of H. pylori detection and treatment, especially in a stable patient.

Graham patch with parietal cell vagotomy is also a very reasonable option but an
open approach is more problematic if laparoscopic experience and resources are available.

The verification of resuscitation is required prior to going to the operating room for patients. The verification in this patient can simply be assessing volume status (e.g.,
urine output of 0.5 cc/kg/hour or normal heart rate for a patient not on a beta-blocker.

Truncal vagotomy with pyloroplasty is not a first-line treatment in the modern era of H. Pylori. Anterior seromyotomy, division of the seromuscular layer of the lesser curvature in order to achieve a highly selective vagotomy effect, is a reasonable approach but not as a first option.

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26
Q

A 78-year-old female with arthritis and asthma presents to the emergency room with an acute onset of epigastric pain a couple of hours ago. Her pulse is 104, her blood pressure is unchanged trom her baseline of 110/74 mmHg, and her temperature is 98.2 Fahrenheit. Her medi¬
cations include occasional naproxen and prednisone for occasional exacerbations of her asthma. On physical exam, her abdomen demonstrates significant epigastric
tenderness with rebound. She has a mild leukocytosis of 12.5 cells/mcL. Her acute abdominal series demonstrates a small amount of free air.

If she does not demonstrate improvement during the 12 hours after onset of symptoms, what is the most reasonable and expedient next step?

A. Truncal vagotomy with antrectomy and a Billroth II reconstruction

B. Continued observation

C. Selective angioembolization

D. Laparoscopic Graham patch only and H. Pylori testing with possible treatment

E. Laparoscopic Graham patch with parietal cell vagotomy

A

D. Laparoscopic Graham patch with H. Pylori testing and subsequent testing is the best choice of those presented.

Truncal vagotomy with antrectomy is no longer a first- line option in the modern era of H. Pylori detection and treatment.

Observation is not reasonable if the patient is not improving and a more aggressive management choice is most likely necessary.

Angioembolization maybe considered for
bleeding peptic ulcer disease in selective cases but not for perforation of an ulcer. Parietal cell vagotomy is no longer considered one of the early line treatments but to be reserved as a treatment option for
refractory peptic ulcer disease.

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27
Q

A 78-year-old female with arthritis and asthma presents to the emergency room with an acute onset of epigastric pain a couple of hours ago. Her pulse is 104, her blood pressure is unchanged trom her baseline of 110/74 mmHg, and her temperature is 98.2 Fahrenheit. Her medications include occasional naproxen and prednisone for occasional exacerbations of her asthma. On physical exam, her abdomen demonstrates significant epigastric tenderness with rebound. She has a mild leukocytosis of 12.5 cells/mcL. Her acute abdominal series demonstrates a small amount of free air.

What testing should be done for follow-up?

A. Secretin stimulation test

B. H. pylori stool antigen testing

C. Emergent urea breath testing

D. Colonoscopy

E. Both A and C

A

B.

H. Pylori stool antigen testing is a very reasonable approach and can even be ordered semi emergently in the emergency room at some institutions to help in decisions with early treatment options.

Secretin stimulation test is utilized for gastrinoma work-up, which is not yet necessary during this part of the work-up for this patient since recalcitrant peptic ulcer disease is not yet identified.

Urea breath testing for H. pylori is reasonable but is not an emergent process as obtaining this test requires a clinical lab.

Colonoscopy is reasonable in a patient over the age of 50 who has not had a screening process done but is not required to address the follow-up for peptic ulcer disease perforation.

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28
Q

A 78-year-old female with arthritis and asthma presents to the emergency room with an acute onset of epigastric pain a couple of hours ago. Her pulse is 104, her blood pressure is unchanged trom her baseline of 110/74 mmHg, and her temperature is 98.2 Fahrenheit. Her medications include occasional naproxen and prednisone for occasional exacerbations of her asthma. On physical exam, her abdomen demonstrates significant epigastric tenderness with rebound. She has a mild leukocytosis of 12.5 cells/mcL. Her acute abdominal series demonstrates a small amount of free air.

What further follow-up is necessary if she has no further symptoms?

A. Long-term intravenous pantoprazole

B. Nothing

C. Chronic suppressive antibiotics

D. Serum gastrin level

E. Esophagogastroduodenoscopy with biopsy of ulcer if still present

A

E.

Esophagogastroduodenoscopy (EGD) is necessary to rule out a gastric carcinoma that caused the perforation, especially in older patients. Pantoprazole, another proton-pump inhibitor, or H2 blockers
are reasonable to start on admission for perforated peptic ulcer disease but long-term treatment is not absolutely necessary, especially after treatment for H. Pylori.

Treatment of H. Pylori with a course of
antibiotics but chronic suppression should not be necessary. Serum gastrin level can be checked for a patient who is suspected of gastrinoma but is not necessary if the patient’s peptic ulcer is healed.

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29
Q

A 51-year-old female presents to the emergency department. She complains of abdominal pain that has gotten worse over the last several days. The pain is sharp and
located right under her “breast bone.” It seems to happen right after she eats or drinks and this morning it doubled her over.

She relates that she has had this feeling
before, but it was never this bad. She has some nausea but no vomiting.

Past medical history is significant for hypertension, obstructive sleep apnea on CPAP, hypercholesteremia, and type 2 diabetes (which she states has been normal since her one month post op visit).

Her surgical history is significant for one C-section about 15 years ago and a laparoscopic gastric bypass 9 months ago. She denies any drug use. She drinks a glass of red wine most evenings to “help her heart.”

After much probing she relates that even though she quit smoking 6 months prior to surgery, she resumed smoking about 6 months ago and is back up to one pack per day. She relates that at the time of her surgery she weighed 345 lbs with a BMI of 59 kg/m2 and now has lost 120 lbs with a BMI of 38.6 kg/m2. She hasn’t seen a bariatric surgeon since her 3 month postoperative visit, mostly because she is embarrassed that she started smoking
again. She stopped taking her omeprazole 4 months ago when her prescription ran out. She also started taking 81mg aspirin after watching a documentary on heart disease and obesity.

Vital signs are: HR 115, BP 97/62, RR 18, Pulse Ox 98% on RA. Her exam is noted to have diffuse abdominal tenderness, significant tenderness in the epigastrium, with voluntary guarding. Bowel sounds are absent. Hemo-occult testing is positive.

Which of the following is a factor that is potentially contributing to this patient’s current problem?

A. Hypercholesterolemia

B. Active smoking

C. Obstructive sleep apnea

D. Increase in carbohydrate intake

E. Age >50

A

B.

This patient most likely has a marginal ulcer,
which, at a rate of about 5% after Roux-en-Y gastric bypass, is one of the more common complications.

Risk factors associated with the development of marginal (gastrojejunal/anastomotic) ulcers include environmental (smoking and alcohol), medication (NSAIDs), anatomical (gastro-gastric fistula or an enlarged gastric pouch), and technique (use of nonabsorbable sutures).

There is no link associated with specific food types and ulcer formation. Other risk factors that are associated with marginal ulcer (MU)
are increased acid exposure via a gastro-gastric fistula (not confirmed in this patient but more commonly seen with patients that have had an open gastric bypass versus laparoscopic), hypertension, and use of non-absorbable suture in the anastomosis and recent surgery.

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30
Q

Which of the following is the most common
complication (early or late) following laparoscopic gastric bypass?

A. Internal hernias

B. Small bowel obstruction

C. Marginal ulceration (anastomotic/gastro-jejunal ulcer)

D. Gastrojejunal leak

A

C.

Marginal ulcers are a late complication of gastric bypass surgery. Along with gastrojejunostomy (GJ) stricture they are one of the most common complications (early or late) of gastric bypass surgery.

Reported rates of MU range from 1% to 25%, with most series indicating 5% incidence. GJ stricture rates are reported between 3% to 27%. The incidence of internal hernia after gastric bypass is nearly non-existent in the open gastric bypass, but after laparoscopic gastric bypass occurs in approximately 2.5% of patients.

Small bowel obstruction is linked to internal hernia formation and the rates are equivalent. GJ leaks are an early complication after gastric bypass.

In the laparoscopic approach, rates are reported at about 1% to 1.8%.

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31
Q

Which of the following statements is true with regards to marginal ulcer following gastric bypass?

A. Most marginal ulcers are asymptomatic.

B. Over one-third of patients with marginal ulcer formation smoke.

C. Active H. pylori infection is an independent risk factor for ulcer perforation.

D. Use of proton pump inhibitors is not protective of ulcer formation in the setting of nonsteroidal anti-inflammatory drugs (NSAID) use.

E. Suture material or type of anastomosis performed does not relate to ulcer formation.

A

B.

Of patients presenting with MU, over 30% are found to be smoking at the time of diagnosis. Most MU are symptomatic (72%).

Those symptoms that are most common after surgery that lead to the diagnosis of MU are: pain (34%), dysphagia (17%), weight gain (13%), nausea and vomiting (8%), and GI bleed (3%).

Active H. pylori infection has not been determined to be an independent risk factor in the development of perforated MU. There is data that suggests that in the setting of patients that must use NSAIDs following gastric bypass that proton pump inhibitors (PPIs) are protective of MU formation.

While there is still debate as to whether hand-sewn gastrojejunostomy (GJ) versus stapled anastomosis is better with relationship to post operative outcomes, the data clearly relates that non-absorbable suture material at the anastomosis has a high association with MU formation. Because of this fact, the use of non-absorbable suture at the GJ anastomosis has essentially ceased.

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32
Q

Regarding treatment of marginal ulcers (MU) following gastric bypass:

A. The majority can be successfully managed medically.

B. Nearly half of patients will require revision of the gastrojejunostomy for persistent and/or recurrent ulcers.

C. Late MU are self-limiting and rarely require treatment.

D. H. pylori infection pre-operatively or persistence postoperatively increases perforation rates.

E. Endoscopy is of limited value in the treatment of marginal ulcer.

A

A. The Ireatment of MU is largely medical. The standard of treatment is PPI therapy initiation/continuation and cytoprotective agents (i.e., sucralfate or carafate).

Additionally cessation of smoking and/or NSAID use is critical, as recurrence is high
in patients that continue with these high level risk factors.

Studies report the incidence of surgical intervention for MU to be 4% to 10%. This usually occurs in this subset of MU for recalcitrant and/or recurrent ulcers. Continued smoking and NSAID use were found to be independent risk factors for
continued non-healing ulcers. Late ulcers (those that occur after 30 days) are rarely self-limiting. In a study by Csendes they did a prospective evaluation of patients and performed endoscopy at 1 month and at 1 to 2 years. They found a 12% rate of MU at 1 month. Many authors believe this to be part of the natural progression and healing process of the anastomosis within such a short time frame. Most clinicians advocate for PPI use in the immediate postoperative period because of this. Clinically apparent MU is unlikely to heal without intervention (as mentioned above).

While the data is not completely clear about the role of II. pylori infection and ulcer formation, the risk of perforation of MU is not increased by the presence of H. pylori. One study found that in patients that were H. pylori positive and eradicated prior to surgery, the rate of MU after surgery with short term PPI use was significantly reduced.

Endoscopy should be part of the armamentarium of diagnosing and treating MU. Most ulcers become apparent within the first 12 months following surgery. While they can develop beyond 18 months following surgery this is not the most common time frame that they are seen.

The incidence of perforation in all patients undergoing laparoscopic gastric bypass is approximately 1% and the incidence of MU on average is 5% (range l%to 16%), therefore the rate of perforation of MU is 20%.

Felix et al. in 2008 found that many cases could be managed laparoscopically. In their series, over 30% were managed by oversewing of the ulcer and utilizing an
omental patch. Other series have confirmed similar treatment strategies for MU perforation utilizing the omental patch.

Times when it may be necessary or more appropriate to consider revising the G-J may
include MU with bleeding, with or without perforation; recurrent ulceration, when a gastro-gastric fistula is present; or when the pouch is greatly enlarged.

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33
Q

A 41-year-old female has a history of a Billroth II gastric bypass. Since the operation, the patient has had frequent nausea and vomiting and experiences palpitations dizziness, and flushing after meals. All of the following are management options for this patient except:

A. High protein diet

B. Octreotide

C. Conversion to Roux-en-Y bypass

D. Shortening of the afferent limb

E. Creation of a jejunal pouch

A

D. Shortening of the afferent limb

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34
Q

A 62-year-old male comes to the emergency room complaining of abdominal pain and bilious vomiting. He had a Billroth II procedure performed two weeks ago for intractable ulcer disease. A contrast barium study shows an obstructed loop of bowel. Which of the following is true regarding limb obstruction after a Billroth II?

A. An efferent loop obstruction is treated with a Roux-en-Y gastrojejunostomy

B. Chronic afferent loop obstruction may lead to megaloblastic anemia

C. Afferent loop obstructions often occur due to a retrocolic position of the anastomosis

D. Obstruction of the efferent limb can lead to accumulation of hepatobiliary secretions in a blind loop

E. Complete obstructions of the afferent loop often resolve with conservative management

A

B. Chronic afferent loop obstruction may lead to megaloblastic anemia

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35
Q

A 52-year-old male with a past medical history of peptic ulcer disease presents to the emergency department with burning abdominal pain and dark, tarry stools. An EGD is performed to evaluate a possible bleeding ulcer. Which of the following findings has the highest risk of rebleeding?

A. Ulcer with a central black spot

B. Nonbleeding visible vessel

C. Diffuse gastritis

D. An adherent clot

E. Ulcer with a clean base

A

B. Nonbleeding visible vessel

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36
Q

Which of the following is associated with large sliding hiatal hernias?

A. Curling’s ulcer

B. Cushing’s ulcer

C. Cameron’s ulcer

D. Marjolin’s ulcer

E. Marginal ulcer

A

C. Cameron’s ulcer

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37
Q

A 52-year-old male presents to the emergency room with hematemesis. He undergoes an EGD which shows active bleeding from a duodenal ulcer. There is a visible vessel at the base of the ulcer which is clipped, and epinephrine is injected. The bleeding is controlled, and the patient is transferred to the ICU for further management. Twelve hours later, he develops recurrent hematemesis. He is hemodynamically stable. What is the next best course of action?

A. Antrectomy and Billroth II reconstruction

B. Duodenotomy and oversewing of the gastroduodenal artery (GDA) with sutures placed superiorly, inferiorly, medially to the ulcer

C. Duodenotomy and oversewing of the GDA with sutures placed superiorly, inferiorly and laterally to the ulcer

D. Repeat endoscopy

E. Angiogram with attempted embolization

A

D. Repeat endoscopy

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38
Q

A 55-year-old female presents to the ER complaining of substernal chest pain and blood stools. She has a history of poorly controlled peptic ulcer disease. An NG lavage is performed, which is positive for bright red blood. The patient is taken to the OR for repair of a bleeding ulcer. The surgeon decides to proceed with a truncal vagotomy once the bleeding is controlled. Which of the following is TRUE regarding a truncal vagotomy?

A. Shown to benefit Type I and Type IV ulcers

B. Complications include a slowed emptying of liquids due to a loss of receptive relaxation

C. Majority of patients will have post-operative chronic diarrhea

D. A truncal vagotomy decreases acidic output by 50%

E. Incomplete transection of the left vagus is more common than the right

A

D. A truncal vagotomy decreases acidic output by 50%

Review Modified Johnson Classification

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39
Q

A 45-year-old female with a history of Crohn’s disease presents to the ER with abdominal pain, vomiting, and distension. A CT scan shows inflammatory changes and a stricture located at the proximal duodenum causing an obstruction. After one week of conservative management, the patient has no improvement in symptoms. What is the BEST surgical option for the patient?

A. No surgery unless complicated by perforation, fistula or abscess to avoid bowel shortening

B. Heineke-Mikulicz stricturoplasty

C. Finney stricturoplasty

D. Gastrojejunostomy

E. Whipple procedure

A

D. Gastrojejunostomy

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40
Q

The consistently largest artery to the stomach is the

A. Right gastric

B. Left gastric

C. Right gastroepiploic

D. Left gastroepiploic

A

B

The consistently largest artery to the stomach is the left gastric artery, which usually arises directly from the celiac trunk and divides into an ascending and descending branch along the lesser gastric curvature. Approximately 20% of the time, the left gastric artery supplies an aberrant vessel that travels in the gastrohepatic ligament (lesser omentum) to the left side of the liver.

Rarely, this is the only arterial blood supply to this part of the liver, and inadvertent ligation may lead to clinically significant hepatic ischemia in this unusual circumstance.

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41
Q

Which of the following inhibits gastrin secretion?

A. Histamine

B. Acetylcholine

C. Amino acids

D. Acid

A

D

Luminal peptides and amino acids are the most potent stimulants of gastrin release, and luminal acid is the most potent inhibitor of gastrin secretion.

The latter effect is predominantly mediated in a paracrine fashion by somatostatin released from antral D cells.

Gastrin-stimulated acid secretion is significantly blocked by H2 antagonists, suggesting that the principal mediator of gastrin-stimulated acid production is histamine from mucosal enterochromaffin-like (ECL) cells.

Acetylcholine released by the vagus nerve leads to stimulation of ECL cells, which in turn produce histamine.

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42
Q

Helicobacter pylori infection primarily mediates duodenal ulcer pathogenesis via

A. Antral alkalinization leading to inhibition of somatostatin release

B. Direct stimulation of gastrin release

C. Local inflammation with autoimmune response

D. Upregulation of parietal cell acid production

A

A

Helicobacter pylori possess that enzyme urease, which converts urea into ammonia and bicarbonate, thus creating an environment around the bacteria that buffers the acid secreted by the stomach.

H. pylori infection is associated with decreased levels of somatostatin, decreased somatostatin messenger RNA production, and fewer somatostatin-producing D cells.

These effects are probably mediated by H. pylori-induced local alkalinization of the antrum (antral acidification is the most potent antagonist to antral gastrin secretion), and H. pylori-mediated increases in other local mediators and cytokines.

The result is hypergastrinemia and acid hypersecretion, presumably leading to the parietal cell hyperplasia seen in many patients with duodenal ulcer.

Other mechanisms whereby H. pylori can induce gastrointestinal mucosal injury include the production of toxins (vacA and cagA), local elaboration of cytokines (particularly interleukin-8) by infected mucosa, recruitment of inflammatory cells and release of inflammatory mediators, recruitment and activation of local immune factors, and increased apoptosis.

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43
Q

The effect of erythromycin on gastric emptying is through its function as a

A. Dopamine antagonist

B. Cholinergic agonist

C. Motilin agonist

D. Cholinergic antagonist

A

C

Erythromycin is a common prokinetic agent used to treat delayed gastric emptying, and works as a motilin agonist.

Domperidone and metoclopramide, two other commonly used medications, function as dopamine antagonists.

Metoclopramide 10mg PO QID (Dopamine antagonist)

Erythromycin 250mg PO QID (Motilin agonist)

Domperidone 10mg PO QID (Dopamine antagonist)

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44
Q

Which if the following is secreted by gastric parietal cells?

A. Pepsinogen

B. Intrinsic factor

C. Gastrin-releasing peptide

D. Ghrelin

E. Histamine

A

B

Activated parietal cells secrete intrinsic factor in addition to hydrochloric acid. Presumably the stimulants are similar, but acid secretion and intrinsic factor secretion may not be linked.

Intrinsic factor binds to luminal vitamin B12, and the complex is absorbed in the terminal ileum via mucosal receptors.

Vitamin B12 deficiency can be life-threatening, and patients with total gastrectomy or pernicious anemia require B12 supplementation by a non-enteric route.

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45
Q

The most accurate diagnostic test or Zollinger-Ellison Syndrome (ZES) is

A. Fasting serum gastrin

B. Computed tomography (CT) scan

C. Endoscopy

D. Secretin stimulation test

A

D

All patients with gastrinoma have an elevated gastrin level, and hypergastrinemia in the presence of elevated basal acid output (BAO) strongly suggests gastrinoma.

Patients with gastrinoma usually have a BAO >15mEq/h or >5 mEq/h if they have had a previous procedure or peptic ulcer.

Acid secretory medications should be held for several days before gastrin measurement, because acid suppression may falsely elevate gastrin levels.

Causes of hypergastrinemia can be divided into those associated with hyperacidity and those associated with hypoacidity.

The diagnosis of Zollinger-Ellison syndrome (ZES) is confirmed by the secretin stimulation test.

An intravenous (IV) bolus of secretin (2 U/kg) is given and gastrin levels are checked before and after injection. An increase in serum gastrin of 200 pg/mL or greater suggests the presence of gastrinoma.

Patients with gastrinoma should have serum calcium and parathyroid hormone levels determined to rule out multiple endocrine neoplasia type 1 (MEN1) and, if present, parathyroidectomy should be considered before resection of gastrinoma.

See figure 26-1 (p.205, Schwartz ABSITE 10th Ed)

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46
Q

Which of the following is the preoperative imaging study of choice for gastrinoma?

A. CT scan

B. Magnetic resonance imaging (MRI)

C. Endoscopic ultrasound (EUS)

D. Angiographic localization

E. Somatostatin receptor scintigraphy

A

E

CT will detect most lesions >1cm in size and magnetic resonance imaging (MRI) is comparable.

Endoscopic ultrasound (EUS) is more sensitive than these other noninvasive imaging tests, but it still misses many of the smaller lesions, and may confuse normal lymph nodes for gastrinomas.

Currently, the preoperative imaging study of choice for gastrinoma is somatostatin-receptor scintigraphy (the octreotide scan).

When the pretest probability of gastrinoma is high, the sensitivity and specificity of this modality approach 100%.

Gastrinoma cells contain type II somatostatin receptors that bind the indium-labeled somatostatin analogue (octreotide) with high affinity, making imaging with a gamma camera possible.

Currently, angiographic localization studies are infrequently performed for gastrinoma. (See Schwartz 10th ed., pp.1072–1073.)

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47
Q

Patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin need concomitant acid suppressing medication if which of the following is present?

A. Age over 50

B. Heavy smoking history

C. Concurrent steroid intake

D. Heavy alcohol consumption

A

C

The overall risk of significant serious adverse gastrointestinal (GI) events in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) is more than three times that of controls.

This risk increases to five times in patients older than 60 years.

Factors that clearly put patients at increased risk for NSAID-induced GI complications include age >60, prior GI event, high NSAID dose, concurrent steroid intake, and concurrent anticoagulant intake.

Alcohol is commonly mentioned as a risk factor for peptic ulcer disease (PUD), but confirmatory data are lacking.

High doses of H2 blockers have been shown to be less effective than proton pump inhibitors (PPIs) in preventing GI complications in these high risk patients on antiplatelet therapy, but clearly they are better than no acid suppression.

(See Schwartz 10th ed., table26-6,p.1058.)

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48
Q

The optimal initial management of a patient hospitalized for a bleeding peptic ulcer is

A. Ulcer oversew

B. Vagotomy and pyloroplasty

C. Distal gastrectomy

D. Intravenous PPIs

A

Answer: D

The management of bleeding peptic ulcer is summarized in the algorithm in Fig. 26-2.

All patients admitted to hospital with bleeding peptic ulcer should be adequately resuscitated and started on continuous IV PPI.

Seventy-five percent of patients will stop bleeding with these measures alone, but 25% will continue to bleed or will rebleed in hospital.

Among the high risk group, endoscopic hemostatic therapy is indicated and usually successful. Only then should surgical intervention be considered, with indications including massive hemorrhage unresponsive to endoscopic control and transfusion requirement of more than four to six units of blood, despite attempts at endoscopic control.

Long-term maintenance PPI therapy should be considered in all patients admitted to hospital with ulcer complications.

(See Schwartz 10th ed., Figure 26-42, pp. 1061, 1064–1065, and 1069.)

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49
Q

Which of the following options is the least preferable reconstruction for patients undergoing antrectomy for PUD?

A. Billroth I.

B. Billroth II.

C. Roux-en-Y gastrojejunostomy.

D. All are equally preferable.

A

C

Following antrectomy, GI continuity may be reestablished with a Billroth I gastroduodenostomy or a Billroth II loop gastrojejunostomy.

Since antrectomy routinely leaves a 60 to 70% gastric remnant, routine reconstruction as a Roux-en-Y gastrojejunostomy should be avoided.

Although the Roux-en-Y operation is an excellent procedure for keeping duodenal contents out of the stomach and esophagus, in the presence of a large gastric remnant, this reconstruction will predispose to marginal ulceration and/or gastric stasis.

(See Schwartz 10th ed., p. 1063.)

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50
Q

A 55-year-old executive who is seen because of severe epigastric pain is found on esophagogastroduodenoscopy to have a large ulcer in the duodenal bulb and tests positive for H. pylori.

He is treated for H. pylori and instructed to quit smoking, but his symptoms persist and he is referred to you for further management. At this time, it would be most appropriate to recommend

A. NSAID cessation and urea breath test

B. Highly selective vagotomy

C. Truncal vagotomy and antrectomy

D. Truncal vagotomy and pyloroplasty

A

A

The indications for surgery in PUD are bleeding, perforation, obstruction, and intractability or nonhealing.

Intractability should be an unusual indication for peptic ulcer operation nowadays. The patient referred for surgical evaluation because of intractable PUD should raise red flags for the surgeon: maybe the patient has a missed cancer, is noncompliant, or has Helicobacter despite the presence of a negative test or pre- vious treatment (differential for intractability, Table 26-3).

In this setting, the patient with persistent symptoms despite appropriate treatment requires further evaluation before any consideration of operative treatment.

If surgery is necessary, a lesser operation may be preferable.

(See Schwartz 10th ed., Table 26-13, pp. 1059 and 1069–1071.)

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51
Q

Which blood group is associated with an increased risk of gastric cancer?

A. A

B. B

C. AB

D. O

A

Answer: A

Gastric cancer is more common in patients with pernicious anemia, blood group A, or a family history of gastric cancer.

When patients migrate from a high-incidence region to a low-incidence region, the risk of gastric cancer decreases in the subsequent generations born in the new region.

This strongly suggests an environmental influence on the development of gastric cancer.

Environmental factors appear to be more related etiologically to the intestinal form of gastric cancer than the more aggressive diffuse form.

The commonly accepted risk factors for gastric cancer are listed in Table 26-4.

(See Schwartz 10th ed., Table 26-15, pp. 1074–1075.)

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52
Q

A subtotal gastrectomy with D2 dissection performed for Stage 3 gastric adenocarcinoma in the antrum includes

A. Grossly negative margins of 2cm

B. More than 15 lymph nodes removed

C. Billroth II reconstruction

D. Splenectomy

A

Answer: B

Surgical resection is the only curative treatment or gastric cancer and most patients with clinically resectable locoregional disease should have gastric resection.

The standard operation or gastric cancer is radical subtotal gastrectomy, which entails ligation of the left and right gastric and gastroepiploic arteries at the origin, as well as the en bloc removal of the distal 75% of the stomach, including the pylorus and 2cm of duodenum, the greater and lesser omentum, and all associated lymphatic tissue.

Generally, the surgeon strives for a grossly negative margin of at least 5cm.

More than 15 resected lymph nodes are required or adequate staging, even in the low-risk patient. The operation is deemed an adequate cancer operation provided that tumor-free margins are obtained, >15 lymph nodes are removed, and all gross tumor is resected.

In the absence of involvement by direct extension, the spleen and pancreatic tail are not removed.

Reconstruction is usually by Billroth I gastrojejunostomy or Roux-en-Y reconstruction.

(See Schwartz 10th ed., p. 1081.)

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53
Q

The standard treatment for an isolated 3cm gastrointestinal stromal tumor (GIST) in the body of the stomach is

A. Imatinib

B. Endoscopic ablation

C. Wedge resection

D. Subtotal gastrectomy

A

Answer: C

Gastrointestinal stromal tumors (GISTs) are submucosal tumors that are slow growing, and arise from interstitial cells of Cajal (ICC).

Prognosis in patients with GISTs depends mostly on tumor size and mitotic count, and metastasis, when it occurs, is typically by the hematogenous route.

Any lesion >1cm can behave in a malignant fashion and may recur. Thus, all GISTs are best resected along with a margin of normal tissue—wedge resection with clear margins is adequate surgical treatment.

True invasion of adjacent structures by the primary tumor is evidence of malignancy.

If safe, en bloc resection of involved surrounding organs is appropriate to remove all tumor when the primary is large and invasive.

Five-year survival following resection for GIST is about 50%. Most patients with low-grade lesions are cured (80% 5-year survival), but most patients with high-grade lesions are not (30% 5-year survival).

Imatinib, a chemotherapeutic agent that blocks the activity of the tyrosine kinase product of c-kit, yields excellent results in many patients with metastatic or unresectable GIS, and is also recommended in high risk groups as an adjuvant therapy.

Fig. 26-3 shows an algorithm
for treatment of patients with GIST.

(See Schwartz 10th ed., Figure 26-59, pp. 1085–1086.)

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54
Q

Which of the following options is the best management of a low-grade gastric lymphoma of the gastric antrum?

A. H. pylori eradication

B. Chemotherapy ± radiationtherapy

C. Wedge resection

D. Antrectomy

A

Answer:A

Low-grade mucosa-associated lymphoid tissue (MALT) lymphoma, essentially a monoclonal proliferation of B cells, presumably arises from a background of chronic gastritis associated with H. pylori.

These relatively innocuous tumors then undergo degeneration to high-grade lymphoma, which is the usual variety seen by the surgeon.

Remarkably, when the H. pylori are eradicated and the gastritis improves, the low- grade MALT lymphoma often disappears.

Thus, low-grade MALT lymphoma is NOT a surgical lesion.

An algorithm or gastric lymphoma treatment is found in Fig. 26-4.

(See Schwartz 10th ed., Figure 26-58, pp. 1084–1085.)

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55
Q

Type III gastric carcinoid tumors

A. Often do not require resection

B. Are associated with hypergastrinemia

C. Are sporadic lesions

D. Have better outcomes than typeI and II tumors

A

Answer: C

Type III gastric carcinoids are sporadic tumors, most often solitary (usually>2cm), occur more commonly in men, and behave more aggressively than types I and II.

Unlike types 1 and II, they are not associated with hypergastrinemia.

Type I gastric carcinoids are the most common type of gastric carcinoid, and occur in patients with chronic hypergastrinemia secondary to pernicious anemia or chronic atrophic gastritis.

Type II is rare, and is associated with MEN1 and ZES.

Gastric carcinoids should all be resected,
and small lesions (<2cm) conjoined to the mucosa may be treated endoscopically with endoscopic mucosal resection (EMR) if there are only a few lesions (<5) and if margins are histologically negative.

Locally invasive lesions, or those >2 cm, should be removed by radical gastric resection and lymphadenectomy.

Survival is excellent for node-negative patients (>90% 5-year survival); node-positive patients have a 50% 5-year survival.

The 5-year survival or patients with type I gastric carcinoid is close to 100%; for patients with type III lesions, the 5-year survival is less than 50%.

Most type III patients have nodal or distant metastases at the time of diagnosis, and some present with symptoms of carcinoid syndrome.

(See Schwartz 10th ed., p. 1086.)

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56
Q

Watermelon stomach is best treated by

A. Acid-reducing agents

B. Beta-blockers

C. Antrectomy

D. Total gastrectomy

A

Answer: C

The parallel red stripes atop the mucosal folds of the distal stomach give this rare entity its name.

Histologically, gastric antral vascular ectasia (GAVE) is characterized by dilated mucosal blood vessels that often contain thrombi, in the lamina propria.

Mucosal fibromuscular hyperplasia and hyalinization often are present (Fig. 26-5). The histologic appearance can resemble portal hypertensive gastropathy, but the latter usually affects the proximal stomach, whereas watermelon stomach predominantly affects the distal stomach.

Beta blockers and nitrates, useful in the treatment of portal hypertensive gastropathy, are ineffective in patients with gastric antral vascular ectasia.

Patients with GAVE are usually elderly women with chronic GI blood loss requiring transfusion.

Most have an associated autoimmune connective tissue disorder, and at least 25% have chronic liver disease.

Nonsurgical treatment options include estrogen and progesterone, and endoscopic treatment with the neodymium yttrium- aluminum garnet (Nd:YAG) laser or argon plasma coagulator.

Antrectomy may be required to control blood loss, and this operation is quite effective but carries increased morbidity in this elderly patient group.

Patients with portal hypertension and antral vascular ectasia should be considered for transjugular intrahepatic portosystemic shunt (TIPSS).

(See Schwartz 10th ed., Figure 26-61, pp. 1088–1089.)

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57
Q

Treatment for severe early dumping after gastrectomy that is persistent despite an antidumping diet and fiber is

A. Expectant management

B. Oral glucose for symptoms

C. Octreotide

D. Surgical conversion to a Roux-en-Y drainage

A

Dumping is a phenomenon consisting of a constellation of postprandial symptoms thought to be the result o the abrupt delivery of a hyperosmolar load into the small bowel due to ablation of the pylorus or decreased gastric compliance.

Early dumping occurs 15 to 30 minutes after a meal, with patients becoming diaphoretic, weak, light-headed, and tachycardic.

Late dumping occurs hours later, and is due to a reactive hypoglycemia. Late dumping is relieved by the administration of sugar.

The medical therapy for the dumping syndrome consists of dietary management and somatostatin analogue (octreotide). Often, symptoms improve if the patient avoids liquids during meals.

Hyperosmolar liquids (eg, milk shakes) may be particularly troublesome. There is some evidence that adding dietary fiber compounds at mealtime may improve the syndrome.

If dietary manipulation fails, the patient is started on octreotide, 100 μg subcutaneously twice daily. This can be increased up to 500 μg twice daily if necessary. The long-acting depot octreotide preparation is useful. Octreotide not only ameliorates the abnormal hormonal pattern seen in patients with dumping symptoms, but also promotes restoration of a fasting motility pattern in the small intestine (ie, restoration o the migrating motor complex [MMC]).

Only a very small percentage of patients with dumping symptoms ultimately require surgery. Therefore, the surgeon should not rush to re-operate on the patient with dumping syndromes.

(See Schwartz 10th ed., p. 1091.)

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58
Q

Ménétrier disease is characterized by

A. Hypertrophic gastric folds and hypoproteinemia

B. A tortuous submucosal congenital arteriovenous malformation

C. Gastric antral vascular ectasia

D. Epithelial hyperplasia and hypergastrinemia

A

Answer: A

There are two clinical syndromes characterized by epithelial hyperplasia and giant gastric folds: ZES and Ménétrier disease.

The latter is characteristically associated with protein-losing gastropathy and hypochlorhydria.

A few patients with these unusual diseases have been successfully treated with the epidermal growth factor receptor blocking monoclonal antibody cetuximab.

There may be an increased risk of gastric cancer with this disease, and gastric resection may be indicated for bleeding, severe hypoproteinemia, or cancer.

The other options describe Dieulafoy lesions, watermelon stomach, and ZES, respectively.

(See Schwartz 10th ed., p. 1088.)

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59
Q

A 52-year-old male presents to the emergency department with hematemesis. He undergoes an EGD which shows active bleeding from a duodenal ulcer. There is a visible vessel at the base of the ulcer which is clipped, and epinephrine is injected. The bleeding is controlled, and the patient is transferred to the ICU for further management. Twelve hours later, he develops recurrent hematemesis. He is hemodynamically stable. What is the next BEST course of action?

a. Antrectomy and Billroth II reconstruction
b. Duodenotomy and oversewing of the gastroduodenal artery
c. Repeat endoscopy
d. Angiogram with attempted embolization

A

c. Repeat endoscopy

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60
Q

A 66-year-old female presents to your office with severe epigastric abdominal pain, bilious vomiting, and weight loss. The vomiting sometimes awakens her from sleep. It is not projectile in nature. She does not get any relief with over the counter antacids or omeprazole. There is no relief with food. She has a history of a stomach surgery 25 years ago for “ulcer disease”.What is the BEST treatment option for this patient?

a. Cholecystectomy
b. Nissen fundoplication
c. Conversion of previous gastric surgery to Roux-en-Y reconstruction
d. Shortening the afferent limb

A

c. Conversion of previous gastric surgery to Roux-en-Y reconstruction

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61
Q

A 44-year-old female presents to the emergency department with severe epigastric pain and nausea. She has recently been taking Ibuprofen for headaches daily. A chest x-ray shows air under the diaphragm. She is hemodynamically stable. She is brought to the operating room and is found to have a duodenal ulcer. What is the MOST appropriate surgical management?

a. Omental patch repair
b. Primary suture repair of perforation
c. Omental patch repair with highly selective vagotomy
d. Antrectomy, truncal vagotomy, and Billroth II reconstruction

A

a. Omental patch repair

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62
Q

Endoscopic evaluation of a 32/F with UGIB shows a 1 cm ulcer at the pre-pyloric area with adherent black slough at the ulcer base. Vital signs are stable. Hb is 9.9 gm%. The abdomen is unremarkable. The most logical treatment of the case is:

a. Emergency surgery
b. Transfusion and treatment with H2 receptor antagonist
c. Selective arteriography with embolization
d. Sclerotherapy followed by elective surgery

A

b. Transfusion and treatment with H2 receptor antagonist

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63
Q

Where does the lesser curvature abruptly angle to the right and the body of the stomach ends and the antrum begins?

A

Angularis incisura

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64
Q

Term for where the fundus forms with the left margin of the esophagus:

A

Angle of His

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65
Q

What is the arterial blood supply to the stomach?

A

4 main arteries: left gastric and right gastric arteries along the lesser curvature and left and right gastroepiploic arteries along the greater curvature; blood is also supplied to the proximal stomach by the inferior phrenic arteries and short gastric arteries and to the pylorus by the gastroduodenal artery

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66
Q

Approximate percentage that an aberrant left hepatic artery originates from the left gastric artery:

A

15% to 20%.

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67
Q

What is the largest artery to the stomach?

A

Left gastric artery

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68
Q

In general, what is the maximal number of arteries that can be ligated, provided that the arcades along the greater and lesser curvatures are intact, that will still supply enough blood flow for the stomach to survive?

A

3 of 4 arteries can be ligated

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69
Q

Describe the venous drainage of the stomach:

A

Left gastric (coronary) and right gastric veins usually drain into the portal vein; left gastroepiploic vein drains into the splenic vein; right vein drains into the superior mesenteric vein

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70
Q

What happens to the left vagus and right vagus at the gastroesophageal (GE) junction?

A

Left vagus becomes anterior and the right vagus becomes posterior (LARP mnemonic)

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71
Q

Where does the stomach receive its extrinsic parasympathetic and sympathetic innervation?

A

Parasympathetic via the vagus and sympathetic via the celiac plexus

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72
Q

Where does the sympathetic nerve supply to the stomach originate from?

A

From T5 to T10 (travels in splanchnic nerve to celiac ganglion)
Sensation of gastroduodenal pain via afferent sympathetic fibers

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73
Q

Which vagus gives off a hepatic branch to the liver and continues along the lesser curvature as the anterior nerve of Latarjet?

A

The left vagus

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74
Q

Which nerve gives off a branch to the celiac plexus and continues posteriorly along the lesser curvature?

A

The right vagus

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75
Q

Which nerve is the first branch of the risbt or posterior vagus nerve and can lead to recurrent ulcers if left undivided?

A

The criminal nerve of Grassi

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76
Q

Where along the vagus is a truncal vagotomy performed?

A

Above the celiac and hepatic branches of the vagi

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77
Q

Where along the vagus nerve is a selective truncal -vagotomy performed?

A

Below the celiac and hepatic branches of the vagi

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78
Q

Where along the vagus nerve is a highly selective vagotomy performed?

A

At the crows feet to the proximal stomach while preserving the portion innervating the antrum and pylorus

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79
Q

The intrinsic or enteric nervous system of the stomach consists of which autonomic plexuses?

A

Auerbach and Meissner autonomic plexuses

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80
Q

What layer of the stomach lies between the mucosa and the muscularis propria that is the strongest layer of the gastric wall?

A

Submucosa

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81
Q

How many layers of smooth muscle make up the muscularis propria (muscularis externa) of the stomach?

A

3 layers of smooth muscle

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82
Q

Which layer of the muscularls propria (muscularis externa) is the only complete muscle layer of the stomach wall, is circular, and becomes progressively thicker and functions as a true anatomic sphincter at the pylorus?

A

The middle layer of smooth muscle

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83
Q

Gastric mucosa consists of what kind of epithelium?

A

Columnar glandular epithelium

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84
Q

Where are parietal cells in the stomach mainly found? What do parietal cells secrete?

A

Body; secretion of intrinsic factor and acid

Intrinsic factor binds to B12 and is taken up in the terminal ileum

Pernicious anemia etiology is frequently an autoimmune process that destroys parietal cells, leading to a deficiency in intrinsic factor;
low B12 levels lead to a macrocytic anemia

Parietal cells are inhibited by somatostatin, PGEl, secretin, and CCK

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85
Q

Where in the stomach will there be a complete absence of parietal cells?

A

The cardia and prepyloric antrum

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86
Q

Where are chief cells in the stomach mainly found? What do chief cells secrete?

A

Body; pepsinogen

Converted to pepsin by gastric acid and is first enzyme of proteolysis

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87
Q

Where are G cells in the stomach mainly found? What do G cells secrete?

A

Antrum; gastrin
Release stimulated by amino acids and acetylcholine; inhibited by acidification of the duodenum
Why antrectomy can decrease acid secretion

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88
Q

Where are D cells in the stomach mainly found? What do D cells secrete?

A

Body and antrum; somatostatin Release stimulated by acidification of antrum and duodenum; inhibits gastrin and acid release

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89
Q

Where are gastric mucosal interneurons mainly found? What peptide is released by gastric mucosal interneurons?

A

Body and antrum; gastrin-releasing peptide

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90
Q

Where are endocrine cells in the stomach mainly found? What hormone do endocrine cells in the stomach release?

A

Body; ghrelin Stimulates appetite, increases food intake, promotes fat storage; released when stomach is empty and inhibited by stomach stretch; acts on hypothalamic brain cells Stomach

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91
Q

Process by which the proximal portion of the stomach relaxes in anticipation of food intake:

A

Receptive relaxation and gastric accommodation

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92
Q

Name ulcerogenic (excess add secretion) causes of hypergastrinemia:

A
Antral G-cell hyperplasia or hyperfunction, 
gastric outlet obstruction, 
retained excluded antrum, 
short-gut syndrome, 
Zollinger-Ellison syndrome
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93
Q

Name nonulcerogenic (normal or low add secretion) causes of hypergastrinemia:

A
Acid-reducing procedure (vagotomy), 
antisecretory agents (proton pump inhibitors [PPis] ), 
atrophic gastritis, 
chronic renal failure, 
Helicobacter pylori infection, 
pernicious anemia
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94
Q

What are the 3 local stimuli that regulate gastric add secretion by the parietal cell?

A

Acetylcholine,
gastrin, and
histamine

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95
Q

The basal level of acid secretion accounts for roughly what percentage of maximal add output?

A

10%

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96
Q

What is the approximate rate of hydrochloric add production during basal add secretion?

A

1 to 5 mmol/h

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97
Q

What are the 3 phases of add secretory response to a meal?

A

Cephalic, gastric, and intestinal

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98
Q

Histamine utilizes which second messenger to stimulate add secretion by parietal cells?

A

Intracellular cyclic AMP

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99
Q

Acetylcholine and gastrin utilize which second messenger to stimulate add secretion by parietal cells?

A

Calcium (phospholipase C converts membrane-bound phospholipids into inositol triphosphate [IP3], which mobilizes calcium from intracellular stores)

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100
Q

Mechanism by which PPis inhibit add secretion:

A

A covalent disulfate bond forms between the drug and the cysteine residues on the subunit of the H/K-ATPase leading to irreversible inhibition of the proton pump

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101
Q

Why do PPls have a longer duration of action than their plasma half-life?

A

The drug is covalently bonded to the H/K-ATPase leading to irreversible inhibition, so new proton pumps need to be synthesized before the recovery of acid secretion occurs

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102
Q

What converts pepsinogen into pepsin?

A

Gastric acid

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103
Q

How is the maximal acid output (MAO) determined after gastric analysis?

A

By averaging the output of the last two 15-minute periods after secretagogue administration

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104
Q

What is the usual range for MAO?

A

10 to 15 mEq/h 190

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105
Q

How is the peak acid output obtained after gastric analysis?

A

It is the highest rate of secretion obtained during a 15-minute period following secretagogue administration

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106
Q

Gastric motility begins with the depolarization of which cells?

A

Gastric pacemaker cells of Cajal located in the midbody of the stomach along the greater curvature

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107
Q

How many phases are in the myoelectric migrating complex (MMC)?

A

4 phases

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108
Q

How long does each cycle of the MMC last?

A

90 to 120 minutes

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109
Q

What happens in phase I of the MMC?

A

Also known as the quiescent phase; slow waves are present without action potentials; increase in gastric tone but no gastric contraction

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110
Q

What happens in phase II of the MMC?

A

Motor spikes are associated with slow waves and occasional gastric contractions; gallbladder contraction

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111
Q

What happens in phase III of the MMC?

A

Motor spike activity is associated with each slow wave; forceful gastric contractions happen every 15 to 20 seconds; the stomach is cleared oflarge indigestible food substances

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112
Q

What happens in phase IV of the MMC?

A

A brief recovery period before the next MMC cycle

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113
Q

List protective factors to gastric barrier function:

A

Blood flow, bicarbonate secretion, cell renewal, endogenous prostaglandins, growth factors, mucus production

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114
Q

List damaging factors to gastric barrier function:

A

Duodenal reflux of bile, ethanol ingestion, H. pylori, hydrochloric acid secretion, hypoxia, ischemia, nonsteroidal antiinflammatory drugs (NSAIDs}, pepsins, smoking

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115
Q

Approximate percentage of gastric ulcers associated with H. pylori:

A

75%

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116
Q

Approximate percentage of duodenal ulcers associated with H. pylori:

A

90%

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117
Q

Most common cause of peptic ulcer disease:

A

H. pylori infection; eradication is imperative-treated with a combination of PPI and antibiotics

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118
Q

What is the second most common cause of peptic ulcer disease?

A

NSAID ingestion; blocks COX-1 enzyme, disrupts prostaglandin production leading to less protective mucus

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119
Q

Where do gastric ulcers usually occur?

A

On the lesser curve near the incisura (60%; type I)

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120
Q

What is a type I gastric ulcer?

A

Gastric ulcer occurring on the lesser curvature near the incisura

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121
Q

What is a type II gastric ulcer?

A

Gastric ulcer located in the body of the stomach in combination with a duodenal ulcer

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122
Q

What is a type III gastric ulcer?

A

Prepyloric gastric ulcer

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123
Q

What is a type IV gastric ulcer?

A

Gastric ulcer that occurs high on the lesser curve near the GE junction

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124
Q

What is a type V gastric ulcer?

A

Drug-induced (NSAIDs) gastric ulcer that may occur anywhere in the stomach

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125
Q

Which types of gastric ulcer are not associated with excess acid secretion?

A

Type I and IV

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126
Q

Which types of gastric ulcer are associated with excess acid secretion?

A

Type II and III

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127
Q

Name the ulcer: multiple, superficial erosions that begin in the proximal stomach and progress distally in a patient with central nervous system disease:

A

Cushing ulcer

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128
Q

Name the ulcer: multiple, superficial erosions that begin in the proximal stomach and progress distally in a patient with >30% body surface area burn:

A

Curling ulcer

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129
Q

Where in the stomach is stress gastritis usually seen?

A

Fundus

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130
Q

Initial management for a patient with stress gastritis with UGI bleeding:

A

ABCs; fluid resuscitation with correction of any platelet/coagulation abnormalities; blood transfusion if needed; administration of broad-spectrum IV antibiotics in patients with sepsis, saline lavage of the stomach through a nasogastric (NG) tube; administration of antisecretory agents after the NGT aspirate runs clear

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131
Q

Dose of vasopressin for the control of acute GI bleeding:

A

0.2 to 0.4 IU/min as a continuous infusion for a maximum of 48 to 72 hours

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132
Q

Indications for operation with stress gastritis:

A

Recurrent or persistent bleeding requiring >6 units of blood (3000 mL)

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133
Q

After taking the patient to the operating room, how would you control the bleeding associated with stress gastritis in a hemodynamically stable patient?

A

Make a long anterior gastrotomy along the proximal stomach/fundus; clear the gastric lumen of blood; inspect the mucosa! surface for bleeding points; oversew all bleeding areas with figure-of-eight stitches taken deep within the gastric wall; close the anterior gastrotomy; perform a truncal vagotomy and pyloroplasty (less commonly, a partial gastrectomy with vagotomy can be performed)

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134
Q

After taking a patient with life-threatening hemorrhage refractory to other forms of therapy to the operating room, what procedure would you perform to control the bleeding?

A

Gastric devascularization procedure (faster) versus total gastrectomy

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135
Q

Term for a disruption of the gastric mucosa (high on lesser curve at GE junction) that results from forceful vomiting, retching, coughing, or straining:

A

Mallory-Weiss tear

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136
Q

What percentage of acute UGI bleeds are accounted for by Mallory-Weiss tears?

A

15%

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137
Q

What is the overall mortality rate from a Mallory-Weiss tear?

A

3% to 4%

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138
Q

Treatment for active bleeding from a Mallory-Weiss tear that continues after initial resuscitation?

A

Esophagogastroduodenoscopy (EGD) {band ligation, epinephrine injection, hemoclipping, multipolar electric coagulation) versus angiographic intraarterial infusion of vasopressin or transcatheter embolization (in patients with severe comorbidities)

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139
Q

Indications for surgery in a patient with an acute bleed from a Mallory-Weiss tear?

A

> 6u packed red blood cells (PRBCs) transfused;
failure of EGD to stop bleeding;
failure of angiographic embolization (in patients with severe comorbidities)

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140
Q

If surgery for active bleeding from a Mallory-Weiss tear is indicated, what procedure would you perform?

A

Anterior gastrotomy and oversewing ofthe bleeding site with deep 2-0 silk ligatures with reapproximation ofthe gastric mucosa

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141
Q

If surgery for active bleeding from a Mallory-Weiss tear in the distal esophagus is indicated, how might your operative approach change?

A

Rather than laparotomy and anterior gastrotomy, you may need a left thoracotomy and esophagotomy followed by suture ligation

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142
Q

What disease process is characterized by erosion of the superficial mucosa overlying an abnormally large (1-3 mm) tortuous vessel resulting in bleeding?

A

Dieulafoy lesion

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143
Q

Are Dieulafoy lesions more common in men or in women?

A

Men (M:F= 2:1)

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144
Q

Peak incidence for Dieulafoy lesion:

A

Fifth decade

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145
Q

Diagnostic modality of choice for Dieulafoy lesion:

A

EGD

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146
Q

Where do Dieulafoy lesions usually occur in the stomach?

A

6 to 10 cm from the GE junction, generally in the fundus near the cardia

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147
Q

What is the classic presentation of a patient with a Dieulafoy lesion?

A

Sudden onset of massive, painless, recurrent hematemesis with hypotension

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148
Q

After resuscitation, what initial attempts should be made to stop acute bleeding from a Dieulafoy lesion?

A

Endoscopic modalities (band ligation, heater probe, hemoclipping, injection sclerotherapy, multipolar electrocoagulation, noncontact laser photocoagulation) or angiography if endoscopy cannot identify the bleeding source

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149
Q

Surgical management of a patient with Dieulafoy lesion:

A

Gastric wedge resection to include the offending vessel (laparotomy with gastrotomy vs. laparoscopically with intraoperative endoscopy)

150
Q

What are the 2 ways that gastric varices can develop?

A

In conjunction with esophageal varices in the setting of portal hypertension (HTN);
sinistral HTN from splenic vein thrombosis

151
Q

Treatment for gastric varices in the setting of splenic vein thrombosis:

A

Splenectomy

152
Q

Treatment for gastric varices in the setting of portal HTN:

A

Volume resuscitation and correction of any coagulopathy;
temporary tamponade with Sengstaken-Blakemore tube; endoscopic banding or sclerotherapy;
transjugular intrahepatic portosystemic shunt (with possible balloon-occluded retrograde transvenous obliteration of a gastrorenal shunt with ethanolamine oleate)

153
Q

What study should be performed in patients with bleeding gastric varices prior to surgical intervention?

A

Abdominal ultrasound to document splenic vein thrombosis (portal HTN often accompanies gastric varices)

154
Q

Term for when a gastric volvulus occurs along the stomach’s longitudinal axis:

A

Organoaxial

155
Q

Term for when a gastric volvulus occurs along the stomach’s vertical axis:

A

Mesenteroaxial

156
Q

Which type of gastric volvulus is more common: organoaxial or mesenteroaxial?

A

Organoaxial (two-thirds of cases)

157
Q

What is the Borchardt triad?

A

Sudden onset of constant, severe upper abdominal pain;
recurrent retching with inability to vomit;
inability to pass an NG tube

158
Q

Which type of gastric volvulus more often occurs acutely and is associated with a diaphragmatic defect?

A

Organoaxial gastric volvulus

mesenteroaxial volvulus usually recurrent and not associated with a diaphragmatic defect

159
Q

What might you see on plain film of the abdomen in a patient with gastric volvulus?

A

A gas-filled viscus in the chest or upper abdomen

160
Q

Surgical treatment for a spontaneous gastric volvulus without an associated diaphragmatic defect:

A

Detorsion and fixation of the stomach by gastropexy or tube gastrostomy through a transabdominal approach

161
Q

Surgical treatment for a gastric volvulus with an associated diaphragmatic defect:

A

Reduction and uncoiling of the stomachthrough a transabdominal approach; repair of the diaphragmatic defect; resection of compromised stomach if necessary; consideration to perform fundoplication; fixation of stomach with gastropexy versus tube gastrostomy

162
Q

Term for a collection of nondigestible vegetable matter formed from within the GI trad:

A

Phytobezoar

163
Q

Term for a collection of hair formed from within the GI tract:

A

Trichobezoar

164
Q

What types of patients usually get phytobezoars?

A

Patients with impaired gastric emptying after gastric surgery; diabetics with autonomic neuropathy

165
Q

What enzyme can be administered to attempt dissolution of a bezoar?

A

Papain

166
Q

How is papain administered?

A

1 teaspoon of papain (found in Adolph Meat Tenderizer) in 150 to 300 mL of water is given several times daily

167
Q

Treatment for a phytobezoar:

A

Enzymatic debridement followed by endoscopic fragmentation versus aggressive Ewald tube lavage; surgical removal if these methods fail

168
Q

Describe the typical patient who presents with a trichobezoar:

A

Long-haired females who often deny eating their own hair

169
Q

Treatment for a trichobezoar:

A

Surgical removal; may attempt enzymatic therapy, endoscopic fragmentation, or vigorous lavage for small trichobezoars; psychiatric evaluation (recurrent bezoar formation common)

170
Q

MORBID OBESITY

A

BMI = weight (kg) I height (m); obese: BMI 30 or greater; morbidly obese: BMI 40 or greater or BMI 35 or greater with a significant obesity-related comorbidity, or 100 lb over ideal body weight-these are the same indications to be evaluated for bariatric surgery

171
Q

Obesity-related comorbidities:

A

hypertension, diabetes, obstructive sleep apnea, heart disease, GERD, osteoarthritis, liver disease, increased risk of CVA

172
Q

Most common procedure for morbid obesity:

A

Laparoscopic Roux-en-Y gastric bypass-restrictive and malabsorptive

Early complications: bleeding, anastomotic leak with or without sepsis, DVT/PE

Later complications: vitamin B12, calcium, iron, vitamin D, and protein deficiencies;
anastomotic stenosis with obstruction at the gastrojejunostomy, internal hernia, and
marginal ulcer

173
Q

In what percentage of hyperplastic polyps in the stomach can adenocarcinoma be found?

A

2%

174
Q

Treatment for a patient with a hyperplastic polyp in the stomach:

A

Endoscopic polypectomy for histologic examination

175
Q

In what percentage of adenomatous polyps in the stomach can adenocarcinoma be found?

A

20%

176
Q

Treatment for a patient with an adenomatous gastric polyp:

A

Endoscopic polypectomy, as long as the entire polyp can be removed and no invasive cancer is in the specimen, with close follow-up with serial endoscopies because of the increased risk for coincident gastric carcinoma

177
Q

Name nutritional factors associated with an increased risk of developing gastric cancer:

A

Salted meat or fish, high complex-carbohydrate consumption, high nitrate consumption, low fat or protein consumption

178
Q

Name medical factors associated with an increased risk of developing gastric cancer:

A

Adenomatous polyps, gastric atrophy and gastritis, H. pylori infection, male gender, prior gastric surgery

179
Q

Name environmental factors associated with an increased risk of developing gastric cancer:

A

Lack of refrigeration, low socioeconomic status, poor drinking water (well water), poor food preparation (salted, smoked), smoking

180
Q

What percentage of all malignant gastric neoplasms are adenocarcinomas?

A

95%

181
Q

Term for a diffusely infiltrating gastric carcinoma that involves the entire stomach:

A

Linitis plastica

182
Q

According to the sixth edition of the AJCC Cancer Staging Manual, what is a T1 gastric cancer?

A

Tumor invades lamina propria or submucosa

183
Q

According to the sixth edition of the AJCC Cancer Staging Manual, what is a T2 gastric cancer?

A

Tumor invades muscularis propria or subserosa

184
Q

According to the sixth edition of the AJCC Cancer Staging Manual, what is a T2a gastric cancer?

A

Tumor invades muscularis propria

185
Q

According to the sixth edition of the AJCC Cancer Staging Manual, what is a T1b gastric cancer?

A

Tumor invades subserosa

186
Q

According to the sixth edition of the AJCC Cancer Staging Manual, what is a T3 gastric cancer?

A

Tumor penetrates serosa (visceral peritoneum) without invasion of adjacent structures

187
Q

According to the sixth edition of the AJCC Cancer Staging Manual, what is a T4 gastric cancer?

A

Tumor invades adjacent structures

188
Q

According to the sixth edition of the AJCC Cancer Staging Manual for gastric cancer, what is N1 nodal status?

A

Metastasis in 1 to 6 regional lymph nodes

189
Q

According to the sixth edition of the AJCC Cancer Staging Manual for gastric cancer, what is N1 nodal status?

A

Metastasis in 7 to 15 regional lymph nodes

190
Q

According to the sixth edition of the AJCC Cancer Staging Manual for gastric cancer, what is N3 nodal status?

A

Metastasis in more than 15 regional lymph nodes

191
Q

What is the minimum number of nodes that must be evaluated for accurate staging of gastric carcinoma?

A

15 nodes

192
Q

In regard to gastric cancer, what is an R0 resection?

A

Microscopically margin-negative resection with no gross or microscopic tumor remaining in the tumor bed

193
Q

In regard to gastric cancer, what is an R1 resection?

A

Removal of all macroscopic disease with positive microscopic margins for tumor

194
Q

In regard to gastric cancer, what is an R2 resection?

A

Gross residual disease

195
Q

In regard to gastric cancer, what is a D1 resection?

A

Removal of group I lymph nodes (right paracardial, left paracardial, lesser curvature, short gastric, right gastroepiploic, left gastroepiploic, suprapyloric, infrapyloric)

196
Q

In regard to gastric cancer, what is a D2 resection?

A

Removal of group 1 and 2 lymph nodes (right paracardial, left paracardial, lesser curvature, short gastric, right gastroepiploic, left gastroepiploic, suprapyloric, infrapyloric + left gastric, anterior common hepatic, celiac artery, splenic hilum, proximal splenic, distal splenic, left hepatoduodenal, superior mesenteric vein)

197
Q

In regard to gastric cancer, what is a D3 resection?

A

D2 resection with removal of paraaortic nodes

198
Q

Diagnostic modality of choice for gastric cancer:

A

Flexible upper endoscopy

199
Q

Desired margin of resection for gastric cancer:

A

5 to 6 cm

200
Q

What procedure needs to be performed to completely remove station 10 nodes during a Japanese-style D2 resection?

A

Splenectomy (station 10 nodes are parasplenic)

201
Q

What procedure needs to be performed to completely remove station 11 nodes during a Japanese-style D2 resection?

A

Partial pancreatectomy (station 11 nodes are parapancreatic}

202
Q

Which patients should receive adjuvant chemoradiation following complete surgical resection for gastric cancer?

A

Patients with T3/T4 lesion, node-positive cancers, or microscopically positive resection margins

203
Q

Usual time period for the recurrence of gastric cancer after gastrectomy for gastric cancer:

A

Within the first 3 years after gastrectomy

204
Q

What are the most common sites of locoregional recurrence after gastrectomy for gastric cancer?

A

Gastric remnant at the anastomosis, gastric bed, regional nodes

205
Q

Areas where gastric cancer hematogenously spreads:

A

Liver, lung, bone

206
Q

How should patients treated with gastrectomy for gastric cancer be followed?

A

Complete history and physical examination every 3 to 4 months for 1 year;
Every 6 months for 2 years
Yearly thereafter

Labs (CBC and LFTs} obtained as clinically indicated

CXR/CT A/P where indicated

If a subtotal gastrectomy was performed yearly, endoscopy may be necessary

207
Q

Most common site of lymphoma in the GI tract:

A

Stomach

208
Q

Most common gastric lymphoma:

A

Diffused large B-cell lymphoma (55%)

209
Q

Second most common gastric lymphoma:

A

Extranodal marginal cell lymphoma (mucosa-associated lymphoid tissue [MALT])

210
Q

Treatment for gastric lymphoma:

A

Chemoradiation (cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone [CHOP] regimen usually employed) versus multimodal therapy (resection for gastric lymphoma controversial)

211
Q

Treatment for early-stage gastric MALT lymphoma:

A

H. pylori eradication alone with repeat endoscopy in 2 months to document clearance of infection and biannual endoscopy for 3 years to document regression

212
Q

What characteristics of MALT lymphoma predict failure after H. pylori eradication alone?

A

Nodal involvement, nuclear Bcl-10 expression, transformation into a large-cell phenotype t(11;18), transmural tumor extension

213
Q

Most common mesenchymal tumor of the GI tract?

A

GIST

214
Q

What mutation is associated with GISTs?

A

c-kit

215
Q

What is the goal of surgery in treating GISTs?

A

A margin-negative resection with en bloc resection of adjacent organs if involved by direct extension

216
Q

What competitive tyrosine kinase inhibitor can be given to patients with unresectable and metastatic GISTs and as adjuvant therapy in clinical trials?

A

Imatinib mesylate (Gleevec)

217
Q

What disease is otherwise known as a hypoproteinemic hypertrophic gastropathy and is characterized by gastric mucosa with a cobblestone/cerebriform appearance from massive gastric folds in the fundus and corpus of the stomach?

A

Menetrier disease

218
Q

What will be seen on histologic examination with Menetrier disease?

A

Expansion of surface mucous cells (foveolar hyperplasia); absent parietal cells

219
Q

What is the treatment for a patient with Menetrier disease who develops dysplasia/ carcinoma or continues to have massive protein loss despite optimal medical therapy?

A

Total gastrectomy

220
Q

A 45-year-old male presents with sudden onset of severe abdominal pain and recurrent retching with inability to vomit. Attempts at placing an NG tube are not successful What is the most likely diagnosis?

A. Small-bowel obstruction

B. Gastritis

C. Colonic obstruction

D. Gastric volvulus

A

Answer: D.
This is a classic presentation of gastric volvulus with the Borchardt triad.

Two-thirds of the gastric volvulus are organoaxial with the rest being mesenteroaxial.

221
Q

A 65-year-old male presents with prolonged vomiting. He undergoes an EGD and is diagnosed with a gastric outlet obstruction. Which of the following would correspond with the metabolic abnormality seen with this type of patient?

A. Hypochloremic, hypokalemic metabolic alkalosis

B. Hyperchloremic, hyperkalemic metabolic acidosis

C. Hyponatremic, hypochloremic metabolic acidosis

D. Hypernatremic, hypochloremic metabolic alkalosis

A

Answer: A.

With prolonged vomiting and loss of hydrochloric acid and potassium, a hypochloremic, hypokalemic metabolic alkalosis is encountered. Primary treatment is replacement of lost volume with normal saline.

222
Q

A 55-year-old critically ill intubated patient has a large amount of bloody drainage from his NG tube. He is hemodynamically labile and received 8 U of PRBC and is not coagulopathic. What is the next step in treatment of this patient?

A. EGD

B. Observation with IV PPI

C. Angiogram

D. Operative intervention

A

Answer: D.

The patient is hemodynamically labile and has already received 8U of PRBC. He needs to go to the operating room for operative intervention, which would include exploratory laparotomy, gastrotomy, and oversewing of bleeding areas.

If the patient is stable preoperatively, a highly selective vagotomy or a pyloroplasty and truncal vagotomy can be performed.

223
Q

A 35-year-old woman underwent an EGD, which shows a prepyloric ulcer. What type of ulcer is this?

A. Type I

B. Type II

C. Type III

D. Type V

A

Answer: C.

A type III ulcer is located in the prepyloric area. Management includes antrectomy with incorporation of the ulcer and vagotomy.

224
Q

Where are the chief cells of the stomach found?

A. Fundus

B. Body

C. Antrum

D. Pylorus

A

Answer: B.

The chief cells are found in the body and secrete pepsinogen.

225
Q

A 35-year-old burn patient with 40% TBSA burns is being treated in the intensive care unit (ICU). The patient undergoes an EGD after UGI bleeding, and a stomach ulcer is seen during this procedure. What is the name of this type of ulcer?

A. Marginal ulcer

B. Cushing ulcer

C. Curling ulcer

D. Dieulafoy lesion

A

Answer: C.

The Curling ulcer is typically seen in burn patients and is a type of stress ulcer. Prophylaxis is with H2 blockers.

226
Q

Which of these patients has to be on stress gastritis prophylaxis with H2 blockers?

A. Intubated patient (>48 hours) with an international normalized ratio of 3

B. Stable trauma patient with an isolated pelvic fracture

C. Long-term ICU patient tolerating tube feeds at goal for 2 weeks

D. NPO patient with a postoperative ileus following elective colon resection

A

Answer: A.

A coagulopathic state and intubation for more than 48 hours is the classic indication for stress ulcer prophylaxis.

227
Q

Where is the most common site for a lymphoma in the GI tract?

A. Small bowel

B. Duodenum

C. Right colon

D. Stomach

A

Answer: D.

The most common site to develop a lymphoma in the GI tract is the stomach.

228
Q

What is the treatment for an early-stage gastric MALT lymphoma?

A. Gastrectomy

B. Radiation treatment

C. Chemotherapy

D. H. pylori eradication followed by regular EGD follow-up

A

Answer: D.

The treatment of choice for early-stage gastric MALT lymphoma is eradication of H. pylori and EGD follow-up in regular intervals.

229
Q

An aberrant left hepatic artery originates from the:

A. Right gastric artery

B. Left gastric artery

C. Left gastroepiploic artery

D. SMA

A

Answer: B.

An aberrant left hepatic artery originates from the left gastric artery, and an aberrant right hepatic artery originates from the SMA 15% of the time.

230
Q

A patient with refractory peptic ulcer disease now has indications for an antrectomy. During the resection, you will ligate which of the 4 main arteries that supplies blood to the stomach:

A. Right gastric artery

B. Left gastric artery

C. Right gastroepiploic artery

D. Gastroduodenal artery

A

Answer: A.

The right gastric artery is divided during an antrectomy. Three of the 4 main arteries that supply blood to the stomach can safely be ligated.

231
Q

A 40-year-old female is POD 4 status-post laparotomy Roux-en-Y gastric bypass. She has had persistent sinus tachycardia since surgery, but it is worse today.
Her pain is well controlled. What must be thoroughly worked up in the post-op bariatric population with persistent tachycardia?

A. Pulmonary embolism

B. Acute hemorrhage

C. Anastomotic leak

D. All of the above

A

Answer: D.

Pulmonary embolism, bleeding, and anastomotic leak are the 3 most common life-threatening post-op complications associated with bariatric surgery.

The mortality rate is less than 1% for this procedure, but these must be taken seriously.

232
Q

You perform an EGD on a patient with symptoms of peptic ulcer disease. You note a type I ulcer. This type of ulcer is sometimes associated with H. pylori infection. Where is the best place to take the biopsy to test for infection?
A. Lesser curve at incisura

B. Antrum

C. Body

D. Cardia

A

Answer: B.

The antrum is the most common location for H. pylori infection.

233
Q

Long-term PPI use is associated with all of the following adverse effects except:

A. Clostridium difficile colitis

B. Chronic kidney disease

C. Malabsorption of minerals and vitamins

D. All of the above

A

Answer: D.

PPI-related adverse effects include C. difficile; microscopic colitis;
malabsorption of magnesium, calcium, B12, and iron; 
hypergastrinemia; 
atrophic gastritis; 
CKD; 
drug-induced lupus; 
dementia; 
pneumonia; and 
mortality
234
Q

What length should the afferent limb be in a Billroth II?

A. Greater than 40 cm

B. There should not be an afferent limb

C. Less than 20cm

D. Less than 30cm

A

Answer: C.

The preferred reconstruction is Billroth I. Anatomy does not always allow for this, as the anastomosis might be under too much tension despite maximal mobilization.

An afferent limb less than 20 cm decreases the incidence of afferent loop syndrome.

The Roux limb in a Roux-en-Y gastric bypass should be greater than 40 cm to prevent bile reflux.

235
Q

One month after an antrectomy with Billroth II reconstruction, a patient presents with colicky abdominal pain, distention, bilious emesis, and failure to pass gas. This most likely represents:

A. Blind loop syndrome
B. Afferent loop syndrome 
C. Reflux gastritis
D. Efferent loop syndrome 
E. Vitamin deficiency
A

ANSWER: D

236
Q

As opposed to the above condition, the patient presents with chronic vague abdominal discomfort and cramping with postprandial explosive bilious emesis, which relieves the pain. He continues to be able to pass gas. What is the best management for this patient?

A. Dietary modification to reduce the meal size

B. Emergent surgery to reduce the internal hernia

C. Iron and calcium supplementation

D. Conversion to a Roux-en-Y with a longer afferent limb

E. Conversion to a Roux-en-Y with a shorter afferent limb

A

ANSWER: E

237
Q

Following a Billroth II reconstruction, a patient presents with epigastric abdominal pain, bilious emesis that does not relieve the pain, and weight loss. Which of the following tests would reveal the diagnosis?

A. Hydroxy iminodiacetic acid (HIDA) scan

B. Computed tomography (CT) scan

C. Barium swallow

D. Kidney, ureter, and bladder (KUB) test

E. Gastric emptying study

A

ANSWER: A

COMMENTS: Postgastrectomy complications range from nutritional deficiencies to mechanical malfunctions requiring surgical intervention.

The most common metabolic disturbance is anemia, either iron deficiency or megaloblastic secondary to B12 deficiency.

Loss of a significant portion of the stomach reduces the amount of intrinsic factor that is required to absorb vitamin B12.

Calcium deficiencies are also observed, leading to osteoporosis and osteomalacia, as calcium is primarily absorbed in the duodenum.

All of these conditions are treated with supplementation. Afferent loop syndrome occurs as a result of a partial or complete obstruction in the afferent limb.

It can be acute or chronic and progress to blind loop syndrome in which bacterial overgrowth occurs.

In the case of blind loop syndrome, megaloblastic anemia can develop due to bacterial consumption of vitamin B12.

The presentation of afferent loop syndrome includes postprandial pain and fullness with eventual purely bilious emesis, which relieves the pain.

Diagnosis is made with a CT scan.

Treatment consists of antibiotics for bacterial overgrowth and conversion to a Roux-en-Y with a short afferent limb.

Efferent loop obstruction presents the same as a small bowel obstruction.

Diagnosis can be established by demonstrating a lack of filling of the efferent limb on barium swallow or by CT scan.

Operative management consists of correction of the cause for the obstruction be it adhesions, internal herniation, etc.

Finally, alkaline reflux gastritis most commonly plagues patients who have undergone a Billroth II reconstruction and consists of bile refluxing into the stomach remnant.

Patients present with bilious emesis that does not tend to relieve their pain.

Diagnosis can be made with a HIDA scan, demonstrating biliary secretion into the stomach.

The surgical management of this condition involves conversion to a Roux-en-Y with a Roux limb that is greater than 40 cm in length.

238
Q

Which of the following pairs of diagnostic measures and their role in the management of a patient with gastric cancer is correct?

A. Physical examination/identify occult metastatic disease

B. Esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS)/examine for locoregional staging

C. CT scan/monitor for response to neoadjuvant therapy

D. Positron emission tomography (PET) scan/detect intraabdominal metastatic disease

E. Diagnostic laparoscopy/resect intraabdominal metastases

A

ANSWER: B
COMMENTS: The workup of a patient with gastric cancer begins with a thorough physical examination in which care is taken to identify signs of advanced disease.

Prominent supraclavicular or periumbilical nodes, hepatomegaly, ascites, palpable ovaries on pelvic examination, or a firm Blumer’s shelf on rectal examination all represent possible metastasis.

After an initial examination, patients should undergo an EGD with EUS for locoregional staging purposes and a CT scan for the detection of intraabdominal metastatic spread.

PET scans do not have a reliable role in the staging workup of a patient; however, they have been used to track response to neoadjuvant therapy.

Because CT scan has an overall detection rate of 85% for intraabdominal spread and only 50% for peritoneal metastasis, diagnostic laparoscopy can be utilized to identify the occult metastatic disease.

In a 2007 study that included 106 patients with gastric cancer, 33% of patients previously thought to be resection candidates based on preoperative imaging were found to have CT occult disease on laparoscopy.

There is no role for the laparoscopic resection of intraabdominal metastases.

239
Q

Which of the following is true regarding dumping syndrome?

A. Late dumping syndrome is the result of a massive influx of high osmolarity contents into the intestines.

B. It is more common after Billroth I reconstructions versus Billroth II.

C. It can include cardiovascular effects such as palpitations, diaphoresis, fainting, and flushing.

D. Early dumping syndrome is made worse by high-carbo- hydrate foods.

E. Most patients require long-acting octreotide agonists to control their symptoms.

A

ANSWER: C

COMMENTS: Dumping syndrome can be divided into early and late phases, with the early occurring 20 to 30 min after eating and the late 2 to 3 h after eating.

Early dumping occurs when high osmolarity contents enter the intestines at a rapid rate, inducing a large shift of extracellular fluid into the lumen.

Symptoms include cramping, nausea and vomiting, epigastric fullness, and diarrhea.

Late dumping occurs when contents high in carbohydrates enter the intestines, stimulating an overcompensatory insulin release that, in turn, results in profound hypoglycemia.

Cardiovascular effects occur with both types; however, they are more common with late dumping.

Most patients find effective relief with dietary modification alone including smaller portions, slower eating, avoiding foods high in sugars, and separating liquids from solids.

Octreotide agonists are reserved for the few who do not respond to these measures.

Overall, dumping is more common after Billroth II reconstructions.

240
Q

Which of the following is true concerning the pharmacologic
regulation of acid secretion?

A. Proton pump inhibitors (PPIs) exert their effect at a final common pathway of acid secretion.

B. H2 blockers inhibit the release of histamine from the enterochromaffin-like (ECL) cells.

C. PPIs function as reversible receptor antagonists.

D. H2 blockers have a more prolonged inhibition of gastric acid secretion than do PPIs.

E. Antisecretory agents do not affect serum gastrin levels.

A

ANSWER: A

COMMENTS: Both H2 blockers and PPIs work to decrease acid secretion by parietal cells.

H2 blockers function as histamine receptor antagonists at the level of the parietal cell but do not influence the release of histamine from the ECL cells.

PPIs more completely inhibit acid secretion by irreversibly inhibiting the final common pathway, the proton pump.

For the recovery of acid secretion to occur, new proton pumps need to be synthesized, giving them a longer duration of action than H2 blockers.

All antisecretory agents result in the elevation of serum gastrin levels and hyperplasia of the G cells and ECL cells.

241
Q

A patient presents after several episodes of violent emesis, which eventually turned bloody. Which of the following is the best diagnostic tactic?

A. Upright chest x-ray

B. Placement of a nasogastric (NG) tube

C. Barium swallow

D. CT of the chest and abdomen

E. Endoscopy

A

ANSWER: E

COMMENTS: Mallory-Weiss tears are the result of violent retching, vomiting, or coughing.

They generally occur high on the lesser curvature and involve only the mucosa, not a full perforation.

They comprise around 15% of upper gastrointestinal (GI) hemorrhages.

The majority of patients can be effectively diagnosed and managed with endoscopy alone. In the rare case that endoscopic control is unsuccessful, operative intervention can be carried out via an anterior gastrotomy and oversewing of the injury with mucosal reapproximation.

None of the other answers would accurately diagnose this condition.

242
Q

Concerning duodenal diverticula, which of the following
statements is false?

A. They are twice as common in women as in men.

B. Duodenal diverticula are the second most common congenital diverticula of the intestine after Meckel’s diverticulum.

C. The majority of duodenal diverticula are found in the periampullary region.

D. Most of them are asymptomatic and found incidentally.

E. They can result in cholangitis and pancreatitis from the
obstruction of the biliary or pancreatic ducts, respectively.

A

ANSWER: B

COMMENTS: Duodenal diverticula are false diverticula containing only mucosa and submucosa, as opposed to a true diverticulum, which contains all layers of the intestinal wall (e.g., Meckel’s diverticulum).

Duodenal diverticula are the second most common cause of acquired diverticula after those in the colon.

They are more commonly seen in women than in men (2:1) and usually occur later in life, similar to colonic diverticula.

The majority of these diverticula (∼75%) are found within a 2-cm radius from the ampulla of Vater and generally protrude through the medial wall of the duodenum.

These duodenal diverticula are rarely symptomatic and do not require intervention.

Surgery is reserved for those that are symptomatic and in which complications develop. Symptoms are usually the result of hemorrhage, perforation, blind loop syndrome, cholangitis, or pancreatitis from the obstruction of the biliary or pancreatic ducts. Juxtapyloric diverticula have been noted to be associated with choledocholithiasis.

Their presence increases the difficulty of successful completion of endoscopic retrograde cholangiopancreatography (ERCP).

When treatment is required, surgical excision (diverticulectomy) is recommended.

243
Q

A 23-year-old thin (92 lb) woman with a history of surgical correction of her scoliosis is evaluated for symptoms of postprandial epigastric pain, fullness, nausea, and vomiting. Her physical examination is unremarkable except for her thin physique/stature. Barium upper GI series showed a dilated duodenum and stomach with minimal flow of barium into the jejunum. Which of the following is the operative manage- ment of choice for this patient’s condition?

A. Segmental duodenectomy

B. Pancreaticoduodenectomy

C. Gastrojejunostomy

D. Duodenojejunostomy

E. Roux-en-Y hepaticojejunostomy

A

ANSWER: D

COMMENTS: The patient in this scenario has compression of the third portion of the duodenum by the superior mesenteric artery (SMA) as it passes over it.

This rare condition is known as SMA syndrome or Wilkie syndrome.

This syndrome is usually seen in young asthenic females with predisposing conditions of weight loss, scoliosis or corrective surgery for it, supine mobilization, and place- ment of a body cast.

The diagnosis is usually made with either a barium upper GI series or a CT, with oral and intravenous (IV) contrast enhancement demonstrating a dilated duodenum and stomach with an abrupt or nearly complete cutoff of contrast agent at the third portion of the duodenum and minimal flow into the jejunum.

Conservative management consisting of nutritional supple- mentation can be tried initially.

In patients who fail medical management, the operative treatment of choice is duodenojejunostomy.

244
Q

Which hormone is matched with the correct diagnostic/
therapeutic function?

A. Cholecystokinin (CCK)/treatment of esophageal variceal bleeding

B. Somatostatin/relief of spasm of the sphincter of Oddi

C. Gastrin/measurement of maximal gastric acid secretion

D. Glucagon/provocative test for gastrinoma

E. Secretin/stimulation of gallbladder contraction

A

ANSWER: C

COMMENTS: GI hormones or their analogues have been used clinically as diagnostic or therapeutic agents.

CCK is used to stimulate gallbladder contraction.

This is useful in identifying patients with biliary dyskinesia or acalculous cholecystitis with the help of CCK cholescintigraphy.

Pentagastrin, a gastrin analogue, is used to measure gastric acid secretion.

Somatostatin or its analogues are used in various conditions as a result of their universal inhibitory function.

Because they inhibit the release of GI hormones, somatostatin analogues are used for various endocrine neoplasms such as Zollinger-Ellison syndrome, VIPoma, insulinoma, and carcinoid tumors.

They are also useful in patients with pancreatic fistulas, pancreatic ascites, and enterocutaneous fistulas by decreasing GI secretions.

Additionally, they have been used as a treatment to decrease bleeding from the GI tract.

Glucagon is used by endoscopists to relax the sphincter of Oddi to facilitate ERCP.

Secretin, which inhibits acid secretion, causes a paradoxical increase in serum gastrin levels in patients with gastrinoma.

Pancreatic polypeptide (PP) is predomi- nantly secreted in the pancreatic head.

PP serum levels drop following the Whipple procedure and may be related to the delayed gastric emptying observed after pyloric-preserving pancreatoduodenectomy.

In addition, PP secretion necessitates intact vagal nerve function; thus a blunt response to stimulation by sham feedings has been used to evaluate intact vagal nerve function, particularly in patients suspected of having iatrogenic vagus nerve injury.

245
Q

A patient with gastric outlet obstruction and prolonged vomiting has which of the following metabolic abnormalities?

A. Hypochloremic, hyperkalemic metabolic alkalosis

B. Hyperchloremic, hypokalemic metabolic acidosis

C. Hyponatremic, hypokalemic metabolic acidosis

D. Hypochloremic, hypokalemic metabolic alkalosis

E. Hyperchloremic, hyperkalemic metabolic acidosis

A

ANSWER: D

COMMENTS: The most common cause of gastric outlet obstruction is malignancy.

The classic metabolic abnormality resulting from gastric outlet obstruction and prolonged vomiting is hypochloremic, hypokalemic metabolic alkalosis. Initial loss of hydrochloric acid causes hypochloremia and mild alkalosis compensated for by renal excretion of bicarbonate.

Therefore in the early stages, the urine is alkaline.

Continued vomiting produces a severe extracellular fluid deficit and sodium deficit from both renal and gastric losses.

The kidneys begin to conserve sodium and, in exchange, excrete hydrogen and potassium cations to accompany bicarbonate.

The kidneys are the predominant site of potassium loss, and the urine is paradoxically acidic.

Urine chloride content is reduced throughout and is eventually absent. Serum ionized calcium levels are decreased because calcium is mildly alkaline and shifts to its nonionized form to reduce alkalosis.

Treatment of this metabolic situation is accomplished primarily by the administration of isotonic saline solution, which replenishes the deficits in volume, sodium, and chloride.

Potassium is replaced once the renal function is optimized.

246
Q

Which of the following statements is true with regard to the arterial blood supply of the stomach?

A. The left gastroepiploic artery is the main blood supply to the gastric conduit used in esophagectomies.

B. Ligation of the left gastric artery can result in acute left-sided hepatic ischemia.

C. The stomach is susceptible to ischemia because of poor collateral circulation.

D. The inferior phrenic and short gastric arteries provide significant blood supply to the body of the stomach.

E. A replaced right hepatic artery may originate from the left gastric artery.

A

ANSWER: B

COMMENTS: The arterial blood supply of the stomach is derived primarily from the celiac artery.

The left gastric artery comes off of the celiac artery and supplies the stomach along the lesser curvature.

An aberrant/replaced left hepatic artery origi- nates from the left gastric artery (15%–24%) and can represent the only arterial blood supply to the left hepatic lobe.

This aber- rant/replaced left hepatic artery runs in the gastrohepatic ligament.

The right gastric artery typically arises from the common hepatic artery distal to the gastroduodenal artery.

The right and left gastroepiploic arteries usually originate from the gastroduodenal artery and splenic artery, respectively.

It is the right estroepiploic artery that functions as the main blood supply to the gastric conduit used in esophagectomies.

The short gastric arteries arising from the splenic artery and inferior phrenic arteries also contribute significant blood volume to the proximal part of the stomach.

The stomach is well protected from ischemia and can easily survive with ligation of three of four arteries because of its rich collateral circulation.

247
Q

Choose the correct type of vagotomy with the appropriate
level of vagal transection from the pairs listed below:

A. Truncal vagotomy/criminal nerve of Grassi

B. Highly selective vagotomy/anterior and posterior vagal trunks below the celiac and hepatic branches

C. Selective vagotomy/anterior and posterior vagal trunks above the celiac and hepatic branches

D. Parietal cell vagotomy/terminal branches of the nerve of Latarjet

E. Highly selective vagotomy/hepatic branches

A

ANSWER: D

COMMENTS: In the chest, the vagal trunks are situated to the right and left of the esophagus.

At the level of the cardia, the left vagal trunk is found anterior and the right vagal trunk is found posterior secondary to the embryonic gastric rotation.

The anterior vagal trunk divides into hepatic and anterior gastric (anterior nerve of Latarjet) branches.

The posterior vagus divides into the posterior nerve of Latarjet and celiac branches.

One of the proximal posterior branches of the posterior vagal trunk is known as the criminal nerve of Grassi and is identified as a possible cause of recurrent ulcers if left undivided during selective vagotomy.

Truncal vagotomy is conventionally performed at or just above or below the diaphragmatic esophageal hiatus before it gives off celiac and hepatic branches.

In contrast, a selective vagotomy is performed distal to this location and spares the celiac and hepatic branches.

Highly selective vagotomy (also known as proximal gastric or parietal cell vagotomy) divides individual terminal branches of the nerve of Latarjet in the fundus and corpus of the stomach but spares the vagal branches to the antrum and pylorus, which control gastric motility and emptying— thus obviating the need for a drainage procedure.

248
Q

Concerning the treatment of patients with Zollinger-Ellison
syndrome, which of the following statements is true?

A. Operative treatment of associated hyperparathyroidism takes precedence over abdominal surgery.

B. Pancreatic tumors should not be removed by enucleation.

C. Duodenal tumors usually require pancreaticoduodenectomy.

D. Antrectomy is indicated if the tumor cannot be localized.

E. Resection of liver metastases is not indicated.

A

ANSWER: A

COMMENTS: Treatment of Zollinger-Ellison syndrome is two pronged and aimed at both resecting the tumor when possible and protecting the gastric end organ.

Therapy must be individualized.

Patients with known endocrine tumors should undergo careful evaluation for other potential endocrine tumors.

In patients with gastrinoma and hyperparathyroidism, parathyroidectomy should be performed first to eliminate hypercalcemia.

Abdominal surgery is not urgent with the current antisecretory medications.

Although gastrinomas are often multiple and are usually metastatic, long-term survival is possible.

Aggressive attempts to localize and resect tumors can provide a cure in 5%–20% of patients and can diminish gastrin secretion in others.

Digital palpation through a duodenotomy and intraoperative ultrasound are useful operative adjuncts.

Both pancreatic and duodenal gastrinomas can be resected by enucleation when appropriately located.

Blind pancreatic resections are not generally indicated.

When complete tumor removal is not possible, a gastric operation may be appropriate.

Proximal gastric vagotomy may be useful, but total gastrectomy still provides the best long-term quality of life for some patients.

Life-long pharmacologic treatment with antisecretory agents may control the ulcer diathesis in some patients, but problems with high doses, compliance, and side effects may occur.

Resection or ablation of metastatic disease, although not curative, can provide important palliation and decrease the need for drug therapy.

249
Q

Which of the following clinical conditions is not associated
with delayed gastric emptying?

A. Hypocalcemia
B. Scleroderma
C. Hyperglycemia
D. Myxedema
E. Zollinger-Ellison syndrome
A

ANSWER: E

COMMENTS: Disorders of gastric emptying can be divided into rapid or delayed emptying, both of which can be significantly disabling conditions.

Delayed gastric emptying is the more frequently encountered problem of gastric motility.

Excluding mechanical obstruction, important causes of delayed gastric emptying include metabolic derangements (e.g., myxedema and hyperglycemia), electrolyte abnormalities (e.g., hypoka- lemia and hypocalcemia), drugs (e.g., narcotics and anticho- linergics), and systemic diseases (e.g., diabetes mellitus and scleroderma).

Up to 40% of postvagotomy patients experience delayed gastric emptying.

Rapid gastric emptying is less commonly observed. Causes of rapid gastric emptying include previous gastric resection, conditions with impaired fat absorption resulting in the loss of the inhibition of gastric emptying (e.g., pancreatic insufficiency and short bowel syndrome), and con- ditions with hypergastrinemia such as Zollinger-Ellison syndrome.

250
Q

Which of the following conditions is not associated with
Helicobacter pylori infection?

A. Duodenal ulcer

B. Gastric cancer

C. Mucosa-associated lymphoid tissue (MALT) lymphoma

D. Gastroesophageal reflux disease

E. Chronic gastritis

A

ANSWER: D

COMMENTS: H. pylori is a curved or S-shaped, gram-negative microaerophilic motile bacterium whose natural habitat is the human stomach.

H. pylori infection has been demonstrated to be associated with 90% of duodenal ulcers and 75% of gastric ulcers.

After eradication of the organism as a part of ulcer treatment, recurrence of ulcer is extremely rare.

In addition, H. pylori has been associated with chronic atrophic gastritis, which in turn leads to gastric atrophy and intestinal metaplasia, a suspected precursor of gastric cancer.

H. pylori infection also increases the risk for low-grade MALT lymphoma; eradication of H. pylori results in the resolution of MALT lymphomas in most cases.

There appears to be a negative association between H. pylori infection and GI reflux disease.

251
Q

With regard to H. pylori–negative duodenal ulcer disease,
which of the following statements is true?

A. Nonsteroidal antiinflammatory drugs (NSAIDs) are not a cause of duodenal ulcers in patients who are H. pylori negative.

B. Because of the high prevalence of H. pylori–positive duodenal ulcers, patients should be treated for H. pylori without confirmatory testing.

C. In contrast to H. pylori–positive duodenal ulcers, NSAID-induced ulcers are frequently associated with chronic active gastritis.

D. H. pylori–negative duodenal ulcers are usually large ulcers that are not often associated with bleeding.

E. Older age, multiple comorbid conditions, and sepsis are independently associated with H. pylori–negative duodenal ulcers.

A

ANSWER: E

COMMENTS: Initial studies have demonstrated that H. pylori infection is present in more than 90% of patients with duodenal ulcers.

However, more recently, it has been shown that the preva- lence of H. pylori–associated duodenal ulcers is only 75% and is found to be decreasing.

Thus it is important to first make the diagnosis of an active H. pylori infection rather than initiating empirical therapy.

H. pylori–negative duodenal ulcers are independently associated with NSAID use, older age, multiple medical problems, and sepsis. Use of NSAIDs is the major cause of duodenal ulcers in patients who are H. pylori negative.

Bleeding is the initial manifestation in these patients, and they have large and multiple ulcers.

252
Q

If the patient in Question 21 was found to have a perfo- rated gastric ulcer instead of a duodenal ulcer, which additional procedure would need to be conducted during the operative intervention besides closure of the perforation?

A. Feeding jejunostomy
B. Gastrojejunostomy
C. Gastrostomy tube placement D. Excision or biopsy of the ulcer E. Pyloroplasty

A

ANSWER: D

COMMENTS: The preferred treatment of a perforated duodenal ulcer is resuscitation and prompt surgery.

Nonoperative management is reserved for old contained perforations or for terminally ill patients who otherwise cannot undergo surgery.

The diagnosis is a presumptive one based on clinical grounds and should not be excluded if pneumoperitoneum cannot be demonstrated, because about 20% of patients with perforations do not have this typical radiographic feature.

Operative management requires the closure of the perforation, which is generally best accomplished with an omental (Graham) patch.

Closure of the perforation is usually sufficient in patients with duodenal ulcers; however, excision of the ulcer is necessary to rule out malignancy in patients with gastric ulcers before closure.

Following simple repair alone, the traditional natural history has been that about one-third of patients have no further ulcer problems, one-third have ulcer recurrence amenable to medical management, and one-third require a subsequent operation for ulcer disease.

It is not clear how precisely this applies to patients with H. pylori infection or those with NSAID-induced ulcers.

Definitive operations should be performed only in stable patients and in those with documented failure after appropriate H. pylori eradication.

Truncal vagotomy can be performed expeditiously but has a greater incidence of side effects.

Highly selective vagotomy is an excellent choice but is time consuming and requires a surgeon with the expertise to perform it.

Resective procedures are generally avoided in the setting of perforation because of higher morbidity.

Following surgery, ulcerogenic drugs should be withheld, and any concomitant H. pylori infection should be treated.

253
Q

A 45-year-old man requires surgery for an intractable duodenal ulcer. Which operation best prevents ulcer recurrence?

A. Subtotal gastrectomy

B. Truncal vagotomy and pyloroplasty

C. Truncal vagotomy and antrectomy

D. Selective vagotomy

E. Highly selective vagotomy

A

ANSWER: C

254
Q

Which operation for duodenal ulcer is least likely to produce
undesirable postoperative symptoms?

A. Subtotal gastrectomy

B. Truncal vagotomy and pyloroplasty

C. Truncal vagotomy and antrectomy

D. Selective vagotomy

E. Highly selective vagotomy

A

ANSWER: E

COMMENTS: The goal of surgical therapy for duodenal ulcers is to reduce acid production in a manner that is safe and has the fewest possible side effects.

Acid can be reduced by eliminating vagal stimulation, removing the antral source of gastrin, and removing the parietal cell mass.

Traditionally, subtotal two-thirds gastrectomy has carried the highest mortality rate.

Truncal vagotomy with antrectomy has the lowest recurrence rate.

Procedures involving antrectomy, pyloroplasty, or truncal vagotomy may be complicated by diarrhea, postprandial dumping, or bile reflux.

Selective vagotomy, which preserves the hepatic and celiac vagal branches, has been associated with a lower rate of diarrhea than truncal vagotomy.

Highly selective vagotomy, also known as parietal cell vagotomy, aims to denervate the parietal cell–bearing portion of the stomach but preserves innervations to the pyloroantral region and thus maintains more normal gastric emptying.

This operation carries the lowest mortality rate and the lowest incidence of side effects, but the highest recurrence rate, which ranges from 5% to 15%.

255
Q

A 75-year-old man taking NSAIDs for arthritis has an acute abdomen and pneumoperitoneum. His symptoms are 6 h old, and his vital signs are stable after the infusion of 1 L of normal saline solution. What should be the next step in the management of this patient?

A. CT of the abdomen

B. EGD

C. Antisecretory drugs, broad-spectrum antibiotics, and surgery if he fails to improve in 6 h

D. Antisecretory drugs, antibiotics for H. pylori, and surgery if he fails to improve in 6 h

E. Surgery

A

ANSWER: E

256
Q

During an operation for a bleeding duodenal ulcer, three- point “U” stitches are placed to ligate which of the following arteries after longitudinal pyloroduodenotomy?

A. Common hepatic, right gastric, and gastroduodenal arteries

B. Proximal and distal gastroduodenal and transverse pancreatic arteries

C. Right gastric, gastroduodenal, and right gastroepiploic arteries

D. Right gastric and anterior and posterior inferior pancreati- coduodenal arteries

E. Common hepatic, gastroduodenal, and superior mesen- teric arteries

A

ANSWER: B

COMMENTS: Massive bleeding is usually the result of posterior erosion of a duodenal ulcer into the gastroduodenal artery.

Emergency surgical intervention is indicated when bleeding is refractory to endoscopic therapy or in the presence of hemorrhagic shock.

After expeditious preoperative resuscitation, the abdomen is entered and a longitudinal pyloroduodenotomy is performed.

Digital pressure is applied over the ulcer base to temporize the bleeding and allow resuscitation before suture control is obtained.

Proper control of bleeding requires three-point suture ligation of the duodenal ulcer.

These “U” stitches are placed superior and inferior to the site of penetration to ligate the proximal and distal gastroduodenal artery.

A third suture is placed on the medial aspect of the ulcer to control the transverse pancreatic branch coming off the gastroduodenal artery.

After the bleeding is controlled, biopsy of gastric mucosa should be performed for histo- logic analysis of H. pylori.

The longitudinal pyloroduodenotomy is then closed transversely (Heineke-Mikulicz or Weinberg pyloroplasty).

257
Q

Which gastric ulcer corresponds with the correct recommended surgical management?

A. Type I/Billroth I or II reconstruction

B. Type II/truncal vagotomy and pyloroplasty

C. Type III/Csendes gastrectomy with Roux-en-Y gastrojeju- nostomy or Pauchet gastrectomy and Billroth I reconstruction

D. Type IV/Billroth I or II reconstruction with truncal vagotomy

E. Type IV/total gastrectomy

A

ANSWER: A

COMMENTS: Benign gastric ulcers have been classified in terms of their anatomic location.

Type I ulcers are the most common (50%) and occur in the body of the stomach along the lesser curvature.

These ulcers are associated with low to normal acid secretion.

Type II gastric ulcers (25%) also occur in the body of the stomach but have associated duodenal ulcers.

Type III gastric ulcers (20%) are located in the prepyloric region. Both type II and type III ulcers are associated with excessive acid secretion.

Type IV ulcers are the least common (<10%) and occur near the GE junction along the lesser curve.

Like type I ulcers, they are associated with low or normal acid secretion.

Surgical intervention is indicated for patients who have failed maximal medical therapy (12 weeks), for those in whom complications develop, or for those in whom malignancy cannot be ruled out.

Surgical therapy for benign gastric ulcers depends on the type of ulcer and its associated acid secretion.

Type I ulcers are usually well treated with antrectomy or hemigastrectomy (including removal of the ulcer) without vagotomy. Type IV ulcers do not require vagotomy either.

Type IV ulcers near the GE junction can be treated by modifications of distal gastrectomy that include ulcer excision.

Distal gastrectomy with extension along the lesser curvature to include the ulcer (Pauchet procedure) and Billroth I reconstruction can be performed for ulcers that are 2 to 5 cm from the GE junction.

For type IV ulcers at the GE junction, subtotal gastrectomy with Roux-en-Y jejunal reconstruction (Csendes procedure), a rotational Tanner gastrectomy, or a Kahler-Muhlenberg procedure should be performed.

Because type II and type III ulcers are associated with acid hypersecretion, they are treated as duodenal ulcers.

Truncal vagotomy with Bill- roth I or II reconstruction is the preferred surgical therapy because it accomplishes both goals of a decrease in acid secretion and excision of the ulcer.

258
Q

Which of the following tests is best to document eradication of H. pylori infection in patients with peptic ulcer disease (PUD)?

A. Urea breath test

B. Histologic examination of mucosa

C. Rapid urease test

D. Culture and sensitivity testing

E. H. pylori serology

A

ANSWER: A

COMMENTS: It is important to document the presence or absence of H. pylori to adequately treat patients with PUD.

Both invasive and noninvasive tests are available for the diagnosis of H. pylori infection.

Invasive tests require endoscopic mucosal biopsy and include histologic examination, rapid urease test, and culture. Noninvasive tests include the urea breath test and serology.

Histologic examination can accurately diagnose H. pylori with two biopsy specimens with high sensitivity and specificity (90%).

The rapid urease test on a mucosal biopsy specimen uses a change in pH resulting from the breakdown of urea by a urease enzyme produced by H. pylori.

This test is considered the initial test of choice because of its simplicity, accuracy, and rapid results.

Culture of H. pylori has the most specificity (100%) but is difficult to perform and is currently not widely available.

Cultures should usually be reserved for research purposes or for patients with suspected antibiotic resistance.

The urea breath test is a noninvasive test that analyzes breath for labeled carbon dioxide produced by bacterial urease from the conversion of ingested labeled urea.

Because of its noninvasiveness plus high sensitivity and specificity (95%), the urea breath test is considered the test of choice for documentation of H. pylori eradication.

Serologic tests are quick and inexpensive but cannot differentiate between active infection and previous exposure.

Serology is useful for the initial diagnosis of H. pylori infection in patients in whom endoscopy is not indicated.

259
Q

Which of the following conditions is not associated with gastric cancer?

A. Chronic atrophic gastritis

B. H. pylori infection

C. Hereditary nonpolyposis colorectal cancer

D. Adenomatous gastric polyps

E. Fundic gland polyps

A

ANSWER: E

COMMENTS: Certain gastric lesions have a significant associa- tion with gastric adenocarcinoma and can be considered precursors to malignancy.

Chronic atrophic gastritis, of which several forms are recognized, underlies most gastric cancers.

The epithelial changes of intestinal metaplasia and dysplasia are premalignant. Autoimmune chronic gastritis involves the body and fundus of the stomach.

It is associated with pernicious anemia, achlorhydria, very high gastrin levels, and a high risk for cancer.

Hypersecretory chronic gastritis involves the gastric antrum and is associated with PUD but not malignancy. H. pylori infection may be the most important risk factor for gastric adenocarcinoma worldwide.

The immunoglobulin (Ig)G antibody positivity in various populations correlates with the local incidence of gastric cancer.

Hereditary nonpolyposis colorectal cancer is an inheritable risk factor for gastric cancer.

Adenomatous gastric polyps have malignant potential similar to colonic adenomatous polyps.

The risk increases with increasing size of the polyp.

Fundic gland polyps are benign and have no malignant potential.

260
Q

With regard to the surgical treatment of gastric adenocarci-
noma, which of the following statements is true?

A. Total gastrectomy for antral lesions results in longer survival than does partial gastrectomy.

B. Routine splenectomy does not improve survival rates.

C. Extended lymph node dissection improves survival rates in patients with stages I and II lesions.

D. Total gastrectomy for palliation is contraindicated.

E. Linitis plastica should be resected to histologically
negative margins.

A

ANSWER: B

COMMENTS: Gastric adenocarcinoma is preferably treated by resection, although resection usually proves to be palliative.

The general strategy for curative resection is to remove as much of the stomach as necessary to obtain free margins and to perform limited node dissection.

Although data from Japan support the benefit of extended nodal dissection (celiac, mesenteric, hepatic, and paraaortic), studies in the United States have not generally confirmed this benefit.

Furthermore, these extended dissections can be associated with substantial morbidity. Most resections entail distal subtotal gastrectomy.

Total gastrectomy is appropriate for locally extensive tumors, proximal tumors (to avoid esophageal anastomosis to the distal stomach remnant), and even palliation if necessary.

Extending clear margins on a distal tumor by total rather than subtotal gastrectomy is of no benefit.

Resections for linitis plastica are palliative, usually necessitate total gastrectomy, and are carried out to grossly negative margins only.

Splenectomy is performed according to the location of gastric resection, but its routine performance does not improve the survival rate.

The number of lymph nodes resected, the number of positive nodes, and the ratio of positive to the total number of lymph nodes have important staging implications.

Furthermore, a minimum number of 15 lymph nodes should routinely be examined.

261
Q

With regard to gastrointestinal stromal tumors (GISTs),
which of the following statements is incorrect?

A. A combination of cellular morphology on hematoxylin– eosin staining and KIT immunohistochemistry are required for the diagnosis of GIST.

B. After the small intestine, the stomach is the second most common location for GISTs, followed by the colon and rectum.

C. The majority of GISTs have an activating mutation in the KIT oncogene.

D. GISTs are usually resistant to conventional chemotherapy and radiation therapy.

E. Complete surgical resection is the standard of treatment.

A

ANSWER: B

COMMENTS: GI stromal tumors are the most common mes- enchymal neoplasms of the GI tract.

The majority of these GISTs occur in the stomach (60%), followed by the small bowel (30%), esophagus (1%–5%), and colon and rectum (5%).

The diagnosis of GIST is based on the presence of characteristic pathologic findings on hematoxylin–eosin staining and expres- sion of the KIT receptor on immunohistochemistry.

Rarely, KIT might not be overexpressed, and in such cases molecular evaluation may be necessary.

These tumors do not usually metastasize to lymph nodes. Complete surgical resection is the standard of treatment of primary, localized GISTs.

The majority of GISTs have an activating mutation in the KIT protooncogene that can be effectively inhibited by tyrosine kinase inhibitors such as imatinib mesylate (Gleevec).

GISTs are resistant to conventional chemoradiation therapy.

Laparoscopic resection is increasingly being used, provided that a negative margin can be obtained. Both the size and number of mitoses per 50 high- power field have been used to categorize tumor aggressiveness.

Tumor location may have prognostic implications in that extra- gastric tumors may carry a worse prognosis.

Large or unresectable tumors that show KIT overexpression may initially be treated with Gleevec.

262
Q

Which of the following statements regarding Crohn’s disease of the duodenum is false?

A. Duodenal Crohn’s disease accounts only for 2%–4% of all patients with Crohn’s disease.

B. Because of its location, operative intervention is fre- quently needed for duodenal Crohn’s disease.

C. When an operation is required, a bypass such as gastroje- junostomy is performed rather than duodenal resection.

D. In well-selected patients, strictureplasty can be carried out with good results.

E. Adenocarcinoma is the leading cause of disease-specific death in patients with Crohn’s disease.

A

ANSWER: B

COMMENTS: Crohn’s disease of the duodenum is not common and is seen in only 2%–4% of patients with Crohn’s disease.

Medical therapy remains the mainstay of treatment of duodenal Crohn’s disease, with surgical intervention being reserved for patients who do not respond to medical therapy or in whom a complication such as obstruction or perforation develops.

In patients who do need a surgical procedure, bypass is preferred over duodenal resection.

In a few select patients, their anatomy might be amenable to strictureplasty.
Irrespective of the location of Crohn’s disease, GI cancer remains the leading cause of death in patients with Crohn’s disease.

263
Q

With regard to gastric volvulus, which of the following
statements is true?

A. The Borchardt’s triad includes acute epigastric pain, retching without vomiting, and inability to pass an NG tube.

B. Its symptoms consist of severe nausea with bilious emesis.

C. It more frequently involves rotation around the axis that bisects the greater and lesser curvatures.

D. Its surgical management is via a transthoracic approach.

E. Surgical management of volvulus without a diaphrag- matic defect involves only detorsion of the stomach.

A

ANSWER: A

COMMENTS: Gastric volvulus is a serious complication of paraesophageal hernia. Two types of gastric volvulus may occur, depending on the axis of rotation.

Organoaxial volvulus, the more common type, involves rotation around the axis of a line connecting the cardia and pylorus.

Mesenteroaxial volvulus is not associated with a diaphragmatic defect and involves rotation around the line that bisects the greater and lesser curvatures.

Combined types have also been described. Patients classically present with Borchardt’s triad, which includes acute epigastric pain, violent retching without vomiting, and the inability to pass an NG tube.

Acute gastric volvulus is a surgical emergency and requires prompt reduction via a transabdominal approach. Repair of the diaphragmatic defect should follow with possible fundoplication.

In the setting of volvulus without an associated diaphragmatic defect, detorsion of the stomach and either gastropexy or tube gastrostomy is performed to reduce the risk for recurrence.

264
Q

In a patient who presents with intractable ulcer disease,
which of the following statements is true?

A. A fasting serum gastrin level of >200 pg/mL is diagnostic of a gastrinoma.

B. A CT scan may demonstrate a mass within the tail of the pancreas.

C. In the setting of Zollinger-Ellison syndrome, endoscopy would demonstrate atrophic gastric mucosa.

D. The most sensitive and specific diagnostic test for Zollinger-Ellison syndrome is the secretin stimulation test.

E. Testing for associated multiple endocrine neoplasia II (MEN II) endocrine tumors should be considered.

A

ANSWER: D

COMMENTS: Intractable ulcer disease is defined as that occurring after an adequate duration of antacid therapy, documentation of eradication of H. pylori infection, and elimination of NSAID use.

In these patients, malignancy must be ruled out and a serum gastrin level should be drawn to evaluate for a gastrinoma. Zollinger-Ellison syndrome is the triad of gastric acid hypersecretion, severe PUD, and non–beta islet cell tumors of the pancreas.

Gastrinomas occur most commonly within the gastrinoma triangle as defined by the confluence of the cystic and common bile duct, the junction of the second and third portions of the duodenum, and the junction of the neck and body of the pancreas.

They are found almost equally within the wall of the duodenum as the head of the pancreas but not in the tail of the pancreas.

Endoscopy often reveals prominent rugal folds, which result from the trophic effect of the hypergastrinemia. Fasting serum gastrin levels are usually elevated above 200 pg/mL, but a value greater than 1000 pg/mL is diagnostic.

In the setting of equivocal gastrin levels, the most sensitive test is the secretin stimulation test.

A rise in gastrin levels of greater than 200 pg/ mL above baseline is specific for gastrinoma.

Gastrinomas are associated with MEN I syndrome, not MEN II syndrome.

Testing for associated endocrine tumors should be performed.

265
Q

Which of the following is true with regard to gastric
carcinoid neoplasms?

A. The incidence is decreasing.

B. They commonly present with abdominal pain, bleeding, and carcinoid syndrome.

C. The subtypes associated with low acid states have a
better prognosis.

D. Long-term use of PPIs has not been shown to increase the risk for developing a gastric carcinoid neoplasm.

E. The treatment is based largely on nonsurgical manage- ment with somatostatin analogues.

A

ANSWER: C

COMMENTS: Long thought to be a rare location for carcinoid malignancies, gastric carcinoid neoplasms (or neuroendocrine tumors, NET) are increasing in incidence.

Many patients are asymptomatic and diagnosed incidentally during endoscopy, though rarely they can present with abdominal pain, bleeding, and symptoms of carcinoid syndrome.

The rise in the use of endoscopy has been postulated to account for some of the increase in incidence; however, the increase in the long-term use of PPIs may also play a part as it has been shown to be an independent risk factor for the development of gastric carcinoid tumors.

There are three types of gastric carcinoids.

The majority of these are type 1 and are associated with a low acid state (normally from atrophic gastritis), resulting in hypergastrinemia, which in turn is thought to cause ECL cell hyperplasia and eventual dysplasia.

This type carries a better prognosis than sporadic types, type 3, not associated with low acid states.

The final type is type 2, which is associated with Zollinger-Ellison syndrome and high gastrin levels.

Treatment is based on complete resection whether accomplished via endoscopic removal, wedge resection, or total gastrectomy, depending on the extent of the disease.

Somatostatin analogues can serve to decrease tumor burden and address symptoms of carcinoid syndrome in patients with recurrent or metastatic disease.

266
Q

On the cellular level, which of the following is true regarding
acid secretion?

A. Acid secretion is stimulated only by gastrin.

B. Acid secretion is stimulated by gastrin and secretin.

C. The final common pathway of acid secretion is the
hydrogen-potassium adenosine triphosphatase (H+, K+-ATPase).

D. Histamine activates acid secretion via increases in intracellular calcium.

E. Acid secretion is stimulated by CCK.

A

ANSWER: C

COMMENTS: It is important to have the knowledge of the cellular basis for parietal cell acid secretion to understand the pharmacologic control of acid.

The parietal cell has three specific plasma membrane receptors that stimulate acid secretion: acetylcholine, histamine, and gastrin receptors.

All three receptors eventually activate the H+, K+-ATPase pump via different mechanisms, which results in the secretion of a hydrogen ion for potassium.

Acetylcholine- and gastrin-stimulated secretion depends on increases in intracellular calcium levels, with subsequent phosphorylase kinase–induced phosphorylation and H+, K+-ATPase activity.

Histamine activates the adenylate cyclase pathway.

Somatostatin, CCK, and secretin inhibit acid secretion.

267
Q

Which of the following statements is true regarding the gross or microscopic anatomy of the stomach?

A. The angularis incisura marks the transition from the body of the stomach to the antrum along the greater curvature.

B. The angle of His is formed by the junction of the fundus with the left diaphragmatic crus.

C. The cardia is dominated by mucus-secreting cells.

D. The majority of the parietal cells exist in the fundus and the proximal body.

E. The GE junction is normally found at the diaphragmatic hiatus.

A

ANSWER: C

COMMENTS: The most proximal region of the stomach is the cardia. This is dominated by mucus-secreting cells, which provide a mechanical barrier to injury.

Gastric ulcers in this area are deemed type IV ulcers and are associated with a breakdown of this mucus barrier.

The uppermost part of the stomach is the fundus. The junction of the fundus and the left margin of the esophagus forms the angle of His.

The GE junction is normally found about 2 to 3 cm below the diaphragmatic esophageal hiatus.

The extension of the esophagus into the abdominal cavity creates an anatomically important pressure differential between the distal esophagus within the positive pressure abdomen and the midesophagus within the negative pressure thoracic cavity that helps to prevent reflux.

This relationship is disturbed in patients with type I hiatal hernias.

The body is bound by the lesser curvature on the right and greater curvature on the left.

Parietal cells exist primarily within the body, with few in the fundus and antrum and none in the cardia or pre- pyloric antrum.

As the lesser curvature meets the pylorus, it angles abruptly to the right, identifying the angularis incisura.

268
Q

Which of the following statements is true regarding the management of upper GI bleeding?

A. The return of clear fluid from an NG lavage rules out upper GI bleeding.

B. Primary hemostasis is only achieved in 60% of patients by endoscopy alone.

C. The majority of upper GI bleeding will require intervention.

D. Patients with an upper GI bleed should undergo endos- copy within 24 h of presentation.

E. All patients should be placed on PPI and octreotide infusions.

A

ANSWER: D

COMMENTS: The majority of upper GI bleeding requires no intervention and ceases spontaneously.

However, if it persists, it is associated with a mortality rate of 6%–8%. Initial management should include IV access, fluid resuscitation, and blood products as indicated.

Placement of an NG tube can confirm upper GI bleeding with return of bloody or coffee ground lavage; however, only return of bilious lavage can effectively rule out an upper GI source of a bleed.

Regardless of the degree of severity, patients who present with upper GI bleeding should undergo endoscopy within 24h of presentation for both diagnostic and therapeutic purposes.

Endoscopic control results in primary hemostasis in approximately 90% of patients.

Patients should be closely monitored in an intensive care unit (ICU) setting in case of persistent bleeding, and all high-risk patients should be placed on PPI infusion.

Octreotide infusions are reserved for upper GI bleeding as a result of esophageal varices.

269
Q

Which cell type is matched with the appropriate secretory
product?

A. Chief cell/gastrin

B. Delta cell/somatostatin

C. Parietal cell/pepsin

D. G cell/histamine

E. ECL cell/intrinsic factor

A

ANSWER: B

270
Q

Which cell type is matched with the correct primary
anatomic location?

A. Chief cell/gastric antrum

B. G cell/gastric cardia

C. D cell/gastric fundus

D. Parietal cell/gastric fundus

E. Endocrine cell/gastric body

A

ANSWER: E

COMMENTS: The gastric mucosa consists of surface columnar epithelial cells and glands containing various cell types.

The mucosal cells vary in their anatomic location and secretory function.

Within the cardia, the glands contain primarily mucus-secreting cells and the pits are short.

In the body of the stomach, the glands retain their mucus-secreting cells at their luminal end but the pits extend deeper and begin to include other secretory cells.

Parietal and chief cells are located predominately in the body.

Parietal cells produce hydrochloric acid and intrinsic factor, whereas chief cells secrete pepsinogen.

The G cells of the antrum are the primary source of gastrin.

Somatostatin is synthesized and stored in delta cells located in the gastric corpus and antrum.

Ghrelin, produced by endocrine cells of the gastric body, probably plays a role in the neuroendocrine response to changes in nutritional status and has been shown to enhance appetite and increase food intake.

Removal of a significant portion of the gastric body resulting in decreased ghrelin levels is thought to be the mechanism of appetite control after a sleeve gastrectomy.

271
Q

Which of the following statements is true regarding gastric MALT lymphoma?

A. Negative histologic H. pylori testing confirms an H.
pylori–negative MALT lymphoma.

B. Less than 10% of gastric lymphomas have associated H.
pylori infection.

C. Upper GI endoscopy with gastric biopsy for the determi- nation of the presence of H. pylori and the histologic type of lymphoma is the diagnostic test of choice.

D. Surveillance includes repeat endoscopy in 6 months to document clearance of the infection.

E. CT of the abdomen, chest radiography, bone marrow biopsy, and diagnostic laparoscopy are required for complete staging.

A

ANSWER: C

COMMENTS: Gastric MALT lymphoma is associated with chronic H. pylori infection in more than 90% of cases.

Chronic infection with H. pylori results in monoclonal B-cell proliferation and development of lymphoid tissue resembling Peyer’s patches in the stomach.

Treatment directed toward H. pylori eradication results in the resolution of MALT lymphomas in 75% of cases.

Upper endoscopy with biopsy is the diagnostic test of choice. Gastric biopsies are used to evaluate the presence of H. pylori and the histologic type of lymphoma.

The depth of gastric wall invasion and the presence of nodal involvement can be determined with the help of endoscopic ultrasonography.

Histologically, H. pylori– negative MALT lymphomas should be confirmed as such with serologic testing.

Staging is completed with a chest radiograph, bone marrow biopsy, and CT of the abdomen.

Surveillance is achieved with repeat endoscopy in 2 months with biopsy to document clearance of infection and subsequent endoscopy every 6 months for 3 years.

Certain genetic translocations, large cell phenotype, nodal involvement, or transmural tumor extension all predict failure of H. pylori eradication alone.

272
Q

Which of the following statements about high-grade gastric lymphoma is true?

A. Diffuse large B-cell lymphoma is the second most common gastric lymphoma after MALT lymphoma.

B. The addition of surgery to chemotherapy alone has been shown to improve outcomes.

C. Hemorrhage is a frequent complication of chemotherapy.

D. Surgical treatment is usually reserved for patients with limited gastric disease, localized persistent lymphoma, or complications associated with nonsurgical treatment.

E. Perforation is a frequent complication after chemotherapy.

A

ANSWER: D

COMMENTS: Diffuse large B-cell lymphoma is the most common type of gastric lymphoma, with MALT lymphoma being the second most common. High-grade gastric lymphoma is gener- ally treated with chemotherapy or chemoradiation.

Compared with surgical treatment, patient survival has been shown to be equivalent or better with nonsurgical treatment in several prospective clinical trials (randomized and nonrandomized).

It was previously believed that surgery was superior to chemotherapy due to the risk for complications such as perforation and hemorrhage with chemotherapy.

However, these risks have been found to be only approximately 5%. It is postulated that these risks may be increased with full- thickness involvement of the gastric wall.

EUS can be used to determine the depth of invasion, and this information can be offered to the patient when discussing risks and benefits of treatment options.

Operative intervention is therefore largely reserved for limited gastric disease in which R0 resection is a reasonable goal, patients undergoing chemoradiation with treatment failure, or for the management of rare complications of nonsurgical treatment including perforation, hemorrhage, and obstruction.

273
Q

Regarding gastric varices, which of the following is false?

A. Gastric varices develop via increased flow and pressure transmitted through the short and posterior gastric veins.

B. Isolated gastric varices are the result of splenic vein thrombosis.

C. Gastric varices are more often associated with generalized
portal hypertension than with splenic vein thrombosis.

D. Isolated gastric varices should be managed with endo- scopic banding and sclerotherapy.

E. Gastric varices associated with portal hypertension should be managed with endoscopic banding and sclerotherapy.

A

ANSWER: D

COMMENTS: There are two types of gastric varices: those that occur in the setting of portal hypertension and those that are secondary to splenic vein thrombosis (isolated gastric varices).

To establish the diagnosis of isolated gastric varices, there must be no evidence of portal hypertension, cirrhosis, or esophageal varices on endoscopy.

In either type, an increased flow and pressure is trans- mitted via the short and posterior gastric veins.

For isolated gastric varices, splenectomy is curative.

Splenectomy is neither curative nor indicated when the varices are associated with portal hypertension.

Rather, this type is best managed similarly to esopha- geal varices with endoscopy, banding, and sclerotherapy.

274
Q

Regarding the gross anatomy of the duodenum, which of the
following is true?

A. The length of the duodenum is approximately 20 cm.

B. The second, third, and fourth portions of the duodenum are retroperitoneal.

C. The SMA marks the transition point between the second and third portions.

D. Lack of collateral blood supply puts the duodenum at a high risk for ischemia.

E. The minor papilla is located in the first portion of the duodenum and the major in the second.

A

ANSWER: A

COMMENTS: The duodenum is the first portion of the small intestine and the most distal foregut-derived structure. It is approximately 20 cm in length and is divided into four portions, of which the second and third are found retroperitoneally.

Although the minor papilla is found superiorly to the major, they are both located within the second portion.

The acute angle between the aorta and the SMA marks the transition point between the third and fourth portions.

The blood supply to the duodenum is via the superior and inferior pancreaticoduodenal arteries, both of which have posterior and anterior divisions and constitute a rich bed of vascular collaterals.

The anastomosis of these two vessels also represents the only connection between celiac and SMA blood supply.

275
Q

With regard to adenocarcinoma of the small bowel, which of
the following statements is false?

A. Small bowel adenocarcinoma is found in decreasing order of frequency in the ileum, jejunum, and duodenum.

B. Villous adenomas of the small bowel are commonly found in the duodenum around the ampulla of Vater.

C. Adenocarcinoma of the duodenum usually occurs earlier than small bowel adenocarcinoma elsewhere in the jejunum and ileum.

D. Villous adenomas of the duodenum are frequently associated with familial adenomatous polyposis (FAP).

E. Operative resection is the treatment modality of choice and has curative potential.

A

ANSWER: A

COMMENTS: Small bowel adenocarcinoma accounts for the majority (35%–50%) of small bowel malignant neoplasms, followed by carcinoid tumors, lymphomas, and sarcomas.

Adenocarcinoma of the small bowel is more common in the duodenum, whereas carcinoid tumors and lymphoma are more frequently seen in the ileum.

Small bowel adenocarcinoma is found in decreasing order of frequency in the duodenum, jejunum, and ileum.

Most patients have nonspecific symptoms initially; however, adenocarcinoma of the duodenum is manifested earlier with signs and symptoms of obstruc- tive jaundice, gastric outlet obstruction, and abdominal pain.

Operative resection (pancreaticoduodenectomy and local excision) is the treatment of choice, depending on the size and location of the adenocarcinoma, the patient’s health, and the surgeon’s expertise.

Although rare in the small bowel, villous adenomas are frequently found in the duodenum and are associated with FAP syndrome (31%–92%).

These villous adenomas have high malignant potential, especially if they are larger than 5 cm or are accompanied by bleeding or obstruction.

The Spigelman criteria are used to grade duodenal polyposis seen in FAP.

They consist of five incremental stages of severity (0 to IV). Points are earned for the number of polyps, size of polyps, histology, and grade of dysplasia.

This classification also correlates with the risk for malignancy as follows: stage II, 2.3% risk; stage III, 2.4% risk; and stage IV, 36% risk.

Pancreaticoduodenectomy is recommended for stage IV.

276
Q

First-line therapy for routine peptic duodenal ulcer disease includes:

A. Vagotomy and antrectomy

B. Upper endoscopy and biopsy to rule out tumor

C. Evaluation for Helicobacter pylori

D. Sucralfate

E. Spicy food

A

C. Evaluation for Helicobacter pylori

277
Q

All of the following are complications of peptic ulcer surgery except:

A. Duodenal stump blowout

B. Dumping

C. Diarrhea

D. Delayed gastric emptying

E. Steatorrhea

A

E. Steatorrhea

278
Q

Which of the following statement/s is/are correct concerning the diagnostic studies for esophageal carcinoma?

A. A chest CT scan is more useful than endoscopic ultrasound for determining tumor invasion

B. A barium swallow is an unnecessary test in a patient with dysphagia

C. Bronchoscopy should be performed in all patients with carcinoma of the upper and middle thirds of the esophagus

D. Bone and brain scans should be obtained routinely to rule out distant mets

E. Endoscopic ultrasound is indicated to check for lung metastases

A

C. Bronchoscopy should be performed in all patients with carcinoma of the upper and middle thirds of the esophagus

279
Q

In an effort to improve survival following esophageal resection, trials of multimodality therapy in combination with surgery have been completed, Which of the following statements are true concerning such treatment?

A. Therapy appears to be indicated in SCC but no adenocarcinoma

B. Chemotherapy alone without radiation therapy is enough for patients with lymph node mets

C. Trials would suggest improved survival compared to patients receiving surgery alone

D. Perioperative morbidity is increased due to preoperative radiation and chemotherapy

E. Monoclonal antibody therapy is favored over chemotherapy and radiation treatment in the adjuvant setting in the Philippines.

A

C. Trials would suggest improved survival compared to patients receiving surgery alone

280
Q

With regard to operative treatment of gastric carcinoma, which of the following statements is/are correct?

A. Resectional margins of 1mm are necessary to prevent recurrence due to intramural metastases

B. Prophylactic splenectomy has been shown to improve outcome in similarly staged patients

C. Extended lymphadenectomy including nodes along the aorta and esophagus may improve survival

D. Laparoscopic peritoneal lavage has no role in gastric cancer diagnosis

E. Palliative total gastrectomy in stage IV gastric cancer is not indicated in patients with massive bleeding.

A

C. Extended lymphadenectomy including nodes along the aorta and esophagus may improve survival

281
Q

H. Pylori eradication regimens?

A

1) Bismuth triple therapy
- Bismuth 2 tabs QID
- Metronidazole 250mg TID
- Tetracycline 500ng QID

2) Quadruple therapy
- PPI BID
- Bismuth 2 tabs QID
- Metronidazole 250mg TID
- Tetracycline 500mg QID

3) PPI triple therapy
- PPI BID
- Amoxicillin 1g BID
- Clarithromycin 500mg BID

10-14 days treatment is recommended

282
Q
  1. A 45-year-old man complains of burning epigastric pain that wakes him up at night. The
    pain is relieved by eating or using over-thecounter antacids and H2 blockers. Diagnosis is
    best confirmed by which of the following?
    (A) Urea breath test
    (B) Serum gastrin levels
    (C) Barium meal examination
    (D) Upper endoscopy
    (E) Upper endoscopy and biopsy
A
  1. (E) Duodenal ulcer is best diagnosed by upper
    endoscopy and biopsy. Findings of gastritis
    and the presence of H.pylori are indications to
    prescribe appropriate therapy. This typically
    includes a PPI and two antibiotics (one regimen
    includes amoxicillin and clarithromycin).
    Although the urea breath test is the most sensitive and specific test used to detect H. pylori,
    it is not readily available in all settings.
283
Q
  1. A 64-year-old woman with arthritis is a chronic
    NSAID user. She develops severe epigastric pain and undergoes an upper endoscopy. She is told that she has an ulcer adjacent to the pylorus. Which of the following is TRUE about the pylorus?

(A) It cannot be palpated at laparaotomy.

(B) It is not covered completely by omentum.

(C) It is a distinct anatomic entity that can
be distinguished during laparotomy.

(D) It is a true physiologic sphincter.

(E) It is a site where cancer is rarely found.

A
  1. (C) The pylorus is palpable but it is not a true
    physiologic sphincter.

It does not demonstrate reciprocal contraction when the stomach relaxes, nor does it relax when the stomach contracts.

The pylorus is normally in tonic contraction. It is partially covered by omentum and cancer is commonly found there.

284
Q
  1. A 30-year-old executive learns that he has a duodenal ulcer. His gastroenterologist prescribes and outlines medical therapy. The patient worries
    that if medical therapy fails he may need surgery.
    Which of the following is the best indication for
    elective surgical therapy for duodenal ulcer
    disease?

(A) An episode of melena

(B) Repeated episodes of pain

(C) Pyloric outlet obstruction due to scar
formation from an ulcer

(D) Frequent recurrences of ulcer disease

(E) Referral of pain to the back, suggestive
of pancreatic penetration

A
  1. (C) Surgical intervention for peptic ulcer disease
    is uncommon.

It is indicated by four clinical situations—intractable pain, hemorrhage, perforation, and obstruction.

Noncompliance with medication is often the cause of recurrence.

Patients with gastric decompression need a nasogastric tube and fluid and electrolyte correction prior to surgery.

285
Q
  1. A 44-year-old dentist was admitted to the hospital with a 1-day history of hematemesis caused by a recurrent duodenal ulcer. He has shown considerable improvement following operative treatment by a truncal vagotomy and pyloroplasty, 10 years prior to this incident.
    Which is TRUE of truncal vagotomy?

(A) It is performed exclusively via the thorax.

(B) It can be performed in the neck.

(C) If complete, it will result in increased acid secretion.

(D) It requires a gastric drainage procedure.

(E) It has been abandoned as a method to
treat ulcer disease.

A
  1. (D) If vagotomy alone is performed, gastric stasis occurs in more than 40% of cases.

Branches of the vagus nerve innervate the pylorus. A drainage procedure is necessary; a pyloroplasty or a gastroenterostomy should be performed and both of these require a laparotomy.

Truncal vagotomy can also be done through a thoracic approach. Transection of the vagus nerve in the neck results in paralysis of the recurrent laryngeal nerve.

286
Q
  1. A 42-year-old executive has refractory chronic
    duodenal ulcer disease. His physican has suggested several surgical options. The patient has
    chosen a parietal (highly selective) vagotomy instead of a truncal vagotomy and antrectomy
    because?

(A) It results in a lower incidence of ulcer recurrence.

(B) It benefits patients with antral ulcers the most.

(C) It reduces acid secretion to a greater extent.

(D) The complication rate is lower.

(E) It includes removal of the ulcer.

A
  1. (D) In highly selective vagotomy (Fig. 5–6), the nerve supply to the pylorus is left intact (and therefore no drainage procedure is necessary).

During this operation, the branches of the vagus nerve that supply the parietal cell mass are meticulously divided, leaving the main anterior and posterior nerves of Latarjet intact.

The main vagal trunks are also left intact, thus sparing the nerve supply to the liver, gallbladder, pancreas, and intestines.

To ensure completeness of the procedure, great care is taken to divide the proximal (criminal) nerve of Grassi.

Although the complication rate is lower, the recurrence rate is higher than that of an antrectomy and truncal vagotomy.

287
Q
  1. A 63-year-old woman is admitted to the hospital with severe abdominal pain of 3-hour duration. Abdominal examination reveals board-like rigidity, guarding, and rebound tenderness. Her blood pressure is 90/50 mm Hg, pulse 110 bpm (beats per minute), and respiratory rate is 30 breaths per minute. After a thorough history and physical, and initiation of fluid resuscitation, what diagnostic study should be performed?

(A) Supine abdominal x-rays

(B) Upright chest x-ray

(C) Gastrograffin swallow

(D) Computerized axial tomography (CAT) scan of the abdomen

(E) Abdominal sonogram

A
  1. (B) An upright chest x-ray will demonstrate free air below the diaphragm in about 70–75% of patients presenting with a perforated duodenal ulcer.

An abdominal sonogram may demonstrate free fluid, but not free air.

Although a CAT scan will show both free fluid and free air, it will take longer to perform and may delay the definitive treatment.

The combination of an acute abdomen and an upright chest x-ray with free air under the diaphragm provides enough information to take the
patient to the operating room for exploration.

288
Q
  1. A frail elderly patient is found to have an anterior perforation of a duodenal ulcer. He has a recent history of nonsteroidal anti-inflammatory drug (NSAID) use and no previous history of peptic ulcer disease. A large amount of bilious fluid is found in the abdomen. What should be the next step?

(A) Lavage of the peritoneal cavity alone

(B) Lavage and omental patch closure of the ulcer

(C) Total gastrectomy

(D) Lavage, vagotomy, and gastroenterostomy

(E) Laser of the ulcer

A
  1. (B) Although surgery is generally recommended for perforation, conservative measures can be considered in select cases.

A patient who has a benign clinical presentation or one who is improving, might be considered for treatment with antibiotics and nasogastric decompression.

Patients who have an acute abdomen and are hemodynamically unstable should not be observed.

Board-like rigidity of the abdomen occur as a result of chemical peritonitis.

These patients should have fluid and electrolyte
repletion, and antibiotics followed by surgery.

Choice of the operative procedure should be guided by the information obtained during the history, the presence of comorbid disease, and hemodynamic stability during the operation.

A omental (Graham) patch will seal the ulcer, but it will not prevent recurrence.

289
Q
  1. Three months after recovery from an operation to treat peptic ulcer disease, a patient complains that she has difficulty eating a large meal. A 99m Tc-labeled chicken scintigraphy test confirms a marked delay in gastric emptying. A delay in gastric emptying may be due to which of the following?

(A) Zollinger-Ellison syndrome (ZES)

(B) Steatorrhea

(C) Massive small-bowel resection

(D) Previous vagotomy

(E) Hiatal hernia

A
  1. (D) Following truncal land selective vagotomy,
    gastric empyting is delayed.

If a vagotomy (truncal or selective) is performed, a drainage procedure is necessary (e.g., pyloroplasty).

A disturbance is gastric motility with a delay in gastric emptying may occur with a mechanical gastric outlet obstruction, diabetes, myxedema,
hypokalemia, or the administration of anticholinergic or opiate drugs.

Rapid gastric emptying may be seen with ZES, retained gastric antrum syndrome, steatorrhea, or massive small bowel resection where there is impaired ability to reduce gastric acid secretion.

Failure of switch-off mechanism to inhibit acid secretion also results in increased motility and emptying of the stomach.

290
Q
  1. A 64-year-old supermarket manager had an elective operation for duodenal ulcer disease. He has not returned to work because he has diarrhea
    with more than 20 bowel movements per day. Medication has been ineffective. The exact details
    of his operation cannot be ascertained. What
    operation was most likely performed?

(A) Antrectomy and Billroth I anastomosis

(B) Gastric surgery combined with cholecystectomy

(C) Truncal vagotomy

(D) Highly selective vagotomy

(E) Selective vagotomy

A
  1. (C) Although a milder type of diarrhea is not
    uncommon after gastrectomy, fulminant diarrhea may be a problem after vagotomy (it is one
    of the many complications collectively referred
    to as post vagotomy syndromes).

The exact mechanism is not known. It occurs in 1-2% of patients following truncal vagotomy and is less likely to be found after selective or highly selective vagotomy.

291
Q
  1. A 40-year-old man has had recurrent symptoms
    suggestive of peptic ulcer disease for 4 years. Endoscopy reveals an ulcer located on the greater curvature of the stomach. A mucosal biopsy reveals Helicobacter pylori. What is TRUE about H. pylori?

(A) Active organisms can be discerned by serology.

(B) It is protective against gastric carcinoma.

(C) It is associated with chronic gastritis.

(D) It causes gastric ulcer but not duodenal ulcer.

(E) It can be detected by the urea breath test in <60% of cases.

A
  1. (C) H. pylori (previously called Campylobacter
    pylori) is associated with chronic gastritis, duodenal ulcers, gastric ulcers, and gastric cancer.

Serology can accurately detect H. pylori but remains positive for up to 1 year post treatment.

The urea breath test is highly sensitive (96%) and specific (94%).

In 2005, Barry Marshall and J. Robbin Warren won the Nobel Prize in medicine for their work on H. pylori and its role in gastritis and peptic ulcer disease.

292
Q
  1. A 35-year-old CEO underwent an antrectomy and vagotomy for a bleeding ulcer. Although usually careful with his diet, he ate a large meal during a business lunch. Within 1 hour, he felt lightheaded and developed abdominal cramping and diarrhea. His symptoms may be attributed to:

(A) Anemia

(B) Jejunogastric intussusception

(C) Dumping syndrome

(D) Afferent loop syndrome

(E) Alkaline reflux gastritis

A
  1. (C) Postgastrectomy syndromes collectively refer
    to complications that can occur after gastric surgery.

This constellation of syndromes includes delayed gastric emptying, recurrent ulcers, diarrhea, anemia, jejunogastric intussusception, afferent loop syndrome, alkaline reflux gastritis, and dumping syndrome.

There are two types of dumping syndrome, early and late.

Early dumping occurs within 30 minutes and is caused by rapid gastric emptying of a hyperosmolar load into the small bowel.

Late (hypoglycemic) dumping occurs 1–3 hours after eating.

Symptoms are mostly vasomotor. They are related to the excessive release of insulin in response to the rapid rise in postprandial glucose.

293
Q
  1. A 63-year-old man has an upper gastrointestinal
    (UGI) study as part of his workup for abdominal pain. The only abnormal finding was in the antrum, where the mucosa prolapsed into the duodenum. There were no abnormal findings on endoscopy. What should he do?

(A) Sleep with his head elevated.

(B) Be placed on an H2 antagonist.

(C) Undergo surgical resection of the antrum.

(D) Be observed and treated for pain accordingly.

(E) Have laser treatment of the antral mucosa.

A
  1. (D) Prolapse of gastric mucosa into the duodenum may be difficult to distinguish from a
    polyp in the antrum.

It may be detected in a patient who is asymptomatic.

Surgical correction should be reserved for patients with obstructive symptoms (e.g., vomiting).

Sleeping with they head elevated, H2 antagonist, and laser treatment have no role.

294
Q
  1. A 63-year-old man underwent gastric resection for severe peptic ulcer disease. He had complete relief of his symptoms but developed “dumping syndrome.” This patient is most likely to complain of which of the following?

(A) Gastric intussusception

(B) Repeated vomiting

(C) Severe diarrhea

(D) Severe vasomotor symptoms after eating

(E) Intestinal obstruction

A
  1. (D) Dumping syndrome is a symptom complex
    occurring after gastric surgery.

It is characterized by fatigue, abdominal distention, pain, and vasomotor symptoms caused by the rapid entry of food into the small intestine.

Tachycardia, sweating, and feeling lightheaded after eating are symptoms patients may feel.

There are two types of dumping syndrome, early and late.

295
Q
  1. A 65-year-old man was admitted to the hospital for severe bilious vomiting following gastric surgery. This occurs in which circumstance?

(A) Following ingestion of gaseous fluids

(B) Spontaneously

(C) Following ingestion of fatty foods

(D) Following ingestion of bulky meals

(E) In the evening

A
  1. (B) Bilious vomiting is usually spontaneous and should be differentiated from vomiting that occurs after eating.

The most likely cause of this complication is reflux of bile into the stomach.

Bile gastritis with intestinalization of the gastric mucosa is a likely cause.

296
Q
  1. A 64-year-old man has had intermittent abdominal pain as a result of duodenal ulcer disease for the past 6 years. Symptoms recurred
    6 weeks before admission. He is most likely to
    belong to which group?

(A) A and secretor (blood group antigen in body fluid)

(B) B and Lewis antigen

(C) AB

(D) O and nonsecretor

(E) O and secretor

A
  1. (D) Group O is the most common blood type in
    patients with duodenal ulcer disease.

In patients who have bled from a duodenal ulcer, this observation is even more striking.

Secretors have an excess of blood group antigen that is absent in nonsecretors.

The secretor antigen on the red blood cell appears in body fluids also.

Nonsecretors are more prone to develop dueodenal ulcers than secretors.

297
Q
  1. A 64-year-old man was evaluated for moderate protein deficiency. He underwent a gastrectomy 20 years earlier. He is more likely to show which of the following?

(A) Porphyria

(B) Hemosiderosis

(C) Aplastic anemia

(D) Hemolytic anemia

(E) Iron deficiency anemia

A
  1. (E) There is a varying degree of impairment in
    carbohydrate, fat, protein, and mineral absorption after gastrectomy.

These changes are most severe after a subtotal gastrectomy and gastrojejunostomy (Billroth II) (Fig. 5–7), in most patients these changes are mild.

An acid environment is necessary to release ferric ion from food and make it available for absorption in the small intestine.

298
Q
  1. A 68-year-old woman has been diagnosed with a benign ulcer on the greater curvature of her stomach, 5 cm proximal to the antrum. After 3 months of standard medical therapy, she continues to have guaiac positive stool, anemia, and abdominal pain with failure of the ulcer to heal. Biopsies of the gastric ulcer have not identified a malignancy. The next step in management is which of the following?

(A) Treatment of the anemia and repeat all studies in 6 weeks

(B) Endoscopy and bipolar electrocautery or laser photocoagulation of the gastric ulcer

(C) Admission of the patient for total parenteral nutrition (TPN), treatment of anemia, and endoscopic therapy

(D) Surgical intervention, including partial gastric resection

(E) Surgical intervention, including total gastrectomy

A
  1. (D) In general, vagotomy with a gastric drainage
    procedure is less satisfactory in the treatment of
    primary gastric ulcer.

Treatment of a gastric ulcer may include partial gastrectomy with a gastroduodenal anastomosis (Billroth I).

Vagotomy is not necessary because gastric ulcers are usually not associated with acid hypersecretion.

A gastric ulcer that fails to heal despite medical therapy should be excised.

299
Q
  1. Investigations of a 43-year-old woman with pluriglandular syndrome were scheduled to determine if a gastrinoma (ZES) was present. The serum gastrin level was slightly elevated. Further assessment to establish the diagnosis can be made by repeating the serum gastrin level after stimulation with which of the following?

(A) Phosphate

(B) Potassium

(C) Calcium

(D) Chloride

(E) Magnesium

A
  1. (C) In ZES gastrin levels may be only mildly
    elevated but can be increased with provocation with intravenous calcium or secretin.

Most patients with gastrinoma have serum gastrin levels that exceed 500 pg/mL.

When the range is lower than 200–500 pg/mL, a stimulation test is performed to confirm the diagnosis.

A rise of 200 pg/mL after 15 minutes, or a doubling of the fasting level is diagnostic.

ZES can occur sporadically or as part of multiple endocrine neoplasia (MEN) I.

300
Q
  1. Over the past 6 months, a 60-year-old woman with long standing duodenal ulcer disease has been complaining of anorexia, nausea, weight loss and repeated vomiting. She recognizes undigested food in the vomitus. Examination and workup reveal dehydration, hypokalemia, and hypochloremic alkalosis. What is the most likely diagnosis?

(A) Carcinoma of the fundus

(B) Penetrating ulcer

(C) Pyloric obstruction due to cicatricial stenosis of the lumen of the duodenum

(D) ZES (Zollinger Ellison Syndrome)

(E) Anorexia nervosa

A
  1. (C) Chronic duodenal ulcer, with recurrent
    episode of healing and repair, may lead to
    pyloric obstruction due to scarring and stenosis
    of the duodenum.

Painless vomiting of undigested food may occur once or twice a day.

Surgical intervention should be carried out after
correction of fluid and electrolyte imbalances.

Preoperative antibiotics should be used due to bacterial overgrowth secondary to gastric stasis.

301
Q
  1. A 50-year-old woman presents with duodenal
    ulcer disease and high basal acid secretory outputs. Secretin stimulated serum gastrin levels are in excess of 1000 pg/mL. She has a long history of ulcer disease that has not responded to
    intense medical therapy. What is the most likely
    diagnosis?

(A) Hyperparathyroidism

(B) Pernicious anemia

(C) Renal failure

(D) ZES

(E) Multiple endocrine neoplasia

A
  1. (D) ZES is characterized by duodenal ulcer disease, high basal acid secretory output, and a
    pancreatic tumor.

Stimulated serum gastrin levels may be in excess of 1000 pg/mL or as high as 10,000 pg/mL.

ZES is due to a true pancreatic tumor in adults, but may be secondary to hyperplasia in children.

Growth of the tumor is usually slow and survival is often prolonged.

If an isolated tumor is found on CAT scan, surgical resection is indicated.

About two-thirds of these tumors are malignant.

About one-fourth of patients have MEN I syndrome tumors of parathyroid pituitary and pancreas.

302
Q
  1. A 44-year-old man underwent partial resection of the stomach. Following the operation, there was a reduction in serum gastrin levels. The site of resection of the stomach that removed the normal source of gastrin is which of the following (Fig. 5–1)?

(A) Gastroduodenal junction

(B) Lower esophagus

(C) Antrum

(D) Body of the stomach

(E) Fundus of the stomach

A
  1. (C) Gastrin is produced in the antrum, duodenum, and small intestine.

It is not present in the fundus of the stomach.

When the distal stomach is removed gastrin levels decrease significantly.

Gastrin stimulates parietal cells to secrete acid and it stimulates chief cells to secrete pepsinogen.

303
Q
  1. A 50-year-old man presents with vague gastric
    complaints. Findings on physical examination
    are unremarkable. The serum albumin level is markedly reduced (1.8 g/100 mL). A barium study of the stomach shows massive gastric folds within the proximal stomach. These findings are confirmed by endoscopy. What is the correct diagnosis?

(A) Hypertrophic pyloric stenosis

(B) Gallstone ileus

(C) Mallory-Weiss tear

(D) Hypertrophic gastritis

(E) Crohn’s disease

A
  1. (D) Hypertrophic gastritis is characterized by
    massive loss of plasma protein through the
    affected gastric mucosa.

Most cases can be managed medically by maintenance of adequate nutrition.

An increased incidence of gastric cancer has been reported in some series.

304
Q
  1. A 2-cm ulcer on the greater curvature of the
    stomach is diagnosed in a 70-year-old woman by a barium study. Gastric analysis to maximal acid stimulation shows achlorhydria. What
    is the next step in management?

(A) Antacids, H2 blockers, and repeat barium study in 6 to 8 weeks

(B) Proton pump inhibitor (PPI) (e.g., omeprazole) and repeat barium study in 6 to 8 weeks

(C) Prostaglandin E (misoprostol) and repeat barium study in 6 to 8 weeks

(D) Immediate elective surgery

(E) Upper endoscopy with multiple biopsies (at least 8 or 9) for the ulcer

A
  1. (E) The distinction between a benign and
    malignant ulcer can be difficult.

The presence of achlorhydria rules out peptic ulceration.

Endoscopy is indicated so that biopsy can be performed.

305
Q
  1. A 55-year-old school bus driver was diagnosed
    3 months ago with an antral ulcer. He was treated for H. pylori and continues to take a PPI. Repeat endoscopy demonstrates that the ulcer has not healed. What is the next treatment option?

(A) Treatment with H2 blockers

(B) Vagotomy alone without additional surgery

(C) Endoscopy and laser treatment of the ulcer

(D) Distal gastrectomy with gastroduodenal anastomosis (Billroth I)

(E) Elevating the head of the bed when asleep

A
  1. (D) A gastric ulcer that does not respond to
    medical therapy requires surgical intervention.

An appropriate operation for an antral ulcer is an antrectomy with a gastroduodenal anastomosis (Billroth I).

Vagotomy is not nearly as effective in preventing recurrences in gastric ulcers.

It is important to realize that the management of gastric and duodenal ulcers is not identical because the etiologies are different.

Duodenal ulcers are associated with acid hypersecretion while gastric ulcers are associated with impaired mucosal defense mechanisms.

Both are associated with H. pylori (duodenal ulcers 90% and gastric ulcers 75%).

A gastric ulcer is much more likely to harbor a malignancy as compared to a duodenal ulcer.

A gastric ulcer should always be biopsied.

If a gastric ulcer fails to heal after appropriate medical management, it should be excised.

306
Q
  1. A 70-year-old woman complains of abdominal
    discomfort, anorexia, and a 10-lb weight loss. Endoscopy reveals a polypoid lesion in the antrum. The lesion is biopsied and the patient is informed that she has early gastric cancer (EGC). Why?

(A) Because it involves only the mucosa and does not invade the muscular wall of the stomach

(B) Because it is demonstrable on a barium study

(C) Because it has a 5 year survival rate of 5%

(D) Because surgery always cures it

(E) Because it does not require tumor free margins when resected

A
  1. (A) EGC is found only in the mucosa and submucosa.

Regional lymph nodes may or may not be involved.

EGC can be missed on a UGI series (low sensitivity).

Treatment is gastric resection with care to ensure that the resection margins and the anastomosis are tumor free.

Selected cases may be treated by endoscopic
mucosal resection.

In the United States, EGC is found in only 15% of patients diagnosed with gastric cancer.

In Japan the incidence is up to 40%.

Up to 14% of patients will have synchronous cancers.

Five-year survival is 85–90%.

307
Q
  1. A 62-year-old man presents with guaiac positive stool. He is asymptomatic. Workup reveals
    a 2-cm ulcerated carcinoma on the antral lesser
    curvature. Tumor markers are negative. A CAT
    scan is negative for metastatic disease and lymphadenopathy liver function tests are normal.
    What is the correct treatment for this patient?

(A) Chemotherapy only

(B) Radiation therapy only

(C) Combination chemotherapy and radiation therapy without resection

(D) Total gastrectomy

(E) Distal gastrectomy with en bloc removal of lymph nodes

A
  1. (E) The treatment of an antral gastric cancer is
    distal subtotal gastrectomy with lymph node
    dissection (provided there is no metastatic disease).

Surgical resection is the only potential curative therapy.

Proximal margins should be 5–6 cm.

Total gastrectomy does not improve 5-year survival.

Postoperative chemoradiation may increase 5-year survival (limited studies).

308
Q
  1. A 55-year-old man complains of anorexia, weight loss, and fatigue. An UGI study demonstrates an ulcerated lesion at the incisura.
    Where is the incisura?

(A) Cardia

(B) Fundus

(C) Greater curvature

(D) Lesser curvature

(E) Gastrocolic ligament

A
  1. (D) The incisura is located at the distal portion
    of the lesser curvature.

It is the point at which the body of the stomach ends and the antrum begins.

309
Q
  1. A 36-year-old man presents with weight loss and a large palpable tumor in the upper abdomen. Endoscopy reveals an intact gastric mucosa without signs of carcinoma. Multiple biopsies show normal gastric mucosa. A UGI study shows a mass in the stomach. At surgery, a 3-kg mass is removed. It is necessary to remove the left side of the transverse colon. What is the most likely diagnosis?

(A) Gastric cancer

(B) Gastrointestinal stromal tumor (GIST)

(C) Choledochoduodenal fistula

(D) Eosinophilic gastroenteritis

(E) Linitis plastica

A
  1. (B) GISTs were previously called leiomyosarcomas. They are rare (4% of all gastrointestinal tumors).

They can cause confusion because the overlying mucosa may remain intact.

They grow slowly, invade locally, and are not responsive to radiation or chemotherapy.

Eosinophilic gastroenteritis is an infiltrative lesion that usually involves the gastric antrum.

It is of unknown origin and differs from Menetrier’s
disease, where the mucosal folds of the proximal stomach are intially involved.

310
Q
  1. A 74-year-old man presents with anorexia and
    self-limited hematemesis. During endoscopy a mass is discovered and a biopsy is done. A hematopathologist diagnoses non-Hodgkin’s
    lymphoma. What is the recommended therapy?

(A) Chemotherapy alone

(B) Immunotherapy

(C) Radiation and chemotherapy

(D) Surgery, radiation, and chemotherapy

(E) Surgery alone

A
  1. (C) The stomach is the most common site of
    involvement in extranodal non-Hodgkin’s lymphoma (NHL).

Lymphoma is the second most common malignancy of the stomach.

Surgery was previously the treatment of choice for gastric lymphoma.

More recent studies show that nonoperative treatment with chemotherapy and radiation therapy results in similar 5-year survival and is currently first-line therapy.

Surgery is used mainly to treat complications of gastric lymphoma (e.g., perforation, bleeding).

Mucosa associated lymphoid tissue (MALT) lymphoma is a type of NHL. It is associated with H. pylori.

Treatment with a PPl and antibiotics will cure up
to 75% of low-grade MALTomas.

311
Q
  1. A 63-year-old woman is admitted to the hospital with a UGI bleed that subsides spontaneously within a short time after admission. A barium study shows a gastric ulceration that is
    described by the radiologist as having a “doughnut sign.” What is the most likely diagnosis?

(A) Lipoma

(B) Gastric ulcer

(C) Ectopic pancreas

(D) GIST

(E) Carcinoma

A
  1. (D) A GIST (previously called leiomyoma or
    leiomyosarcoma) can occur in any part of the
    stomach.

Most commonly they are found in the submucosa and grow towards the lumen.

Ulceration may occur and give rise to the characteristic “doughnut sign” on barium studies.

Hematemesis and/or melena may sometimes be massive.

Local resection is curative.

312
Q
  1. A 50-year-old woman is diagnosed with multiple hyperplastic polyps in the stomach during endoscopy and biopsy. How are these best treated?

(A) Total gastrectomy

(B) Partial gastrectomy

(C) Staged endoscopic removal after brushing for cytologic examination

(D) Ablation by laser

(E) No treatment other than repeated endoscopy and multiple brush biopsies

A
  1. (C) Hyperplastic polyps are unlikely to harbor
    carcinoma.

Multiplicity of hyperplastic polyps does not seem to predispose to the development of cancer.

Adenomatous polyps occur more commonly in the antrum.

Hyperplastic polyps are distributed more evenly throughout the stomach.

For this reason, antral polyps should be removed first.

(Adenomatous polyps may have a focus of cancer within them.)

313
Q
  1. During a surveillance upper endoscopy, a 35-year-old woman who was successfully treated for multiple familial polyposis of the colon, is found to have several polyps in the antrum. Biopsies show adenomatous polyps. What is the best therapy?

(A) Observation and repeated endoscopy at
frequent intervals

(B) Antrectomy

(C) Endoscopic polypectomies with repeat endoscopy to monitor subsequent polyp
development

(D) Endoscopic laser ablation of the polyps

(E) Total gastrectomy to remove all existing polyps and to prevent the formation of potential future polyps

A
  1. (C) Adenomatous polyps of the stomach resemble colon polyps. Coexisting carcinoma
    may be present in up to 20% of cases.

The incidence of carcinoma is increased if lesions are larger than 2 cm. Both hyperplastic and adenomatous polyps are more common in long-term follow-up of patients treated successfully
for familial polyposis.

All adenomatous polyps should be removed.

314
Q
  1. A 64-year-old woman presents with severe
    upper abdominal pain and retching of 1-day duration. Attempts to pass a nasogastric tube
    are unsuccessful. X-rays show an air-fluid level
    in the left side of the chest in the posterior
    mediastinum. An incarcerated paraesophageal
    hernia and gastric volvulus is diagnosed. What
    is the next step in management?

(A) Insertion of a weighted bougie to untwist the volvulus

(B) Elevation of the head of the bed

(C) Placing the patient in the Trendelenburg
position with the head of the bed lowered

(D) Laparotomy and vagotomy

(E) Surgery, reduction of the gastric volvulus, and repair of the hernia

A
  1. (E) Gastric volvulus is often associated with a
    large paraesophageal hiatal hernia.

The twist causes a cut-off at the cardia above and at the pylorus below leading to distension and
ischemia, which may progress to gangrene.

Organoaxial volvulus is more common and rotation occurs along the axis between the cardia and the pylorus.

In the less common type of gastric volvulus, rotation occurs through an axis that is at the right angle to the organoaxial axis described.

315
Q
  1. A 78-year-old woman undergoes an uncomplicated minor surgical procedure under local anesthesia. At the completion of the operation, she suddenly develops pallor, sweating, bradycardia, hypotension, abdominal pain, and gastric distension. What is the next step in management?

(A) Rapid infusion of 3 L of Ringer’s lactate

(B) Digoxin

(C) Insertion of a nasogastric tube

(D) Morphine

(E) Neostigmine

A
  1. (C) Acute gastric distension can lead to a vasovagal reaction.

Treatment consists of nasogastric decompression for 24–48 hours to allow normal gastric tone to return.

Appropriate parenteral fluids should also be administered.

316
Q
  1. A 35-year-old teacher has a family history of
    gastric cancer. She has an upper endoscopy performed for epigastric symptoms. The endoscopy is negative. The patient ask her endoscopist if there are any conditions that predispose to gastric carcinoma. He provides her with the following answer.

(A) Environmental metaplastic atrophic gastritis (EMAG)

(B) Autoimmune metaplastic atrophic gastritis (AMEG)

(C) Menetrier’s disease

(D) Duodenal ulcer

(E) Hiatal hernia

A
  1. (B) Autoimmune metaplastic atrophic gastritis
    is associated with hypochlorhydia parietal cell antibodies, and high gastrin levels.

There is an increased risk for developing gastric carcinoid tumors or adenocarcinomas.

Other premalignant conditions include adenomatous polyps, gastric ulcer, previous gastric resection (>15 years), chronic atrophic gastritis, and
histologic changes showing intestinal metaplasia and dysplasia.

317
Q
  1. A 48-year-old man undergoes surgery for a
    chronic duodenal ulcer. The procedure is a truncal vagotomy and which of the following?

(A) Gastroenterostomy

(B) Removal of the duodenum

(C) Closure of the esophageal hiatus

(D) Incidental appendectomy

(E) No further procedure

A
  1. (A) In 1948, Dragstedt introduced a gastric
    drainage procedure to overcome stasis that
    occurred in over 30–40% of cases following
    vagotomy.

Pyloroplasty, gastrojejunostomy, and antrectomy are the three recognized drainage procedures performed in conjunction with vagotomy.

The decision on which one to perform is based on the overall condition of the patient and the severity of the ulcer, amongst other things.

A drainage procedure is not necessary with a
highly selective vagotomy because the innervation to the pylorus is left intact.

318
Q
  1. A healthy 75-year-old man bleeds from a duodenal ulcer. Medical management and endoscopic measures fail to stop the bleeding. What is the next step in management?

(A) Continued transfusion of 8 U of blood

(B) Administration of norepinephrine

(C) Oversewing of the bleeding point

(D) Oversewing of the bleeding point,
vagotomy, and pyloroplasty

(E) Hepatic artery ligation

A
  1. (D) In general, surgery for peptic ulcer bleeding
    is indicated at an earlier stage in an older patient
    because vessels are atherosclerotic and less
    likely to stop bleeding spontaneously.

In addition, diminished perfusion of the heart, brain,
and kidneys is less well tolerated in elderly patients.

At surgery, the gastroduodenal artery is oversewn, and a vagotomy and drainage procedure is performed.

319
Q
  1. A 60-year-old woman undergoes vagotomy
    and pyloroplasty for duodenal ulcer disease.
    Gallstones are noted at the time of the original
    operation. Eight days following surgery, she
    develops abdominal pain and right upper
    quadrant tenderness. To determine if the gallbladder is the cause of her symptoms, she
    should undergo which study?

(A) Supine x-ray

(B) Hepatobiliary scan (HIDA)

(C) Ultrasound

(D) Erect x-ray

(E) Cholangiogram

A
  1. (B) The scan will fail to visualize the gallbladder
    if acute cholecystitis is present.

In a patient with cholelithiasis, the incidence of cholecystitis and associated biliary complications is increased following truncal vagotomy.

A sonogram will show gallstones but may not distinguish acute cholecystitis.

320
Q
  1. A recent immigrant to the United States has
    had persistent epigastric discomfort. He delays
    seeking treatment because he could not afford
    to pay a doctor. He finally went to the emergency department and was referred to an endoscopist. A submucosal mass was seen and it was thought to be a GIST. The most common site of a GIST is which of the following?

(A) Esophagus

(B) Stomach

(C) Jejunum

(D) Ileum

(E) Colon

A
  1. (B) GIST is the most common sarcoma of the
    gastrointestinal tract.

It is most commonly found in the stomach (60–70%).

Other sites include small intestine (25%), rectum (5%), esophagus (2%), and other less frequent locations.

It may be difficult to distinguish between malignant and benign GISTs.

Factors that are correlated with improved prognosis include gastric location, low mitotic index <2 cm diameter, and absence of tumor rupture and spillage during resection.

321
Q
  1. A 60-year-old woman complains of early satiety and undergoes an upper endoscopy. A small mass is seen in the antrum with sparing of the mucosa. GIST is suspected. A CAT scan of the chest, abdomen, and pelvis is performed. What does she require next?

(A) Fulguration of the tumor

(B) Distal gastrectomy

(C) Laser therapy followed by radiation therapy

(D) Chemotherapy alone

(E) Total gastrectomy

A
  1. (B) If the mass is deemed resectable, the goal of surgery is resection with grossly negative margins.

Precautions should be taken to prevent rupture of the mass.

Radiation and chemotherapy have traditionally been ineffective.

Clinical trials with the drug imatinib mesylate (Gleevec) are promising.

322
Q
  1. A 67-year-old woman complains of paresthesias in the limbs. Examination shows loss of vibratory sense, positional sense, and sense of light touch in the lower limbs. She is found to have pernicious anemia. Endoscopy reveals an ulcer in the body of the stomach. What does she most likely have?

(A) Excess of vitamin B12

(B) Deficiency of vitamin K

(C) Cancer of the stomach

(D) Gastric sarcoma

(E) Esophageal varices

A
  1. (C) Patients with pernicious anemia have achlorhydria and an increased risk (about 5%)
    of developing gastric carcinoma.

There is a deficiency in vitamin B12 that leads to megaloblastic anemia and neurologic involvement
(subacute degeneration of the dorsal and lateral
spinal columns).

323
Q
  1. Following an emergency operation for hepatic
    and splenic trauma, the surgeon inserts a finger into the foramen of Winslow in an attempt to stop the bleeding. Which is TRUE of the hepatic
    artery?

(A) It is called the common hepatic artery at this level.

(B) It is medial to the common bile duct and anterior to the portal vein.

(C) It is posterior to the portal vein.

(D) It is posterior to the inferior vena cava.

(E) It forms the superior margin of the epiploic foramen.

A
  1. (B) The hepatic artery is medial to the common
    bile duct and anterior to the portal vein.

The inferior vena cava passes posterior to the (epiploic) foramen of Winslow, where it lies
behind the portal vein.

The foramen represents the only natural communication between the lesser and greater peritoneal bursa (sac).

324
Q
  1. A 44-year-old patient develops a mass on the
    anterior abdominal wall. He notes that the mass has gradually increased in size over the last 3 months. On examination, the lesion is a 5 × 8
    cm mass in the left iliac fossa and hypogastrium. Which test will establish whether the tumor is arising from the abdominal wall or the abdominal cavity?

(A) Needle biospy

(B) Ability to elicit a cough impulse

(C) Transillumination

(D) Examination of the mass with the
patient in a prone position

(E) Examination of the mass with the
patient instructed to attempt sitting up

A
  1. (E) This test is a useful method of determining if
    a mass is due to an abdominal wall lesion or an
    intra-abdominal lesion.

Attempts by the patient to sit up will make the anterior abdominal wall muscles taut and thus reduce the palpability definition of an intra-abdominal mass.

An abdominal wall mass will still be palpable after
this maneuver.

This is called Fothergill’s sign.

325
Q
  1. A 26-year-old man is diagnosed with adenocarcinoma of the stomach. He wants to know
    what could have caused him to develop this
    condition. He does an internet search. Which of the following is a risk factor for developing gastric cancer?

(A) Exposure to ionizing radiation

(B) Blood group B

(C) A diet high in fiber

(D) H. pylori infection

(E) North American descent

A
  1. (D) H. Pylori infection, smoking, and a high salt intake are all risk factors for gastric cancer.

A diet high in fruits, vegetables, and fiber may lower the risk for gastric cancer.

The incidence of gastric cancer is low in North America.

Gastric cancer is one of the most common cancers in Japanese men.

326
Q
  1. A 44-year-old woman is scheduled for gastric
    surgery. She has no comorbid disease. The anesthesiologist has difficulty inserting the orotracheal tube. In between intubation attempts
    he uses an ambu-bag to oxygenate the patient.
    The patient’s abdomen gets distended and tympany is noted in the left upper quadrant.
    Suddenly the patient becomes hypotensive. Which of the following can cause a vasovagal response during anesthesia?

(A) The gastric remnant following a distal gastrectomy

(B) Corrosive gastritis

(C) Pernicious anemia

(D) Gastric volvulus

(E) Acute gastric dilatation

A
  1. (E) Acute gastric dilatation may result in a vasovagal response.

This response is characterized by typical signs and symptoms of marked gastric and abdominal distension.

These are clearly demonstrable in an awake patient.

Unfortunately, this condition may occur after anesthesia is administered and thus go unrecognized.

Vomiting, aspiration, hypoxia, or bleeding from erosive stress gastritis may occur.

Gastritis, gastric volvulus, and pernicious anemia do not cause a vasovagal response.

327
Q
  1. A 42-year-old taxi driver is diagnosed with a
    gastric tumor. He delays definitive therapy because he is afraid of losing his job. He finally has surgery and the mass is invading the transverse colon. Which of the following has the best long term survival despite local invasion?

(A) Adenocarcinoma

(B) Lymphosarcoma

(C) Linitis plastica

(D) Chordoma

(E) GIST

A
  1. (E) GISTs are the most common mesenchymal
    tumors of the gastrointestinal tract.

They may be benign, malignant, or intermediate grade.

They demonstrate a mutation of the c-kit oncogene.

Distant metastases occur late.

Prolonged survival follows resection, including adjucent organs if necessary (e.g., colon, pancreas).

Hemorrhage can result if the tumor erodes through the gastric mucosa.

Malnutrition results from compromise of the capacity of the stomach.

328
Q
  1. A 46-year-old man remains disease free following a total colectomy for familial adenomatous polyposis 24 years ago. He now presents with obstructive jaundice of 1 month’s duration and guaiac positive stool. He does not have calculus disease. What is his diagnosis?

(A) Adenomatous gastric polyps

(B) Leiomyosarcoma

(C) Lymphosarcoma

(D) Linitis plastica

(E) Ampullary carcinoma

A
  1. (E) Patients with familial adenomatous polyposis are at risk for developing carcinoma in adenomatous polyps arising in the stomach
    and duodenum.

Ampullary and bile duct cancers will result in jaundice.

329
Q
  1. A 40-year-old woman complains of heartburn
    located in the epigastic and retrosternal areas.
    She also has symptoms of regurgitation. Endoscopy shows erythema of the esophagus
    consistent with reflux esophagitis. The patient
    has tried conservative measures, including PPls
    with no improvement in symptoms. Which of
    the following is TRUE?

(A) Manometry does not add any additional information.

(B) The 24-hour pH test is no longer used.

(C) If endoscopy has been done, an esophagogram is unnecessary.

(D) Nissen fundoplication is the surgical
treatment of choice.

(E) Toupet fundoplication is 360 nic nerve.

A
72. (D) Conservative treatment of GERD includes
lifestyle modifications (e.g., smoking cessation,
decreased caffeine intake, avoidance of large
meals before lying down, elevation of the head
of the bed, and avoidance of constrictive clothing). 

PPl’s are very effective.

If nonoperative management fails, surgical intervention should be considered.

Preoperative evaluation includes manometry, 24-hour pH test and esophagogram, in addition to endoscopy.

Manometry evaluates the LES resting pressure and effectiveness of peristalsis.

The 24-hour pH test is the gold standard for diagnosing and quantifying acid reflux.

Esophagogram shows the external anatomy of the esophagus and proximal stomach, as well as demonstrating the presence of a hiatal hernia.

Nissen fundoplication is a 360° gastric wrap. It can be performed as an open or laparoscopic procedure.

It is the most common operation performed for GERD.

Partial fundoplications (e.g., Thal, Dor, Toupet) are done if esophageal motility is poor.

330
Q
  1. A 50-year-old man is involved in a major motor
    vehicle collision and suffers multiple trauma. He is admitted to the intensive care unit. After 2 days of hospital admission he bleeds massively from the stomach. What is the probable cause?

(A) Gastric ulcer

(B) Duodenal ulcer

(C) Hiatal hernia

(D) Mallory-Weiss tear

(E) Erosive gastritis

A
  1. (E) Critically ill patients who have multiple organ
    involvement, from trauma or other diseases, are
    at risk for developing bleeding from erosive gastritis.

Risk factors include multiorgan dysfunction, sepsis, trauma, and respiratory failure requiring mechanical ventilation.

The pathogenesis of acute stress gastritis is multifactorial.

One factor is thought to involve hypoperfusion
of the gastric mucosa and ischemia.

331
Q
  1. A 65-year-old lawyer has an elective colon
    resection. On postoperative day number five,
    the patient develops fever, leukocytosis, and
    increasing abdominal pain and distension. An
    anastomotic leak is suspected. During the preparation for a CAT scan, fresh blood and
    coffee grounds are seen in the nasogastric tube.
    Acute stress gastritis is best diagnosed by?

(A) CAT scan

(B) UGI series

(C) Angiogram

(D) Capsule endoscopy

(E) Upper endoscopy

A
  1. (E) Endoscopic findings range from petechiae to
    multiple ulcers in the body of the stomach and
    duodenum.

Endoscopy can safely be performed at the bedside in the intensive care unit.

Because bleeding may be secondary to shallow mucosal erosions, a CAT scan, UGI series, and angiogram will not be diagnostic.

Capsule endoscopy is sometimes used in the diagnosis of occult gastrointestinal bleeding when other methods have not been helpful.

332
Q
  1. A previously healthy florist presents to the emergency department after vomiting blood in his flower shop. While waiting to be seen he has another episode of hematemesis. What is the most likely cause of his bleeding?

(A) Peptic ulcer disease (stomach or duodenum)

(B) Hiatal hernia

(C) Mallory-Weiss tear

(D) Gastric carcinoma

(E) Esophagitis

A
  1. (A) Peptic ulcer disease is the most common
    cause of UGI bleeding in patients presenting to
    the emergency department.

Most bleeding ulcers (80%) will stop with conservative measures.

A visible vessel seen during endoscopy can have up to a 55% chance of rebleeding.

Other causes of bleeding include gastritis, gastric cancer, esophagitis, Mallory-Weiss tear, Dieulafoy’s lesion, and esophageal varices, but these occur less commonly than peptic ulcer as a likely cause of bleeding.

333
Q
  1. A 22-year-old student is involved in a motorcyle
    accident. He sustains multiple injuries including an intracranial hemorrage and a pelvic fracture. Despite ulcer prophylaxis he develops a
    UGI bleed. Which of the following is effective in
    protecting the gastric mucosa but has not
    proven useful in the management of erosive
    gastritis because of side effects (diarrhea)?

(A) H2 blockers

(B) Intrinsic factor

(C) Cortisone

(D) Adrenaline

(E) Prostaglandin E (misoprostol)

A
  1. (E) Prostaglandin E (misoprostol) has not been
    useful in the management of erosive gastritis
    because diarrhea has been a troublesome side
    effect.

At lower doses it can be used as prophylaxis against NSAID associated gastropathy.

334
Q
  1. A 33-year-old man is admitted to the hospital for evaluation and treatment of a gastrojejunal ulcer. At age 25, he was treated surgically with an omental (Graham) patch for a perforated duodenal ulcer. At age 30, he was treated with a truncal vagotomy and antrectomy for a chronic duodenal ulcer. He now has a stomal (gastrojejunal) ulcer that is refractory to medical therapy. Which of the following should be checked?

(A) Intrinsic factor

(B) Gastrin level

(C) Adrenaline

(D) Cortisol

(E) Potassium

A
  1. (B) Gastrinoma (ZES) should always be excluded
    in patients presenting with severe peptic ulcer
    disease that fails to respond to therapy.

It accounts for 0.1–1% of peptic ulcers.

It is usually caused by a gastrinoma (a non b-cell tumor found in the pancreas or duodenum).

The diagnosis is based partly on an elevated fasting serum gastrin level (normal 60 pg/mL; in ZES >150 pg/mL and can be over 1000 pg/mL).

Basal acid secretion is increased above 15 mEq/h.

Duodenal ulcers are the most common ulcers, but ulcers in unusual locations (e.g., jejunum) may also be seen.

335
Q
  1. A 73-year-old woman is admitted to the hospital with a mild UGI hemorrhage that stopped spontaneously. She did not require transfusion. She had ingested large amounts of aspirin in the past 4 months to relieve the pain caused by severe rheumatoid arthritis. Endoscopy confirms the presence of a duodenal ulcer. A biopsy is done. What is the next step in the management of a duodenal ulcer associated with a positive biopsy for H. pylori?

(A) H2 blockers

(B) Bipolar electrocautery of the ulcer

(C) Triple therapy

(D) Photocoagulation

(E) Elective surgery

A
  1. (C) Since the patient is stable, she does not require any therapeutic endoscopic or surgical
    procedures.

Triple therapy (a PPI and two antibiotics) should be initiated to eradicate the H. pylori organism.

She should also be educated about the association of aspirin and NSAIDs with peptic ulcer disease.

336
Q
  1. A 52-year-old artist develops epigastric pain that is relieved by antacids. She also complains that
    her stool has changed color and is black and tarry. What is the most important cause of the entity presenting above other than H. pylori?

(A) Submucosal islet cells

(B) Hyperglycemia

(C) Diet

(D) Acid secretion

(E) Acute erosive gastritis

A
  1. (D) Duodenal ulcers are associated with acid
    hypersecretion and impaired neutralization of
    aid in the duodenum. The other choices are not
    associated with duodenal ulcers.
337
Q
  1. An 80-year-old grandfather gets admitted to
    the hospital for a UGI bleed. He undergoes upper endoscopy and bleeding ulcer is visualized. Attempts at endoscopic cauterization and epinephrine injection are unsuccessful at stopping the bleeding. A previous attempt at angioembolization was also unsuccessful. What is the next definitive step in therapy?

(A) Elective surgery

(B) High-dose antibiotics

(C) Blood transfusion

(D) Repeated attempts at bipolar electrocautery

(E) Emergency surgery

A
  1. (E) If all nonoperative measures have failed to
    control bleeding from an ulcer, the next definitive step is surgery.

Although the patient may require continued resuscitation with crystalloids and blood products, the bleeding will not stop without surgical intervention.

Elderly patients have poor toleration for hypotension due to comorbidities, therefore emergency surgery not elective is appropriate.

338
Q
  1. An elderly patient delayed seeking medical attention for his early satiety and weight loss because he attributed these changes to aging.
    When he underwent upper endoscopy a large mass was seen in the stomach. Which statement is TRUE regarding gastric carcinoma?

(A) During resection, it is safe to leave cancer at the cut edges.

(B) The incidence is increased in patients with gastric ulcer disease.

(C) Draining lymph nodes should not be removed.

(D) It is caused by diverticulitis.

(E) It is associated with hyperchlorhydria.

A
  1. (B) There is an increased incidence of gastric
    cancer in patients with gastric ulcer disease.

The overall 5-year survival is 12%, but it can be as high as 35% if the nodes are negative (and 7% if the nodes are involved).

It is important that the cut edges are free of tumor otherwise the cancer will recur.

Proximal lymph nodes should be removed from the stomach.

The extent of lymph node dissection remains controversial.

Extended D2 lymph nodes dissections are performed in Japan and demonstrate improved survival.

These results have not been replicated in the West.

339
Q
  1. An alert nursing home patient is unable to swallow because of a neurologic disease and has lost a significant amount of weight. What treatment should be offered?

(A) Central hyperalimentation

(B) Intralipids

(C) Percutaneous endoscopic gastrostomy (PEG)

(D) Nasogastric feeding

(E) Cervical esophagostomy

A
  1. (C) Endoscopic gastrostomy by percutaneous
    means is rapid and safe.

It should be considered in patients who are unable to maintain an appropriate caloric intake orally.

The procedure is performed under local anesthesia and sedation.

340
Q
  1. A 32-year-old waitress is interested in learning
    about gastric bypass surgery. She consults her primary care physician to see if she is a candidate. Her doctor refers her to an obesity center because?

(A) She has not lost enough weight after her pregnancies.

(B) She is hypertensive and overweight.

(C) Her weight is 50 lb greater than her ideal body weight.

(D) She has a body mass index (BMI) greater than 35 kg/mg.

(E) She is tired of diet and exercise.

A
  1. (D) A patient is a candidate for bariatric surgery if he or she meets certain criteria.

A patient whose weight is 100 lb greater than his ideal body weight or whose BMI is greater than
35 mg/kg is morbidly obese.

Prior to surgery, a patient must have a thorough evaluation by a multidisciplinary team (e.g., internist, dietician, psychologist, surgeon, and the likes).

Patients who are not morbidly obese and simply want to lose weight are not candidates for these procedures.

Patients are at risk for multiple complications, including fatal pulmonary embolus.

341
Q
  1. A morbidly obese patient is told that he qualifies for bariatric surgery. He is given several
    options. He chooses to undergo a gastric bypass procedure (GBP). Which of the following is TRUE?

(A) Malabsorptive jejunoileal bypass is a more effective operation with less complications.

(B) Vertical banded gastroplasty is technically easier and more effective than gastric bypass surgery.

(C) Patients lose up to two-thirds of their excess weight.

(D) Gastrojejunal leakage rate is in excess
of 20%.

(E) The gastric pouch capacity should be
100cc.

A
  1. (C) There are multiple morbid obesity operations.

Jejunoileal bypass has a higher incidence of both early and late complications.

Gastric restrictive procedures (e.g., vertical banded
gastroplasty) are generally less effective than GBP.

GBP patients can be expected to lose up to two-thirds of their weight initially. The gastric pouch capacity should be no larger than 30cc.

Anastomotic leak rate should be less than 5%.

342
Q
  1. A 60-year-old man has been having vague symptoms of upper abdominal discomfort, early satiety, and fatigue. He is referred to a gastroenterologist, who performs an upper endoscopy. Although a discrete mass is not
    visualized, the stomach looks abnormal. It does
    not distend easily with insufflation. A biopsy shows signet ring cells. Which of the following is TRUE?

(A) Signet ring cells are typically found in intestinal type gastric adenocarcinoma.

(B) Signet ring cell cancer is the most common type of gastric cancer.

(C) “Leather bottle stomach” is a term used to describe a nondistensible stomach infiltrated by cancer.

(D) The gross appearance of the stomach always shows classic findings of linitis plastica.

(E) Linitis plastica has an excellent prognosis.

A
  1. (C) The Lauren classification divides gastric
    adenocarcinomas into two histologic types—
    an intestinal type and a diffuse type.

The intestinal type is more common and usually forms a discrete lesion.

The diffuse infiltrating type is less common and a mass may not be seen.

In the intestinal type, cells form glandular strictures.

in the diffuse type, cells are poorly organized and full of mucin (signet ring cells). The diffuse type may extensively infiltrate the muscles of the stomach, thus leading to rigidity.

Gross appearance may be unremarkable, but
palpation aids in the diagnosis.

“Leather bottle stomach” refers to a stomach that is entirely involved with diffuse type cancer.

The 5-year survival is poor.

343
Q
  1. A patient presents to the emergency department with obstructive jaundice. A percutaneous transhepatic cholangiogram and biliary drainage is performed. Shortly afterward, the patient develops a UGI bleed. What is the most likely cause?

(A) The patient has developed stress gastritis.

(B) The patient has ingested NSAIDs after the procedure.

(C) The patient has developed hemobilia.

(D) The patient is bleeding from esophageal varices.

(E) The catheter has migrated from the biliary tree into the stomach.

A
  1. (C) Hemobilia may be secondary to instrumentation of the biliary tree, or malignancy, or
    trauma.

It involves bleeding from the biliary tract that transits through the ampulla into the duodenum.

Bleeding may be subacute or massive.

Endoscopic retrograde cholangiopancreatography (ERCP) or angiogram may be diagnostic.

Angioembolization may be therapeutic.

344
Q
  1. A 56-year-old woman with Sjörgen’s syndrome
    complains of fatigue and melena. She is pale and anemic. Endoscopy reveals ectatic vessels radiating from the pylorus. Which of the following is TRUE?

(A) These findings are very common.

(B) This condition occurs exclusively in patients with autoimmune diseases.

(C) The only treatment for this condition is surgery.

(D) It occurs more often in women.

(E) Ectatic vessels are frequently found in the colon.

A
  1. (D) “Watermelon stomach” is a term used to
    describe the appearance of the stomach in a
    condition called GAVE (gastic antral vascular
    ectasis) syndrome.

Dilated blood vessels radiate from the pylorus to the antrum in a pattern that resembles the stripes of a watermelon.

It is an uncommon cause of gastrointestinal bleeding.

It has been associated with certain autoimmune diseases, however, it may also be seen in individuals not affected by these conditions.

It may also be seen with portal hypertension.

It is most commonly seen in elderly women.

Endoscopic laser treatment is usually effective.

345
Q
  1. A 54-year-old man presents with a massive
    UGI bleed. After resuscitation, endoscopy is
    performed. No esophageal varices, gastritis, or
    gastric ulcers are seen. After copious irrigation,
    a pinpoint lesion is seen near the GE junction.
    What can be said about this lesion?

(A) It is a carcinoid.

(B) It is related to alcohol use.

(C) It is exclusively a mucosal lesion.

(D) Surgery is first-line therapy.

(E) Bleeding is from a submucosal vessel.

A
93. (E) A dieulafoy lesion is an uncommon cause of
UGI bleeding (0.3–7%). 

It can occur anywherein the gastrointestinal tract, but is most commonly found in the stomach (near the GE junction).

It is often difficult to visualize because of its small size.

A dilated submucosal artery is the source of the bleeding.

First-line management is therapeutic endoscopy.

There is no association with NSAIDs or alcohol.

These lesions are more common in men.

346
Q
  1. A 60-year-old diabetic woman had a partial gastrectomy 15 years ago for peptic ulcer disease. She now complains of nausea, vomiting, early satiety, and weight loss. She has palpable upper abdominal mass. She reluctantly agrees to have an
    upper endoscopy because she is fearful of being
    told that she has cancer. She is happy to hear
    that she does not have a maligancy and agrees to
    ingest meat tenderizer and have a repeat
    endoscopy. Which of the following is TRUE?

(A) She has a GIST.

(B) She is in denial.

(C) She has a cancer at the gastrojejunal anastomosis.

(D) A barium study is nondiagnostic.

(E) She has a phytobezoar.

A
  1. (E) Patients with impaired gastric emptying,
    such as those who have had previous gastric
    surgery or those with diabetes, can develop
    bezoars.

Bezoars can be classified as two types—phytobezoars (undigested vegetable matter) and
trichobezoars (hair).

The diagnosis can be made by EGD or barium study.

Nonoperative management is often successful. Patients are told to ingest meat tenderizer (which contains papain) and repeat endoscopy is performed for further fragmentation and removal of the bezoar.

If the patient is obstructed and endoscopic therapy is unsuccessful, surgery is indicated.

Patients who ingest their hair should be referred for psychiatric evaluation.

347
Q
  1. A 70-year-old man has surgery for an abdominal aortic aneurysm. About 1 month later the patient presents with a massive UGI bleed. Which of the following statements is TRUE?

(A) He should be given PPIs and observed in the intensive care unit.

(B) Most aortoenteric fistulas are primary.

(C) Most aortoenteric fistulas occur between the aorta and duodenum.

(D) It is not improtant to separate the aorta from the eosphagus after aortic surgery.

(E) This condition is always fatal.

A
  1. (C) An aortoenteric fistula should be suspected
    in any patient who has had previous aortic surgery and presents with massive UGI bleed.

Most aortoenteric fistulas are secondary to this type of surgery.

It is important to separate an aortic graft from intestine (e.g., retroperitoneal tissue).

Most aortoenteric fistulas occur between the aorta and duodenum.

Mortality is high, but timely surgical intervention can be successful.

Surgery may involve performing an extraanatomic bypass and removing the aortic graft.

348
Q

What does a radical subtotal gastrectomy entail?

A

Resection of:

1) Distal 75% of the stomach
2) Pylorus
3) 2cm of proximal duodenum
4) Greater and lesser omentum
5) Associated lymph node

Reconstruction by Billroth II gastrojejunostomy or Roux-en-Y gastrojejunostomy

349
Q

What does a radical total gastrectomy entail?

A

1) Removal of stomach
2) Roux-en-y limb sewn to esophagus

Indicated for:

  • All lesions in the midbody or fundus (proximal) of the stomach
  • Linitis plastica
  • Cancers associated with Menetrier disease, gastric remnant carcinoma, and multiple diffuse gastric polyps
350
Q

D0 Resection?

A

Gastrectomy + incomplete resection of N1 nodes

351
Q

D1 Resection?

A

Gastrectomy + complete dissection of N1 nodes

352
Q

D2 Resection?

A

Gastrectomy + resection of N1 and N2 nodes

353
Q

D3 Resection?

A

Gastrectomy + resection of N1 to N3 nodes

354
Q

D4 Resection?

A

Most extensive, includes all lymph node levels

355
Q

N1?

A

Perigastric nodes along greater and lesser curvatures (levels 1-6)

356
Q

N2?

A

Adjacent to the celiac axis and its major branches (levels 7, 8a, 9, 10, 11p, 11d, 12a, 14v)

357
Q

N3?

A

Hepatoduodenal ligament, retropancreatic region, celiac plexus, SMA

358
Q

N4?

A

Paraaortic nodes

359
Q

Stage 0 Gastric CA?

A

Tis N0 M0

360
Q

Stage IA Gastric CA?

A

T1 N0 M0

361
Q

Stage IB Gastric CA?

A

T1 N1 M0

T2 N0 M0

362
Q

Stage IIA Gastric CA?

A

T1 N2 M0
T2 N1 M0
T3 N0 M0

363
Q

Stage IIB Gastric CA?

A

T1 N3 M0
T2 N2 M0
T3 N1 M0
T4a N0 M0

364
Q

Stage IIIA Gastric CA?

A

T2 N1 M0
T3 N2 M0
T4a N3 M0

365
Q

Stage IIIB Gastric CA?

A

T3 N3 M0
T4a N2 M0
T4b N1 M0
T4b N0 M0

366
Q

Stage IIIC Gastric CA?

A

T4a N3 M0
T4b N3 M0
T4b N2 M0

367
Q

Stage IV Gastric CA?

A

Any T Any N M1

368
Q

Management of Early Gastric Adenocarcinoma?

A

EMR/Submucosal Resection

Tumors <2cm, limited to mucosa/submucosa

369
Q

Lymph node groups?

A

1: R cardiac
2: L cardiac
3: Lesser curvature
4: Greater curvature
5: Suprapyloric
6: Infrapyloric
7: L gastric artery
8: Common hepatic artery
9: Celiac artery
10: Splenic hilar
11: Splenic artery
12: Hepatic pedicle
13: Retroduodenal
14: Mesenteric root
15: Middle colic artery
16: Paraaortic
17: Around lower esophagus
18: Supradiaphragmatic

370
Q

Types of gastric carcinoids?

A

Type I:

  • Type A chronic atrophic gastritis, with/without pernicious anemia
  • Autoimmune (antibodies to parietal cells)
  • Most common
  • Hypergastrinemia
  • Women
  • Benign

Type II:

  • Carcinoid-associated with Zollinger-Ellison Syndrome
  • MEN Type 1

Type III:

  • Carcinoid tumor of sporadic form or neuroendocrine carcinoma
  • Not associated with hypergastrinemia
  • More common in men
  • Usually solitary
  • Worst prognosis
  • Larger tumors and more advanced stage
371
Q

Management of Gastric carcinoids?

A

Caused by:

  • Hormonal excess, local tumor growth, or metastases
  • Incidental at surgery
  • Only 10% present with carcinoid syndrome (usually associated with hepatic mets)

Sx:

  • Secretory diarrhea
  • Flushing
  • Telangiectasia
  • Valvular heart disease
  • Pellagra
  • Cramping
  • Edema
  • Bronchial constriction

Dx:

  • Endoscopy + biopsy
  • EUS
  • Plasma chromogranin A and NSE
  • 24-h urine 5-HIAA
  • Localizing test (somatostatin analogue like indium octreotide)

Tx:

  • Carcinoid syndrome: Debulking surgery + Octreotide
  • H1 and H2 receptor antagonists, methoxamine, cyproheptadine, diphenoxylate sodium with atropine
  • Resistant to most chemotherapeutic agents
  • By type:

TYPE I: Endoscopic polypectomy

TYPE II: Treat gastrinoma, somatostatin analogues, local excision or antrectomy

TYPE III: En-bloc resection with regional lymph nodes, chemoRT