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Flashcards in Surgery - Upper GI Deck (57):
1

Do you ppx varices w/ sclerotherapy?

NO!

Only do after 1st episode bleeding

2

How do we know an NG tube is in correct place to eval for UGI bleed?

Need to get bile back

Know is sampling stomach and duodenum

3

How long after acid ingestion does fibrosis result?

6-13 weeks

Commonly pyloric stricture

4

How long do you have diabetes to get diabetic gastroparesis?

> 10 years

5

Dx esophageal perforation

Contrast (usually H2O soluble) esophogram
- Gastrografin-contrast esophography

Need broad spectrum abx, TPN, and surgical repair

6

Causes pill esophagitis

Can cause esophageal perforation!

Tetracyclines
Aspirin
NSAIDs
Alendronate
KCl
Quinidine
Iron

7

Young pt, no smoking w/ Chronic fixed, fleshy growth on hard palate

Torus palatinus
- benign bony growth on midline suture of hard palate
- congenital, usually in younger pts, women, and Asians
- usually < 2 cm in size and can inc in size during life

8

Acute bacterial parotitis

Dehydrated post op pts and elderly most prone to develop infection

Can avoid w/ fluid hydration + oral hygiene

Usually staph aureus infection

9

Dx esophageal perforation

water soluble contrast

10

Tx esophageal perforation

Surgery - closure of esophagus
Drain mediastinum

Need to do in 6 hrs to prevent development of mediastinitis

11

Best 1st diagnostic tool for GI Bleed?

NGT lavage

UGIB more common than lower GIB

12

Secretion contents of
- bile
- SI
- saliva
- gastric juice
- colon
- pancreatic

Bile + SI
- like LR

Saliva, gastric, colon
- high K
- low Na

Pancreatic
- high bicarb

13

Esophagitis

Assoc w/ reflex or infection or lye ingestion

HSV 1 = punched out ulcers

CMV = linear ulcers

Candida = pseudomembrane

14

Plummer Vinson syndrome

Due to Fe deficiency

Dysphagia
Glossitis
Iron deficiency anemia

Increases risk of SCC of esophagus

15

Barrett's esophagus

Glandular metaplasia

Nonkeratinzed stratified squamous --> columnar epithelium

Due to chronic acid reflux

Assoc w/ esophagitis, esophageal ulcers, increased risk of esophageal cancer

16

Menetrier's disease

Gastric hypertrophy w/ protein loss, parietal cell atrophy, and increase mucous cells

Precancerous

SUPER hypertrophy of rugae of stomach

17

Gastric vs duodenal ulcer

Gastric
- GREATER pain w/ meals
- H. pylori is majority
- due to decreased mucosal protection against acid
- increased risk of cancer

Duodenal ulcer
- DECREASED pain w/ meals
- 100% have H. pylori
- Hypertorphy of Brunner's glands
- Never malignant

18

Tx peptic ulcers

3x therapy

PPI
Clarithromycin
Amoxicillin (metronidazole if PXN allergy)

19

Most common serious complication of peptic ulcer disease

Hemorrhage

Tx:
- fluid + blood resuscitation
- med tx
- endoscopic intervention

Usually will stop bleeding spontaneously

20

When do surgery for GERD?

Nissen fundoplication for:

Long standing symptomatic disease cannot be controlled by medical means

Intolerant to PPIs

Don't want to take long term meds

Complications - ulceration, stenosis


Resection for:
Severe Dysplasia (if only on sub-medical therapy; try optimal med therapy if not on it first)

21

Dx esophageal dysmotility

Manometry is definitive

Barium 1st

22

Esophageal cancer
- signs
- types
- dx

Signs:
- dysphagia for solids --> softs --> liquids
- wt loss

SCC in smokers
Adenocarcinoma in GERD

High incidence in those w/ corrosive esophagitis

ALWAYS do barium before endoscopy to avoid perforation
Have to do endoscopy and bx for diagnosis

23

Tx
- Mallory Weiss tear
- Boerhaave syndrome

MW tear
- endoscopy + photocoagulation

Boerhaave
- dx w/ gastrografin 1st, then barium if it is negative
- emergency surgery repair

24

Tx MALToma of stomch

Tx h pylori and can reverse it if it is low grade!

25

Esophageal atresia
- sx
- work up
- tx

Sx:
- excess salivation after birth
- choking spells after 1st feeding
- NGT coils in chest

Most common type is upper esophagus is blind, fistula between lower esophagus and trachea

Workup:
- R/o VACTER

Tx:
- primary surgical repair
- if delayed, put in gastrostomy to protect lungs from acid reflux

26

Green vomiting in newborn + double bubble sign

What could it be?

Duodenal atresia
Annular pancreas
Malrotation of intestine (most dangerous and at risk for ischemia)

27

Green vomiting in newborn + multiple air fluid levels on xray - what is it?

Intestinal atresia

Usually vascular event in utero

28

Indications for bariatric surgery

BMI > 40

or

BMI > 35 + comorbidities

29

N/v and dilated bowel loops s/p bariatric surgery

what is the dx?

these symptoms and signs along with X Rays represent bowel obstruction.

In a patient with gastric bypass, this is often due to an internal hernia.

Retrocolic position of the Roux limb predisposes patients to developing an internal hernia through the transverse mesocolon.

30

Vit deficiency to watch out for s/p gastric bypass

Vit B12 - b/c no stomach to make intrinsic factor to bind

31

The inability to tolerate a diet that has progressed from solids to liquids in an otherwise stable patient s/p gastric bypass is very suggestive of......

a stenosis of the gastrojejunostomy.

dx w/ UGI series w/ contrast.

Endoscopy can also visualize the stenosis and can also be used to treat the stenosis using balloon dilators.

32

Inability to tolerate a diet after a laparoscopic band suggests

either the band is too tight or has slipped.

An UGI series or even plain X Rays can diagnose a slipped band but, if the band is too tight then an UGI series will be needed.

Emergent treatment is to decompress the band by removing fluid from the port (band adjustment).

33

Billroth I

Remove pylorus (distal stomach)

Proximal stomach - duodenum connectino

34

Billroth II

Connect lower stomach (greater curvature) to jejunum directly side-to-side

Resect lower antrum stomach

For refractory peptic ulcer disease

35

Alcoholic person +
UGI bleed +
evidence of cirrohosis
S/p resusscuitation w/ fluids, what do you do next?

Endoscopy!

Sclerotherapy can contorl hemorrhage in most cases

Angiography will r/o arterial hemorrhage but will not show bleeding varices

36

When do you do surgery on sliding esophageal hernia?

Symptomatic + objectively documented esophagitis or stenosis

Refulx is not an indication unless progresses to the 2 above

Size of hernia is not important

37

Massive hematemesis in children - what is this due to?

Variceal bleeding (almost always)

Results from extrahepatic portal V obstruction 2/2 bacterial infection from patent umbilical v during infancy

Tx electively for recurrent bleeding episodes. Bleeding usually stops and is self limited

38

Tx Zolinger ellison syndrome

Most will die of mets than primiary

Highly selective vagotomy + tumor resection

Dx:
Gastrin levels
If gastrin levels not diagnostic, secretin stim test (usually will decrease gastrin) will confirm ZES

39

Most common presentation of idiopathic retroperitoneal fibrosis

Ureteral obstruction

40

Most reliable objective indicator of GERD

24 hr pH monitoring

41

Assoc sx of esophageal perforation

Chest pain (ASAP)
SubQ emphysema (1 hr)
Pleural effusion usually on L (immediate or > 6h later)
Fever, leukocytosis 2/2 sepsis from mediastinis (>4 hr)
Death

42

Dx esophageal perforation

Water-soluble contrast esophogram - Gastrographin

Barium is more sensitive but it can be assoc w/ mediastinitis adn peritonitis if there is a tear

43

#1 cause esophageal perforation

Iatrogenic (endoscopy)

44

Person w/ duodenal ulcers
Failed med therapy (ppi+ amoxicillin + clarithromycin) and ulcer is getting larger
What do you do?

How about gastric ulcer?

Surgery

Highly selective vagotomy (chice procedure)
- fundus and body denervated + antrum and pylorus innveration intact so gastric emptying and mixing can stll happen
Truntal vagotomy
Pyloroplasty
Vagotomy + antrectomy

Billroth I partial gastrectomy (no vagotomy)

45

When do you resect gastric ulcers?

If treated medically for 18 weeks and no healing

No vagotomy performed

46

What should be done for all gastric ulcers?

biopsied to r/o malignancy

47

Types of gastric ulcers & treatments

I & 2 - low acid output
3& 4 - high acid output

1 - lesser curvature of body of stomach possibly 2/2 to NSAIDs or steroids
- tx: antrectomy +/- vagotomy if intractable

2- gastric and duodenal
- tx: vagotomy + pylorplasty w/ oversewing of ulcer in duodenal ulcer
- tx: vagotomy + gastrojejunostomy if gastric outlet obstruction

3 - pyloric and prepyloric
- tx: antrectomy + vagotomy

4 - At GE junction,
- tx: partial gastrectomy but NO vagotomy

48

For perforated ulcers, you close most of them but when do you do a vagotomy?

When the person has had the ulcer for a while and managed on meds but the meds have not worked.

49

gastric pH needed to reduce risk of rebleeding

5

50

Where is an actively bleeding ulcer usually?

In posterior duodenum involving gastroduodenal A

51

Tx difference for gastric vs. duodenal ulcers

Need to bx gastric ulcers b/c may have underlying gastric cancer

Will excise gastric ulcers rather than oversew
Only oversew duodenal ulcers that are new - recurrent ones, will resect and do a vagotomy

52

Tx actively bleeding esophagea varices

Band bleeding esophageal varices w /EGD

correct coagulopathy w/ FFP + Plt transfusion

Tx w/ IV octreotide to lower portal pressure. Can also use IV vasopressin

Continue to bleed...
- repeat endoscopy

Final steps if still bleeding...
portosystemic shunt
balloon tamponade

Beta blockers may lessen chance of rebleeding

53

Gastric lymphoma tx

Get rid of H pylori!

Surgery only if H. pylori eradication doesn't shrink tumor an tumor is stage 1 or 2

54

Dieulafoy's lesion

Often in proximal stomach

Abnormally large submucosal A protruding through small solitary mucosal defect

55

#1 ongenital diaphragmatic hernia in infants

Foramen of Bochdalek

Also most likely to cause ARDS in infants

56

Tx mallory weiss tear

Usually stops bleeding by itself

If not..
Balloon tamponade or
endoscopic control of bleeding or
Gastrotomy and suture ligation

57

Dumping syndrome tx

1) Dietary modification

2) Octreotide in resistant cases

3) Reconstructive surgery for intractable cases