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34-year-old man with sharp epigastric pain over the last four hours. Moderate tenderness in epigastrium. No palpable masses – most likely diagnoses?

(From top to bottom)
1. GERD
2. Gastroenteritis, gastric cancer
3. Peptic ulcer disease
4. Pancreatitis
5. Cholelithiasis

1

34-year-old man with sharp epigastric pain over the last four hours. Moderate tenderness in epigastrium. No palpable masses – CBC, amylase, lipase, bilirubin, alkaline phosphatase, CXR all normal – next steps?

1. Ultrasound to rule out gallstones
2. If ultrasound negative, lifestyle changes empiric treatment for GERD (H2 blocker or PPI)
3. If fails, EGD and biopsies to rule out cancer and H. pylori
4. If no pathology from EGD, symptomatic treatment with H2-blockers or PPIs

2

45-year-old man with epigastric pain gets EGD. Diagnosed with GERD. However is refactory even with maximal therapy. Management? Surgical procedure?

1. EGD with biopsy and esophageal manometry (demonstrate in tact esophageal peristalsis)
2. If manometry shows normal LES tone or atypical symptoms (cough or asthma), 24 hour pH probe testing
3. If patient has dysphasia or suspect short esophagus, esophagogram

Nissan fundoplication – Restores gastroesophageal junction and the LES position + wraps segment of stomach around distal esophagus to augment LES tone

3

45-year-old man with epigastric pain gets EGD. Diagnosed with distal esophagitis. Complication of? Test? Approximate time before patient responds to treatment?

GERD;

24-hour pH probe and manometry

Moderate esophagitis usually responds to PPI's within 8-12 weeks

4

45-year-old man with epigastric pain gets EGD. Diagnosed with Barrett's esophagus. Next steps?

1. Biopsy
2. If mild dysplasia, treat as GERD with surveillance endoscopy/biopsy every 18-24 months
3. If severe dysplasia, resection is necessary

5

Types of hiatal hernias? Management for each?

Type 1: Sliding hiatal hernia (Stomach shifts above diaphragm) – treat as GERD

Mixed type hiatal hernia – either
1. pure paraesophageal (No organs involved except stomach)
2. Sliding and paraesophageal
both surgical repair due to risk of strangulation and necrosis

Type 2 – paraesophageal hiatal hernia (contains other organs in addition to stomach). Must be prepared surgically, surgical emergency patient presents with acidosis and hypertension.

6

60-year-old patients undergoing elective abdominal surgery. Surgeon discovers type II hiatal hernia – next step?

If found incidentally, still should be repaired

7

45-year-old man with epigastric pain gets EGD. Diagnosed with pyloric channel ulcer – associated with? Tests?

H. pylori infection

urease breath testing, urease testing, Serum antibody testing, gastric biopsy for culture, Warthin-Starry silver stain

8

Triple therapy for H. pylori?

Treatment with an even higher eradication rate?

PPI (omeprazole) + metronidazole + clarithromycin/amoxicillin

Bismuth, tetracycline, metronidazole, and omeprazole

9

Types of gastric ulcers? Acid outputs?

1 – lesser curvature
2 – gastric ulcer AND duodenal ulcer
3 – ulcer near pyloric sphincter
4 – ulcer by cardiac area

Types 1 and 4 have low acid output; types 2 and 3 have high output

10

Management of a gastric ulcer?

1. Endoscopy for biopsies (gastric ulcers increased risk of gastric cancer)
2. If benign, H2-blockers or triple therapy
3. It symptoms do not resolve, repeat endoscopy with repeat biopsies, partial gastrectomy
4. vagotomy if type 1 or type 4 to lower acid production

11

Patient gets biopsy for gastric ulcer – biopsy indicates the gastric cancer. Management?

1. Attempt to Stage cancer using CT or endoscopic ultrasound for metastasis or lymph node spread
2. If Fails, stage cancer via abdominal exploration
3. For early cancers of the antrum or middle stomach, distal subtotal gastrectomy
4. If infiltrating gastric carcinoma, resection of stomach, omentum, perigastric lymph nodes

13

Stomach biopsy indicates infiltrating gastric carcinoma. Wall of stomach appears fixed and rigid – likely diagnosis? Management? Prognosis?

Lentis plastica; involves all layers of the stomach wall with marked desmoplastic reaction;

Gastrectomy with splenectomy; poor prognosis

14

Stomach biopsy indicates gastric carcinoma at gastroesophageal junction – prognosis compared to cancer in antrum? Treatment?

Less favorable

1. Gastric resection 6 cm distally below the tumor
2. If cancer extends into gastroesophageal junction, may need to perform esophagogastrectomy and interposition graft from colon/small bowel

17

Types of infiltrating gastric carcinoma?

1. Intestinal – forms glands (more favorable prognosis)
2. Diffuse – extends into submucosa (worse prognosis)

18

40-year-old male presents with four hour history of epigastric pain. Marked tenderness to involuntary guarding and rebound tenderness. WBC is 18,000 with a left shift. Next step?

CXR first to look for free air diaphragm (perforation of G.I. tract) – If present, go to OR after resuscitation

19

40-year-old male presents with four hour history of epigastric pain, guarding, the white count – CXR shows free air under diaphragm. Management if Fresh gastric contents in peritoneal cavity, perforation appears several hours old, patient has no history of ulcer disease

Closure of the perforation, potentially using Graham patch (omentum is placed over perforation and sutured in)

20

40-year-old male presents with four hour history of epigastric pain, guarding, the white count – CXR shows free air under diaphragm. Management if fresh gastric contents, perforation of ulcer several hours old, ulcer symptoms were present the past six months and patient was taking H2-blockers?

Because patient has prior ulcer, at risk for future complications unless definitive procedure is performed

Close perforation and perform highly selective vagotomy or truncal vagotomy and pyloroplasty

21

40-year-old male presents with four hour history of epigastric pain, guarding, the white count – CXR shows free air under diaphragm. Management if fresh gastric contents in peritoneal cavity, perforation is several hours old, patient has history of progressive rheumatoid arthritis and needs daily NSAIDs and steroids?

Close ulceration with Graham patch and discontinue NSAIDs if possible.

If NSAIDs necessary (likely) considered definitive ulcer operation (vagotomy and pyloroplasty)

22

40-year-old male presents with four hour history of epigastric pain, guarding, the white count – CXR shows free air under diaphragm. Management if fresh gastric contents paratonia cavity, perforation several hours old, patient is hypotensive likely due to sepsis?

1. Complete operation as quickly as possible with a Graham patch
2. stabilize in ICU with antibiotics, and omeprazole

23

40-year-old male presents with four hour history of epigastric pain, guarding, the white count – CXR shows free air under diaphragm. Concern if perforation appears 24 hours old? Management if fibrinous exudate and evidence of infection in peritoneal cavity?

If perforation occured 12 hours ago or more, high morbidity and mortality, high chance of sepsis

1. Most simple possible operation – closure of ulcer with Graham patch and Peritoneal debridement
2. ICU management
3. Definitive ulcer surgery planned for later after the patient recovers