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Flashcards in Upper GI Surgery Deck (35):

How do you manage dysphagia?

Barium swallow and esophagoscopy with biopsy
DDx achalasia, Zenker diverticulum, esophageal cancers, strictures


What are the types of esophageal cancers?

SCC in upper 2/3 due to cigarettes and EtOH, adenocarcinoma in the lower 1/3 due to Barrett's
Sx: progressive dysphagia and weight loss


How do you manage esophageal cancer?

Esophagoscopy and biopsy, then staging via endoscopic ultrasound and CT scan, then specific tx


How do you treat esophageal cancer?

Upper 1/3: chemo and radiation only
Middle 1/3: chemo and radiation to shrink the tumor, then esophagectomy
Lower 1/3: esophagectomy and proximal gastrectomy
Never operate on stage IV cancer


What is Zenker diverticulum?

Pulsion diverticulum that develops at upper esophagus due to abnormal coordination of cricopharyngeal constriction; Sx dysphagia, regurgitation, and bad breath
Manage by barium swallow, cricopharyngeus myotomy


What is a traction diverticulum?

Diverticulum at the middle esophagus due to LN traction, indicates cancer


What are the esophageal motility disorders?

Achalasia: hypertonic and non-relaxing LES with poorly relaxing esophagus, sx of dysphagia of lipids>solids
Nutcracker esophagus: painful swallowing due to high amplitude action potentials, tx with nifedipine
Diffuse esophageal spasms: uncoordinated third degree peristalsis, tx medically
hypertensive LES: high LES pressure at baseline but relaxes with swallow, tx medically


How do you manage achalasia?

Dx bird's beak on barium swallow and increase LES pressure on manometry, tx with Heller myotomy


What is on the differential for acute epigastric pain?

DDx acute pancreatitis, GERD, PUD (gastric ulcers or duodenal ulcers), cholelithiasis, gastroenteritis
gallstones or alcoholism = acute pancreatitis
NSAIDs or steroid use = PUD


How do you manage esophageal varices?

Present as UGIB due to portal HTN, often alongside coagulopathy (liver failure)
-management: band the bleeding varices, correct any coagulopathy, IV octreotide to lower portal pressure --> if bleeding continues, repeat endoscopic banding --> if bleeding continues, TIPS or gastric balloon tamponade
Follow up with beta blockers to lessen chance of rebleeding


How does Mallory-Weiss syndrome present?

UGIB due to retching lacerating the lower esophagus, bleeding usually stops spontaneously


How does Boerhaave syndrome present?

Presents as epigastric pain and fever due to retching perforating the esophagus
Dx contrast swallow, tx emergent surgical repair


How do you treat GERD?

PPIs -- if persistent after six weeks, do EGD with biopsy


How do you treat esophagitis?

Multiple, nonulcerating erosions in the stomach; mild to moderate esophagitis --> PPIs for 8-12 weeks, severe esophagitis --> lap Nissen, uncontrollable esophagitis --> subtotal gastrectomy


How do you treat Barrett esophagus?

intestinal metaplasia of esophageal epithelium
no dysplasia --> tx PPIs or lap Nissen
low grade dysplasia --> tx lap Nissen + annual surveillance
high grade dysplasia --> esophagectomy


What is Lap Nissen dundoplicaiton?

Wraps fundus of stomach around LES to keep it in the abdominal cavity
Contraindicated in morbidly obese patients (do gastric bypass instead)


What are the types of hiatal herias?

Hernia from abdominal cavity, through diaphragm, into chest cavity
Type 1: sliding hernia, risk of reflux esophagitis, Tx PPIs
Type 2: paraesophageal hernia, risk of incarceration/strangulation, surgical repair as tx
Type 3: presence of both types 1 + 2, tx surgical repair


What are the indications for PUD surgery?

Intractability, perforation, obstruction, bleeding


Duodenal ulcers

Caused by increased acid secretion; most commonly in 1st part of the duodenum, DU in 2nd-4th part indicates Zollinger-Ellison syndrome (gastrinoma)
types: posterior ulcers bleed due to gastroduodenal artery, anterior ulcers perforate
Tx: triple therapy-- if ulcer persists, surgery is indicated, also get serum gastrin levels to rule out ZE syndrome


What do you see on CXR if there is a DU?

free air under the diaphragm


How do you treat a perforated DU?

Use omentum to patch the ulcer, then stop acid with PPIs or HSV
If with sepsis, also give IV abx
if bleeding due to posterior ulceration into GDA, oversew the ulcer


Gastric ulcers

Caused by decreased mucosal protection
Type 1: lesser curvature at incisure
Type 2: duodenum and stomach
Type 3: pylorus
Type 4: GE junction
Tx: PPIs, if ulcer persists after six weeks, do endoscopy and multiple marginal biopsies for possibility of gastric cancer. If persists after 18 weeks, surgery is indicated
If the GU is bleeding, then tx is excision


What is GU surgery?

Wedge resection or distal gastrectomy (due to possibility of cancer), TV +P for types II and III due to increased acid production


What are the types of gastric cancers?

Gastric adenocarcinoma: often spreads to left supraclavicular node and ovaries
Linitis plastica: infiltrating carcinoma with desmoplastic reaction causing stomach to look fixed and rigid
Gastric lymphoma
GIST: any soft tissue tumor of stomach


How do you treat the gastric cancers?

Adenocarcinoma: if proximal, total gastrectomy
if distal, distal gastrectomy with anastomosis, take out D1 LN at lesser curvature

Linitis plastica: total gastrectomy with splenectomy

Gastric lymphoma: determine cancer stage, partial thickness--> radiation, full thickness --> surgical resection

GIST: wedge resection with 1 cm negative margins


How do gastric varices present?

UGIB due to portal HTN
Tx uncontrollable bleeding with TIPS or splenectomy instead of banding


What are the four complications of gastric ulcers?

1) Bleeding
2) Perforation
3) Gastro-pancreatic fistula
4) Gastric dysmotility


When do you worry about a gastric ulcer that does not go away after six weeks?

Gastric cancer


What causes duodenal ulcers?

H. pylori


Which ulcer type gets better with food?

Duodenal ulcer


What are the types of ulcers?

Type II: lesser curvature of the stomach
Type IV: diffuse, due to NSAIDs
If anywhere else, then you are concerned for a malignant process


What is a Sister Mary Joseph node?

Metastatic node from abdominal cancer at the umbilicus


What is Vircov's node?

Visceral cancer that has crossed the diaphragm.
Will also see acanthosis nigricans and Bloomer's node (metastasis in the pouch of Douglas)


What are the types of gastric cancer?

1) adenocarcinoma
2) intestinal type
3) superficial spreading
4) MALToma (associated with H. pylori)
5) GIST cell tumor
6) Lymphoma


How do you treat duodenal cancer?

Duodenum, head of the pancreas, and extrahepatic biliary tree
Whipple procedure