Forget Nots > GI Tract > Flashcards

GI Tract Flashcards

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1
Q
  • What is secretin normally supposed to do to gastrin?
  • Describe the secretin stim test
  • What’s a positive test?
A
  • Secretin normally inhibits gastrin
  • 1) 1 week before the test, change the PPI to an H2 blocker
  • 2) measure fasting serum gastrin
  • 3) administer 0.4mcg/kg of secretin
  • 4) measure serum gastrin @ 2, 5, 10 min
  • Positive test: increase in gastrin >120pg/mL over basal fasting level
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2
Q
  • What is a normal LES pressure high?
  • What is normal LES pressure on relaxation?
  • What pathology causes super high amplitude >200 on manometry?
  • Achalasia has high or low amplitude?
A
  • High > 24
  • Relaxed > 5
  • Super high amplitude >200: nutcracker esophagus. High amplitude >80: diffuse esophageal spasm
  • Achalasia has low amplitude
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3
Q

Esophagus.

  • What are primary, secondary, tertiary contractions?
  • Tertiary contraction is pathognimonic for what?
A
  • Primary: peristaltic
  • Secondary: localized contraction without proximal contraction to clear things from the esophagus. Normal
  • Tertiary: random contraction. Goes from bottom to top.
  • Tertiary is pathognomonic for abnormal Diffuse esophageal spasm
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4
Q
  • Low grade Barrett on initial EGD. When do you repeat? Follow-up?
  • High grade Barrett on initial EGD. When do you repeat? Follow-up?
A
  • Low grade: rpt EGD in 6mo then yearly until no dysplasia x2
  • High grade: rpt EGD in 3mo then q3 mo. EMR
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5
Q

Thoracic duct leak.

  • What’s high output vs low output? Treatment?
    *
A
  • High output > 500cc. OR. ligate it on the right side just above the diaphragm. Low output < 500cc. Npo, tpn, octreotide
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6
Q
  • Most common site of esophageal perforation during endoscopy?
  • Second most common?
A
  • At the level of cricopharyngeus because it is a narrow opening into the esophagus
  • Proximal to the lower esophageal sphincter
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7
Q
  • What does the artery of Hyrtl supply?
  • Where does it come from?
A
  • It’s an aberrant left hepatic artery running alongside the hepatic branch of the vagus nerve. Provides the majority of arterial inflow to the left lateral segment of the liver
  • Aberrant left: from left gastric Aberrant right: from SMA They’re supposed to branch off from proper hepatic.
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8
Q

Leiomyomas originate from what layer of the esophagus? Should all esophageal cysts be removed?

A
  • Muscularis propria
  • All esophageal cysts should be removed due to the risk of infection
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9
Q

What is the Siewert classification and how are they treated differently?

A

Anatomical classification for GE junction tumors

  • Siewert I: within +1-5 cm above the GEJ - treat like esoph tumor. Esophagogastrectomy
  • Siewert II: located within the cardia (between +1 and -2). Pretty much right at the GEJ - treat like esoph tumor. Eaophagogastrectomy
  • Siewert III: subcardial tumor (between -2 and -5) - Treat like gastric tumor
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10
Q

Blood supply for:

  • Cervical esophagus
  • Thoracic aorta
  • Abdominal aorta
A
  • Cervical esophagus: inferior thyroid artery
  • Thoracic aorta: bronchial arteries, branches directly from the aorta
  • Abdominal aorta: left gastric and inferior phrenic
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11
Q

What is the Los Angeles classification?

A

Classification for esophagitis

  • Class A: one or more mucosal break less than 5mm in length, not extending between the tops of two mucosal folds
  • Class B: one or more mucosal breaks more than 5mm, not extending between two mucosal folds
  • Class C: one or more mucosal break continuous between the tops of two or more mucosal folds but <75% circumference
  • Class D: two mucosal breaks that involve at least 75% of the esophageal circumference
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12
Q
  • Parietal cells produce what two things?
  • Chief cells produce what?
  • B12 gets absorbed where?
  • Antrum makes what two things?
A
  • Parietal: acid + intrinsic factor
  • Chief cells: pepsin
  • B12 in terminal ileum
  • Antrum: mucous. also, G cells make gastrin
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13
Q

What are the gastric phases of acid stimulation?

A
  • Cephalic phase: vagally mediated. Acetylcholine on parietal cells -> release acid
  • Gastric phase: distention of stomach with food -> acid secretion
  • Intestinal phase: release of gastrin from duodenal G cells
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14
Q

Gastric ulcers types.

Which ones are associated with increased acid production? Surgical options for each type?

A
  • II and III - acid production
  • Type V: NSAIDs. Diffuse ulcers
  • I: vagotomy and antrectomy first. Billroth 2 or RNY acceptable
  • II and III: truncal or selective vagotomy + Antrectomy including the ulcer, try Billroth 1 first
  • IV: at GE junction. Goal is to preserve maximal healthy stomach. Pauchet (B1 or B2) and Csendes (RNY) procedure
  • Truncal vagotomy must be accompanied with a drainage procedure
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15
Q

H. Pylori tests

  • which one is used to test eradication? How long after treatment?
  • culture vs. histology. Which one has 100% specificity?
  • H. Pylori treatment
A
  • carbon labeled urea breath test. >95% sensitive and specific. 4 weeks after treatment
  • culture has 100% specificty
  • treatment: PPI + Clarithromycin + Amoxicillin/flagyl
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16
Q

Dumping syndrome

  • you get this after what?
  • early vs. late. Timeframe?
  • Treatment?
A
  • after B1 or B2
  • Early: < half an hr. hyperosmolar food bolus Late: 1-2hrs postprandial. rapid systemic insulin response
  • Treatment: dry diet, separating solids from liquids. Octreotide may or may not help. Remedial surgery: convert to RNYGB
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17
Q

Afferent limb syndrome

  • you get this after what?
  • what is a major risk with this? treatment?
  • What is Efferent loop syndrome?
A
  • after Billroth II when you have a duodenal limb obstruction. May be due to excessive length. Then you get all the duodenal juice build up and build up and build up so you have pain. When it’s finally released, you get explosive bilious emesis and you get relief.
  • major risk is the duodenal stump blowout. treatment: RNYGB or Braun enteroenterostomy -> basically make a side to side anastomosis between the duodenal afferent limb and the efferent SB
  • Efferent loop: gastric outlet obstruction caused by kinking or herniation. More than half occurs in first post-op month.
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18
Q

Bile reflux

  • you get this after what?
  • in terms of symptoms how to distinguish between this and afferent limb syndrome?
  • treatment?
A
  • after B1 or B2 (when the pylorus is removed) or vagotomy and pyloroplasty
  • bile reflux doesn’t have relief in symptoms after bilious vomiting because this is a gastritis. Afferent limb syndrome you get symptom relief.
  • treatment: RNYGB with an intestinal limb of 50-60cm to prevent reflux of intestinal contents
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19
Q

Most common postgastrectomy syndrome requiring revision?

A

Bile alkaline reflux gastritis. Convert to RNY

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20
Q

Gastric stasis / Roux stasis

  • what is it?
  • treatment?
A
  • difficulty in gastric emptying. Epigastric pain, vomiting, wt loss. Egd will show dilated remnant stomach or roux limb
  • treatment: ngt, reglan or IV erythromycin. Surgery is rarely helpful. Reattempt rny
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21
Q
  • What is a normal gastrin level?
  • Two things you need to diagnose zollinger Ellison syndrome
  • how long should they be off of PPI?
  • describe the secretin stimulation test
  • usual location of gastrinoma?
  • pancreatic neuroendocrine tumor is primarily in the tail of the pancreas
  • primarily in the head
  • Evenly distributed?
  • how do you rule out MEN 1?
  • what % of MEN 1 pts have gastrinoma?
A
  • Normal gastrin lvl < 110 oh/mL
  • 1) elevated gastrin lvl 2) gastric aspirate pH < 2
  • 72hrs before the test
  • secretin 0.4 ug/kg given. Gastrin levels at 0, 2, 5, 10, 20 min. Increase in gastrin lvl > 200 pg/mL
  • gastrinoma triangle (including duodenum) and throughout the pancreas
  • tail: VIPoma and glucagonoma
  • head: somatostatinoma
  • evenly distributed: insulinoma +/- glucagonoma
  • pituitary: prolactin lvl Parathyroid: PTH - 25% of MEN 1 have ZES
  • up to 40% of MEN1 pts have gastrinoma. 2nd most common (parathyroid is #1)
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22
Q

Gastric adenocarcinoma.

  • Margin and lymph nodes?
  • LND. what’s d0, d1, d2? D3? D4?
A
  • 5cm margin, 16 nodes
  • D0: palliative
  • D1: peri-gastric -> nodes along greater and lesser curvature
  • D2: D1 + nodes along celiac axis, common hepatic artery, left gastric, splenic artery
  • D3: D2 + hepatoduodenal ligament, root of the mesentery, retropancreatic
  • D4: D3 + paraaortic, paracolic
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23
Q
  • What tumor derives from interstitial cell of Cajal?
  • Locations most common to least common?
A

CaJal: JIST.

gastric pacemaker cells Stomach (50-70%) > small bowel (25-35%) > colorectal (5-10%) > mesentery/omentum (7%) > esophagus (<5%) > duodenum

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24
Q

How is malignancy defined in GIST?

A
  • < 2cm and < 5 mitoses per HPF -> benign
  • >10cm and > 5 mitoses -> malignant
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25
What do each of these hormones do and what does RNYGB do to their levels? - Ghrelin: - PYY: - GLP-1:
- decreases Ghrelin: Decreased hunger - increases PYY: delays gastric empting, increases satiety - increases GLP-1: increase satiety, increases insulin production and sensitivity tangent. GLP-2 improves nutrient absorption and nutritional status in short-bowel patients with no colon. this is gattex
26
% excess weight loss for * RNYGB * lap bands * sleeve
* RNYGB: 70% * lap bands: 40% * sleeve: 60%
27
Most common type of gastric lymphomas? What is the CHOP therapy?
Large B cell type (55%) MALToma (40%) Cyclophosphamide Hydroxydaunomycin (doxorubicin) Oncovin (vincristine) Prednisone
28
Appropriate length for * afferent limb for B2 recon? * for duodenal switch, where is the TI divided?
- B2 afferent limb: 20cm. As short as possible to prevent afferent loop syndrome. Longer -\> higher risk - divide the TI 250cm from the ileocecal valve and divide the duodenum at D1. make a duodenoileostomy. Make an ileoileostomy at 100cm from the ileocecal valve
29
* Most common nutrition abnormality after RNYGB? * Nutrition deficiency in vomiting RNYGB?
iron deficiency anemia \> hypocalcemia/megaloblastic anemia Thiamine in vomiting rnygb
30
What are the three types of gastric Carcinoid tumors?
Higher the type: more aggressive Type I: chronic atrophic gastritis, small (\<1cm) and often multiple and polypoid. Slow growing, only rarely metastasize Type II: associated with zollinger Ellison syndrome and MEN I. slow growing but more likely to met Type III: most aggressive. Often large (\>1cm), not associated with hypergastrinemia. Frequently met to nodes and liver
31
Which type of gastric Carcinoid is associated with * MEN I: * least aggressive Mets: * often larger than 1cm and not associated with hypergastrinemia: * zollinger Ellison syndrome: * chronic atrophic gastritis:
- MEN I: type II - least aggressive Mets: type I - often larger than 1cm and not associated with hypergastrinemia: type III - zollinger Ellison syndrome: type II - chronic atrophic gastritis: type I
32
Anterior or posterior vagus? * ends at a higher level: * which one has criminal nerve of grassi * stomach pain is transmitted via what? * runs along the lesser curvature * has more branches * shorter * latarjet. Which vagus? What does this do? * where do right and left vagus nerves become anterior/posterior vagal trunks?
* - ends at a higher level: posterior * - which one has criminal nerve of grassi: posterior * - stomach pain is transmitted via what? Sympathetic chain * - runs along the lesser curvature: posterior * - has more branches: anterior * - shorter: posterior * - latarjet: anterior. Innervates the anterior wall of the stomach * - just below the tracheal bifurcation
33
What's a normal demeester score?
Shouldn't exceed 14-15
34
Most common cause of failure to maintain weight loss after vertical banded gastroplasty?
Change in pts diet.
35
Enterochromaffin like cells. What do they do?
Aid in gastric secretion via histamine release They are also the cells that Carcinoid tumors originate from.
36
Short bowel syndrome * minimum length required with intact pylorus and ileocecal valve * minimum length needed without colon
- 75cm - 150cm
37
* What's a high output fistula? * Does long fistula tract help with spontaneous closure? * What's the overall fistula closure rate? * After how many weeks is it unlikely to close
* \>500cc/24hr * Yes. * Short tract is a inhibiting factor for closure. long tract is preferred * Overall 10-40% closure rate
38
Treatment for Carcinoid tumor * in the duodenum \< 1cm * in the duodenum 1-2cm, low grade * in the duodenum \> 1.5cm, high grade * jejunum and ileum * appendix
* - in the duodenum \< 2cm, low grade: endoscropic resection or trans-duodenal rxn * - in the duodenum \> 1.5cm, high grade: whipple * - jejunum and ileum: check for synchronous lesions (30% of cases) * - appendix: Appendectomy if \<2cm and does not involve the base Rest: right hemi
39
* Celiac disease is associated with what kind of cancer? * What is the most common malignancy involving small bowel mesentery
* T cell lymphoma. Non hodgkin. Celiac is predisposing to B cell lymphoma too. * Large B cell lymphoma (also the most common stomach lymphoma. Large B cell \> MALToma)
40
Most likely location of GI lymphoma in small bowel?
Ileum. It parallels the lymphoid tissue distribution. Ileum has the most abundant lymphoid tissue
41
What drugs can cause paralytic ileus besides opioids?
Alpha agonists: midodrine, phenylephrine Anti-histamines Anticholinergics
42
Has to be bleeding this much to be detectable by: * nuclear scintigraphy * mesenteric angiography * CT angio If colonoscopy isn't able to identify a focus of bleeding and the pt bleeds more, repeat colonoscopy?
* - nuclear scintigraphy: 0.04-0.1 mL/min * - mesenteric angiography: 0.5 mL/min * - CT angio: 0.3 mL/min Repeat colonoscopy not recommended. CT angio
43
* incidental meckel in adult vs kids? * broad base vs. narrow base? * true or false diverticulum?
* - kids: cut it out. Adults: leave it alone * - narrow base: cut it out. Broad base: can leave alone * - true diverticulum
44
* SMA embolism usually spares what? * Why transverse arteriotomy? * When to use longitudinal arteriotomy? * Where does blood supply come from when doing an "antegrade SMA bypass" vs "retrograde"? * Ischemic bowel. Ex-lap. Resection first or bypass/embolectomy first? Why
* Spares the stomach, duodenum, distal colon * Transverse arteriotomy allows for easier closure without narrowing the lumen. * Longitudinal: bypass * Antegrade: celiac to SMA Retrograde: common iliac or infrarenal aorta to SMA * Vascular part first. Allows for maximum intestinal salvage. True viability can't be determined until revasc'd.
45
Perforated appendix with abscess * failure rate of non-op management * complication rate of interval appendectomy * risk of recurrent appendicitis - in pts \> 40 what needs to be done after initial mngmt? For what reason? * What is the incidence of appendiceal tumor in ALL pts with appendicitis? * what are the odds of concurrent malignancy in pts \>40
* - failure rate of non-op management: ~5% * - complication rate of interval appendectomy: 2-23% * - risk of recurrent appendicitis: ~8% * - in pts \> 40 what needs to be done after initial mngmt? For what reason? Colonoscopy. To rule out malignancy * - in ALL pts with appendicitis, tumor rate is ~2% - 15% concurrent malignancy
46
* Initial medical therapy for high output ECF? If ineffective? * What if hypomagnesemia develops?
* PPI + loperamide Then codeine * HypoMg: change PPI to H2 blocker
47
Uncomplicated appendicitis: non-op vs. op mngmt * readmission rate * length of hospital stay * cost - complication rate/duration of pain?
* - non-op: higher readmission rate within 1 year for recurrent appendicitis (up to 1/3 recur) * - length of hospital stay: non-op has longer length of stay * - cost: lower in non-op group - complication rate/duration of pain? No difference
48
Can you do surveillance for GIST?
Yes, for lesions 1cm or less with no high risk features on endoscopic ultrasound such as irregular borders, echogenic foci, ulceration
49
Hereditary diffuse gastric cancer * when to do prophylactic gastrectomy? * Do you need to send frozen? Why or why not? * do you need to get lymph nodes? Why or why not? * anything special with women with HDGC? Whats the screening recommendation?
* - between ages 18-40 * - yes, to confirm that all gastric tissue has been removed. You want to see esophagus proximally and duodenum distally * - no need for lymph nodes * - increased risk for breast cancer. screening is same as those with BRCA. Annual mammography + MRI alternating 6 months
50
1. Post-vagotomy diarrhea is more common among TRUNCAL vs. SELECTIVE vs. HIGHLY SELECTIVE vagotomy? 2. Does octreotide help with post-vagotomy diarrhea? What about cholestyramine? 3. What is the surgical procedure of choice for post vagotomy diarrhea? 4. how do you distinguish between post vagotomy diarrhea vs. Dumping syndrome 5. treatment and usual prognosis?
1. Most common after TRUNCAL Least common after HIGHLY SELECTIVE 2. Octreotide doesn't help. Cholestyramine does. 3. Interposition of antiperistaltic 10cm of jejunum 100 cm from the ligament of Treitz is the procedure of choice 4. dumping syndrome: correlation with meals Post vagotomy diarrhea: no correlation to meals 5. increase fiber, decrease carbs, eliminate caffeine, add cholestyramine
51
* Two most specific predictive factors for choledocholithiasis? * Which one is more specific?
* Tbili \> 4 (83-94%) * Choledocho on US (94-97%)
52
Diagnostic test of choice for insulinoma Is c peptide going to be high or low?
Prolonged fasting test. Fast for 72 hrs. Measure insulin (going to be high. Should be low with high glucagon), glucose, c peptide, proinsulin lvl
53
* Which enzyme is the first enzyme to activate everything else? * How is this enzyme related to trypsin
* Enterokinase aka enteropeptidase (secreted from duodenum, not pancreas) It activates trypsinogen into trypsin. * Trypsin activates everything else including trypsinogen
54
Where is: * Cullen sign * Grey Turner sign * Fox sign
* Cullen sign: periumbilical * Grey Turner sign: flank * Fox sign: inguinal All signs of retroperitoneal hemorrhage
54
For zenkers, what's one advantage of transoral repair vs. open cervical?
decreased risk of a fistula due to a leak from an open diverticulectomy
54
For gb cancer found after lap CCY, what % of port site Mets occur at non-extraction site?
Up to 50%
54
* What tumor derives from Kulchitsky cells? * Locations most common to least common?
* Kulchitsky: Karcinoid * Appendix (~50%) \> small bowel \> colorectal \> stomach
54
- NHL staging? What's stage IIE?
* Stage 1: single lymph node region. * Stage 1E: single extra-lymphatic organ/site * Stage 2: two or more lymph node regions, same side of the diaphragm * Stage 2E: 2 or more extra-lymphatic organs/sites * Stage 3: both sides of the diaphragm * Stage 4: diffuse disseminated involvement of one or more extra-lymphatic sites (liver, bone marrow, lung)
55
Most common sequela of carcinoid syndrome?
heart disease
56
Most common location for small bowel adenocarcinoma?
duodenum
57
non-hodgkin lymphoma most common location to least common?
NHL: stomach \> small bowel \> large bowel
58
When do you get * Bile reflux * afferent/efferent loop syndrome * dumping syndrome * roux stasis
* bile reflux: after B1 or B2 or vagotomy, pyloroplasty. most common post-gastrectomy syndrome * convert to RNY or do braun enterostomy. you vomit but don't feel better after vomiting. afferent loop you feel better * Afferent/efferent loop syndrome: after B2. This is why you should make afferent limb as short as possible ~20cm * afferent loop: bile and panc juice collect and collect then you vomit and feel better. risk: duodenal stump blowout * efferent loop: hernia or kinking. more than half occurs within 1 month postop * dumping syndrome: after B1 or B2 * conservative management, convert to RNY * roux stasis: after RNYGB * use erythromycin. no good surgery
59
Describe the course of the thoracic duct Originates at what level? Traverses the diaphragm through what hole? In the chest it's between what structures? Relationship to carotid/jugular vein? At what level does it drain into what?
* Originates at T12 in the abdomen. * Traverses the diaphragm through the aortic aperture. Courses up in the chest between the thoracic aorta and the azygous vein. * Then it courses posteriorly to the left carotid a. and jugular vein at. At T5 drains into the confluence of left subclavian and internal jugular vein.
60
what is the most common cause of atraumatic splenic rupture?
malignant hematologic disorders (30%. non-hodgkin lymphoma, leukemia, etc) \> infection (20% mononucleosis)
61
predictive factors to indicate that non-op management is not going to successful for SBO (3)
* presence of 2 or more beak signs * posterior adhesion * free intraperitoneal fluid fecalization is actually associated with 5x DECREASE in need for surgery
62
appendectomy vs. abx/non-op mngmt for uncomplicated acute appendicitis: * [T/F]: Costs associated with laboratory testing, imaging, and medications account for the majority of cost incurred with nonoperative management * [T/F]: The overall societal costs associated with antibiotic therapy are lower than the costs for surgical management.
* false. most of the cost comes from lost productivity * true. abx is cheaper than surgery
63
Appendectomy vs. abx/non-op mngmt for non-complicated acute appendicitis * [T/F]: During the initial treatment period, patients who are treated with antibiotics are more likely to have complications than those who are treated with initial appendectomy * [T/F:]: Those patients who require appendectomy for failed nonoperative management have a high rate of complications. * 1yr readmission rate for non-op vs. surgery?
* false. appendectomy actually has higher complication rate (22% vs 7%) * apparently even if they fail antibiotics complication rate isn't higher when they finally undergo appendectomy * non-op readmission rate for non-op is higher than surgery (up to 1/3)
64
* for small bowel adenocarcinoma, which one has worse prognosis- ileum or jejunum? * how many nodes do you need?
* ileal location has worse prognosis. * you need at least 10 nodes. fewer than that -\> worse prognosis
65
eosinophilic esophagitis * presenting symptoms * peak incidence at what age? * surgery?
* reflux and dysphagis main presenting symptoms * peak age 30-50's * no role for antireflux surgery
66
single incision laparoscopic surgery vs. traditional lap * post-op pain? * hernia rate? * operative time? * conversion rate? * return to activity?
* same post-op pain * higher hernia rate (8% vs. 1%) * longer operative time * same conversion rate * same return to activity
67
what to do with 1cm GIST in the stomach with low risk features?
surveillance. no surgery. Tumors of the stomach have a lower malignant potential than those of the small intestine or rectum, Tumors that are 1 cm in size are referred to as mini GISTS. These tumors have very low malignant potential and are managed by endoscopic ultrasound surveillance. High-risk features include the presence of echogenic foci, irregular borders, or ulceration. Endoscopic removal of GISTs is not well supported by evidence and risk perforations. SESAP
68
T/F: Herniation through the Peterson window is the most common type of internal hernia
apparently false. herniation through the mesojejunal window (56%) is more common than peterson defect (27%)
69
for esophageal foreign body impaction: * [T/F]: foreign body obstruction is the #1 most common indication for urgen EGD * [T/F]: Less than 25% of patients will have underlying esophageal pathology * [T/F]: Flexible endoscopic retrieval is successful in less than 75% of cases. * [T/F]: barium swallow is not recommended * [T/F]: complication rate after endoscopic retrieval of food impaction is 10%
* GI bleed is the #1 most common indication for urgent EGD * actually more than 75% of the ppl will have an underlying pathology such as strictures, esophagitis, motility, etc * endoscopic retrieval is successful in \>95% of the case * correct. barium swallow is not recommended to prevent aspiration and decreases visualization during EGD * \<5% complication rate
70
splenic vein thrombosis and gastric varices after acute pancreatitis. * do you have to anticoagulate? * splenectomy?
* studies have shown that splenectomy from variceal bleeding is actually uncommon (4%). no need to anticoagulate or splenectomize
71
what's the difference between H. pylori gastric polyps vs. chronic PPI polyps?
H. pylori polyps: hyperplastic. 0.5-1.5cm. can be stalked. smooth dome-shaped. PPI polyps: smaller (0.1-0.8cm), sessile. exclusively in the fundus
72
what is the most sensitive test for C. diff infection?
toxigenic stool cltulre \> PCR PCR cannot distinguish between colonized c diff vs those who truly have INFECTION
73
gastric lymphoma vs. colonic lymphoma difference in treatment
gastric: if not maltoma then radiation \> chemo colonic: resection with lymphadenectomy (especially for large tumors) followed by chemo
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