Absite Pearls

Front 1

What are the characteristic manometric findings in achalasia?

Back 1

Failure of the lower esophageal sphincter (LES) to relax completely, with swallowing associated with an absence of
organized propulsive peristalsis, elevated resting LES pressure, and nonpropulsive simultaneous contractions
(tertiary waves) on manometry.

Front 2

What is the most common complaint of patients with a duodenal ulcer?

Back 2

Epigastric pain.

Front 3

T/F: Elevated serum gastrin levels during fasting are typically seen in patients with a duodenal ulcer.

Back 3

False.

Front 4

What findings on esophagogastroduodenoscopy (EGD) and upper gastrointestinal (UGI) contrast studies
are associated with achalasia?

Back 4

The bird beak esophagus is the classic UGI finding in achalasia. The gastroesophageal (GE) junction should not
appear strictured, and, except in end-stage cases, an adult endoscope should easily pass through the GE junction
with steady pressure.

Front 5

What does the parietal cell secrete?

Back 5

HCl and intrinsic factor.

Front 6

What does intrinsic factor assist in?

Back 6

It binds to vitamin B12 and allows B12 absorption in the terminal ileum.

Front 7

What are the treatment options available to an otherwise healthy patient with achalasia?

Back 7

Endoscopic balloon dilation and operative (Heller) esophagomyotomy. Myotomy is far more durable and should be
the first-line option in patients of acceptable surgical risk.

Front 8

An 80-year-old man with severe achalasia, caused by unrelated medical problems, who is not a candidate for
surgery, requests treatment for his dysphagia. What is your recommendation?

Back 8

Endoscopic dilation or botulinum injection.

Front 9

What is involved in the Belsey procedure?

Back 9

Two layers of plicating sutures placed between the gastric fundus and the lower esophagus with subsequent creation
of a 280-degree anterior gastric wrap and posterior approximation of the crura.

Front 10

What is the best test to diagnose GERD?

Back 10

24-hour pH probe.

Front 11

Which cells produce pepsinogen?

Back 11

The chief cells produce pepsinogen, which initiates gastric proteolysis.

Front 12

Which peptide activates the digestive cascade?

Back 12

Enterokinase, which then acts on trypsinogen to trypsin.

Front 13

A 70-year-old man with a 30-year history of achalasia presents with recurrence of his symptoms after a
successful balloon dilation several years previously. What is the appropriate treatment?

Back 13

Esophagomyotomy after carcinoma is ruled out.

Front 14

A 45-year-old woman presents with manometrically documented primary achalasia. Her esophagus is
massively dilated and contains a significant amount of undigested food. She has failed several prior attempts
at modified Heller myotomies and has had several hospital admissions. What is the treatment of choice?

Back 14

Total esophagectomy.

Front 15

What are the potential intraoperative complications during transhiatal esophagectomy?

Back 15

Recurrent laryngeal nerve injury, tear in the membranous wall of the trachea, azygous vein disruption, hemothorax,
and pneumothorax.

Front 16

T/F: Stage for stage, the survival rate after radical en bloc esophagectomy is better than that after transhiatal
esophagectomy.

Back 16

False.

Front 17

A patient with severe reflux symptoms has virtually complete relief with proton-pump inhibitor therapy. The
patient still requests an operation so that medication will not be required. Is the patient a candidate for
surgery?

Back 17

Yes. Surgery for gastroesophageal reflux (GER) is an option for patients who are concerned about the
inconvenience, cost, and long-term medical consequences of daily medication, provided the patients are medically
fit for an operation.

Front 18

How is GER most objectively documented?

Back 18

By 24-hour esophageal pH monitoring.

Front 19

What is Barrett’s esophagus?

Back 19

The presence of 2 to 3 cm of columnar intestinal epithelium along the esophageal mucosa. Intestinal metaplasia is
diagnostic of Barrett’s, regardless of its proximal extent. It is important to sample the tissue to ensure that high-grade
dysplasia or malignancy is not concurrently present. Serial surveillance with EGD is critical in these patients.

Front 20

What is meant by a highly selective vagotomy?

Back 20

Division of individual branches of the nerve of Latarjet, preserving the crow’s foot.

Front 21

T/F: Esophageal manometry is a necessary part of the evaluation of a patient being considered for an antireflux condition.

Back 21

True.

Front 22

What is the classic metabolic abnormality associated with gastric outlet obstruction?

Back 22

Hypochloremic, hypokalemic metabolic acidosis.

Front 23

The best method of establishing the diagnosis of an esophageal leiomyoma is by what means, and what is the preferred treatment?

Back 23

Dx: typical appearance on EGD; TX: enucleation, not esophagectomy.

Front 24

What is the most common type of gastric polyp?

Back 24

Hyperplastic polyps.

Front 25

What is the criminal nerve of Grassi?

Back 25

A proximal branch of the posterior vagus nerve, which can be missed during vagotomy and can lead to persistent gastric acid secretion.

Front 26

What are the three main peptides that stimulate the parietal cell?

Back 26

Acetylcholine, histamine, and gastrin, which, through calcium, activate protein kinase C, which then increases HCl secretion.

Front 27

Which cells produce gastrin?

Back 27

G cells. They are located in the antrum of the stomach. They are stimulated by amino acids and acetylcystine.
These are inhibited by acid.

Front 28

What cell hyperplasia is increase in gastrin levels associated with?

Back 28

Enterochromaffin hyperplasia (precarcinoid lesions).

Front 29

What is the secretin stimulation test?

Back 29

Test for gastrinoma. In normal patients, the gastrin level goes down with administration of secretin. In gastrinoma, there is a paradoxical rise in serum gastrin levels with secretin administration.

Front 30

What is the effect of antrectomy for ulcer treatment?

Back 30

Removal of the G cells, which are located in the antrum, and therefore remove stimulation of G cells.

Front 31

What is the mechanism of omeprazole?

Back 31

There is blocking of H/K ATPase of parietal cell with a secondary decrease in acid production.

Front 32

A 50-year-old otherwise healthy patient, who has suffered from recurrent lobar pneumonia, is referred for antireflux surgery. Under what circumstances would you be willing to operate?

Back 32

When GER can be objectively demonstrated on a 24-hour esophageal pH study. Evidence of reflux into the proximal esophagus, presence of laryngeal inflammation, and a good response of pulmonary symptoms to a 3-month trial of high-dose proton-pump inhibitors also correlate with a good response to surgery. Other etiologies for pulmonary symptoms must be eliminated.

Front 33

A patient who underwent a Nissen fundoplication 2 weeks ago continues to have trouble swallowing. What is your recommendation?

Back 33

Allow time for the edema to resolve; then re-evaluate.

Front 34

T/F: Traction diverticula are associated with tuberculosis.

Back 34

True.

Front 35

What is a Schatzki’s ring?

Back 35

A dense annular band in the submucosa at the squamocolumnar junction.

Front 36

What is the most potent stimulant for gastric acid secretion?

Back 36

Ingestion of a mixed high-protein meal.

Front 37

A patient whose reflux symptoms resolved following a Nissen fundoplication presents several years later with recurrent symptoms. What is the diagnostic test of choice?

Back 37

UGI contrast study.

Front 38

A 45-year-old patient with Barrett’s esophagus, containing high-grade dysplasia on endoscopic biopsy specimens from the distal esophagus, is referred to you. What is the treatment of choice?

Back 38

Distal esophagectomy.

Front 39

A 50-year-old woman with a known reflux-induced stricture of the distal esophagus presents with dysphagia. She had successful endoscopic dilatation 1 year previously and was free of dysphagia until now. Her symptoms of GER are mild and controlled with H2 blockers as needed. How should she be managed?

Back 39

Malignancy must be ruled out prior to undertaking any therapy. Assuming that her stricture is reflux induced, repeat endoscopic dilation should successfully treat her dysphagia. Refractory benign strictures should be treated with short-segment focal esophageal resection.

Front 40

T/F: GER occurs in all patients with a sliding hiatal hernia.

Back 40

False.

Front 41

What are the most common complications of type II hiatal hernias?

Back 41

Occult gastrointestinal bleeding, ulceration in the herniated portion of the stomach, and gastric volvulus.

Front 42

A patient with a long history of reflux symptoms presents with a peptic stricture of the distal esophagus that cannot be dilated by flexible or rigid endoscopy. What is the treatment of choice?

Back 42

Resection.

Front 43

What is the most important predictor of stomach ulcer recurrence?

Back 43

Slow healing of the initial ulcer (longer than 3 months).

Front 44

T/F: Routine splenectomy improves survival in patients with gastric adenocarcinoma.

Back 44

False.

Front 45

An 80-year-old man presents with dysphagia that prevents him from adequately clearing his pharynx of food. He also notices gurgling in his neck when he swallows. What is the most likely diagnosis?

Back 45

A Zenker’s diverticulum.

Front 46

What is the diagnostic test of choice for a Zenker’s diverticulum?

Back 46

Barium swallow.

Front 47

What is the proper surgical approach for repair of a Zenker’s diverticulum?

Back 47

A left lateral neck incision.

Front 48

What are the painful abdominal conditions that increased PTH is associated with?

Back 48

Renal stones, pancreatitis, and gastritits/peptic ulcer disease (PUD).

Front 49

What does somatostatin do?

Back 49

Pan-GI inhibition. It inhibits gastrin, insulin, secretin, Ach, and pancreatic and biliary output. Its release is stimulated by acid in duodenum.

Front 50

What is the most common complicating symptom post vagotomy?

Back 50

Diarrhea.

Front 51

What are the types of dumping and the treatment?

Back 51

Early—because of hyperosmotic load, and fluid shifts.
Late—because of increased insulin and decreased glucose.
These both can usually be treated with dietary changes. 90% respond favorably to low carbohydrate loads.

Front 52

What is peptide YY role and where is it released?

Back 52

Released in terminal ileum and acts to inhibit acid secretion and GI motility.

Front 53

What is treatment of gastric lymphoma?

Back 53

This is an area of controversy for surgery versus primary chemotherapy. Hard indications for surgery as the primary treatment are an obstructing, perforated, or bleeding lesion. Small bowel lymphoma is always treated with surgery.