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162 Cards in this Set
- Front
- Back
What are the 2 target cells of Gastrin?
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parietal cells and chief cells
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What 3 things are increased as a result of Gastrin?
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HCI, intrinsic factor and pepsinogen
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Somatostatin is produced by what cells and where?
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D cells in the antrum
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What stimulates the secretion of somatostatin?
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acid in duodenum
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What is somatostatin also called?
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the great inhibitor
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What drug can be used to decrease pancreatic fistula output?
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octreotide
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What cells produce gastric inhibitory peptide and where?
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K cells in duodenum
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What are the 2 target cells of gastric inhibitory peptide? and response stimulated?
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parietal cells of stomach and beta cells of pancreas
decreases HCl secretion and pepsin; increases insulin release |
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What cells produce CCK and where?
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I cells of duodenum and jejunum
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What cells produce secretin and where?
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S cells in duodenum
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What is the response caused by secretion of secretin?
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increased pancreatic HCO3-, increased bile flow, inhibits gastrin release (this is reversed in pts with gastrinoma)
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What cells in the pancreas release insulin? and glucagon?
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beta cells, alpha cells
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What cells produce pancreatic polypeptide? and what is the response?
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islet cells in pancreas
decreases pancreatic and gallbladder secretion |
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Released from terminal ileum following a fatty meal → inhibits acid secretion and stomach contraction; inhibits gallbladder contraction and pancreatic secretion
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Peptide YY
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What is the time from for recovery of small bowel? stomach? large bowel?
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Small bowel 24 hours
Stomach 48 hours Large bowel 3–5 days |
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What are the layers of the esophagus?
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stratified squamous epithelium (mucosa), circular inner muscle layer, outer longitudinal muscle layer; no serosa
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What is the blood supply of the cervical esophagus? and abdominal esophagus?
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Cervical esophagus – supplied by the inferior thyroid artery
Abdominal esophagus – supplied by the left gastric artery and inferior phrenic arteries |
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Which direction does the lymphatics of the esophagus drain?
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upper 2/3 drains cephalad, lower 1/3 caudad
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What kind of muscle is in the upper esophagus? lower esophagus?
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striated muscle, smooth muscle
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Right vagus nerve – travels on ____ portion of stomach as it exits chest; becomes ____ plexus; also has the criminal nerve of ___ → can cause persistently high acid levels postoperatively if left undivided
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posterior, celiac, Grassi
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Left vagus nerve – travels on ____ portion of stomach; goes to liver and biliary tree
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anterior
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The upper esophageal sphincter is how far from the incisors? and lower?
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15 cm, 40 cm
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What is the most common site of esophageal perforation (usually occurs with EGD)?
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cricopharyngeus muscle
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What muscle comprises the upper esophageal sphincter and prevents air swallowing?
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cricopharyngeus muscle
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What are the 3 anatomic areas of narrowing of the esophagus?
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cricopharyngeus muscle,
compression by the left mainstem bronchus and aortic arch, diaphragm |
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What is the surgical approach to the cervical esophagus? upper 2/3 thoracic? Lower 1/3 thoracic?
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Cervical esophagus – left
Upper ⅔ thoracic – right (avoids the aorta) Lower ⅓ thoracic – left (left-sided course in this region) |
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What is the cause in primary esophageal dysfunction? secondary?
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unknown in primary
secondary includes systemic disease, gastroesophageal reflux disease (GERD; most common), scleroderma, polymyositis |
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What is the diagnostic procedure of choice for dysphagia and odynophagia?
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barium swallow (better at picking up masses)
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What is the usual cause of cervical esophageal dysphagia?
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plummer-vinson syndrome
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What is the 3 parts of tx for plummer-vinson syndrome?
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dilation, Fe, screen for oral CA
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What can occur between the cripharyngeus and pharyngeal constrictors?
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Zenker's diverticulum
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What is the tx for Zenker's diverticulum?
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cricopharyngeal myotomy; Zenker's itself can either be resected or suspended
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What do you get on POD #1 after a cricopharyngeal myotomy for Zenker's?
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esophagogram
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How is a traction diverticulum different from Zenker's?
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Zenker's is a false diverticulum and lies posterior; traction is a true diverticulum is usually lateral in the mid esophagus
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What is the tx for a traction diverticulum of the esophagus?
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excision and primary closure; may need palliative therapy if due to invasive CA
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What is caused by failure of peristalsis and lack of LES relaxation after food bolus, and is secondary to neuronal degeneration in muscle wall?
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Achalasia
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What is the medical tx for achalasia (2)? what is next step?
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CCB, nitrates
LES dilation (effective in 60%) |
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What is the next step in tx of achalasia if CCB, nitrates and LES dilation fail?
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Heller myotomy
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What infection can produce similar sx to achalasia?
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T. cruzi
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Chest pain; other sx similar to achalasia. May have psych history, normal LES tone, strong unorganized contractions.
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Diffuse esophageal spasm
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What are 4 types of tx for diffuse esophageal spasm?
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CCB, nitrates, antispasmotics, Heller myotomy
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Causes dysphagia, loss of LES tone; most have strictures, fibrous replacement of smooth muscle ■ Tx: esophagectomy; Nissen may be effective in some
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Scleroderma
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GERD sx with bloating suggests what?
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aerophagia and delayed gastric emptying
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What is the best test for GERD?
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pH probe
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What is the surgical tx for GERD?
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Nissen
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The key maneuver in Nissen is identifcation of what?
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left crura
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What is name of the approach through the chest in a Nissen?
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Belsey
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During a Nissen, when not enough esophagus exists to pull down into abdomen, can staple along stomach and create a “new” esophagus. What is this called?
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Collis gastroplasty
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Name the type of hiatal hernia:
Sliding hernia from dilation of hiatus (most common); often associated with GERD |
Type I
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Name the type of hiatal hernia:
Paraesophageal; hole in the diaphragm alongside esophagus, normal GE junction. |
Type II
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What is a Type III hiatal hernia? and type IV?
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Type III – combined ■ Type IV – entire stomach in the chest plus another organ (i.e., colon, spleen)
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Almost all pts with Schatzki's ring have an associated ___
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sliding hiatal hernia
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What is the tx for Schatzki's ring?
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dilatation of the ring usually sufficient; may need antireflux procedure
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What is the transformation in pts with Barrett's esophagus?
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squamous metaplasia to columnar epithilium
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Pts with Barrett's esophagus are at 50x increased risk for what?
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adenomcarcinoma
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Severe Barrett's dysplasia is an indication for what?
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esophagectomy
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Uncomplicated Barrett's can be treated like GERD with PPI or Nissen and surgery will decrease esphagitis and further metaplasia but it will not prevent what?
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malignancy or cause regression of the columnar lining
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Pts with Barrett's esophagus who get a Nissen still need careful lifetime follow up with what?
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EGD
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Esophageal tumors are almost always malignant. How does it spread?
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submucosal lymphatic channels
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What is the best test for unresctablity in esophageal CA?
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Chest/abdominal CT
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What is the #1 esophageal CA? What type occurs most often in the upper 2/3?
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Adenocarcinoma
Squamous cell carcinoma |
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Supraclavicular nodes in esophageal CA indicate what?
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unresectability
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Distant metastases with esophageal CA is a contraindication to what? what is the survival?
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esophagectomy, < 12 mos
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What is the mortality from surgery in esophagectomy for CA? and what percentage is it curative?
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5%, 20%
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What is the primary blood supply to stomach after replacing esophagus in esphagectomy?
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right gastroepiploic artery (have to divide left gastric and short gastrics)
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What is the name of the type of esophagectomy with an abdominal incision and right thoracotomy -> exposes all of the esophagus; intrathoracic anasomsis
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Ivor Lewis
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What type of esophagectomy may be choice in young pts with benign disease when you want to preserve gastric function.
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Colonic interposition
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What do you need after esophagectomy on post op day 7?
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contrast study to rule out leak
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Name two chemo agents that can be used with esophageal CA for node positive disease or use preop to shrink tumors?
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5FU and cisplatin
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In esophageal CA with malignant fistulas, most die within 3 months due to what?
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aspiration
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What is the most common benign tumor of the esophagus?
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Leiomyoma
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Diagnosis of Leiomyoma is esophogram, endoscopy to rule out CA. Why don't you bx?
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can form scar and make subsequent resection difficult
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Tx for Leiomyoma of the esophagus is excision via thoractomy. What are the 2 indications?
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>5 cm or sx
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Caustic esophageal injury:
NG tube? Induce vomiting? Irrigation? |
no, no, no
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What is first step in dx in caustic esophageal injury? then what?
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CXR and AXR to look for free air,
endoscopy to assess lesion (but not with suspected perforation) |
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What is the most common cause of esophageal perforation?
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EGD
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What is the most common site of esophageal perforation?
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cricopharyngeus muscle
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How to dx esophageal perforation?
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gastrograffin swallow followed by barium swallow
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What is the tx for esophageal perforation that is contained, self-draining and no systemic effects?
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Conservative: IVF, NPO, spit
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What type of flap can be used with repair of esophageal perforation to help the area heal?
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intercostal muscle pedicle flap
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What is Hartmann's sign?
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mediastinal crunching on ascultation
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How to dx Boerhaave's syndrome?
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gastrofrafin swallow
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What is the stomach transit time?
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3-4 hours
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Where does peristalsis occur in the stomach?
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only in the distal stomach
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What are the branches of the Celiac trunk?
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left gastric, common hepatic, splenic
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Left gastroepiploic and short gastrics are branches of what artery?
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splenic
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What is the blood supply of the greater curvature of the stomach?
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right and left gastroepiploics, short gastrics
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What is the blood supply of the lesser curvature of the stomach?
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right and left gastrics
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The right gastric is a branch of what artery?
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common hepatic
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What is the blood supply of the pylorus?
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gastroduodenal artery
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What is the mucosa of the stomach lined with?
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simple columnar epithelium
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What is the first enzyme in proteolysis and what cell secretes it?
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Pepsinogen, secreted by chief cells
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What do the parietal cells secrete?
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H+ and intrinsic factor
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What 2 things do Brunner's glands in the duodenum secrete?
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pepsinogen and alkaline mucus
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Antrectomy with gastroduodenal anastomosis? Why are antrectomies helpful for ulcer disease?
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1. Billroth I
2. Removal of the Gastrin secreting G cells |
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Antrectomy with gastrojejunal anastomosis?
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Billroth II
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What is a Dieulafoy's Ulcer?
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vascular malformation in the stomach
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What is Menetrier's disease
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Mucous cell hyperplasia, increased rugal folds of the stomach.
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What is the tx for gastric volvulus? Commonly what kind of volvulus?
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1. reduction and Nissen
2. organoaxial volvulus |
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Gastric Volvulus association? Presentation?
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Associated with type II (paraesophageal) hernia ■ Nausea without vomiting; severe pain.
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Where is the tear usually located in a Mallory-Weiss tear? Tx?
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1. near lesser curvature of the stomach near GE junction
2. Most stop spontaneously. EGD with hemo-clips. May need gastrotomy and oversewing |
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What is the result of a vagotomy
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vagal denervation of all forms increase liquid emptying (vagally mediated receptive relaxation is removed) results in increased gastric pressure that accelerates liquid emptying
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In complete vagotomy (truncal or selective) there is ________ emptying of solids. In highly selective vagotomy there is ________emptying of solids. Addition of what procedure to either results in increased solid emptying?
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1. decreased
2. normal 3. Pyloroplasty |
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What is the most common problem following vagotomy (30-50%)? Why? Tx?
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1.diarrhea; sustained MMC forcing non-conjugated bile salts in the colon
2. cholestyramine, octreotide |
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Upper GI bleed and having trouble localizing source with EGD. What can be done next?
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tagged RBC scan
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What are the 3 biggest risk factor for rebleeding of an upper GI bleed at the time of EGD?
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spurting blood vessel, visible blood vessel, diffuse oozing
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In a pt with liver failure, what is the most likely source of an upper GI bleed?
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esophageal varices
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What is the tx for a bleeding esophageal varices?
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EGD with sclerotherapy or TIPS, not OR
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What location of duodenal ulcers usually perforate? what location bleed from GDA?
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anterior ulcers perforate, posterior ulcers bleed from GDA
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Describe the incision and closure of a Heineke-Mikulicz pyloroplasty.
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longitudunal incision of the plyloric sphincter followed by a transverse closure
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What is the most frequent complication of duodenal ulcers?
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bleeding
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The 1st surgical option for bleeding duodenal ulcer is duodenstomy and what? what if the pt has been on PPI therapy?
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GDA ligation,
truncal vagotomy and pyloroplasty |
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With GDA ligation for bleeding duodenal ulcer, it is important to avoid hitting what structure?
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common bile duct
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What is the initial treatment of choice for obstruction due to duodenal ulcer? Surgical options?
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1. serial dilation and PPI
2. antrectomy and truncal vagotomy |
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Pt on H-pump inhibitor develops a perforated duodenal ulcer. What is the best surgical option? what if they were not on H-pump inhibitor?
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Graham patch and highly selective vagotomy; just do Graham patch and place on omeprazole
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What is the test for Zollinger-Ellison Syndrome?
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Secretin test results in high gastrin level
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In Zollinger-Ellison syndrome, what size tumors can be enucleated?
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<2 cm
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What is the most common location for gastric ulcers? and the most common cause?
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lesser curvature; decreased mucosal defense (normal acid secretion)
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Hemorrhage is associated with higher mortality in duodenal or gastric ulcers?
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gastric
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Best test for H. pylori? Location?
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histiologic examination of biopsies from antrum
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List the locations of gastric ulcers types I-V
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Type I - lesser curve along body of stomach
Type II - 2 ulcers, lesser curve and duodenal Type III - prepyloric Type IV - lesser curve high along cardia of stomach Type V - associated with NSAIDs |
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What is the timing after event for stress gastritis? Tx?
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1. 3-10 days after event
2. PPI |
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Chronic gastritis has types A and B what is their location and what are they associated with?
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Type A (fundus) – associated with pernicious anemia, autoimmune disease
Type B (antral) – associated with H. pylori |
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Where are 40% of gastric cancers located?
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antrum
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What is the difference in the pain with gastric cancer vs gastric ulcer?
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gastric ulcer pain is relived by eating but recurs 30 min later.
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What blood type is a risk factor for gastric cancer?
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type A
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What is Krukenberg tumor?
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gastric cancer with mets to ovaries
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What is Virchow's nodes?
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gastric cancer with metastases to supraclavicular nodes
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What size margins in subtotal gastrectomy for gastric cancer?
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10 cm
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MC gastric CA in the US? Where does it invade? Surgical Tx? Prognosis?
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1. linitis plastic
2. lymphatics, no glands 3. gastrectomy 4. less favorable than intestinal type |
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In palliation for gastric cancer, proximal obstruction can be treated with what? and distal? Tx for bleeding or pain?
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1. proximal can be stented, distal lesions can be bypassed with gastrojejunostomy
2. XRT |
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What is the most common benign gastric neoplasm? aka? Consider malignant when?
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1. gastric leiomyomas, also called gist tumors
2. > 5 cm or > 5 mitoses/50 HPF |
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Surgical Tx of GIST Tumors? If malignant? MOA?
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1. resection with 1 cm margins
2. Gleevec (tyrosine kinase inhibitor) |
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What is the proto-oncogene are most gastric leiomyomas positive for?
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c-kit (CD117)
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What route does gastric leiomyosarcoma spread?
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hematogenous
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What is the relation for mucosa associated lymphoid tissue lymphoma (MALT lymphoma)? Tx? and if it does not regress?
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1. H. pylori
2. Triple therapy abx for H. pylori (usually regresses) 3. XRT |
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What are the surgical eligibility criteria for bariatric surgery? (Need all 4)
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1. BMI >40 kg or BMI >35 kg with coexisting comorbidities
2. failure of conservative measures 3. psychological stability 4. No drug/alcohol abuse |
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What is the medical and surgical tx for dumping syndrome?
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octreotide may be effective. Surgery is rarely needed but includes converting a billroth I or II to a roux-en-Y gastrojejunostomy. Or increasing the gastric reserve with a jejunal pouch or increasing emptying type with a reversed jejunal loop
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Physiology of dumping syndrome?
What is the dietary tx for dumping syndrome? |
1. rapid entering of carbs into the small bowel causing fluid shift into the bowel (hypotensive, diarrhea, dizziness)
2. small, low-fat, low-carb, increased-protein meals; no liquids with meals; no lying down after meals |
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What are two surgical options for treating dumping syndrome after gastrectomy?
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conversion of billroth I or billroth II to Roux-en-Y gastrojejunostomy
Operations to increase gastric reservoir (jejunal pouch) or increase emptying time (reversed jejunal loop) |
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Presentation of alkaline reflux gastritis? Dx? Tx?
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1. After a gastrectomy there is postprandial epigastric pain associated with N/V; pain not relived with vomiting.
2. Evidence of bile reflux into stomach and histologic evidence of gastritis. |
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What are 3 medical options for the tx of alkaline reflux gastritis after gastrectomy?
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PPI's, cholestyramine, metoclopramide
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What is the surgical option for treating alkaline reflux gastritis after gastrectomy?
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Conversion of Billroth I or Billroth II to Roux-en-Y gastrojejunostomy with afferent limb 60 cm distal to original gastrojejunostomy
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In roux-en-y which limb is the roux limb? Which is the afferent limb?
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The roux limb goes from the gastrojejunostomy to the jejunojenuostomy. The afferent limb is the portion of duodenum and jejunum feeding the jejunojenunostomy.
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What is the cause of roux stasis?
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stasis of chyme in Roux limb due to loss of jejunal motility.
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How do you dx Roux stasis?
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EGD, emptying studies
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What are 2 treatment options for Roux stasis?
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metoclopramide/prokinetics
shorten Roux limb to 40 cm |
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What is caused by delayed gastric emptying after vagotomy?
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chronic gastric atony
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What is the surgical treatment for chronic gastric atony after gastrecomy?
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near total gastrectomy with Roux-en-Y
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What is the surgical option for small gastric remnant and early satiety after gastrectomy?
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jejunal pouch reconstruction
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What is blind loop syndrome? Caused by?
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After Billroth II or Roux-en-Y, symptoms include pain, diarrhea, malabsorption, B12 deficiency, steatorrhea. Caused by bacterial overgrowth and stasis in affarent limb from poor motility
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What is the medical and surgical treatment options for blind-loop syndrome?
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tetracycline, Flagyl, metoclopramide
reanastomosis with shorter (40 cm) afferent limb |
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Causes of rapid gastric emptying?
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previous surgery (#1), ulcers
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Highest risk factor for rebleeding with non-variceal UGI bleed?
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continued or rebleeding
|
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Medical treatment for duodenal ulcerations?
|
1. PPI's; triple therapy for H. pylori (BAM of BAT)
- bismuth salts, amoxicillin, metronidazole - bismuth salts, amoxicillin, tetracycline |
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What needs to be ruled out in a patient with complex ulcer disease? What is Zollinger-Ellison syndrome?
|
1. Gastrinoma
2. gastric acid hypersecretion, peptic ulcers, and gastrinoma |
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Best option for reconstruction after an antrectomy?
|
1. Roux-en-Y gastrojejunostomy
2. less dumping syndrome and reflux gastritis |
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Surgical Tx of gastric ulcers? What special consideration?
|
1. truncal vagotomy and antrectomy
2. needs to include the ulcer in antrectomy. If not, you need a separate ulcer incision |
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MC location for extra-nodal lymphoma? Usually?
|
1. Stomach
2. non-Hodgkin's lymphoma (B cell) |
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When to perform a cholecystectomy with gastric bypass?
|
If there are stones
|
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MC cause of leak after gastric bypass? Dx? Tx (early/late)?
|
1. ischemia
2. UGI 3. Early - re-op; Late - percutaneous drain, abx |
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Significance of SBO in patient with gastric bypass? High risk of? Tx?
|
1. surgical emergency
2. high risk for small bowel herniation, strangulation and infarction 3. Surgical exploration |