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74 Cards in this Set
- Front
- Back
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During embryonic development of the stomach, separation from the trachea is accomplished by the formation of this septum.
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Tracheosophageal septum.
Failure to form results cheoesophageal fistula and esophageal atresia. |
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How much of the esophagus is covered by striated muscle?
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Only the top 1/3. Formed from the caudal pharyngeal arches.
The lower 1/3 is smooth muscle, and the middle 1/3 is a transition zone. |
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Discuss the relationship of the esophagus to the aorta at the level of the aortic arch:
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Esophagus is posterior and to the right of the aorta.
However, further down, the esophagus is anterior to the aorta. |
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Discuss the arterial supply to the esophagus:
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Cervical esophagus: Inferior thyroid artery
Thoracic esophagus: Branches of the bronchial artery and aortoesophageal artery Abdominal esophagus: Left gastric and phrenic arteries. |
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Which veins are the culprit in patients with esophageal varices?
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Left gastric or coronary veins which drain the lower esophagus
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What is the difference between primary peristalic contractions, and secondary and tertiary contractions?
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Primary: Occur following swalling
Secondary: Occur following distention from food or refluxed gastric contents. Tertiary: Non peristaltic contraction |
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This is a largely idiopathic disease where the smooth muscle of the esophagus doesn't function leading to incomplete relaxation of the LES:
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Achalasia
Loss os neurons in the myenteric plexus |
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Non idiopathic infective cause of achalasia:
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Chagas disease: Trypansoma cruzi
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Clinical presentation of achalasia (5):
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Dysphagia (EQUALLY difficult wiht solids and liquids)
Regurgitation - often positional Chest pain Weight Loss Pulmonary complications (cough, aspiration) |
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Bird beak appearance of esophagus on barium swallow:
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Achalasia
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Gold standard for diagnosing achalasia:
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Esophageal manomery - looking for aperistalsis and abnormal relaxation of LES
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Botulinum toxin is a treatment for achalasia. How does botulinum toxin work?
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Blocks release of acethyl choline from receptors
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Two medications that relax smooth muscle used in Rx of achalasia:
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Nitrates - symptomatic relief
CCB - symptomatic relief |
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Most effect non-surgical therapy for achalasia:
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Pneumatic dilation
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What is the name for the surgical procedure that is often done to fix achalasia?
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Heller Myotomy
-Splitting the longitudinal muscle fibers and dividing the circular muscles. Lowers LES pressure more reliably than non-surgical therapy |
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Most common cause of LES dysfunction leading to GERD:
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Hypocontractile LES and increased transient LES relaxations.
Positioning of the LES is also important, that is why hiatal hernias often lead to GERD |
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45% of adult asthma is associated with this condition:
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GERD
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Gold standard test for diagnosis of GERD:
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Esophageal pH analysis.
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Treatment for GERD secondary to hiatal hernia:
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Fundoplication to correct hernia.
Can be done by laproscopy |
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Of the four types of hiatal and paraesophageal hernias, which one(s) are most associated with spontaneous reduction of the hernia?
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Type I (Sliding)
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Positioning of the GEJ in a type II paraesophageal hernia:
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Intra-abdominal
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Distinguish a type III hiatal hernia from a type IV hernia:
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Type III contains only the fundus and body of the stomach, while type IV contains other organ contents.
Both causes positioning of GEJ in the intrathoracic cavity, and do not spontaneous reduction |
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Two diagnostic methods for esophageal hernias:
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Barium esophagram and EGD
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What is the Killian triangle?
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A relatively weak area in the osterior hypopharynx between the inferior pharyngeal constrictors and the cricopharyngeus muscle. Site of many Zenker diverticulum
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87 year old female complains of painful swallowing, and regurgitation of recently chewed food and small left sided neck mass.
Diagnosis |
Zenker diverticulum
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Diagnostic test for a suspected zenker diverticulum:
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Barium esophagram.
Want to avoid esophagoscopy due to fear of perforation |
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Medical therapy for Zenker?
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Trick question - There is none!
You want to do cricopharyngeal myotomy or endoscopic myotomy. |
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What are epiphrenic diverticula?
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Pulsion diveticula.
Uncommon. Usually associated with an underlying otility disorder. |
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Diagnostic tests for epiphrenic diverticula:
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Barium swallow - best test
Flex esophagoscopy Esophageal manometry is mandatory to rule out underlying motility disorder. |
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Treatment of diffuse esophageal spasm:
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Symptommatic relief: Nitrates, CCP, antimuscarinics,
Trazodone and imipramine for visceral pain, botulism toxin. Surgery - Heller myotomy with partial fundoplication |
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Test of choice for esophageal perforation:
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Contrast esophaagography.
Avoid barium since it may cause or worsen mediastinitis |
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Test of choice for bleeding secondary to trauma or caustic ingestion:
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Flex esophagoscopy
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Treatment for esophageal bleeds:
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Almost always surgery!
First focus on volume resuscitation and limiting mediastinal contamination. Incision and drainage, or buttressing of the repair if within 24 hours. (Primary repair within 24 hrs) Primary repair |
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Treatment for mallory-Weiss sndrome:
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Endoscopic sclerotherapy, banding, and hemoclipping - basically anything to control the hermorrhage.
Note that bleeding usually spontaneously stops in 90% of cases |
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Which cells in the stomach secrete intrinsic factor?
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Parietal cells
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Which cells secrete HCl in the stomach?
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Parietal cells
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Location of parietal cells:
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Fundus and body of the stomach
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Where are the G-cells located?
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Antrum of the stomach. Secrete gastrin
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Anterior or posterior perforation of duodenal ulcer?
Free air in the diaphragm |
Anterior
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Anterior or posterior perforation of duodenal ulcer?
Pancreatitis / GI bleeding |
Posterior
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Three things that stimulate HCL secretion by parietal cells:
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Vagus nerve, histamine, gastrin
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Inhibitor hormone of gastrin:
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Somatostatin
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Duodenal ulcer or gastric ulcer:
Gnawing pain that occurs between meals |
Duodenal ulcer
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Duodenal ulcer or gastric ulcer:
Gnawing pain that occurs shortly after meals |
Gastric Ulcer
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Blood type associated with duodenal ulcers
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Type O
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Blood type associated with gastric ulcers:
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Type A
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Which MEN syndrome is associated with ZE?
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MEN-I
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Why do NSAIDs cause peptic ulcers?
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Due to inhibition of prostaglandin E
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Triple therapy for PUD:
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PPI, Clarithromyocin, and amoxicillin/metronidazole
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Complications of surgery for PUD (lots):
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Dumping syndrome
Afferent loop syndrome Postvagotomy diarrhea Duodenal stump leak Efferent loop obstruction Marginal ulcer Alkaline reflux gastritis Chronic gastoparesis Postgastrectomy stump cancer |
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Why should you biopsy any gastric ulcer?
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Because there is a 3% association with gastric cancer
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Common causes of gastric outlet obstruction:
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Tumors of the stomach & Pancreas
Obstructing ulcers (mainly duodenal) Chronic ulcers which cause scarring |
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Diagnosis of gastric outlet obstruction:
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Endoscopy
Barium swallow |
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Symptoms of gastric outlet obstruction:
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Early on:
Satiety Reflux Weight Loss Distention Later on: Vomiting Dehydration Metabolic Alkalosis |
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Criteria for bariatric surgery
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BMI > 40 or >35 with complications
Other sources say weight must be 100 pounds over ideal body weight |
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Advantages and disadvantages of gastric banding versus Roux-en-Y bypass
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Advantages: Banding doesn't mess with anatomy or physiology of the stomach.
Disadvantage: Higher recurrence rate |
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Advantages and disadvantages of Roux-en-Y bypass versus gastric banding:
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Advantages: Better success rates than banding
Disadvantages: More complications, especially dumping syndrome, ulcers, or stenosis, and anemias |
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Risk factors for stomach adenocarcinoma:
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FAP
Chronic atrophic gastritis H.Pylori infection Post-partial gastrectomy Pernicious anema Diet high in nitrites (Japanese diet) Cigarette smoking |
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Most common symptom of gastric cancer:
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Anorexia / weight loss
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What is a krukenberg's tumor?
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Gastric adenocarcinoma with mets to the ovaries
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Where is Virchow's node:
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Lymph node palpable in the left supraclavicular fossa - seen in gastric cancer
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What is a Sister Mary Joseph Nodule
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Gastric cancer mets to the umbilical lymph nodes
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Diagnostic test of choice for gastric cancer:
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upper GI endoscopy.
Upper GI series may be a good choice too Abdominal CT not the best, but okay Ultra sound is good for depth |
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Treatment for gastric cancer
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Early stages - subtotal gastrectomy
Late stages (more common presentation) Palliative radiation |
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Risk factors for gastric lymphoma
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HIV
Male predominant |
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Diagnosis of gastric lymphoma
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Same as gastric adenocarcinoma
Endoscopic biopsy Also bone marrow aspiration / gallium bone scans |
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Treatment for MALT lymphoma
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Stage 1 (N0 M0): Treat H. pylori
Higher stages: Radiation / chemo Only do stomach resection if bleeding or perforation |
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What is the only type of gastric polyp that has malignant potential?
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Adenomatous polyps
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What is the cushion sign?
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Used to test for lipoma in the stomach. Pushing on them with forceps will feel like a pillow cushion
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Most common location for lipomas in the stomach:
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Antrum
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What is Menetrier's disease?
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Autoimmune hypertrophic gastritis leading to protein losing enteropathy, with tortuous gastric rugae and mucosal thickening.
This is not a form of gastritis! |
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Diagnosis of Menetrier's disease:
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Endoscopy with biopsy
Also barium swallow (will show large gastric folds and thickened rugae) |
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Treatment of Menetrier's disease:
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Anticholinergis and H2 blockers to reduce protein loss
High protein diet Treat any ulcers Screening for gastric ulcers and cancers (complications) Gastrectomy for severe cases |
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Dumping syndrome often occurs after gastric surgery.
What are signs and symptoms of dumping syndrome? |
5-15 minutes after eating, patient will experience:
Nausea and vomiting Diarrhea Belching Flushing / Dizziness |
