Nms Surgery Upper Gi

Front 1

Initial conservative mgmt of GERD?

Back 1

Avoid foods that decrease lower esophageal sphincter tone: chocolate, coffee, tea, alcohol, don't sleep flat in bed: 60-70% of pts will improve

Front 2

What to do if Initial conservative mgmt of GERD fails?

Back 2

EGD+biopsies+culture for malignancies and/or H.pylori

Front 3

Triple therapy for h.pylori?

Back 3

PPI+Amoxicillin/Clarithromycin+Metronidazole

Front 4

Steps if conservative mgmt of GERD is unsuccessful?

Back 4

1. EGD w/biopsy
2. Esophageal manometry: ensure proper peristalsis so that they'll be able to swallow normally postop
3. If LES tone normal: 24h pH probe testing
4. Dysphagia or short esophagus suspected?: cine-esophagram
5. Nissen fundoplication

Front 5

If Barrett's esophagus diagnosed, how often is surveillance endoscopy and biopsy?

Back 5

q 18-24 mo to monitor degree of dysplasia

Front 6

Barrett's with severe dysplasia is likely to become what cancer? Treatment?

Back 6

Occult adenocarcinoma in distal esophagus. Needs esopageal resection.

Front 7

Two types of hiatal hernias?

Back 7

Type I: sliding hiatal hernia
Type II: paraesophageal hiatal hernia where gastroesophageal junction stays in place but part of stomach herniates. Surgical emergency.

Front 8

5 ways of diagnosing H.pylori?

Back 8

1. Serum Ab testing
2. Gastric biopsy for culture
3. bacterial staining
4. Urease testing
5. Urea breath test

Front 9

Alternative to triple therapy for H. pylori?

Back 9

Quadruple therapy: Bismuth: inhibits adhesion to gastric epithelium+Tetracycline+Metronidazole+PPI

Front 10

Duration of medical treatment for PUD?

Back 10

4-6 weeks. Extend to 8-12 wks for severe dz.

Front 11

2 types of ulcerogenic drugs?

Back 11

NSAIDS and steroids

Front 12

Procedure of choice for uncomplicated PUD?

Back 12

HSV: highly selective vagotomy: fundus and body denervated, antrum and pylorus innervation left intact: allows gastric mixing and emptying to occur normally

Front 13

4 types of gastric ulcers?

Back 13

1. lesser curvature, low acid output
2. lesser curvature+duodenal ulcer high acid output
3. prepylorus high acid output
4. gastric cardia (GEJ), low acid output

Front 14

duration of medical tx for gastric ulcers?

Back 14

12-18 weeks after which requires surgery

Front 15

operation for benign nonhealed gastric ulcers?

Back 15

partial gastrectomy or antrectomy

Front 16

Tx of type 2 and 3 ulcers?

Back 16

resection (antrectomy) and vagotomy (to stop increased acid production)

Front 17

If biopsy shows early gastric cancer, steps to take?

Back 17

1.Staging: CT+EUS for depth of spread, maybe abdominal exploration
2. Distal subtotal gastrectomy if antrum or middle stomach + regional lymphadenectomy

Front 18

2 main types of gastric carcinoma?

Back 18

1. Intestinal (forms glands, better prog)
2. Diffuse (linitis plastica)

Front 19

Bad prognostic indicators in gastric carcinoma?

Back 19

Fixed and rigid stomach, GEJ involvement

Front 20

What clinical signs would you see with perforated ulcer?

Back 20

Rigid abdomen (involuntary guarding), increased WBC with left shift, low grade fever, pain

Front 21

what steps to take with perforated ulcer?

Back 21

1. upright CXR w/ obstructive series to check for free air under diaphragm. Maybe left lateral decub film
2.

Front 22

how to treat new perfed ulcer with no prior ulcer sxs?

Back 22

Graham patch, postop medical tx

Front 23

how to treat new perfed ulcer but with prior ulcer sxs despite medical therapy?

Back 23

Graham patch, HSV/V&P. V&A/gastrectomy can't be done in emergent setting

Front 24

how to treat new perfed ulcer but becomes hypotensive during surgery?

Back 24

Graham patch quickly, terminate operation. Give IV abx + omeprazole SICU

Front 25

how to treat perfed ulcer 24 hours old with fibrinous exudate and evidence of peritoneal infection?

Back 25

Graham patch, peritoneal debridement. IV abx, PPI, IVF, definitive surgery for later after recovery from sepsis

Front 26

Initial mgmt of coffee ground material in NG tube?

Back 26

1. PPI + gastric pH monitoring
2. Sucralfate (only for duodenal ulcers not gastric)
3. Misoprostol (E1 analog for gastric mucosa protection)s if taking NSAIDS

Front 27

If coffee grounds turns to BRB, next steps?

Back 27

1. Access: 2 large bore IVs
2. IVF
3. type and screen
4. NG lavage till no more blood
5. monitor hemodynamics
6. PPI+monitor gastric pH
7. After stabilization, upper endoscopy to localize bleeding

Front 28

Upper endo shows duodenal ulcer with clean white base, no active bleeding. What to do?

Back 28

observe and cont medical mgmt and monitoring

Front 29

Upper endo shows fresh clot. What to do?

Back 29

Evidence of recent bleed: 10-15% chance of rebleeding: Endoscopic injection of epi/cautery/laser/suture

Front 30

Upper endo shows fresh clot and visible artery?

Back 30

High risk of rebleeding (40%). Inject epi, attempt local control, elective operation

Front 31

Where do ulcers with fresh clots and visible arteries usually occur? which artery involved?

Back 31

posterior duodenum and involves gastroduodenal a

Front 32

If pt becomes hypotensive during upper endo, what to do?

Back 32

1. NS
2. transfuse
3. urgent oversewing of vessel
4. OR

Front 33

Why might patient with acute renal failure and high creatinine have an upper gi bleed? treatment?

Back 33

Uremia causes platelet dysfunction, bleeding more likely. Treat with desmopressin (ddAVP) and dialysis

Front 34

3 clinical uses for ddAVP?

Back 34

1. bedwetting (decreases urine production)
2. coagulopathies (releases vWF, thus increasing factor VIII survival. good for von willebrand's dz, mild hemophilia A, thrombocytopenia)
3. Central DI

Front 35

Bleeding duodenal ulcer in pt with alcoholic cirrhosis can be treated how?

Back 35

FFP (high PT due to II, VII, IX, X def), platelet transfusion (congestive splenomegaly)

Front 36

Mgmt of bleeding gastric ulcers?

Back 36

Same as for duodenal ulcers but after bleeding has stopped and pt stabilized, needs biopsy after days to weeks to check for malignancy

Front 37

5 cond assoc w gastritis

Back 37

1. Vent dependence
2. Major trauma
3. Sepsis
4. severe burns
5. Renal failure

Front 38

How to treat gastritis if seen on upper endo?

Back 38

1. Keep gastric pH above 5
2. Sucralfate
3. If unresponsive to medical tx, subtotal gastrectomy

Front 39

How to treat gastric varices?

Back 39

1. cyanoacrylate glue
2. portosystemic shunting
3. TIPS (transjugular intrahepatic portosystemic shunt)
4. Splenectomy

Front 40

How to treat esophageal varices+cirrhosis?

Back 40

1. FFP+VitK+platelets
2. IV Octreotide/Vasopressin to lower portal pressure (watch out for coronary vasoconstriction! contraindicated in old people and those with CAD) and beta blocker also lowers portal pressure but watch for brady and hypotension
3. Endoscopic sclerotherapy/variceal banding (rebleeds in 25% of cases, always need to repeat in 48 hours. banding preferred.)
4. If nothing works, portosystemic shunt (50% mortality) or Balloon tamponade or TIPS

Front 41

How to treat severe Mallory Weiss tear?

Back 41

Injection/cautery/oversewing

Front 42

Mgmt of gastric lymphoma?

Back 42

1. Chest and abd CT for det of spread
2. Biopsy of enlarged periph nodes
3. Bone marrow biopsy
4. Oropharynx exam for additional lymphoma in Waldeyer's ring

Front 43

Tx of gastric lymphoma?

Back 43

H.pylori eradication, resection, radiation/chemo/both depending on stage

Front 44

origin of gastric lymphomas?

Back 44

NHL of B cell origin