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Section II General Surgery P203Surgical Recall Sixth > Upper GI Bleeding, C40 P254-270 > Flashcards

Upper GI Bleeding, C40 P254-270 Flashcards

1
Q

What is it?

P254

A

Bleeding into the lumen of the proximal
GI tract, proximal to the ligament of
Treitz

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2
Q

What are the signs/symptoms?

P254

A 
Hematemesis, melena, syncope,
shock, fatigue, coffee-ground emesis,
hematochezia, epigastric discomfort,
epigastric tenderness, signs of
hypovolemia, guaiac-positive stools
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3
Q

Why is it possible to have
hematochezia?
P254

A

Blood is a cathartic and hematochezia
usually indicates a vigorous rate of
bleeding from the UGI source

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4
Q

Are stools melenic or melanotic?

P254

A

Melenic (melanotic is incorrect)

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5
Q

How much blood do you
need to have melena?
P254

A

>50 cc of blood

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6
Q

What are the risk factors?

P254

A 
Alcohol, cigarettes, liver disease, burn/
trauma, aspirin/NSAIDs, vomiting,
sepsis, steroids, previous UGI bleeding,
history of peptic ulcer disease (PUD),
esophageal varices, portal hypertension,
splenic vein thrombosis, abdominal aortic
aneurysm repair (aortoenteric fistula),
burn injury, trauma
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7
Q

What is the most common
cause of significant UGI
bleeding?
P255

A

PUD—duodenal and gastric ulcers (50%)

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8
Q

What is the common
differential diagnosis of
UGI bleeding?
P255

A
  1. Acute gastritis
  2. Duodenal ulcer
  3. Esophageal varices
  4. Gastric ulcer
  5. Esophageal
  6. Mallory-Weiss tear
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9
Q

What is the uncommon
differential diagnosis of
UGI bleeding?
P255

A 
Gastric cancer, hemobilia, duodenal
diverticula, gastric volvulus, Boerhaave’s
syndrome, aortoenteric fistula,
paraesophageal hiatal hernia, epistaxis,
NGT irritation, Dieulafoy’s ulcer,
angiodysplasia
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10
Q

Which diagnostic tests are useful?

P255

A

History, NGT aspirate, abdominal x-ray,

endoscopy (EGD)

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11
Q

What is the diagnostic test of
choice with UGI bleeding?
P255

A

EGD ( >95% diagnosis rate)

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12
Q

What are the treatment
options with the endoscope
during an EGD?
P255

A

Coagulation, injection of epinephrine
(for vasoconstriction), injection of
sclerosing agents (varices), variceal ligation
(banding)

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13
Q

Which lab tests should be performed?

P255

A

Chem-7, bilirubin, LFTs, CBC,

type & cross, PT/PTT, amylase

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14
Q

Why is BUN elevated?

P255

A

Because of absorption of blood by the GI

tract

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15
Q

What is the initial treatment?

P255

A 
1. IVFs (16 G or larger peripheral
    IVS x 2), Foley catheter (monitor
    fluid status)
2. NGT suction (determine rate and
    amount of blood)
3. Water lavage (use warm H(2)O—will
    remove clots)
4. EGD: endoscopy (determine etiology/
    location of bleeding and possible
    treatment—coagulate bleeders)
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16
Q

Why irrigate in an upper GI bleed?

P256

A

To remove the blood clot so you can see

the mucosa

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17
Q 
What test may help identify
the site of MASSIVE UGI
bleeding when EGD fails to
diagnose cause and blood
continues per NGT?
P256
A

Selective mesenteric angiography

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18
Q

What are the indications for
surgical intervention in UGI
bleeding?
P256

A

Refractory or recurrent bleeding and site
known, >3 u PRBCS to stabilize or
>6 u PRBCs overall

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19
Q

What percentage of patients
require surgery?
P256

A

≈10%

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20
Q

What percentage of patients
spontaneously stop bleeding?
P256

A

≈80% to 85%

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21
Q

What is the mortality of acute
UGI bleeding?
P256

A

Overall 10%, 60–80 years of age 15%,

older than 80 years of age 25%

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22
Q

What are the risk factors for
death following UGI bleed?
P256

A

Age older than 60 years
Shock
>5 units of PRBC transfusion
Concomitant health problems

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23
Q

PEPTIC ULCER DISEASE (PUD)
What is it?
P256

A

Gastric and duodenal ulcers

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24
Q

PEPTIC ULCER DISEASE (PUD)
What is the incidence in the
United States?
P256

A

≈10% of the population will suffer from

PUD during their lifetime!

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25
Q

PEPTIC ULCER DISEASE (PUD)
What are the possible
consequences of PUD?
P256

A

Pain, hemorrhage, perforation, obstruction

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26
Q 
PEPTIC ULCER DISEASE (PUD)
What percentage of patients 
with PUD develops bleeding
from the ulcer?
P256
A

≈20%

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27
Q

PEPTIC ULCER DISEASE (PUD)
Which bacteria are associated with PUD?
P256

A

Helicobacter pylori

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28
Q

PEPTIC ULCER DISEASE (PUD)
What is the treatment?
P257

A 
Treat H. pylori with MOC or ACO
2-week antibiotic regimens:
    MOC: Metronidazole, Omeprazole,
      Clarithromycin (Think: MOCk)
or
ACO: Ampicillin, Clarithromycin,
      Omeprazole
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29
Q 
PEPTIC ULCER DISEASE (PUD)
What is the name of the sign
with RLQ pain/peritonitis as
a result of succus collecting
from a perforated peptic ulcer?
P257
A

Valentino’s sign

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30
Q

DUODENAL ULCERS
In which age group are
these ulcers most common?
P257

A

40–65 years of age (younger than

patients with gastric ulcer)

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31
Q

DUODENAL ULCERS
What is the ratio of male to
female patients?
P257

A

Men > women (3:1)

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32
Q

DUODENAL ULCERS
What is the most common location?
P257

A

Most are within 2 cm of the pylorus in

the duodenal bulb

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33
Q

DUODENAL ULCERS
What is the classic pain
response to food intake?
P257

A

Food classically relieves duodenal ulcer pain (Think: Duodenum = Decreased with food)

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34
Q

DUODENAL ULCERS
What is the cause?
P257

A

Increased production of gastric acid

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35
Q 
DUODENAL ULCERS
What syndrome must you
always think of with a
duodenal ulcer?
P257
A

Zollinger-Ellison syndrome

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36
Q

DUODENAL ULCERS
What are the associated risk factors?
P257

A

Male gender, smoking, aspirin and other
NSAIDs, uremia, Z-E syndrome,
H. pylori, trauma, burn injury

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37
Q

DUODENAL ULCERS
What are the symptoms?
P257

A

Epigastric pain—burning or aching, usually
several hours after a meal (food, milk,
or antacids initially relieve pain)
Bleeding
Back pain
Nausea, vomiting, and anorexia
↓ appetite

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38
Q

DUODENAL ULCERS
What are the signs?
P258

A

Tenderness in epigastric area (possibly),
guaiac-positive stool, melena,
hematochezia, hematemesis

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39
Q

DUODENAL ULCERS
What is the differential diagnosis?
P258

A

Acute abdomen, pancreatitis, cholecystitis,
all causes of UGI bleeding, Z-E
syndrome, gastritis, MI, gastric ulcer,
reflux

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40
Q

DUODENAL ULCERS
How is the diagnosis made?
P258

A

History, PE, EGD, UGI series

if patient is not actively bleeding

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41
Q

DUODENAL ULCERS
When is surgery indicated
with a bleeding duodenal ulcer?
P258

A

Most surgeons use: >6 u PRBC
transfusions, >3 u PRBCs needed to
stabilize, or significant rebleed

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42
Q

DUODENAL ULCERS
What EGD finding is
associated with rebleeding?
P258

A

Visible vessel in the ulcer crater, recent

clot, active oozing

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43
Q

DUODENAL ULCERS
What is the medical treatment?
P258

A

PPIs (proton pump inhibitors) or H(2)
receptor antagonists—heal ulcers in
4 to 6 weeks in most cases
Treatment for H. pylori

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44
Q

DUODENAL ULCERS
When is surgery indicated?
P258

A 
The acronym “I HOP”:
    Intractability
    Hemorrhage (massive or relentless)
    Obstruction (gastric outlet obstruction)
    Perforation
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45
Q

DUODENAL ULCERS
How is a bleeding duodenal
ulcer surgically corrected?
P258

A

Opening of the duodenum through the
pylorus
Oversewing of the bleeding vessel

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46
Q

DUODENAL ULCERS
What artery is involved with
bleeding duodenal ulcers?
P258

A

Gastroduodenal artery

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47
Q 
DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Truncal vagotomy?
P258
A

Pyloroplasty

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48
Q 
DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Duodenal perforation?
P259
A 
Graham patch (poor candidates, shock,
    prolonged perforation)
Truncal vagotomy and pyloroplasty
    incorporating ulcer
Graham patch and highly selective
    vagotomy
Truncal vagotomy and antrectomy
    (higher mortality rate, but lowest
    recurrence rate)
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49
Q

DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Duodenal obstruction resulting from duodenal
ulcer scarring (gastric outlet obstruction)?
P259

A

Truncal vagotomy, antrectomy, and
gastroduodenostomy (BI or BII)
Truncal vagotomy and drainage procedure
(gastrojejunostomy)

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50
Q 
DUODENAL ULCERS
What are the common surgical options for the
following conditions:
Duodenal ulcer intractability?
P259
A 
PGV (highly selective vagotomy)
Vagotomy and pyloroplasty
Vagotomy and antrectomy BI or BII
    (especially if there is a coexistent
    pyloric/prepyloric ulcer) but
    associated with a higher mortality
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51
Q 
DUODENAL ULCERS
Which ulcer operation has
the highest ulcer recurrence
rate and the lowest dumping
syndrome rate?
P259
A

PGV (proximal gastric vagotomy)

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52
Q 
DUODENAL ULCERS
Which ulcer operation has
the lowest ulcer recurrence
rate and the highest
dumping syndrome rate?
P259
A

Vagotomy and antrectomy

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53
Q 
DUODENAL ULCERS
Why must you perform a
drainage procedure
(pyloroplasty, antrectomy)
after a truncal vagotomy?
P259
A

Pylorus will not open after a truncal

vagotomy

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54
Q 
DUODENAL ULCERS
Which duodenal ulcer
operation has the lowest
mortality rate?
P259
A 
PGV (1/200 mortality), truncal vagotomy
    and pyloroplasty (1–2/200), vagotomy
    and antrectomy (1%–2% mortality)
Thus, PGV is the operation of choice
    for intractable duodenal ulcers with
    the cost of increased risk of ulcer
    recurrence
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55
Q

DUODENAL ULCERS
What is a “kissing” ulcer?
P260

A

Two ulcers, each on opposite sides of the

lumen so that they can “kiss”

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56
Q

DUODENAL ULCERS
Why may a duodenal rupture
be initially painless?
P260

A

Fluid can be sterile, with a nonirritating

pH of 7.0 initially

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57
Q

DUODENAL ULCERS
Why may a perforated duodenal ulcer present as lower quadrant abdominal pain?
P260

A

Fluid from stomach/bile drains down
paracolic gutters to lower quadrants and
causes localized irritation

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58
Q

GASTRIC ULCERS
In which age group are these
ulcers most common?
P260

A

40–70 years old (older than the duodenal
ulcer population)
Rare in patients younger than 40 years

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59
Q

GASTRIC ULCERS
How does the incidence in
men compare with that of women?
P260

A

Men > women

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60
Q

GASTRIC ULCERS
Which is more common
overall: gastric or duodenal ulcers?
P260

A

Duodenal ulcers are more than twice as
common as gastric ulcers
(Think: Duodenal = Double rate)

61
Q

GASTRIC ULCERS
What is the classic pain
response to food?
P260

A

Food classically increases gastric ulcer

pain

62
Q

GASTRIC ULCERS
What is the cause?
P260

A

Decreased cytoprotection or gastric
protection (i.e., decreased bicarbonate/
mucous production)

63
Q

GASTRIC ULCERS
Is gastric acid production
high or low?
P260

A

Gastric acid production is normal or low!

64
Q 
GASTRIC ULCERS
Which gastric ulcers are
associated with increased
gastric acid?
P260
A

Prepyloric
Pyloric
Coexist with duodenal ulcers

65
Q

GASTRIC ULCERS
What are the associated risk factors?
P260

A

Smoking, alcohol, burns, trauma, CNS
tumor/trauma, NSAIDs, steroids, shock,
severe illness, male gender, advanced age

66
Q

GASTRIC ULCERS
What are the symptoms?
P260

A

Epigastric pain

+/- Vomiting, anorexia, and nausea

67
Q

GASTRIC ULCERS
How is the diagnosis made?
P261

A

History, PE, EGD with multiple biopsy

looking for gastric cancer

68
Q

GASTRIC ULCERS
What is the most common location?
P261

A

≈70% are on the lesser curvature; 5% are

on the greater curvature

69
Q

GASTRIC ULCERS
When and why should biopsy
be performed?
P261

A

With all gastric ulcers, to rule out gastric
cancer
If the ulcer does not heal in 6 weeks after
medical treatment, rebiopsy (always
biopsy in O.R. also) must be performed

70
Q

GASTRIC ULCERS
What is the medical treatment?
P261

A

Similar to that of duodenal ulcer—PPIs or

H(2) blockers, Helicobacter pylori treatment

71
Q 
GASTRIC ULCERS
When do patients with
gastric ulcers need to have
an EGD?
P261
A
  1. For diagnosis with biopsies
  2. 6 weeks postdiagnosis to confirm
    healing and rule out gastric cancer!
72
Q

GASTRIC ULCERS
What are the indications for surgery?
P261

A

The acronym “I CHOP”:
Intractability

    Cancer (rule out)
    Hemorrhage (massive or relentless)
    Obstruction (gastric outlet obstruction)
    Perforation
(Note: Surgery is indicated if gastric
    cancer cannot be ruled out)
73
Q 
GASTRIC ULCERS
What is the common
operation for hemorrhage,
obstruction, and perforation?
P261
A 
Distal gastrectomy with excision of the
ulcer without vagotomy unless there is
duodenal disease (i.e., BI or BII)
74
Q 
GASTRIC ULCERS
What are the options for
concomitant duodenal and
gastric ulcers?
P261
A

Resect (BI, BII) and truncal vagotomy

75
Q 
GASTRIC ULCERS
What is a common option
for surgical treatment of a
pyloric gastric ulcer?
P261
A

Truncal vagotomy and antrectomy

i.e., BI or BII

76
Q 
c
What is a common option for
a poor operative candidate
with a perforated gastric ulcer?
P261
A

Graham patch

77
Q

GASTRIC ULCERS
What must be performed in
every operation for gastric ulcers?
P262

A

Biopsy looking for gastric cancer

78
Q

GASTRIC ULCERS
Define the following terms:
Cushing’s ulcer
P262

A

PUD/gastritis associated with neurologic
trauma or tumor
(Think: Dr. Cushing = NeuroSurgeon = CNS)

79
Q

GASTRIC ULCERS
Define the following terms:
Curling’s ulcer
P262

A

PUD/gastritis associated with major burn

injury (Think: curling iron burn)

80
Q

GASTRIC ULCERS
Define the following terms:
Marginal ulcer
P262

A

Ulcer at the margin of a GI anastomosis

81
Q

GASTRIC ULCERS
Define the following terms:

P262

A

Dieulafoy’s ulcer

82
Q

PERFORATED PEPTIC ULCER
What are the symptoms?
P262

A

Acute onset of upper abdominal pain

83
Q

PERFORATED PEPTIC ULCER
What causes pain in the
lower quadrants?
P262

A

Passage of perforated fluid along colic

gutters

84
Q

PERFORATED PEPTIC ULCER
What are the signs?
P262

A

Decreased bowel sounds, tympanic
sound over the liver (air), peritoneal
signs, tender abdomen

85
Q

PERFORATED PEPTIC ULCER
What are the signs of posterior duodenal erosion/perforation?
P262

A

Bleeding from gastroduodenal artery

and possibly acute pancreatitis

86
Q

PERFORATED PEPTIC ULCER
What sign indicates anterior
duodenal perforation?
P262

A 
Free air (anterior perforation is more
common than posterior)
87
Q

PERFORATED PEPTIC ULCER
What is the differential diagnosis?
P262

A

Acute pancreatitis, acute cholecystitis,
perforated acute appendicitis, colonic
diverticulitis, MI, any perforated viscus

88
Q

PERFORATED PEPTIC ULCER
Which diagnostic tests are indicated?
P262

A 
X-ray: free air under diaphragm or in
lesser sac in an upright CXR (if upright
CXR is not possible, then left lateral
decubitus can be performed because air
can be seen over the liver and not
confused with the gastric bubble)
89
Q

PERFORATED PEPTIC ULCER
What are the associated lab findings?
P263

A

Leukocytosis, high amylase serum
(secondary to absorption into the blood
stream from the peritoneum)

90
Q

PERFORATED PEPTIC ULCER
What is the initial treatment?
P263

A 
NPO: NGT (↓ contamination of the
    peritoneal cavity)
IVF/Foley catheter
Antibiotics/PPIs
Surgery
91
Q

PERFORATED PEPTIC ULCER
What is a Graham patch?
P263

A

Piece of omentum incorporated into the

suture closure of perforation

92
Q 
PERFORATED PEPTIC ULCER
What are the surgical
options for treatment of a
duodenal perforation?
P263
A 
Graham patch (open or laparoscopic)
Truncal vagotomy and pyloroplasty
    incorporating ulcer
Graham patch and highly selective
    vagotomy
93
Q

PERFORATED PEPTIC ULCER
What are the surgical options
for perforated gastric ulcer?
P263

A

Antrectomy incorporating perforated
ulcer, Graham patch or wedge resection
in unstable/poor operative candidates

94
Q 
PERFORATED PEPTIC ULCER
What is the significance of
hemorrhage and perforation
with duodenal ulcer?
P263
A

May indicate two ulcers (kissing);
posterior is bleeding and anterior is
perforated with free air

95
Q 
PERFORATED PEPTIC ULCER
What type of perforated
ulcer may present just like
acute pancreatitis?
P263
A

Posterior perforated duodenal ulcer
into the pancreas (i.e., epigastric pain
radiating to the back; high serum
amylase)

96
Q 
PERFORATED PEPTIC ULCER
What is the classic difference
between duodenal and
gastric ulcer symptoms as
related to food ingestion?
P263
A

Duodenal = decreased pain
Gastric = increased pain
(Think: Duodenal = Decreased pain)

97
Q

TYPES OF SURGERIES
Define the following terms:
Graham patch
P264

A 
For treatment of duodenal perforation in
    poor operative candidates/unstable
    patients
Place viable omentum over perforation
    and tack into place with sutures
98
Q

TYPES OF SURGERIES
Define the following terms:
Truncal vagotomy
P264

A

Resection of a 1- to 2-cm segment of
each vagal trunk as it enters the
abdomen on the distal esophagus,
decreasing gastric acid secretion

99
Q 
TYPES OF SURGERIES
What other procedure must
be performed along with a
truncal vagotomy?
P264
A 
“Drainage procedure” (pyloroplasty,
antrectomy, or gastrojejunostomy),
because vagal fibers provide relaxation of
the pylorus, and, if you cut them, the
pylorus will not open
100
Q

TYPES OF SURGERIES
Define the following terms:
Vagotomy and pyloroplasty
P264 (picture)

A

Pyloroplasty performed with vagotomy to

compensate for decreased gastric emptying

101
Q

TYPES OF SURGERIES
Define the following terms:
Vagotomy and antrectomy
P265

A

Remove antrum and pylorus in addition
to vagotomy; reconstruct as a Billroth
I or II

102
Q

TYPES OF SURGERIES
What is the goal of duodenal
ulcer surgery?
P265

A

Decrease gastric acid secretion (and fix

IHOP)

103
Q 
TYPES OF SURGERIES
What is the advantage of
proximal gastric vagotomy
(highly selective vagotomy)?
P265 (picture)
A

No drainage procedure is needed; vagal
fibers to the pylorus are preserved; rate
of dumping syndrome is low

104
Q

TYPES OF SURGERIES
What is a Billroth I (BI)?
P265 (picture)

A

Truncal vagotomy, antrectomy, and
gastroduodenostomy (Think: BI = ONE
limb off of the stomach remnant)

105
Q

TYPES OF SURGERIES
What are the contraindica-tions for a Billroth I?
P265

A

Gastric cancer or suspicion of gastric

cancer

106
Q

TYPES OF SURGERIES
What is a Billroth II (BII)?
P266 (picture)

A

Truncal vagotomy, antrectomy, and
gastrojejunostomy (Think: BII = TWO
limbs off of the stomach remnant)

107
Q

TYPES OF SURGERIES
What is the Kocher maneuver?
P266

A

Dissect the left lateral peritoneal
attachments to the duodenum to allow
visualization of posterior duodenum

108
Q

STRESS GASTRITIS
What is it?
P266

A

Superficial mucosal erosions in the

stressed patient

109
Q

STRESS GASTRITIS
What are the risk factors?
P266

A

Sepsis, intubation, trauma, shock, burn,

brain injury

110
Q

STRESS GASTRITIS
What is the prophylactic treatment?
P266

A

H(2) blockers, PPIs, antacids, sucralfate

111
Q

STRESS GASTRITIS
What are the signs/symptoms?
P266

A

NGT blood (usually), painless (usually)

112
Q

STRESS GASTRITIS
How is it diagnosed?
P266

A

EGD, if bleeding is significant

113
Q

STRESS GASTRITIS
What is the treatment for gastritis?
P266

A

LAVAGE out blood clots, give a maximum

dose of PPI in a 24-hour IV drip

114
Q

MALLORY-WEISS SYNDROME
What is it?
P266

A

Post-retching, postemesis longitudinal
tear (submucosa and mucosa) of the
stomach near the GE junction; approximately
three fourths are in the stomach

115
Q 
MALLORY-WEISS SYNDROME
For what percentage of all 
upper GI bleeds does this
syndrome account?
P267
A

≈10%

116
Q

MALLORY-WEISS SYNDROME
What are the causes of a tear?
P267

A

Increased gastric pressure, often

aggravated by hiatal hernia

117
Q

MALLORY-WEISS SYNDROME
What are the risk factors?
P267

A

Retching, alcoholism (50%), >50% of

patients have hiatal hernia

118
Q

MALLORY-WEISS SYNDROME
What are the symptoms?
P267

A

Epigastric pain, thoracic substernal pain,

emesis, hematemesis

119
Q

MALLORY-WEISS SYNDROME
What percentage of patients
will have hematemesis?
P267

A

85%

120
Q

MALLORY-WEISS SYNDROME
How is the diagnosis made?
P267

A

EGD

121
Q

MALLORY-WEISS SYNDROME
What is the “classic” history?
P267

A

Alcoholic patient after binge drinking—
first, vomit food and gastric contents,
followed by forceful retching and bloody
vomitus

122
Q

MALLORY-WEISS SYNDROME
What is the treatment?
P267

A

Room temperature water lavage (90% of
patients stop bleeding), electrocautery,
arterial embolization, or surgery for
refractory bleeding

123
Q

MALLORY-WEISS SYNDROME
When is surgery indicated?
P267

A

When medical/endoscopic treatment fails

>6 u PRBCs infused

124
Q 
MALLORY-WEISS SYNDROME
Can the Sengstaken-
Blakemore tamponade
balloon be used for
treatment of Mallory-Weiss
tear bleeding?
P267
A

No, it makes bleeding worse
Use the balloon only for bleeding
from esophageal varices

125
Q

ESOPHAGEAL VARICEAL BLEEDING
What is it?
P267

A 
Bleeding from formation of esophageal
varices from back up of portal pressure
via the coronary vein to the submucosal
esophageal venous plexuses secondary to
portal hypertension from liver cirrhosis
126
Q 
ESOPHAGEAL VARICEAL BLEEDING
What is the “rule of two
thirds” of esophageal
variceal hemorrhage?
P268
A 
Two thirds of patients with portal
    hypertension develop esophageal
    varices
Two thirds of patients with esophageal
    varices bleed
127
Q

ESOPHAGEAL VARICEAL BLEEDING
What are the signs/symptoms?
P268

A

Liver disease, portal hypertension,

hematemesis, caput medusa, ascites

128
Q

ESOPHAGEAL VARICEAL BLEEDING
How is the diagnosis made?
P268

A 
EGD (very important because only 50%
of UGI bleeding in patients with known
esophageal varices are bleeding from the
varices; the other 50% have bleeding
from ulcers, etc.)
129
Q

ESOPHAGEAL VARICEAL BLEEDING
What is the acute medical treatment?
P268

A

Lower portal pressure with somatostatin

and vasopressin

130
Q 
ESOPHAGEAL VARICEAL BLEEDING
In the patient with CAD,
what must you give in
addition to the vasopressin?
P268
A

Nitroglycerin—to prevent coronary
artery vasoconstriction that may result
in an MI

131
Q

ESOPHAGEAL VARICEAL BLEEDING
What are the treatment options?
P268

A

Sclerotherapy or band ligation via

endoscope, TIPS, liver transplant

132
Q

ESOPHAGEAL VARICEAL BLEEDING
What is the Sengstaken-
Blakemore balloon?
P268

A

Tamponades with an esophageal balloon

and a gastric balloon

133
Q

ESOPHAGEAL VARICEAL BLEEDING
What is the problem with shunts?
P269

A

Decreased portal pressure, but increased

encephalopathy

134
Q

BOERHAAVE’S SYNDROME
What is it?
P269

A

Postemetic esophageal rupture

135
Q

BOERHAAVE’S SYNDROME
Who was Dr. Boerhaave?
P269

A

Dutch physician who first described the
syndrome in the Dutch Grand Admiral
Van Wassenaer in 1724

136
Q 
BOERHAAVE’S SYNDROME
Why is the esophagus 
susceptible to perforation
and more likely to break
down an anastomosis?
P269
A

No serosa

137
Q

BOERHAAVE’S SYNDROME
What is the most common location?
P269

A

Posterolateral aspect of the esophagus (on

the left), 3 to 5 cm above the GE junction

138
Q

BOERHAAVE’S SYNDROME
What is the cause of rupture?
P269

A

Increased intraluminal pressure, usually

caused by violent retching and vomiting

139
Q

BOERHAAVE’S SYNDROME
What is the associated risk factor?
P269

A

Esophageal reflux disease (50%)

140
Q

BOERHAAVE’S SYNDROME
What are the symptoms?
P269

A 
Pain postemesis (may radiate to the back,
dysphagia)
141
Q

BOERHAAVE’S SYNDROME
What are the signs?
P269

A

Left pneumothorax, Hamman’s sign, left
pleural effusion, subcutaneous/mediastinal
emphysema, fever, tachypnea, tachycardia,
signs of infection by 24 hours, neck crepitus,
widened mediastinum on CXR

142
Q

BOERHAAVE’S SYNDROME
What is Mackler’s triad?
P269

A
  1. Emesis
  2. Lower chest pain
  3. Cervical emphysema (subQ air)
143
Q

BOERHAAVE’S SYNDROME
What is Hamman’s sign?
P269

A

“Mediastinal crunch or clicking”
produced by the heart beating against
air-filled tissues

144
Q

BOERHAAVE’S SYNDROME
How is the diagnosis made?
P269

A

History, physical examination, CXR,

esophagram with water-soluble contrast

145
Q

BOERHAAVE’S SYNDROME
What is the treatment?
P270

A

Surgery within 24 hours to drain the
mediastinum and surgically close the
perforation and placement of pleural
patch; broad-spectrum antibiotics

146
Q 
BOERHAAVE’S SYNDROME
What is the mortality rate 
if less than 24 hours until
surgery for perforated
esophagus?
P270
A

≈15%

147
Q 
BOERHAAVE’S SYNDROME
What is the mortality rate 
if more than 24 hours until
surgery for perforated
esophagus?
P270
A

≈33%

148
Q 
BOERHAAVE’S SYNDROME
Overall, what is the
most common cause of
esophageal perforation?
P270
A

Iatrogenic (most commonly cervical

esophagus)

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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