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Questions and Answers
What is the primary cause of vomiting in congenital hypertrophic pyloric stenosis?
What is the primary cause of vomiting in congenital hypertrophic pyloric stenosis?
Which of the following syndromes is associated with congenital hypertrophic pyloric stenosis?
Which of the following syndromes is associated with congenital hypertrophic pyloric stenosis?
What notable physical examination finding is commonly observed in patients with congenital hypertrophic pyloric stenosis?
What notable physical examination finding is commonly observed in patients with congenital hypertrophic pyloric stenosis?
What specific patient demographic is most commonly affected by congenital hypertrophic pyloric stenosis?
What specific patient demographic is most commonly affected by congenital hypertrophic pyloric stenosis?
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Which of the following factors is NOT associated with congenital hypertrophic pyloric stenosis?
Which of the following factors is NOT associated with congenital hypertrophic pyloric stenosis?
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Which type of gastric ulcer is most commonly associated with bleeding due to the left gastric artery?
Which type of gastric ulcer is most commonly associated with bleeding due to the left gastric artery?
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What is the primary management for Type II and III gastric ulcers?
What is the primary management for Type II and III gastric ulcers?
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Which clinical feature is most commonly associated with gastric ulcers?
Which clinical feature is most commonly associated with gastric ulcers?
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What is the most common complication associated with gastric ulcers?
What is the most common complication associated with gastric ulcers?
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Which method is recommended for diagnosing gastric ulcers?
Which method is recommended for diagnosing gastric ulcers?
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What is a key feature distinguishing congenital hypertrophic pyloric stenosis (CHPS) from duodenal atresia?
What is a key feature distinguishing congenital hypertrophic pyloric stenosis (CHPS) from duodenal atresia?
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Which sign is associated with CHPS during a contrast study?
Which sign is associated with CHPS during a contrast study?
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What metabolic consequence arises due to vomiting in CHPS?
What metabolic consequence arises due to vomiting in CHPS?
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What is the initial compensatory mechanism for metabolic alkalosis in CHPS?
What is the initial compensatory mechanism for metabolic alkalosis in CHPS?
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Which of the following is NOT a metabolic abnormality associated with CHPS?
Which of the following is NOT a metabolic abnormality associated with CHPS?
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What is the most common cause of upper gastrointestinal hemorrhage?
What is the most common cause of upper gastrointestinal hemorrhage?
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What is the typical management for perforation peritonitis due to an anterior ulcer?
What is the typical management for perforation peritonitis due to an anterior ulcer?
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Which vessel is most commonly implicated in bleeding ulcers?
Which vessel is most commonly implicated in bleeding ulcers?
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The presentation of peritonitis due to anterior ulcer perforation includes which of the following?
The presentation of peritonitis due to anterior ulcer perforation includes which of the following?
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What distinguishes a posterior ulcer perforation from an anterior ulcer perforation?
What distinguishes a posterior ulcer perforation from an anterior ulcer perforation?
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What is the preferred first step in the management of stomach issues?
What is the preferred first step in the management of stomach issues?
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Which type of ulcer is most commonly associated with H. pylori?
Which type of ulcer is most commonly associated with H. pylori?
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Following uneventful Ramstedt’s Pyloromyotomy surgery, when can feeding typically begin?
Following uneventful Ramstedt’s Pyloromyotomy surgery, when can feeding typically begin?
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Which area of the duodenum is most commonly affected by duodenal ulcers?
Which area of the duodenum is most commonly affected by duodenal ulcers?
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What is a common symptom experienced by individuals with duodenal ulcers?
What is a common symptom experienced by individuals with duodenal ulcers?
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Which procedure involves an end-to-end gastro-duodenal anastomosis?
Which procedure involves an end-to-end gastro-duodenal anastomosis?
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What is a key component in the Roux-en-Y Gastrojejunostomy procedure?
What is a key component in the Roux-en-Y Gastrojejunostomy procedure?
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In which reconstruction is the duodenum closed?
In which reconstruction is the duodenum closed?
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Which option correctly identifies the components involved in the Roux-en-Y Gastric Bypass?
Which option correctly identifies the components involved in the Roux-en-Y Gastric Bypass?
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What is the primary procedure used in Billroth I Gastrectomy?
What is the primary procedure used in Billroth I Gastrectomy?
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What is a characteristic feature of the Pauchet Procedure?
What is a characteristic feature of the Pauchet Procedure?
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Which gene is associated with the pathogenicity of H. pylori?
Which gene is associated with the pathogenicity of H. pylori?
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Which complication is NOT associated with H. pylori infection?
Which complication is NOT associated with H. pylori infection?
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What is a potential protective role of H. pylori infection?
What is a potential protective role of H. pylori infection?
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Which surgical procedure primarily involves subtotal gastrectomy?
Which surgical procedure primarily involves subtotal gastrectomy?
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What is the primary purpose of antecolic mobilization of the jejunum?
What is the primary purpose of antecolic mobilization of the jejunum?
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Which branch of the vagus nerve is primarily responsible for ulcer recurrence after vagotomy?
Which branch of the vagus nerve is primarily responsible for ulcer recurrence after vagotomy?
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What complication may arise from cutting the vagus nerve's motor branch to the gallbladder?
What complication may arise from cutting the vagus nerve's motor branch to the gallbladder?
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What surgical procedure is performed to address gastric drainage when pylorus function is impaired?
What surgical procedure is performed to address gastric drainage when pylorus function is impaired?
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Which statement about vagotomy is accurate?
Which statement about vagotomy is accurate?
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What is a common symptom experienced during early dumping syndrome?
What is a common symptom experienced during early dumping syndrome?
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Which characteristic is associated with late dumping syndrome?
Which characteristic is associated with late dumping syndrome?
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In Peterson hernia, where does bowel herniation occur?
In Peterson hernia, where does bowel herniation occur?
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Which dietary recommendation is advised to manage dumping syndrome?
Which dietary recommendation is advised to manage dumping syndrome?
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What is the primary cause of late dumping syndrome's symptoms?
What is the primary cause of late dumping syndrome's symptoms?
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Which type of vagotomy is associated with the least complications?
Which type of vagotomy is associated with the least complications?
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Which nutritional deficiency is most commonly associated with gastric reconstruction and vagotomy?
Which nutritional deficiency is most commonly associated with gastric reconstruction and vagotomy?
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What is a significant symptom of duodenal stump blowout following gastric reconstruction?
What is a significant symptom of duodenal stump blowout following gastric reconstruction?
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Which complication is specifically associated with afferent loop syndrome?
Which complication is specifically associated with afferent loop syndrome?
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What is a common complication following truncal vagotomy that can lead to ulcers?
What is a common complication following truncal vagotomy that can lead to ulcers?
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Study Notes
Johnson's Classification of Gastric Ulcers
- Type 1: Most common, along lesser curvature
- Type 2: Pre-pyloric and duodenal ulcer
- Type 3: Pre-pyloric
- Type 4: High up in the body; bleeds most commonly from Left Gastric Artery
- Type 5: Diffuse; associated with NSAID use
Characteristics of Gastric Ulcers
- Type II and III are caused by acid hypersecretion and respond to PPIs or vagotomy.
- Type IV and V may involve bleeding.
Clinical Features
- Pain worsens after eating.
- Perforation is the most common complication.
- Common implicated vessels:
- Peptic ulcer bleeding: Gastroduodenal artery
- Gastric ulcer bleeding: Left Gastric artery
Management of Gastric Ulcers
- Type I: Distal gastrectomy with Billroth I or II reconstruction.
- Type II and III: Distal gastrectomy with reconstruction, PPIs and vagotomy.
Diagnosis
- Upper GI endoscopy with "u" or "J" maneuver to visualize fundal ulcer.
- Biopsy all gastric ulcers for the risk of cancer.
Venous Supply in Stomach
- Veins corresponds to arteries.
- Left Gastric Vein (coronary vein) is responsible for liver metastases.
Congenital Hypertrophic Pyloric Stenosis
- AKA Idiopathic hypertrophic pyloric stenosis.
- Characterized by thickened pyloric muscle leading to gastric outlet obstruction and projectile, non-bilious vomiting.
- Most common in first-born male children.
Associations with CHPS
- Apert syndrome
- Cornelia de Lange syndrome
- Decreased nitric oxide synthase levels
- Erythromycin intake early in life
Presentation of CHPS
- Asymptomatic during the first 1-3 weeks of life.
- Followed by projectile, non-bilious vomiting.
Examination Findings
- Best done during feeding.
- Olive-shaped swelling on palpation.
- Visible peristalsis from left to right.
Comparison of CHPS and Duodenal Atresia
- CHPS: Non-bilious projectile vomiting starting a few weeks after birth.
- Duodenal atresia: Bilious vomiting present since birth.
Evaluation of CHPS
- IOC: Ultrasound
- Pyloric channel thickness > 74 mm
- Pyloric channel length > 16 mm
- Contrast study: String sign, double tract sign, mushroom sign
- X-ray: Single bubble sign
Metabolic Abnormality in CHPS
- Loss of HCl due to vomiting leading to metabolic alkalosis.
- Compensatory mechanisms:
- Increased elimination of bicarbonate in urine
- Decreased sodium
- Activation of RAS
- Aldosterone release.
- H+ ions eliminated in urine:
- Initially: Potassium
- Later: Paradoxical acidemia
Complications of Congenital Hypertrophic Pyloric Stenosis
- Hypokalemia
- Hyponatremia
- Hypochloremia
- Metabolic alkalosis with paradoxical aciduria
Complications of Peptic Ulcers
- Bleeding:
- Most common complication
- Posterior ulcers commonly involved
- Implicated vessels: Gastroduodenal artery
- Management:
- Endoscopic management: Bleeding stops, H.pylori eradication
- Second trial of endoscopy if re-bleeds.
- Surgery: Ligate the vessel
- Coagulation: Adrenaline
- Perforation:
- Anterior ulcers (most common): Presents with peritonitis, rebound tenderness, guarding, rigidity; X-ray shows gas under diaphragm.
- Management:
- NPO
- IV fluids
- IV antibiotics (aerobic and anaerobic)
- Analgesics
- Omental patch repair or Graham's patch repair.
- Management:
- Posterior ulcers (rare): Perforates into retroperitoneum.
- Renal vein signs: Gas under right kidney.
- Valentino Syndrome: Mimics acute appendicitis.
- Kocherisation: Mobilization of duodenum to view posterior ulcer
- Anterior ulcers (most common): Presents with peritonitis, rebound tenderness, guarding, rigidity; X-ray shows gas under diaphragm.
Management of CHPS
- Correct metabolic abnormalities first.
- Surgical management: Ramstedt's pyloromyotomy (Open/Laparoscopic):
- Feeding started in 4-6 hours if uneventful.
- Feeding started in 24-48 hours if mucosal injury present.
Peptic Ulcer
- Duodenal ulcer most common:
- Associated with H.pylori (90-95%)
- Acid hypersecretion
- Gastric ulcer:
- Associated with H.pylori (60-65%)
- Type I and III ulcers: Increased acid production
Duodenal Ulcer
- Most common site: D1 (First part of duodenum)
- Pain relieved with food
Gastric Reconstruction Procedures
- Billroth I gastrectomy: End-to-end gastro-duodenal anastomosis
- Billroth II gastrectomy (Polya Reconstruction): End-to-side gastro-jejunostomy.
- Roux-en-y gastrojejunostomy (Roux-en-y Gastric Bypass): Establish a gastric bypass.
Methods of Mobilizing Jejunum Towards Stomach
- Antecolic: In front of the colon; Peterson hernia (bowel herniation behind Roux limb)
- Retrocolic: Behind the colon, through transverse mesocolon; Stemmer's hernia (bowel herniation through transverse mesocolon window)
Vagotomy
- Cutting the vagus nerve.
- Not routinely done anymore; replaced by PPIs.
- Indications: Duodenal ulcers and type 2 and 3 gastric ulcers.
- Branches of vagus nerve: Celiac axis branch, Ant trunk, Post trunk, Post N. of Latarjet, Crow's Foot, Criminal N. of Grassi.
- Motor branches: To GB (can lead to stasis and stone formation), To Pylorus (can lead to impaired gastric emptying)
- Procedures: Gastrojejunostomy, Pyloroplasty (longitudinal incision + transverse suturing; makes pylorus incompetent).
Active Space
- Contains procedures related to gastric ulcers.
- Pauchet Procedure, Kelling Madlener Procedure, Csendes Procedure, Subtotal Gastrectomy (Roux-en-y esophagogastrojejunostomy procedure)
H.pylori
- Common cause of gastric ulcer disease.
- CagA and VacA: Genes that encode for toxins.
- Urease enzyme production allows survival in acidic environment.
- Pathogenicity: Peptic ulcers, type B gastritis, gastric cancer, MALTomas.
- Provides mild protection against adenocarcinoma of the esophagus and GERD.
Internal Hernias
- Stemmer's hernia: Bowel herniates through transverse mesocolon.
- Peterson hernia: Bowel herniates behind Roux limb.
Dumping Syndrome
-
Most common after Polya or Roux-en-Y reconstruction.
-
Pathophysiology:
- Early dumping: Rapid fluid influx due to hyperosmolar contents; symptoms: bloating, nausea, vomiting.
- Late dumping: Rapid transit leads to sugar absorption but complete insulin release; excess insulin and rebound hypoglycemia.
-
Early vs. Late dumping:
Feature Early Dumping Late Dumping Pathophysiology Rapid fluid influx due to hyperosmolar contents Rebound hypoglycemia due to excessive insulin Features Nausea, vomiting, bloating, pain (relieved by rest) Headache, sweating, tachycardia Onset 10-15 mins after food 30-40 mins after food Relation with food Worsens with food Improves with food (due to correction of hypoglycemia)
Management of Dumping Syndrome
- Dietary recommendations:
- Avoid large meals
- Avoid liquids with meals
- Avoid sugary liquids
- Small frequent meals
- High fat and protein diet
- Octreotide if dietary recommendations are ineffective.
- Consider conversion to Roux-en-Y if octreotide fails.
Types of Vagotomy
- Highly Selective Vagotomy (HSV)
- Truncal Vagotomy + Gastrojejunostomy
- Truncal Vagotomy + Antrectomy
Comparison of HSV and Truncal Vagotomy + Antrectomy
- HSV: Less acid reduction, more ulcer recurrence, less complications.
- Truncal Vagotomy + Antrectomy: Maximum acid reduction, least ulcer recurrence, maximum complications.
Complications of Gastric Reconstruction and Vagotomy
- Nutritional complications:
- Iron deficiency anemia (microcytic hypochromic anemia)
- Vitamin B12 deficiency (fatigue, neuropathy, megaloblastic anemia)
- Calcium deficiency
- Anastomotic leak: More common in Billroth I reconstruction. Symptoms: Abdominal pain, fever, peritonitis.
- Duodenal stump blowout: Seen in Polya and Roux-en-Y reconstruction; presents on postoperative day 4; Symptoms: Abdominal pain, fever.
- Hemorrhage: From anastomotic site.
- Bilious Vomiting: Bile reflux into stomach.
- Peptic ulcers: Acid drains directly into jejunum.
- Afferent loop syndrome: Seen in Polya reconstruction; Symptoms: Twisting of afferent loop (obstruction and perforation), Obstruction in efferent loop (bile reflux into stomach, bilious vomiting).
- Post-vagotomy diarrhea: Osmotic diarrhea.
- Gallstone formation: Cutting the anterior trunk of the vagus nerve.
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Description
This quiz focuses on the different types of gastric ulcers according to Johnson's classification, their clinical features, and management strategies. It highlights the complications, diagnosis methods, and treatment options available for each type of ulcer. Test your knowledge on this crucial topic in gastroenterology.
