Surgery Pg No 146 -155

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Questions and Answers

What is the most common type of gastric ulcer?

Type II

Along lesser curvature (correct)

Type IV

High up in the body

Peptic ulcer bleeding is primarily associated with the left gastric artery.

False

What is the main management strategy for Type I gastric ulcers?

Distal gastrectomy + reconstruction (Billroth I or II)

The complication most commonly associated with gastric ulcers is __________.

perforation Signup and view all the answers

Match the types of gastric ulcers with their characteristics:

Type II = Associated with acid hypersecretion Type IV = Bleeding ± Type III = Responds to PPI/vagotomy Type I = Requires distal gastrectomy + reconstruction Signup and view all the answers

Which of the following conditions is most commonly associated with congenital hypertrophic pyloric stenosis (CHPS)?

Apert syndrome Signup and view all the answers

Congenital hypertrophic pyloric stenosis is most frequently found in first-born female children.

False Signup and view all the answers

What is a common symptom of congenital hypertrophic pyloric stenosis?

Projectile, non-bilious vomiting Signup and view all the answers

The left gastric vein is responsible for metastases into the _____ which is part of the venous supply related to the stomach.

liver Signup and view all the answers

Match the following features with their respective descriptions related to congenital hypertrophic pyloric stenosis.

Asymptomatic period = First 1-3 weeks Projectile vomiting = Non-bilious vomiting Palpable mass = Olive-shaped swelling Peristalsis = Visible left to right Signup and view all the answers

What feature is characteristic of Congenital Hypertrophic Pyloric Stenosis (CHPS)?

Non-bilious projectile vomiting after a few weeks Signup and view all the answers

Duodenal Atresia typically appears normal at birth.

False Signup and view all the answers

What is the management method for Congenital Hypertrophic Pyloric Stenosis?

Ramstedt pyloromyotomy Signup and view all the answers

In patients with CHPS, vomiting leads to a loss of ______, resulting in metabolic alkalosis.

HCl Signup and view all the answers

Match the following signs or findings with their corresponding studies related to CHPS:

String sign = Contrast Study Double tract sign = Contrast Study Single bubble sign = X-ray Pyloric channel thickness > 74 mm = USG Signup and view all the answers

Which artery is considered the dominant artery of the stomach?

Left gastric artery Signup and view all the answers

The stomach can necrose if its blood vessels are ligated.

False Signup and view all the answers

Name the five main parts of the stomach.

Cardia, Fundus, Body, Antrum, Pylorus Signup and view all the answers

The ______ artery branches from the common hepatic artery and supplies the stomach.

Right gastric Signup and view all the answers

Match the following arteries with their descriptions:

Left gastric artery = Dominant artery of stomach Right gastroepiploic artery = Branch of gastroduodenal artery Left gastroepiploic artery = Branch of splenic artery Right gastric artery = Branch of common hepatic artery Signup and view all the answers

What is the most common benign tumor of the esophagus?

Leiomyoma Signup and view all the answers

The incidence of Leiomyoma is equal between males and females.

False Signup and view all the answers

What is a significant complication associated with Self-Expanding Metallic Stenting (SEMS)?

Migration of stent Signup and view all the answers

Patients with large tumors of Leiomyoma may experience __________.

dysphagia Signup and view all the answers

Match the following features to their descriptions:

Cough = Presentation of malignant tracheo-esophageal fistula Barium Swallow = Investigation showing punched out appearance Enucleation = Management method for benign tumors 3-6 months = Follow-up period after SEMS placement Signup and view all the answers

Which type of esophagectomy involves three incisions?

McKeown's (3 Field Esophagectomy) Signup and view all the answers

Atelectasis is not a common complication following esophagectomy.

False Signup and view all the answers

What is the most commonly used method for esophageal replacement?

Stomach tube Signup and view all the answers

The combined treatment of chemotherapy and radiotherapy is referred to as __________.

combined chemoradiation Signup and view all the answers

Match the following chemotherapy drugs with their descriptions:

Gemcitabine = A nucleoside analog used in the treatment of several types of cancer Cisplatin = A platinum-based drug commonly used for solid tumors 5-FU = A fluoropyrimidine that inhibits DNA synthesis Doxorubicin = An anthracycline antibiotic used in cancer chemotherapy Signup and view all the answers

What is the most common complication associated with gastric ulcers?

Bleeding Signup and view all the answers

Gas under the diaphragm is a common radiographic finding in perforated anterior ulcers.

True Signup and view all the answers

What type of repair is typically performed for perforation peritonitis following stabilization?

Omental patch repair or Graham’s patch repair Signup and view all the answers

The primary management for perforated ulcers includes NPO, IV fluids, IV antibiotics, and __________.

analgesics Signup and view all the answers

Match the following complications with their characteristics:

Bleeding = Commonly involves gastroduodenal artery Perforation = Presents with peritonitis and rebound tenderness Valentino syndrome = Mimics acute appendicitis due to posterior ulcer Omental patch repair = Surgical management for perforation peritonitis Signup and view all the answers

What is the most likely classification for a tumor that invades into the adventitia?

T3 Signup and view all the answers

N1 indicates no positive regional lymph nodes.

False Signup and view all the answers

What is the recommended treatment for T1b N0 esophageal cancer?

Esophagectomy Signup and view all the answers

M1 classification indicates the presence of __________ metastases.

distant Signup and view all the answers

Match the following T statuses with their descriptions:

Tis = High-grade dysplasia T3 = Invasion into adventitia T4a = Invades resectable adjacent structures T1 = Invasion into the lamina propria Signup and view all the answers

Which type of resection indicates that there is no microscopic disease left behind?

R0 Signup and view all the answers

Definitive chemoradiotherapy is used to preserve the larynx in clinical esophageal tumors.

True Signup and view all the answers

What is the primary site for distant metastases in esophageal cancer?

Liver Signup and view all the answers

What is the earliest and more common symptom of gastrointestinal diseases?

Progressive dysphagia Signup and view all the answers

Weight loss is a sign of advanced gastrointestinal disease.

True Signup and view all the answers

What imaging technique is best for T & N staging in gastrointestinal surgery?

EUS (Endoscopic ultrasound) Signup and view all the answers

The Endoscopic ultrasound shows alternate hypo & hyper ______.

bands Signup and view all the answers

Match the following histology layers with their respective numbers as identified in EUS:

Mucosa = 1 Submucosa = 4 Muscularis propria = 5 Muscularis mucosa = 3 Signup and view all the answers

What is the first step in the management of metabolic abnormalities?

Correct metabolic abnormality Signup and view all the answers

Duodenal ulcers are most commonly associated with decreased acid secretion.

False Signup and view all the answers

What is the most common site for duodenal ulcers?

D1 (First part of duodenum) Signup and view all the answers

The surgical procedure used to manage congenital hypertrophic pyloric stenosis is __________.

Ramstedt’s Pyloromyotomy Signup and view all the answers

Match the following types of ulcers with their characteristics:

Duodenal Ulcer = 90-95% associated with H. pylori Gastric Ulcer = 60-65% associated with H. pylori Type I & III Gastric Ulcer = ↑ Acid production Duodenal Ulcer Pain = Relieved with food Signup and view all the answers

Study Notes

Johnson's Gastric Ulcer Classification

Type I: Most common, along the lesser curvature near the incisura.
Type II & III: Prepyloric and duodenal ulcers; associated with acid hypersecretion, responding well to PPIs or vagotomy.
Type IV: High in the body, most prone to bleeding, often involving the left gastric artery.
Type V: Diffuse, often linked to NSAID use.

Gastric Ulcer Characteristics and Clinical Features

Pain worsens after eating.
Perforation is the most frequent complication.
Most implicated vessels in peptic ulcer bleeding: Gastroduodenal artery (for peptic ulcers), Left gastric artery (for gastric ulcers).
Type I ulcers are managed through distal gastrectomy and reconstruction (Billroth I or II).
Types II and III ulcers require distal gastrectomy, reconstruction, and PPIs/vagotomy due to hyperacidity.

Gastric Venous Supply and Metastasis

Gastric veins follow the arterial pattern.
The left gastric/coronary vein is a key route for liver metastasis.

Congenital Hypertrophic Pyloric Stenosis (CHPS)

Also known as idiopathic hypertrophic pyloric stenosis.
Thickened pyloric muscle causes gastric outlet obstruction (GOO), leading to vomiting.
Most common in first-born males.
Associated with Apert syndrome, Cornelia de Lange syndrome, decreased nitric oxide synthase levels, and early erythromycin use.
Presents with projectile, non-bilious vomiting, usually starting after the first few weeks of life.
Olive-shaped swelling and visible peristalsis (left to right) are palpable during feeding.

CHPS vs. Duodenal Atresia

CHPS: Non-bilious projectile vomiting after a few weeks, common in first-born males, diagnosed via USG, treated with Ramstedt pyloromyotomy.
Duodenal Atresia: Bilious vomiting from birth, associated with Down syndrome.

CHPS Evaluation

USG: Measures pyloric channel thickness (>7mm) and length (>16mm).
Contrast studies reveal a string sign, double tract sign, or mushroom sign.
X-ray may show a single bubble sign.

CHPS Metabolic Abnormalities

Vomiting leads to HCl loss, causing metabolic alkalosis (decreased H+ and Cl-).
Compensatory mechanisms include increased urinary NaHCO3 excretion, decreased Na+, RAS activation, and aldosterone release.
Paradoxical acidemia occurs later, while initial compensation involves K+ excretion.
Hypokalemia, hyponatremia, hypochloremia, and metabolic alkalosis with paradoxical aciduria may be present.

Stomach Anatomy and Blood Supply

Stomach regions: Cardia, fundus, body, antrum, pylorus.
Arterial supply: Left gastric artery (from celiac axis), right gastric artery (from common hepatic artery), left gastroepiploic artery (from splenic artery), right gastroepiploic artery (from gastroduodenal artery). Extensive submucosal anastomoses ensure survival even if some vessels are ligated. The left gastric artery is involved in type IV ulcers and Mallory-Weiss tears.

Esophageal Cancer Staging (TMN)

T status: Tis (high-grade dysplasia), T1 (lamina propria/muscularis mucosa/submucosa invasion), T2 (muscularis propria invasion), T3 (adventitia invasion), T4a (resectable adjacent structure invasion), T4b (unresectable adjacent structure invasion).
N status: N0 (no metastasis), N1 (1-2 positive nodes), N2 (3-6 positive nodes), N3 (7+ positive nodes).
M status: M0 (no distant metastasis), M1 (distant metastasis, most commonly liver).

Sievert Classification of Gastroesophageal Junction Tumors

Type I and II categorized as esophageal cancer and Type III as gastric cancer. (Diagram needed here)

Esophageal Cancer Management

T1a lesions (above submucosa): Endoscopic mucosal resection (EMR).
T1b N0/Ta N0 lesions (submucosal invasion): Esophagectomy.
T3 N1/T3/T4 lesions: Neoadjuvant chemotherapy and radiotherapy.
Clinical esophageal tumors: Definitive chemoradiotherapy.

Esophagectomy Principles and Types

Resection margins: Proximal (10cm), distal (5cm). Long margins needed to prevent recurrence.
R0 resection (no microscopic disease), R1 (microscopic disease remaining), and R2 (gross disease remaining).
Esophagectomy types: Transhiatal (Orringer), Ivor Lewis, McKeown's; each varying significantly in incision locations (neck, abdomen, thorax) and anastomosis site. (Table comparing different esophagectomy techniques provided in source material).
Minimum 15 lymph nodes should be removed. Stomach is the most common replacement for the esophagus because of its blood supply. Colon or jejunum used if the stomach is involved.

Esophagectomy Complications

Atelectasis, pneumonia, anastomotic leak (neck anastomosis more dangerous than thoracic), recurrent laryngeal nerve (RLN) injury, chylothorax (injury to thoracic duct, causing turbid fluid in drain).

Chemotherapy and Radiotherapy in Esophageal Cancer

Combined chemoradiation improves outcomes. Chemo acts as a radiosensitizer.
Drugs: Gemcitabine, cisplatin, 5-FU.

Self-Expanding Metallic Stents (SEMS)

Used for malignant tracheo-esophageal fistulas.
Presentation: Cough, pneumonia.
Complications: Stent migration, bleeding, tumor regrowth.
Prognostic factor: Tumor depth.
Follow-up with endoscopy at 3-6 months.

Benign Esophageal Tumors

Leiomyoma: Most common benign esophageal tumor, found in mid-distal esophagus, male-to-female ratio 2:1, usually asymptomatic, large tumors cause dysphagia, barium swallow shows a "punched-out appearance". Managed by enucleation or STER (submucosal tunneling and endoscopic resection).

Peptic Ulcer Complications: Bleeding

Most common complication.
Posterior ulcers more often involved. Gastroduodenal artery commonly implicated. Leading cause of upper GI hemorrhage.
Management: Endoscopic hemostasis, H. pylori eradication. Re-bleeding may require repeat endoscopy, surgery (vessel ligation), or coagulation via adrenaline injection.

Peptic Ulcer Complications: Perforation

Anterior ulcers (most common): Peritonitis, rebound tenderness, guarding, rigidity; X-ray shows gas under diaphragm. Managed with NPO, IV fluids, IV antibiotics (aerobic and anaerobic coverage), analgesics; followed by omental or Graham's patch repair.
Posterior ulcers (rare): Perforate into retroperitoneum, may present as renal vein signs (gas under right kidney) or mimic appendicitis (Valentino syndrome). Kocherization (mobilization of duodenum) needed for visualization and repair.

CHPS Management

Correct metabolic abnormalities first (normal saline with dextrose and KCl, Ringer's lactate).
Ramstedt pyloromyotomy (open or laparoscopic): Feeding begins after 4-6 hours if uncomplicated, or after 24-48 hours if mucosal injury.

Peptic Ulcer Types and Characteristics

Duodenal ulcer (most common): 90-95% associated with H. pylori, characterized by acid hypersecretion, pain relieved by food. Most common site: First part of duodenum (D1)
Gastric ulcer: 60-65% association with H. pylori, Type I and III show increased acid production.

Esophageal Cancer Clinical Features and Investigations

Progressive dysphagia (solids > liquids), weight loss, potential fistula formation with the trachea, and left recurrent laryngeal nerve (RLN) involvement (chronic cough, hoarseness).
Definitive diagnosis: Endoscopic biopsy; overall staging: PET-CT; T&N staging: EUS; barium swallow showing "rat-tail/apple-core" appearance. (Images required here, including histologic layers).

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Description

This quiz covers the various types of gastric ulcers as classified by Johnson, their clinical features, and management strategies. Understand the implications of pain patterns, complications, and the anatomy related to gastric venous supply. Test your knowledge on the specifics of gastric ulcers and their treatments.