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surgery: stomach and duodenum
Terms in this set (22)
A frail elderly patient is found to have an anterior perforation of a duodenal ulcer. He has a recent history of nonsteroidal anti-inflammatory drug (NSAID) use and no previous history of peptic ulcer disease. A large amount of bilious fluid is found in the abdomen. What should be the next step?
Although surgery is generally recommended for perforation, conservative measures can be considered in select cases. A patient who has a benign clinical presentation or one who is improving, might be considered for treatment with antibiotics and nasogastric decompression.
Patients who have an acute abdomen and are hemodynamically unstable should not be observed. Board-like rigidity of the abdomen occur as a result of chemical peritonitis. These patients should have fluid and electrolyte repletion, and anitbiotics followed by surgery.
Choice of the operative procedure should be guided by the information obtained during the history, the presence of comorbid disease, and hemodynamic stability during the operation. A omental (Graham) patch will seal the ulcer, but it will not prevent recurrence.
A 30-year-old executive learns that he has a duodenal ulcer. His gastroenterologist prescribes and outlines medical therapy. The patient worries that if medical therapy fails he may need surgery. Which of the following is the best indication for elective surgical therapy for duodenal ulcer disease?
Surgical intervention for peptic ulcer disease is uncommon. It is indicated by four clinical situations—intractable pain, hemorrhage, perforation, and obstruction. Noncompliance with medication is often the cause of recurrence. Patients with gastic decompression need a nasogastric tube and fluid and electrolyte correction prior to surgery.
A 64-year-old woman with arthritis is a chronic NSAID user. She develops severe epigastric pain and undergoes an upper endoscopy. She is told that she has an ulcer adjacent to the pylorus. Which of the following is TRUE about the pylorus?
The pylorus is palpable but it is not a true physiologic sphincter. It does not demonstrate reciprocal contraction when the stomach relaxes, nor does it relax when the stomach contracts. The pylorus is normally in tonic contraction It is partially covered by omentum and cancer is commonly found there.
A 55-year-old man complains of anorexia, weight loss, and fatique. A UGI study demonstrates an ulcerated lesion at the incisura. Where is the incisura?
The incisura is located at the distal portion of the lesser curvature. It is the point at which the body of the stomach ends and the antrum begins.
A 68-year-old woman has been diagnosed with a benign ulcer on the greater curvature of her stomach, 5 cm proximal to the antrum. After 3 months of standard medical therapy, she continues to have guaiac positive stool, anemia, and abdominal pain with failure of the ulcer to heal. Biopsies of the gastric ulcer have not identified a malignancy. The next step in management is which of the following?
In general, vagotomy with a gastric drainage procedure is less satisfactory in the treatment of primary gastric ulcer. Treatment of a gastric ulcer may include partial gastrectomy with a gastroduodenal anastomosis (Billroth I). Vagotomy is not necessary because gastric ulcers are usually not associated with acid hypersecretion. A gastric ulcer that fails to heal despite medical therapy should be excised.
A 50-year-old woman presents with duodenal ulcer disease and high basal acid secretory outputs. Secretin stimulated serum gastrin levels are in excess of 1000 pg/mL. She has a long history of ulcer disease that has not responded to intense medical therapy. What is the most likely diagnosis?
ZES is characterized by duodenal ulcer disease, high basal acid secretory output, and a pancreatic tumor. Stimulated serum gastrin levels may be in excess of 1000 pg/mL or as high as 10,000 pg/mL. ZES is due to a true pancreatic tumor in adults, but may be secondary to hyperplasia in children. Growth of the tumor is usually slow and survival is often prolonged. If an isolated tumor is found on CAT scan, surgical resection is indicated. About two-thirds of these tumors are malignant. About one-forth of patients have MEN I syndrome tumors of parathyroid pituitary and pancreas.
A 62-year-old man presents with guaiac positive stool. He is asymptomatic. Workup reveals a 2-cm ulcerated carcinoma on the antral lesser curvature. Tumor markers are negative. A CAT scan is negative for metastatic disease and lymphadenopathy liver function tests are normal. What is the correct treatment for this patient?
The treatment of an antral gastric cancer is distal subtotal gastrectomy with lymph node dissection (provided there is no metastatic disease). Surgical resection is the only potential curative therapy. Proximal margins should be 5-6 cm. Total gastrectomy does not improve 5-year survival. Postoperative chemoradiation may increase 5-year survival (limited studies).
A 79-year-old retired opera singer presents with dysphagia, which has become progressively worse during the last 5 years. He states that he is sometimes aware of a lump on the left side of his neck and that he hears gurgling sounds during swallowing. He sometimes regurgitates food during eating. What is the likely diagnosis?
Zenker diverticulum. In the past, the most common recognized sign of pharyngoesophageal dysfunction was the presence of a Zenker's diverticulum, originally described by Ludlow in 1769. The eponym resulted from Zenker's classic clinicopathologic descriptions of 34 cases published in 1878. Pharyngoesophageal diverticula have been reported to occur in 1 of 1000 routine barium examinations, and classically occur in elderly, white males. Zenker's diverticula tend to enlarge progressively with time due to the decreased compliance of the skeletal portion of the cervical esophagus that occurs with aging.
Presenting symptoms include dysphagia associated with the spontaneous regurgitation of undigested, bland material, often interrupting eating or drinking. On occasion, the dysphagia can be severe enough to cause debilitation and significant weight loss. Chronic aspiration and repetitive respiratory infection are common associated complaints. Once suspected, the diagnosis is established by a barium swallow. Endoscopy is usually difficult in the presence of a cricopharyngeal diverticulum, and potentially dangerous, owing to obstruction of the true esophageal lumen by the diverticulum and the attendant risk of diverticular perforation.
A 64-year-old woman presents with severe upper abdominal pain and retching of 1-day duration. Attempts to pass a nasogastric tube are unsuccessful. X-rays show an air-fluid level in the left side of the chest in the posterior mediastinum. An incarcerated paraesophageal hernia and gastric volvulus is diagnosed. What is the next step in management?
Gastric volvulus is often associated with a large paraesophageal hiatal hernia. The twist causes a cut-off at the cardia above and at the pylorus below leading to distension and ischemia, which may progress to gangrene. Requires surgery, reduction of the gastric volvulus, and repair of the hernia.
A 33-year-old man is admitted to the hospital for evaluation and treatment of a gastrojejunal ulcer. At age 25, he was treated surgically with an omental (Graham) patch for a perforated duodenal ulcer. At age 30, he was treated with a truncal vagotomy and antrectomy for a chronic duodenal ulcer. He now has a stomal (gastrojejunal) ulcer that is refractory to medical therapy. Which of the following should be checked?
Gastrinoma (ZES) should always be excluded in patients presenting with severe peptic ulcer disease that fails to respond to therapy. It accounts for 0.1-1% of peptic ulcers. It is usually caused by a gastrinoma (a non -cell tumor found in the pancreas or duodenum). The diagnosis is based partly on an elevated fasting serum gastrin level (normal 60 pg/mL; in ZES > 150 pg/mL and can be over 1000 pg/mL). Basal acid secretion is increased above 15 mEq/h. Duodenal ulcers are the most common ulcers, but ulcers in unusual locations (e.g., jejunum) may also be seen
50-year-old woman is diagnosed with multiple hyperplastic polyps in the stomach during endoscopy and biopsy. How are these best treated?
Hyperplastic polyps are unlikely to harbor carcinoma. Multiplicity of hyperplastic polyps does not seem to predispose to the development of cancer. Adenomatous polyps occur more commonly in the antrum. Hyperplastic polyps are distributed more evenly throughout the stomach. For this reason, antral polyps should be removed first. (Adenomatous polyps may have a focus of cancer within them.)
During a surveillance upper endoscopy, a 35-year-old woman who was successfully treated for multiple familial polyposis of the colon, is found to have several polyps in the antrum. Biopsies show adenomatous polyps. What is the best therapy?
Adenomatous polyps of the stomach resemble colon polyps. Coexisting carcinoma may be present in up to 20% of cases. The incidence of carcinoma is increased if lesions are larger than 2 cm. Both hyperplastic and adenomatous polyps are more common in long-term follow-up of patients treated successfully for familial polyposis. All adenomatous polyps should be removed.
A healthy 75-year-old man bleeds from a duodenal ucler. Medical management and endoscopic measures fail to stop the bleeding. What is the next step in management?
In general, surgery for peptic ulcer bleeding is indicated at an earlier stage in an older patient because vessels are atherosclerotic and less likely to stop bleeding spontaneously. In addition, diminished perfusion of the heart, brain, and kidneys is less well tolerated in elderly patients. At surgery, the gastroduodenal artery is oversewn, and a vagotomy and drainage procedure is performed.
A 61-year-old man undergoes upper endoscopy for evaluation of weight loss and is identified to have a submucosal mass in the stomach. Biopsy is consistent with a gastrointestinal stromal tumor (GIST). Workup reveals the presence of liver metastases. Which of the following is the best initial treatment for this patient?
Greater understanding of cancer biology has led to the development of numerous targeted therapies. Gastrointestinal stromal tumors (GISTs) express the c-kit receptor; c-kit is a tyrosine kinase. Imatinib is a selective tyrosine kinase inhibitor that is used as neoadjuvant or palliative therapy for metastatic GIST. Ceutximab and bevacizumab are monoclonal antibodies directed against epidermal growth factor receptor (EGFR) and vascular endothelial growth factor A (VEGF-A), respectively. Both are used as adjuncts for treating various malignancies. Infliximab, which is a monoclonal antibody against tumor necrosis factor (TNF ), is used for the treatment of autoimmune diseases including inflammatory bowel disease. Daclizumab, which is a monoclonal antibody against a subunit of the interleukin-2 (IL-2) receptor, is used in to treat rejection in organ transplantation.
A 45-year-old woman with history of heavy nonsteroidal anti-inflammatory drug ingestion presents with acute abdominal pain. She undergoes exploratory laparotomy 30 hours after onset of symptoms and is found to have a perforated duodenal ulcer. Which of the following is the procedure of choice to treat her perforation?
In patients with no prior history of peptic ulcer disease, simple closure with an omental patch is recommended. Patients with long-standing ulcer disease require a definitive acid-reducing procedure, except in high-risk situations and if the perforation is more than 24 hours old secondary to extensive peritoneal soilage. The choice of procedure is made by weighing the risk of recurrence against the incidence of undesirable side effects of the procedure, and considerable controversy persists about this issue. Antrectomy and truncal vagotomy offers a recurrence rate of 1%, but carries a 15% to 25% incidence of sequelae such as diarrhea, dumping syndrome, bloating, and gastric stasis. Highly selective vagotomy, if technically feasible, offers a 1% to 5% incidence of side effects but carries a recurrence rate of 10% to 13% in some series, although results are better when gastric and prepyloric ulcers are excluded. Pyloroplasty and truncal vagotomy carries intermediate rates of recurrence and side effects, but has the advantage of speed in the setting of very ill patients with acute perforation.
A 42-year-old man with no history of use of NSAIDs presents with recurrent gastritis. The patient was diagnosed and treated for Helicobacter pylori 6 months ago. Which of the following tests provides the least invasive method to document eradication of the infection?
The carbon-labeled urea breath test is the noninvasive method of choice to document eradication of a H pylori infection. This test samples the entire stomach and has sensitivity and specificity both greater than 95%. The test is performed by having the patient ingest a carbon-isotope labeled urea. After ingestion the urea will be metabolized to ammonia and labeled bicarbonate if a H pylori infection is present. The labeled bicarbonate is excreted in the breath as labeled carbon dioxide, which can then be quantified. Serology is another noninvasive test to establish the diagnosis of H pylori infection. However, it cannot be used to assess eradication after therapy because antibody titers can remain high for over a year. Endoscopy with biopsy is necessary to provide a specimen for the rapid urease test, histologic evaluation, and culturing of gastric mucosa.
A 50-year-old man presents with intractable peptic ulcer disease, severe esophagitis, and abdominal pain. Which of the following is most consistent with the diagnosis of Zollinger-Ellison syndrome?
Zollinger-Ellison syndrome (ZES) refers to hypergastrinemia resulting from an endocrine tumor. ZES must be excluded in all patients with intractable peptic ulcers. The diagnosis depends on elevated levels of gastrin along with increased secretion of gastric acid. Patients with Zollinger-Ellison tumors have very high basal levels of gastric acid (> 35 mEq/h) and serum gastrin (usually > 1000 pg/mL). In equivocal cases, when the gastrin level is not markedly elevated, a secretin stimulation test is usually obtained. In this test, a fasting gastrin level is obtained before and after the administration of secretin (at 2, 5, 10, and 20 minutes). A paradoxical rise in serum gastrin after intravenous secretin is diagnostic of Zollinger-Ellison syndrome. Hypercalcemia is not a finding associated with ZES. However, the presence of hypercalcemia in a patient with ZES should prompt a workup for MEN1 (multiple endocrine neoplasia type 1). In MEN1 patients, the organ most involved is the parathyroid. The next most common syndrome is ZES, followed by insulinoma
A 45-year-old man with a history of chronic peptic ulcer disease undergoes a truncal vagotomy and antrectomy with a Billroth II reconstruction for gastric outlet obstruction. Six weeks after surgery, he returns, complaining of postprandial weakness, sweating, light-headedness, crampy abdominal pain, and diarrhea. Which of the following would be the best initial management strategy?
Though reminiscent of the carcinoid syndrome, this patient's complaints in the context of recent gastric surgery are highly suggestive of the dumping syndrome, which is characterized by intestinal symptoms (bloating, cramping, diarrhea) and vasomotor symptoms (weakness, flushing, palpitations, diaphoresis, and dizziness) after ingestion of a meal following surgical removal of part of the stomach or alteration of the pyloric sphincter. Early dumping occurs within 20 to 30 minutes of eating and is attributed to the rapid influx of fluid with a high osmotic gradient into the small intestine from the gastric remnant. Late dumping syndrome occurs 2 to 3 hours after a meal; symptoms resemble those of hypoglycemic shock. Medical management consists of reassurance and dietary measures (avoidance of large amounts of sugars, frequent small meals, and separation of fluids and solids). The majority of cases will resolve within 3 months of operation on this regimen. Octreotide, a long-acting somatostatin analogue, can be used as well, but cost is a limiting factor. Surgery for intractable dumping consists of creation of an antiperistaltic limb of jejunum distal to the gastrojejunostomy.
A 55-year-old man complains of chronic intermittent epigastric pain. A gastroscopy demonstrates a 2-cm prepyloric ulcer. Biopsy of the ulcer yields no malignant tissue. After a 6-week trial of medical therapy, the ulcer is unchanged. Which of the following is the best next step in his management?
This patient has a persistent gastric ulcer and should undergo surgical resection via either a distal gastrectomy with gastroduodenostomy (Billroth I reconstruction) or with gastrojejunostomy (Billroth II reconstruction) to definitively rule out a malignancy. The initial management of a gastric ulcer consists of antimicrobial therapy directed against H pylori. Indications for surgical intervention are hemorrhage, perforation, disease refractory to medical therapy, and inability to rule out a malignancy. Only ulcers associated with acid hypersecretion require a vagotomy as well (type II—body of stomach, with concomitant duodenal ulcer, or type III—prepyloric). Type I (in the body and along the lesser curvature) and type IV (near the gastroesophageal junction) ulcers do not require vagotomy.
A 52-year-old man with a family history of multiple endocrine neoplasia type 1 (MEN1) has an elevated gastrin level and is suspected to have a gastrinoma. Which of the following is the most likely location for his tumor?
:Ninety percent of gastrinomas are located within the gastrinoma triangle—the 3 corners of the triangle are defined by the junction of the second and third portions of the duodenum, the junction of the neck and body of the pancreas, and the junction of the cystic and common bile duct.
A 36-year-old man is in your intensive care unit on mechanical ventilation following thoracotomy for a 24-hour-old esophageal perforation. His WBC is markedly elevated, and he is febrile, hypotensive, and coagulopathic. His NG tube fills with blood and continues to bleed. Which of the following findings on upper endoscopy would be most suspicious for stress gastritis?
Stress ulceration refers to acute gastric or duodenal erosive lesions that occur following shock, sepsis, major surgery, trauma, or burns. These lesions tend to be superficial and can involve multiple sites. Unlike chronic benign gastric ulcers, which are generally found along the lesser curvature and in the antrum, acute erosive lesions usually involve the body and fundus and spare the antrum. McClelland and associates showed that patients subjected to trauma and subsequent hemorrhagic shock do not have increased gastric secretion, but rather show decreased splanchnic blood flow. Ischemic damage to the mucosa may therefore play a role.
A 54-year-old man presents with sudden onset of massive, painless, recurrent hematemesis. Upper endoscopy is performed and reveals bleeding from a lesion in the proximal stomach that is characterized as an abnormally large artery surrounded by normal-appearing gastric mucosa. Endoscopic modalities fail to stop the bleeding. Which of the following is the most appropriate surgical management of this patient?
The patient has a Dieulafoy lesion. It is characteristically located within 6 cm distal to the gastroesophageal junction. Dieulafoy lesion typically consists of an abnormally large submucosal artery that protrudes through a small, solitary mucosal defect. For unclear reasons, the lesions may bleed spontaneously and massively, in which case they require emergency intervention. Upper endoscopy is usually successful in localizing the lesion, and permanent hemostasis can be obtained endoscopically in most cases with injection sclerotherapy, electrocoagulation, or heater probe. If surgery is required, a gastrotomy and simple ligation or wedge resection of the lesion may be adequate. No large series have yet established the optimal surgical treatment for Dieulafoy lesion; however, acid-reducing procedures have not been successful in preventing further bleeding.
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