ABSITE Review ConferenceTopic Month

Alimentary July 10

Alimentary / Abdomen August 10

Head and Neck / Transplant Sept 10

Pediatric Surgery/ Critical Care Oct 10

Vascular / Pediatric Surgery Nov 11

Endocrine Dec 11

Urology/ Gynecology/ Thoracic Jan 11

Vascular / Orthopedics Feb 11

TBD Mar 11

TBD Apr 11

TBD May 11

Abdomen

The most important etiologic factor in peptic ulcer disease is:

a) Duodenogastric reflux

b) Acid hypersecretion

c) Nonsteroidal anti-inflammatory drug ingestion

d) Helicobacter pylori infection

e) Smoking

Answer D .

H. Pylori is considered the most important etiologic factor in peptic ulcer disease.

It is reportedly found in 80-90% of duodenal ulcers and 70% of gastric ulcers.

Abdomen

AbdomenH. Pylori is a helix shaped, micro-aerophilic GNR with four to six flagella.

As many as 70% of the population in developed countries harbor the infection.

Also causes acute Gastritis.

Exact mechanism of ulcer formation is unknown but it may be the production of local toxic products, induction of a local immune response, or an increase in gastrin levels leading to acid oversecretion.

Abdomen

In duodenal ulcers, the organism causes hypergastrinemia because the infection reduces antral D cells thereby reducing somatostatin levels which disinhibits G cells.

H. Pylori is a potent producer of urease (splits urea into ammonia and bicarbonate) allowing the bacteria to live in a relatively alkaline environment.

It only lives in gastric epithelium because it expresses specific adherence receptors.

Abdomen

After H. Pylori, the most important risk factors are NSAID use and smoking.

Smoking increases gastric acid secretion and duodenaogastric reflux and decreases pancreatic bicarbonate secretion.

The most common gastric polyp is:

A.Adenomatous

B.Hyperplastic

C.Hamartomatous

D.Inflammatory

E.Heterotopic

Abdomen

Answer B.

Hyperplastic polyps are by far the most common gastric polyp (70-90%).

Other types include adenomatous, hamartomatous, inflammatory, and heterotopic.

Abdomen

Hyperplastic polyps are seen with chronic atrophic gastritis which is due to H. pylori infection.

They are further divided into foveolar hyperplasia and typical hyperplastic polyps.

Polypoid foveolar hyperplasia has no malignant potential while typical hyperplastic polyps have a 2 % chance of malignancy.

Abdomen

Adenomatous polyps have the highest risk of malignancy (10-20%).

The risk of malignancy is related to size and histology (villous> tubular).

Hamartomatous, inflammatory, and heterotopic polyps do not seem to have a risk of malignancy.

Abdomen

Treatment is endoscopic polypectomy.

Surgery is indicated for sessile polyps, those > 2 cm, those with areas of invasive tumor, and those causing symptoms (bleeding or pain).

Abdomen

Bleeding from a Dieulafoy gastric lesion is due to:

A.Antral vascular ectasia

B.Abnormal gastric rugal folds

C.Ingested foreign material

D.An abnormal submucosal vessel

E.A premalignant lesion

Abdomen

Answer D.

A Dieulafoy lesion is a congential malformation in the stomach characterized by a submucosal artery that is abnormally large and tortuous.

Due to its superficial location, it may erode through the mucosa and become exposed to gastric juice leading to massive upper GI hemorrhage.

On endoscopy, the mucosa appears normal with a pinpoint defect.

Abdomen

The lesion is easily missed if bleeding is not active.

Treatment is endoscopic with electrocautery, heater probe, injection with a sclerosis agent, or clips.

Surgery which consists of a wedge resection is rarely indicated and reserved for failures.

Abdomen

Antral vascular ectasia is seen in a condition known as watermelon stomach. It is seen in elderly women with autoimmune disease.

Dilated mucosal vessels containing thrombus, mucosal fibromuscular dysplasia, and hyalinization are all prominent features.

It creates mucosal vessels with parallel lines in the mucosal folds.

Dieulafoy lesions are not premalignant and are unrelated to ingestion.

Abdomen

The treatment for low grade early mucosa- associated lymphoid tissue lymphoma is:

A.Cytotoxic multidrug chemotherapy

B.Radiation therapy

C.Gastrectomy

D.Antibiotics

E.Combined chemoradiation therapy

Abdomen

Answer D.

Low grade MALT lymphoma develops in association with H. pylori infection producing a lymphoid infiltrate.

B cells proliferate due to immunogenic stimulation.

The infection releases toxic free radicals by neutrophils that may trigger malignant B cell transformation.

Abdomen

Initial treatment of MALT lymphoma is with antibiotics targeted towrds H. pylori.

Remission is achieved in 79% with antibiotics alone.

For those that persist, treatment with standard lymphoma chemotherapy (CHOP- cyclophosphamide, doxorubicin, vincristine, prednisone) is indicated.

Abdomen

Factors that predict response to antibiotics include depth of invasion on EUS, high grade lesions, spread beyond the initial location, and nodal involvement.

Overall survival rate is 80%.

Antibiotic therapy for H. pylori includes combination regimens: clarithromycin + amoxicillin, metronidazole + amoxicllin, metronidazole + tetracycline.

Abdomen

The most sensitive and specific test for gastrinoma is:

A.Basal and stimulated gastric acid outputs

B.Octreotide scan

C.Fasting serum gastrin

D.Calcium stimulation test

E.Secretin stimulation test

Abdomen

Answer E.

Abdomen

Which of the following is the procedure of choice for an intractable duodenal ulcer that fails to heal despite maximal medical therapy.

A.Truncal vagotomy and pylorplasty

B.Truncal vagotomy and antrectomy with Billroth I reconstruction

C.Truncal vagotomy and anterectomy with Billroth II reconstruction

D.Highly selective vagotomy

E.Distal gastrectomy

Abdomen

Answer D.

Abdomen

Which of the following is true about types of gastric ulcers?

A.Type II ulcers are the most common

B.Type IV ulcers occur near the GE junction

C.Type I ulcers have increased acid secretion

D.Type III ulcers are associated with decreased acid secretion

E.Type I gastric ulcers are prepyloric

Abdomen

AbdomenAnswer B.

Type I- Most common type, usually a single ulcer on the lesser curve, not typically associated with hypersecretion of acid, seen in patients infected with H Pylori or NSAID abusers.Type II- Two ulcers present (duodenal and lesser curve of stomach), strong association with hypersecretion of acid.Type III- Prepyloric ulcers, also have an association with hypersecretion of acidType IV- ulcers near the gastroesophageal junction, not associated with acid hypersecretion.

Abdomen

Which of the following is the procedure of choice for an intractable type I gastric ulcer that fails to heal despite maximal medical therapy?

A.Truncal vagotomy and antrectomy with Billroth I reconstruction

B.Truncal vagotomy and antrectomy with Billroth II reconstruction

C.HSV

D.Distal gastrectomy with Billroth I reconstruction

E.Distal gastrectomy with Billroth II reconstruction

Abdomen

Answer D.

Abdomen

A 68 year old woman presents with an upper GI hemorrhage. She has a history of ulcer disease. Upper endoscopy reveals abrisk arterial bleeding from a duodenal ulcer located on the posterior wall. Despite numerous attempts to control the bleeding endoscopically, the ulcer continues to bleed. Her hematocrit is 25%, her BP is 110/60, and her HR is 120.

Abdomen

Which is the best management option:

A.Duodentomy, oversewing the ulcer, TV and pyloroplasty

B.Duodentomy, oversewing the ulcer

C.Truncal vagotomy and antrectomy with BI reconstruction

D.Truncal vagotomy and antrectomy with BII reconstruction

E.HSV

Abdomen

Answer A.

Abdomen

A 60 year old man presents with 12 hours of severe epigastric pain that is now diffuse. He has a history of a duodenal ulcer and a biopsy 2 weeks ago was H pylori negative. He has an acute abdomen on physical exam with diffuse tenderness and guarding. Upright CXR demonstrates free air under the diaphragm. The patient is hemodynamically stable. At surgery a perforated duodenal ulcer is found.

Abdomen

Which of the following is the best management option?

A.Graham patch of the perforated duodenal ulcer

B.Graham patch of the perforated duodenal ulcer with TV and pyloroplasty

C.Truncal vagotomy and antrectomy with BI reconstruction

D.Truncal vagotomy and antrectomy with BII reconstruction

E.Graham patch of the duodenal ulcer with HSV

Abdomen

Answer E.

Abdomen

Which of the following is the most effective treatment for intractable dumping syndrome?

A.Low fat, lactose free diet

B.Serotonin antagonists

C.Low carbohydrate, high fat diet

D.Octreotide

E.Creation of a reversed jejunal segment

Abdomen

Answer D.

Abdomen

Which of the following is true regarding postvagotomy diarrhea?

A.It is effectively treated with octreotide.

B.It is improved with oral cholestyramine.

C.It is due to dumping syndrome.

D.It is best managed by creating a reversed jejunal segment.

E.It does not respond to dietary interventions.

Abdomen

Answer B.

Abdomen

AbdomenComplications of Ulcer Surgery

Early: Duodenal Stump LeakGastric RetentionAnastamotic BreakdownHemorrhage

Late: Recurrent Ulcer[10% following V & P][2 - 3% following V & A]Gastrocolic/Gastrojejunal FistulaDumping Syndrome - [1 - 2% of patients]Alkaline GastritisAnemia [30% of patients, 5 years post-op]Postvagotomy Diarrhea [5 - 10% of patients]Chronic Gastroparesis* may require a Roux-en-Y Esophagojejunostomy

The treatment for low grade early mucosa- associated lymphoid tissue lymphoma is:

A.Cytotoxic multidrug chemotherapy

B.Radiation therapy

C.Gastrectomy

D.Antibiotics

E.Combined chemoradiation therapy

Abdomen

Answer D.

Abdomen

A 45 year olf woman is undergoing an exploratory laparotomy for Zollinger Ellison syndrome. Preoperative localization studies failed to demonstrate the location of the tumor. At surgery , no obvious tumor is seen despite and extensive Kocher maneuver and careful inspection and palpation. An intraoperative US is negative.

Abdomen

The next step in the management is:

A.Closing the abdomen

B.Distal pancreatectomy and splenectomy

C.Proximal pancreaticoduodenectomy

D.Blind proximal duodenotomy

E.Blind distal duodenotomy

Abdomen

Answer D.

Abdomen

The most accurate means of determining T and N staging of gastric adenocarcinoma is:

A.Triple phase helical CT

B.Diagnostic laparoscopy

C.EUS

D.MRI with gadolinium

E.PET scan

Abdomen

Answer C.

T1: invades lamina propria

T2: invades muscularis propria

T3: invades serosa

T4: invades adjacent structures

Abdomen

TX: The main tumor cannot be assessed.

T0: No signs of a main tumor can be found.

Tis: Cancer cells are only in the top layer of cells of the mucosa (innermost layer of the stomach) and have not grown into deeper layers of tissue such as the lamina propria or muscularis mucosa. This stage is also known as carcinoma in situ.

T1: The tumor has grown from the top layer of cells of the mucosa into the next layers below such as the connective tissue (lamina propria), the muscularis mucosa, or submucosa.

T1a: The tumor is growing into the lamina propria or muscularis mucosa.

T1b: The tumor has grown through the lamina propria and muscularis mucosa and into the submucosa.

T2: The tumor is growing into the muscularis propria layer.

T3: The tumor is growing into the subserosa layer.

T4: The tumor has grown through the stomach wall and into the serosa and may be growing into a nearby organ (spleen, intestines, pancreas, kidney, etc.) or other structures such as major blood vessels.

T4a: The tumor has grown through the stomach wall into the serosa (the outer covering of the stomach), but the cancer hasn't grown into any of the nearby organs or structures.

T4b: The tumor has grown through the stomach wall and into nearby organs or structures.

Abdomen

The N staging of gastric adenocarcinoma is based on the:

A.Number of positive nodes

B.Anatomic distribution of positive nodes

C.Proximity of positive nodes to the primary tumor

D.Immunohistochemical staining of positive nodes

E.Size of the largest positive node

Abdomen

Answer A.

N1 (1-6 nodes)

N2 (7-15 nodes)

N3 (>15 nodes)

N categories of stomach cancer (2010)

NX: Regional lymph nodes cannot be assessed.

N0: No spread to nearby (regional) lymph nodes.

N1: The cancer has spread to a few (1 to 2) nearby lymph nodes.

N2: The cancer has spread to some (3 to 6) nearby lymph nodes.

N3: The cancer has spread to many (more than 7) nearby lymph nodes.

N3a: The cancer has spread to 7 to 15 nearby lymph nodes.

N3b: The cancer has spread to 16 or more nearby lymph nodes.

Abdomen

The term that best describes residual postoperative microscopic disease after gastrectomy is:

A.D1 resection

B.D2 resection

C.R0 resection

D.R1 resection

E.R2 resection

Abdomen

Answer D.

R0: resection of all gross and microscopic tumor

R1: resection of macroscopic disease but microscopic margins are positive

R2: gross residual disease is left behind

In D1 dissections only the perigastric nodes directly attached along the lesser curvature and greater curvatures of the stomach are removed (stations 1-6, N1 level):1 Right cardia lymph nodes2 Left cardia lymph nodes3 Lymph nodes along the lesser curvature4 Lymph nodes along the greater curvature4sa: lymph nodes along the short gastric vessels4sb: lymph nodes along the left gastroepiploic vessels4d:  lymph nodes along the right gastroepiploic vessels5 Suprapyloric lymph nodes6 Infrapyloric lymph nodes

An incomplete N1 dissection is labelled a D0 lymphadenectomy.D2 dissections (N2 level) add the removal of nodes along the left gastric artery (station 7), common hepatic artery (station 8), celiac trunk (station 9), splenic hilus, and splenic artery (station 10 and 11).

D3 dissections include the dissection of lymph nodes at stations 12 through 14, along the hepatoduodenal ligament and the root of the mesentery (N3 level):12 lymph nodes in the hepatoduodenal ligament13 lymph nodes on the posterior surface of the head of the pancreas14 lymph nodes at the root of the mesentery14A lymph nodes along the superior mesenteric artery14V lymph nodes along the superior mesenteric vein

Finally D4 resections add the stations 15 and 16 in the para-aortic and the paracolic region (N4 level)

Abdomen

All of the following are risk factor for gastric cancer except:

A.H. pylori infection

B.Blood group O

C.Achlorydria

D.Li-Fraumeni syndome

E.Ingestion of nitrates

Abdomen

Answer B.

Abdomen

Early gastric cancer is best defined as:

A.LN negative

B.Limited to the mucosa

C.Limited to the mucosa and submucosa with negative nodes

D.Limited to the mucosa and submucosa regardless of nodes

E.In the muscularis propria but not the serosa

Abdomen

Answer D.

Early gastric cancers are defined as limited to the mucosa and submucosa regardless of nodal status. In Japan, because of the high prevalence of gastric cancer, aggressive screening programs have led to 50% of gastric cancers detected as early. In the US, less than 25% are considered early.

LN positivity was 11.9% in one series of 400 early gastric CA patients.

Risk factors for node positivity include: Large tumor size, lymphatic vessel involvement, submucosal invasion

Nodal status is the most important predictor of survival.

Abdomen

The treatment of choice for high grade primary gastric lymphoma is:

A.Radiation therapy

B.Total gastrectomy

C.Subtotal gastrectomy

D.Chemotherapy and radiation

E.Total gastrectomy followed by chemotherapy

Abdomen

Answer D.

Abdomen

A 56 year old man presents with epigastric pain, diarrhea, and weight loss. Upper endoscopy reveals giant gastric folds in the promximal stomach. A biopsy specimen demonstrates diffuse foveolar hyperplasia with no evidence of malignancy. 24 hour gastric pH levels are consistent with achlorydria. All of the following are true regarding this condition except:

A.It is associated with hypoproteinemia.

B.It has a familial inheritance.

C.It is associated with CMV infections in children.

D.It increases the risk of malignancy.

E.It is associated with H. pylori in adults.

Abdomen

Answer B.

Menetrier’s Disease is and acquired condition with no familial predisposition.

It is associated with an in crease in TGF alpha with development of giant rugal folds and achlorydria.

Abdomen

Which of the following is true regarding post-gastrectomy bile reflux:

A.Most patients with bile in the stomach will develop reflux

B.Symptoms usually correlate with the amount of bile entering the stomach

C.In symptomatic patients, medical management is generally effective

D.Creation of RY gastrojejunostomy is an effective surgical option

E.It is more likely to occur after a BI than a BII reconstruction

Abdomen

Answer D.

Abdomen

The best test for localization of a gastrinoma is

A.MRI

B.CT

C.US

D.Octreotide scan

E.Selective angiography

Abdomen

Answer D.

More than 90% of gatrinomas have receptors for somatostatin.

Octreotide scanning is the most sensitive test for localization of a gastrinoma.

It is poor for small lesions <1.1 cm and small primary duodenal tumors. Duodenal lesions are best seen on EUS.

Abdomen

The best test to confirm eradication of H. pylori after treatment is:

A.H. pylori serology

B.Urea breath test

C.Histologic biopsy

D.Rapid urease test

E.Antral mucosal biopsy with culture

Abdomen

Answer B.

A urea breath test is the best way to confirm eradication of H. pylori.

Abdomen

Which of the following is true regarding a HSV?

A.The anterior and posterior vagal trunks are divided

B.The nerve of Grassi is spared

C.The anterior Laterjet nerve is divided

D.The crow’s feet to the antrum are spared

E.The celiac branch is divided

Abdomen

Answer D.

Abdomen

The most common metabolic disorder after gastric resection is a deficiency of:

A.Iron

B.Vitamin B12

C.Folate

D.Calcium

E.Vitamin D

Abdomen

Answer A.

Abdomen

All of the following are true regarding ZES EXCEPT:

A.It is associated with a secretory diarrhea

B.Ulcers are most commonly located in the proximal duodenum

C.It is most commonly familial

D.It is the most common functional neoendocrine tumor in MEN Type I

E.Treatment with PPIs can control symptoms in the majority of patients

Abdomen

Answer C.

Most cases are sporadic with 20% being familial.

Abdomen

A 70 year old man presents with an 8 hour history of acute abdominal pain. On examination, the patient is febrile to 101F, BP 105/70, HR 130, and has diffuse abdominal tenderness with rebound and guarding. The rectal exam is guiac positive. WBC is 16K, HCT 26. CT scan demonstrates extravastion of contrast in the proximal duodenum.

Abdomen

After resuscitation, management consists of:

A.Closure of the perforation and omental patch plus HSV

B.Closure of the perforation and omental patch via an open approach

C.Closure of the perforation and omental patch, vagotomy, duodenotomy with oversewing of the posterior ulcer, and pyloroplasty

D.Vagotomy and antrectomy with oversewing of the posterior ulcer and omental patch

E.Closure of the perforation and omental patch via laparoscopic approach

Abdomen

Answer C.

The presence of perforation and bleeding represents a kissing ulcer.

Abdomen

A 50 year old woman presents with symptoms of early satiety, nausea, vomiting, and epigastric pain. Upper endoscopy reveals a large mass of undigested food particles in the stomach that is partially obstructed pylorus. All of the following are true EXCEPT:

A.It can be treated with oral meat tenderizer

B.It can be treated with oral administration of cellulase.

C.Psychiatric treatment is critical in the long term management

D.It is more common in patients with previous gastric surgery

E.Diabetes is a risk factor

Abdomen

Answer C.

Trichobezoars have a psychiatric predisposition while phytobezoars are typically more functional in etiology.

Abdomen

Which of the following is true regarding surgical resection for gastric adenocarcinoma?

A.For cardia cancers, proximal gastric resection is preferable to total gastrectomy.

B.Splenectomy should be performed to attain adequate nodal sampling

C.Proximal and distal resection margins of 3 cm are considered adequate

D.D2 resections provide improved survivial with morbidity similar to D1 resections

E.Total gastrectomy is an acceptable option for palliation of Stage IV disease

Abdomen

Answer E.

Abdomen

A 70 year old man presents to the ED with sudden onset of severe epigastric pain associated with retching but with little vomitus. BP 140/90, HR 90. NG placement in the ER is unsuccessful. Upright CXR reveals a large gastric bubble above the left diaphragm. All of the following are true except:

A.Mesentericoaxial torsion is more common than organoaxial

B.It can lead to gastric necrosis

C.It is associated with the Borchardt triad

D.It is associated with a wandering spleen

E.It can occur without diaphragmatic defects

Abdomen

Answer A.

Abdomen

Which of the following describes the association between Sister Mary Joseph’s node and gastric cancer?

A.A metastatic left axillary lymph node

B.A metastatic left supraclavicular lymph node

C.An ovarian mass from gastric metastasis

D.Umbilical metastasis suggesting carcinomatosis

E.An anterior nodule palpable on rectal examination suggesting drop metastasis.

Abdomen

Answer C.

Abdomen

All of the following are associated with hypergastrinemia EXCEPT:

A.Retained gastric antrum

B.Hypothyroidism

C.Pernicious Anemia

D.Renal Insufficiency

E.G cell hyperplasia

Abdomen

Answer B.

Abdomen

Which of the following is true regarding gastric stromal tumors?

A.They rarely present with GI bleeding

B.They arise from smooth muscle cells

C.Malignant potential is readily determined by histologic features

D.They can be managed by laparoscopic wedge resection

E.The extent of tumor is best determined preoperatively by endoscopy

Abdomen

Answer D.

Abdomen