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63 Cards in this Set
- Front
- Back
secrete pepsinogen
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chief cells
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1st enzyme in proteolysis
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pepsinogen
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Releases H+ and intrinsic factor
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parietal cells
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Name 3 that causes HCl release
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ACh, gastrin and histamine
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which acts on phospholipase to secrete HCl?
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ACH and Gastrin
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What acts on adenylate cyclase ?
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Histamine to produce cAMP which activates protein kinase A
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4 that inhibits parietal cells
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Somatostatin, PGE1, secretin, CCK
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Type of cells found in antrum
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G and D cells
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Role of G cells
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release gastrin
inhibited by acid in duodenum stimulated by amino acids and ach |
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Role of D cells
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secrete somatostatin
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stimulates release of somatostatin, CCK, and secretin
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duodenal and antral acidificaiton
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causes of increased acid and gastrin
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ZES
antral cell hyperplasia retained antrum renal failure gastric outlet obstruction short bowel syndrome |
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causes of increased gastrin and nl/decreased acid
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pernicious anemia
chronic gastritis gastric CA postvagotomy medical acid supression |
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rapid gastric emptying causes
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#1 previous surgery
ZES ulcers |
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B1/2 vs RYGJ
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more marginal ulceration and diarrhea
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what is Dieulafoy's ulcer
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vascular malformation
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Menetrier's disease
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mucous cell hyperplasia
increased rugal folds |
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Gastric volvlus is a/w?
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Type 2 paraesophageal hernia
usually organoaxial management --> reduction and nissen |
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All vagotomies result in ?
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increased liquid emptying
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Truncal vs selective vs highly selective vagotomy
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decreased solid emptying except in highly seelctive
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effect of pyloroplasty
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increased solid empyting
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Effects of truncal vagotomy
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90% reduction in acid output
increased gastrin gastrin cell hyperplasia decreased exocrine pancreas function decreased postprandial bile flow increased GB volumes |
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MC problem following vagotomy
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diarrhea due to sustained MMcs forcing bile acids into colon
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Chance of rebleeding with
1) Spurting blood vessel 2) visible blood vessel 3) diffuse oozing |
1) 60%
2) 40% 3) 30% |
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Management of esophageal varices
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EGD sclerotherapy or banding --> IV vasopressin, balloon tamponade --> repeat sclerotherapy or banding --> TIPS --> esophageal stapling or portosystemic shunt
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symptoms of duodenal ulcers
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epigastric pain radiating to back that abates with eating but recurs 30mins postprandially
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Surgical options in dudodenal ulcers
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truncal vagotomy and pyloroplsaty
truncal vagotomy, antrectomy, B1 or B2 recon (best for prevention of recurrence) Proximal or highly selective vagotomy - lowest rate of postop complications, 10% recurrence no antral or pylorus procedure needed |
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surgical options for bleeding duodenal ulcer
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1st duodenostomy
GDA ligation plus vagotomy and pyloroplasty if pt had been on PPI |
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Initial management of obstruction from duodenal ulcer
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serial dilation
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obstructing duodenal ulcer near Amp of vater
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B2, antrectomy and vagotomy
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obstructing duodenal ulcer prosimal to amp of vater
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antrectomy with ulcer excision, B2 and vagotomy
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best surgical option for perforated duodenal ulcer
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G patch and highly selective vagotomy if pt had been on PPI
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Other options for perforated duodenal ulcer
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truncal vagotomy and pyloroplasty
TV and antrectomy with B1 or B2 need to include ulcer |
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Intractable duodenal ulcer
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>3 months of PPI without relief
recurrence <1 year after medical therapy based on EGD not symptoms?` |
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Management of pancreatic tumors causing ZES that's <2cm
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enucleation
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test for ZES
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secretin causes high gastrin
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Management of unresectable ZES
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total gastrectomy
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RF for gastric ulcers
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male
tobacco ETOH NSAIDs H. Pylori uremia stress (burns, sepsis, trauma) steroids chemo |
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which types of gastric ulcers have normal acid secretion?
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Type 1 and 4
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Most gastric ulcers are located on
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lesser curve
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T/F bleeding gastric ulcers are a/w higher mortality than duodenal
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true
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biopsy for H. Pylori needs to be from where?
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antrum
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What blood type is associated with type 1 gastric ulcers
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A
type O a/w type II-IV ulcers |
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surgical options for all types of gastric ulcers
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1 distal gastrectomy + B1 or B2
2 & 3 - distal gastrectomy, B1/B2, + truncal vagotomy/pyloroplasty Type 4 - ulcer excision +/- highly selective vagotomy or TV + P |
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H. Pylori treatment regimen
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PPI + amoxicillin (or flagyl) + clarithromycin X 14 days
OR PPI/H2 + bismuth + flagyl + tetracycline for 10-14 days |
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RF for gastric CA
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adenomatous polyps (10-20%)
tobacco previous gastric ops intetinal metaplasia atrophic gastritis pernicious anemia type A blood nitrosamines |
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Intestinal vs diffuse gastric cancer
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blood vs lymphatic invasion
presence of glands less favorable prognosis subtotal vs total gastrectomy Chemo (5FU, doxorubicin, mitomycin C) |
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GIST
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hypoechoic on U/S (smooth edges)
chemo if >5cm? 1cm margins needed |
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How do gastric leiomyosarcomes spread?
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hematogenously
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MALT
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precursor to gastric lymphoma
should regress after H Pylori treatment if not, need CHOP |
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surgical eligibility of morbid obesity
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BMI>40 or >35 with comorbidities
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What is dumping syndrome?
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Diarrhea, dizziness, hypotension from rapid entering of carbs into SB
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Treatment of dumping syndrome
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Small low fat, low carb, increased protein meals
no liq with meals surgery rarely needed (10%) convert to RYGB |
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Name 10 complications from gastrectomy
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Dumping syndrome
Afferent loop obstruction Efferent loop obstruction Gastric atony Alkaline reflux gastritis Roux stasis Small gastric remnant Duodenal stump blowout Blind loop syndrome Postvagotomy diarrhea |
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Alkaline reflux gastritis
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postprandial epigastric pain with N/V (no relief)
evidence of bile reflux into stomach treat w/ H2 blockers, cholestyramine, reglan surgery --> convert to RYGJ |
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Roux Stasis
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Chyme stasis in roux limb due to loss of jejunal motility
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Management of Roux stasis
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reglan, prokinetics, if not shorten roux limb to 40cm
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Blind looop syndrome
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with B2 or RYGJ
pain, diarrhea, malabsorption, B12 deficiency, steatorrhea from bacterial overgrowth and stasis in afferent limb treatment: tetracycline, flagyl, reglan surgery: reanastomosis with shorter afferent limb (40cm) |
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Afferent loop Obstruction
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B2 or RYGJ
Nonbilious vomiting, pain relieved with bilious emesis EGD, dilation?, reanastomosis w/ shorter limb (40cm) |
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efferent loop obstruction
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UGI, EGD, balloon dilation
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postvagotomy diarrhea
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from nonconjugated bile salts in colon (from sustained postprandial MMCs)
cholestyramine, octreotide if not reversed interposition jejunal graft |
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What does not get absorbed in jejunum?
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Iron (duodenum)
Bile acids (ileum) B12 and folate (terminal ileum) |
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classic triad of gastric volvulus
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severe epigatric pain
retching without vomiting inability to pass NGT |