(BQ) Part 1 book Nutshell series for general surgery presents the following contents: Basics in general surgery, shock, blood transfusion and organ transplantation, oral cavity, trauma, head and neck (general), salivary glands, thyroid disorders, parathyroids and adrenal glands, breast disorders, diseases of esophagus, stomach and duodenum.
h tt p /: / iv p p ge ral ur S ene G t-p nee n FMGE/d b/ g Nutshell series for ry n is a r e / r i s s tahir99 - UnitedVRG h tt p /: / iv p p n is a r e / r i s s tahir99 - UnitedVRG ge S ral ur ene G nee n FMGE/d b/ R Rajamahendran MS MRCS (Edinburgh) FAGE FMAS Dip Lap MCh Surgical Gastroenterology (Postgraduate) n is a r e t-p g Nutshell series for ry / r i s s Madras Medical College, Chennai, Tamil Nadu, India p p iv n Founder and Faculty Koncpt Postgraduate Medical Coaching Center, Tamil adu Faculty, Global Institute of Medical Sciences, China Faculty, Karol Institute of Medical Sciences, Chennai and Delhi Faculty, ADR Plexus Postgraduate Medical Coaching Center, Chennai Panchadcharam Harinath MD (Russia) tt p /: / h p Molecular athologist Senior Lecturer Liaoning Medical University China Forewords Seyed Abdul Cader D Arunkumar ® JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • London • Philadelphia • Panama tahir99 - UnitedVRG ® Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices n is a r e s s Jaypee Brothers Medical Publishers Ltd The Bourse 111 South Independence Mall East Suite 835, Philadelphia, PA 19106, USA Phone: + 267-519-9789 Email: joe.rusko@jaypeebrothers.com Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Jaypee Brothers Medical Publishers (P) Ltd Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: jaypee.nepal@gmail.com tt p h Website: www.jaypeebrothers.com Website: www.jaypeedigital.com /: / iv p Jaypee-Highlights edical ublishers Inc City of Knowledge, Bld 237, Clayton Panama City, Panama Phone: +507-301-0496 Fax: +507-301-0499 Email: cservice@jphmedical.com m J.P Medical Ltd 83, Victoria Street, London SW1H 0HW (UK) Phone: +44-2031708910 Fax: +02-03-0086180 Email: info@jpmedpub.com p p / r i © 2013, Jaypee Brothers Medical Publishers All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com This book has been published in good faith that the contents provided by the authors contained herein are original, and is intended for educational purposes only While every effort is made to ensure accuracy of information, the publisher and the authors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work If not specifically stated, all figures and tables are courtesy of the authors Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device S Nutshell series for FMGE/DNB/NEET-PG—General urgery First Edition : 2013 ISBN 978-93-5090-505-0 Printed at tahir99 - UnitedVRG Dedicated to my dear friend tt p /: / iv p p n is a r e / r i s s Late Dr S Karthikeyan, MD, Anesthesia h M Also my parents, wife and children and Especially to the students of Zhengzhou edical University, Zhengzhou, China who really motivated me to write the book tahir99 - UnitedVRG h tt p /: / iv p p n is a r e / r i s s tahir99 - UnitedVRG Foreword / r i I I M KIMS Being the Academic director of karol institute of medical sciences ( ), which has coached thousands of students in preparation for the C screening tests and postgraduate entrance examination with a very good track record of successful candidates since 2005, felt this book to be very concise, illustrative and with a very simple and systematic narrative s s The authors have gone into laborious and painstaking work in bringing out this book They both have a spectacular flare in teaching students and to make them understand the subject conceptually After going through the book, I felt both elated and satisfied at the same moment n is a r e h tt p I eyed Abdul Cader md D irector karol institute of medical sciences Chennai, Tamil Nadu, ndia I /: / iv p p S M I highly recommend this book for F GE and NEET candidates as these materials have already been successfully used for our students in their preparation for the examinations wish them the very best in their efforts to create a knowledgeable and conceptually educated medicos tahir99 - UnitedVRG h tt p /: / iv p p n is a r e / r i s s tahir99 - UnitedVRG Foreword / r i The need for an easily understandable, concise and illustrated guide in surgery has been felt by all concerned at different levels of the medical field in India n is a r e s s M M M I M Dr Rajamahendran and Dr Harinath are highly qualified and experienced faculties teaching in our Academia Grandiosa edicinae (AG ) which is renowned for F GE and PG E teaching programs since 2008 Their unique way of presentation and materials made a quick impact among students and gasped number of students across ndia M KIMS D M M Authors association with AG , A R-Plexus and successfully taught for more than 3000 students yielded in more 750 toppers in F GE and more than 500 toppers in various PG Es till now D Arunkumar md I D D D M p Associate rofessor Academic director Academia Grandiosa edicinae New elhi, ndia irector A R-Plexus Chennai, Tamil Nadu, ndia I h tt p /: / iv M p p M I I I t gives me an immense pleasure to know that these two authors have been endeavored to author an illustrated guidebook in surgery assure this book will be an essential aid for successful exam-preparation and highly recommend it for F GE, NEET-PG and other PG Es tahir99 - UnitedVRG h tt p /: / iv p p n is a r e / r i s s tahir99 - UnitedVRG 11 a An tomy uodenum D Stomach and Stomach is subdivided into two parts Largest cardiac part is divided into Cardia Fundus Pylorus by a line drawn downwards and to the left from incisura angularis Body Incisura angularis is the junction between the vertical and horizonSmallest pyloric part is divided into tal parts on the lesser curvature side of `J’-shaped stomach Pyloric antrum Vein of Mayo is the landmark for pyloro duodenal junction Pyloric canal Blood supply N • Left gastroepiploic artery (branch of splenic artery) • to short gastric vessels from splenic artery erve supply l • Parasympathetic supply: Vagus nerve branches Anterior gastric nerve (Left) Hepatic branch Gastric branches Crow’s foot (Nerve of atarjet) Posterior gastric nerve (Right) Criminal nerve of Grassi Crow’s foot Celiac branch • Left gastric artery (branch of celiac trunk) • Right gastric artery (branch of common hepatic artery) • Right gastroepiploic artery (branch of gastroduodenal artery) Contd tahir99 - UnitedVRG 104 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery Contd a An tomy Lymphatic drainage s l p Pe tic u cer di e e C • 'Peptic ulcer is an imbalance between acid, pepsin and mucin’ • Sites: Stomach Duodenum Lower end of esophagus Meckel’s diverticulum with ectopic gastric mucosa Jejunal site of gastrojejunal anastomosis as • The lymphatic drainage of the stomach consists of four zones as follows: Zone I (inferior gastric): Drains into the subpyloric and omental nodes Zone II (splenic): Drains into the pancreaticosplenic nodes Zone III (superior gastric): Drains into the superior gastric nodes Zone IV (hepatic): Drains into the suprapyloric nodes ommonest sites • Stomach: Lesser curve side of stomach close to incisura angularis • Duodenum: First 2.5 cm of duodenum (most common) Classifications Chronic: Johnson classification • Single • Multiple (Erosions) Type I: Lesser curve gastric ulcer Type II: Combined gastric and duodenal ulcer [dual (or) stasis ulcer] Type III: Prepyloric ulcer (stasis) Type IV: Proximal stomach within a cm from esophagogastric junction ot involves muscularis propria, but ulcer involves muscularis layer also tiology of duodenal ulcer Hyperacidity: Neurological: Type 'A’ personality with anxiety, hurry, worry characters due to vagal stimulation Nonsteroidal anti-inflammatory drugs (NSAIDs): Unusual ulcer Multiple recurrence Unusual site (jejunum, postbulbar) Unusual type Not responds to treatment E hink of Zollinger- llison syndrome if there is E T • Erosion: n Acute Contd tahir99 - UnitedVRG 105 Stomach and Duodenum s l tiology of gastric ulcer e E E p Pe tic u cer di e as Contd Genetic causes: Blood group O—more prone for peptic ulcer Blood group A—more prone for carcinoma stomach Food habits: Smoking, spicy foods, spirit precipitate peptic ulcer Helicobacter pylori: Endocrinal causes: Zollinger-Ellison syndrome; hyperparathyroidism No hyperacidity is seen, ulcer occurs due to defective gastric mucosal barrier NSAID: Damage gastric mucosal barrier Food habits: Similar to duodenal ulcer tiology of duodenal ulcer Features Duodenal ulcer Gastric ulcer Incidence Common Less common Site First part Lesser curve Pain Relieved by food Relieved by vomiting Vomiting Never occurs unless GOO occurs Occurs after every meal Periodicity Common Less common Hematemesis : melena ratio 40 : 60 60 : 40 Built Well built Ill built Tenderness Duodenal point Mid epigastrium Malignancy Never occurs 0.5 to 5% incidence Surgical and treatment Truncal vagotomy with gastrojejunostomy Gastrectomy Helicobacter Pylori infection Type `A’ gastritis Ca stomach in fundus area epeated MC R N nvasive Rapid urease test—result in hours Histology by staining with silver, Giemsa or Genta Culture takes about 3–5 day for result Serology ELISA—test of choice for initial diagnosis Urea breath test (C13 and C 14) method of choice to document eradication ot associated with Associations of H pylori Peptic ulcer (Gastric and duodenal) Ca stomach MALTOMA and even diffuse large cell type a low grade lymphoma Non-ulcer dyspepsia Type 'B' gastritis nvestigations oninvasive I N I • Gram-negative, spiral-shaped bacilli • Organism gets localised deep beneath the mucus layer closely adherent to the epithelial surface • Here the surface pH is close to neutral and any acidity is buffered by the organisms production of the enzyme urease Urease enzyme produces ammonia from urea and raises the pH (alkaline) around bacterium Hence, gastric secretion is increased stimulating the acid level though local alkalinity maintained • H pylori exclusively colonises gastric type epithelium and is only found in the duodenum in association with patches of gastric metaplasia • Around 90% patients of duodenal ulcer and 70% of gastric ulcer are infected with H pylori q’s from H pylori • For H pylori the best noninvasive investigation to diagnose the presence: Serology • The best investigation to diagnose eradication: C13 and C14 urea breath test • The best invasive investigation to diagnose: Rapid urease test • The stain used for H pylori: Giemsa or Warthin-Starry stain tahir99 - UnitedVRG Nutshell Series for FMGE/DNB/NEET-PG—General Surgery ype-B gastritis Reflux gastritis E ype-A gastritis T T 106 rosive gastritis Antrum is not affected* Atrophy of parietal cell mass leads to hypochlorhydria and decrease of intrinsic factor Predisposes to gastric cancer* Antrum is affected Predisposes to peptic ulcer Antrum is affected Does not give rise to peptic ulcer disease Entire stomach affected Treated by H2 blockers or proton pump inhibitors Treat by prokinetics C NSAID induced After gastric surgery or cholecystectomy H pylori associated Autoimmune; antibodies to parietal cell omplications of peptic ulcer disease Gastric outlet obstruction: Peptic ulcer: No mass palpable Ca stomach: Mass palpable Metabolic disturbances: Hypochloremic, hypokalemic, hyponatremic, metabolic alkalosis with paradoxical renal aciduria Deformities of stomach: a Teapot deformity: Long-standing lesser curve ulcer b Hourglass contraction: Saddle-shaped ulcer in lesser curve Malignancy: Gastric ulcer: 0.5% to 5% Duodenal ulcer never turns malignant Perforation: Anteriorly-located peptic ulcer perforates Penetration: Ulcer located posteriorly may penetrate into pancreas or produce hemorrhage Artery of hemorrhage: Gastroduodenal artery If the ulcer is from stomach: The bleeding occurs from splenic artery Dyspepsia Upper gastrointestinal bleeding: Melena, anemia M edical treatment • The antiulcer drug used for H pylori eradication— colloidal bismuth subcitrate • The most potent H2 blocker—famotidine • The H2 blocker that induces microsomal enzymes— cimetidine • The drug of choice for stress gastric ulcers—H2 blockers • The drug of choice for NSAID induced ulcer—omeprazole • The specific drug for NSAID induced ulcer—misoprostol [Prostaglandin E1 (PGE1) analogue] Surgical treatments l u cer Hill procedure (selective vagotomy) Truncal vagotomy with antrectomy High selective vagotomy Taylor procedure (selective vagotomy) ayos operation Selective vagotomy Taylor procedure Posterior truncal vagotomy with anterior lesser curve seromyotomy No need of drainage procedure Hill procedure Anteriorly highly selective with posterior truncal vagotomy ○ Truncal vagotomy with posterior vertical retrocolic isoperistaltic no loop no tension gastrojejunostomy : (Mayo’s GJ) ○ Gastrojejunostomy is the drainage procedure because the nerve to pylorus is cut and hence the motor action of pylorus is lost and may go for stagnation ○ Heinke Mickulicz Pyloroplasty: Pyloroplasty is a procedure to drain the stomach instead of gastrojejunostomy (GJ) M Truncal vagotomy with gastrojejunostomy(Mayo’s GJ) Truncal vagotomy with pyloroplasty uoden al ○ Truncal vagotomy first performed by Dragstaedt D ○ Gastrectomy first performed by Billroth Contd tahir99 - UnitedVRG 107 Stomach and Duodenum u cer l uoden al D Contd High selective vagotomy • In this procedure only the gastric branches (parietal cell) are cut; preserving the nerve of atarjet (crow’s foot) supplying the pylorus • Hence no need of drainage procedure* ecurrence ortality M Procedure R l Advantages of HSV: More physiological with minimal disturbances No drainage procedure is required because pyloric function is preserved Nerve supply to gallbladder and liver are not disturbed No diarrhea which occurs in 5.8% of cases of truncal vagotomy • Disadvantage: High incidence of recurrence (20%) TV with antrectomy 1% * (least recurrence)* TV with GJ 5% 1% Bile stasis + < 1% < 0.2% s s G a ic tion of urgery B D astric resection and anastomosis Iron deficiency anemia due to loss of gastric juice for iron absorbtion Diminished splitting of Fe++protein complex due to reduced pepsin activity Macrocytic anemia due to loss of intrinsic factor leading to B12 deficiency In polya type hypocalcemia occurs; since duodenum is excluded from food absorption (Note: Duodenum is the main site for calcium absorption)* Bone disease (Osteomalacia) Weight loss; anemia: Bile stasis Gallstones Postvagotomy diarrhea Stump carcinoma: Hypoacidity leads to bacterial proliferation and nitrates production Recurrence: pl 5%–10% 2%–10% C Selective vagotomy A ue to vagotomy + < 1% HSV om Side effects E Postcibal syndrome arly dumping • After meals; small bowel gets filled with food stuff Osmotic overload leads to sequestration of fluid from circulation into gastrointestinal tract This leads to vasomotor and abdominal symptoms due to hypovolemia • Occurs immediately • Diagnosed by increased packed cell volume Treatment: • Small, dry meals • Octreotides (analogues of somatostatin) • Revision surgery : Roux-en-Y reconstruction Late dumping • After meals; carbohydrate load causes a rise in plasma glucose level; results in increased insulin release that leads to reactive hypoglycemia • 2nd hour after meals • Diagnosed by measuring blood glucose level Treatment: • Octreotide is effective (side effect: gallstone formation) • Same as for early dumping Contd tahir99 - UnitedVRG 108 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery Contd s s a ic tion of urgery pl C om ue to gastrojejunostomy D C Duodenal stump blow out Afferent loop syndrome Obstruction of afferent loop that cannot empty its contents Partial obstruction: Bilious vomiting Total obstruction: Perforation of loop Bile vomiting Small stomach syndrome: Early satiety Diarrhea: • Frequent loose stools • Intermittent episodes of short lived diarrhea • Severe intractable explosive diarrhea • Etiology is uncertain Gastrojejunocolic fistula GJ colic fistula is best diagnosed by Barium enema* not by barium meal cer Ul R s u e of ecurrent s Ca Stomal obstruction Retrograde jejunal intussusception Narrow stoma Zollinger-Ellison syndrome Hyperparathyroidism Incomplete vagotomy Gastrojejunostomy alone Inadequate gastrectomy h a s Ca ncer tom c H pylori predisposes to Smoking Spirit Spicy foods Salted foods Helicobacter pylori Postgastrectomy/vagotomy (due to achlorrhydria) Bile reflux (as in Billroth II causes stump carcinoma) • Nonulcer dyspepsia • Type `B’ gastritis • Duodenal ulcer • Gastric ulcer • Carcinoma body and antrum (not for carcinoma in cardiac end) • MALT lymphoma Predisposing factors Premalignant factors • Atrophic gastritis (Type A autoimmune and B—H pylori associated) • Biliary gastritis • Chronic gastric ulcer • Hypogammaglobulinemia • Group A blood • • • • Serological marker Site • The only reliable marker in patients with Ca stomach is CA 72-4 • Most common clinical presentation is recent dyspepsia in a patient aged 45 year and above Most common in the antrum lesser curve side Higher groups it is most common in the proximal stomach s ty e p al l s Hi to ogic Gastrinoma Adenomatous polyp (38%), hyperplastic polyps (< 2%) Pernicious anemia Menetrier’s disease (protein losing enteropathy with hypertrophy of gastric mucosa) Undifferentiated Lymphomas Leiomyosarcoma Adenocarcinoma (commonest) Adenosquamous Squamous I Advanced gastric cancer: Bormann classification • Polypoid • Ulceroproliferative • Ulcerative • Diffuse Contd tahir99 - UnitedVRG 109 Stomach and Duodenum Contd s p ty e al l s Hi to ogic II Early gastric cancer: Japanese classification • Protruded • Superficial Elevated • Excavate Flat Depressed ntestinal D Histology I Laurens classification iffuse Areas of intestinal metaplasia Normal gastric mucosa Early cancer Protruding Flat (depressed/excavated) Infiltration Localized Diffuse Peritoneal dissemination Infrequent Frequent Hepatic metastasis Nodular Diffuse Sex incidence Males more common Females more common Age incidence Elderly Young Group A – + Pernicious anemia – + Genetic predisposition – + H pylori association + + Prognosis Good Bad* Spread methods Direct spread Into the layers of stomach wall Into pancreas, colon, liver and diaphargm Lymphatic spread Troisier’s sign : involvement of left supraclavicular node Transperitoneal spread Ascites Bloomer shelf (deposits in the rectovesical pouch) Sister oseph’s nodule (deposits around the umbilicus) Krukenberg tumor (deposits over the ovary, typically bilateral, cut section shows normal ovary with surface deposits)* j Hematogenous spread First to liver Uncommon in the absence of nodal metastasis Signs of inoperability • Fixation to nonremovable adjacent structures (pancreas, diaphargm) • N4 nodes re tment a T • Hematogenous metastasis • Involvement of distant peritoneum • Ascites noperable Palliative anterior gastrojejunostomy I perable Subtotal gastrectomy Antral growth Total gastrectomy Body, fundus growth I O Surgical: Find whether the tumor is operable or inoperable; noperable tumors Palliative procedures to relieve outlet obstructive symptoms Contd tahir99 - UnitedVRG 110 re tment a T Nutshell Series for FMGE/DNB/NEET-PG—General Surgery Palliative procedures Pylorus end • Tanner’s anterior gastrojejunostomy • Devines exclusion bypass, leaving tumor as such (not done nowadays) Cardia end • Stent can be kept • Laser luminization • Souttar’s tube Ultimately inoperable • Linitis plastica-feeding jejunostomy* Subtotal or total radical gastrectomy is treatment option for cancer stomach followed by reconstruction After subtotal gastrectomy Billroth I • Gastroduodenal anastomosis • Mobilization of 1st part of duodenum (kocherization) • Only advantage is maintenance of anatomical continuity Billroth II • Gastrojejunal anastomosis (anterior to transverse colon) • Close the proximal stump Polya: End to side anastomosis Adverse Effect of Billroth II Hypocalcemia** because calcium in diet is absorbed in the 1st part of duodenum and food is bye-passed Duodenal stump blow out MC on 4th day*(no need to intervene immediately, can be treated with USG guided drainage Bile reflux gastritis, stump carcinoma After total gastrectomy 'Esophagojejuno-duodenal anastomosis' Disadvantages: Bile reflux Food reflux Duodenal stump blow out 'Pouch formation: Hunt - Larence pouch’ Jejunum folded on itself to form the pouch Y loop—afferent loop should be small Roux loop should be 40–60 cm to avoid bile reflux Advantage: No bile reflux No food reflux Roux-en-Y loop Jejunal interposition Contd tahir99 - UnitedVRG 111 Stomach and Duodenum O ther treatment options c ECF regimen: ( unningham’s royal marsden regimen) Most effective regimen now • E – Epirubicin • C – Cisplatin • F– 5–flourouracil FAM therapy: 5-Fluorouracil Adriamycin Mitomycin C re tment a T Contd • Radiotherapy only for metastasis Pathology: Diffuse large 'B'-cell lymphoma (55%).** MALT (40%) Burkitt’s lymphoma (3%) Mantle and follicular lymphoma (< 1% each) omplications Bleeding Perforation reatment ndications for surgery in lymphoma I T • Diffuse `B’-cell type and MALT are associated with H pylori infection • Burkitt lymphoma associated with Epstein-Barr virus infection • Burkitt lymphoma is common in younger age group Most common in cardia or body* C ○ Stomach is most common* site for lymphoma in gastrointestinal tract ○ Peak incidence 6th to 7th decade ○ Most common site: Antrum* om ph Gas tric Lym a Ultimately inoperable tumors: Feeding jejunostomy Inoperable tumors in cardiac end: Souttar’s tube; stent; pylorus end—Tanner’s anterior GJ Growth in pylorus and antrum: Subtotal gastrectomy with Billroth I/II Growth in cardiac end: Total gastrectomy with jejunal interposition of Roux-en-Y loop Distant mets: Chemotherapy only S ) T GI s umor ( • Bleeding • Perforation • Fistula • Obstruction • Failure to respond to chemotherapy • Best guide to predict the biological behavior is tumor size • Surgery is the only treatment • Imatinib mesylate; inhibitor of tyrosine kinases is used now in unresectable and metastatic GIST cases ushings ulcers • They are a type of stress ulcers associated with intracranial injury or increased intracranial pressure • M/c sites are—stomach, duodenum, esophagus • Cushings ulcers are more prone to perforate than other type stress ulcers C C • Within the GIT, stomach is most common site (70%)** • UGI scopy: Mucosa overlying tumor is normal, so barium meal only can diagnose the tumor* • Histologically arise from cells of Cajal, autonomic nerve related gastrointestinal pace maker cells that regulate intestinal motility T Strom al al s tro nte tin I Gas Treatment is controversial Localised disease—surgery alone systemic disease—chemotherapy alone There is increased risk of perforation under chemotherapy CHOP regimen: Cyclophosphamide, doxorubicin, vincristine (Oncovin), prednisolone Patients with early MALT and limited B-cell lymphoma may be effectively regressed by H pylori eradication alone urlings ulcers • Seen in burns patients • Shallow multiple erosions tahir99 - UnitedVRG 112 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery D Bezoars • Trichobezoars—hair balls in stomach • Phytobezoars—vegetations in stomach • Both are seen in female, young, psychiatry patients M Acute gastric dilatation enetrier's disease • Hypertrophic gastropathy (epithelial hyperplasia and giant gastric folds)—seen in ZES and menetriers • Premalignant c/b massive gastric folds in the fundus and body of stomach giving the gastric mucosa a cobblestone and cerebriform appearance • Histology shows are foveolar hyperplasia and absence of parietal cells • Characteristically associated with Protein loss from the stomach Excessive mucous production, Achlorhydria or hypochlorhydria D • M/c follows pyloroduodenal disorders or post surgery without nasogastric suction • Stomach is atonic, dilates enormously • Patients are dehydrated and have electrolyte abnormalities • Failure to treat results in sudden vomiting with aspiration • Treat the cause, nasogastric tubes, correct electrolyte abnormalities iverticulum in stomach • M/c site are posterior aspect of cardia • M/c symptom—asymptomatic, diverticulitis causing pain or bleeding • Perforation is rare uodenal stricture • Annular pancreas • Pancreatitis • Cholecystitis astric outlet obstruction Wilkie’s disease: Superior mesentric artery syndrome Duodenum compressed between vertebral column and superior mesentric artery at 3rd part of duodenum* Common in tall, thin individuals* Common in young females* Precipitated by sudden loss of weight* May occur due to body cast application* er gi bl Upp Duodenal ulcer with cicatrisation Prepyloric ulcer with cicatrisation Antral growth with obstruction Carcinoma head of pancreas Annular pancreas Hypertrophic pyloric stenosis (congenital) Duodenal atresia in children Chronic pancreatitis Trichobezoar 10 Superior mesentric artery syndrome G • Peptic ulcer disease • Crohns • Tuberculosis • Cancer head of pancreas eeding • Duodenal ulcer MC in world* • Gastric ulcer • Esophageal varices MC in India* • Gastritis • Mallory-Weiss tear • Ca ctomach (least common) • Of the tumors in stomach, GIST will bleed more commonly* ○ Presents with hematemesis and melena ○ About 60 mL is enough to cause melena ○ Bleeding from proximal to ligament of Trietz m M/c site of ca stomach—antrum on lesser curve /c symptom of ca stomach—weight loss Earliest symptom of ca stomach—vague postprandial heaviness Treatment of resectable tumor at cardia— esophagogastrectomy with splenectomy tahir99 - UnitedVRG 113 arly gastric cancer C E Stomach and Duodenum • Limited to mucosa, submucosa irrespective of lymph node status • Diagnosed by chromoendoscopy • If size < cm and no nodes involved submucous resection is curative • Good prognosis • 10% cases have nodes involved in EGC auses of hypergastrinemia • Pernicious anemia • ZES • G-cell hyperplasia • GOO • Retained antrum • Massive small bowel resection • Renal insufficiency Pernicious anemia: Autoantibodies against parietal cells that produce HCl ○ In all said above conditions, hypergastrinemia is associated with increased acid except pernicious anemia*** which has achlorhydria ○ Pernicious anemia is premalignant with gastric cancers arising in different manner** like ps o y l p al l it e i h Ep Multicentric Low-grade malignancy Polypoid Fundus or cardia Types: Hyperplastic polyps MC type of polyp 75%** (but Bailey and love says metapalstic polyps are most common) Adenomatous polyps 2nd common, high malignant potential*** Hamartamatous Inflammatory Heterotopic EM S s s s l p ic y oric teno i T • Metabolic alkalosis due to severe vomiting • Lump is not always palpable • Non-bilious vomiting increasingly projectile may also be non-projectile* • Constipation may occur in long-term reatment Fluid resuscitation Metabolic correction Ramstedt’s pyloromyotomy*: Pyloric mass is split horizontally without penetrating the mucosa RO BL • Gross hypertrophy of musculature of pylorus and adjacent antrum • Incidence—3 in 1,000 live births • M/c surgical cause of vomiting in infants • M > f [4:1]* • First-born male infants are characteristically affected more* • M/c age of presentation—4 week* • Palpation of a olive live structure in right upper quadrant • USG—accurate in 95% ph y ertro p h al C ongenit P TRIC A EDI P Contd tahir99 - UnitedVRG 114 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery s s s l a rdt’ tri d s Borc p ic y oric teno i ph p y ertro h ongenit al C Contd • Seen in gastric volvulus • Characterised by absence of vomiting** and triad of symp• Stomach can rotate and go for volvulus either in organotoms (Borchardt’s triad) axial or mesentrico-axial Sudden onset of constant retching pain Recurrent retching Inability to pass the Ryles tube s a a B ri tric urgery ypes of bariatric surgery Jejunoileal and jejunocolic bypasses (no longer recommended) Restrictive Vertical banded gastroplasty Adjustable silicone gastric banding Mostly restrictive (and partly malabsorptive) Short-limb (50–100 cm) Roux-en-Y gastric bypass Long-limb (150 cm) Roux-en-Y gastric bypass BMI > 40 kg/sq m or 35 kg/sq m with associated medical comorbidity worsened by obesity Failed dietary therapy Psychiatrically stable Knowledgeable enough about surgery T I ndications for obesity or bariatric surgery Malabsorptive Mostly malabsorptive: Biliopancreatic diversion with or without duodenal switch Adjustable banded gastroplasty Roux-en-Y gastric bypass ○ Band wrapped at upper part of fundus with adjustable subcutaneous port ○ Early satiety occurs and it is a type of pure restrictive surgery • Y limb length 50–100 cm from ligament of Trietz • Gold standard technique in US Disadvantages Iron and vit B12 deficiency Dumping syndrome • Sleeve gastrectomy performed • 1st part of duodenum is anastomosed to ileum • 2nd part of duodenum and remaining jejunum are allowed to anastomose at terminal 100 cm of ileum • Thus, digestive enzymes from 2nd part are allowed to join at terminal ileum 100 cm, hence malabsorption occurs • Main advantage—decreased Dumping syndrome D BP with duodenal switch • Distal gastrectomy performed and 200 cm of jejunum with ileum is anastomosed to stomach remains (150 m ) • Duodenum and its contents (Bile and pancreatic juice) are allowed to join in a common 50 cm of terminal ileum • Hence, partly restrictive (stomach removed) and highly malabsorptive (diversion of digestive enzymes) Disadvantage: Malabsorption of fats and fat-soluble vitamins l Biliopancreatic diversion without duodenal switch tahir99 - UnitedVRG 115 s Trichobezoar is pathological ingestion of: (March 2009) a Vegetable matter b Hair c Coins d Stones Ans: b (Hair) Explanation: Trichobezoar—hair; Phytobezoar—Vegetables Which of the following is not true for ZollingerEllison syndrome: (Sep 2010) a Recurrence after operation b Reduced BAO : MAO ratio c Gastrin producing tumor d Diarrhea may be a presenting feature Ans: b (Reduced BAO : MAO ratio) Commonest operation done for gastric outlet obstruction with peptic ulcer is: (Sep 2010) a Truncal vagotomy with gastrojejunostomy b Truncal vagotomy with pyloroplasty Metabolic disturbance seen with pyloric stenosis: (Sep 2009) a Hypokalemic hyponatremic alkalosis b Hyperkalemia c Hyperchloremic acidosis d Hypematremia Ans: a (Hypokalemic hyponatremic alkalosis) Explanation in topic Commonest cause of peptic ulcer disease: (Sep 2008) a NSAID ingestion b Smoking c H pylori d Genetic factors Ans: c (H pylori) Explanation (Page: 1054; Bailey and Love; 25th Edition) • It is now widely accepted that H pylori is the most important risk factor in development of peptic ulceration c Highly selective vagotomy with pyloroplasty d Gastrojejunostomy Ans: a (Truncal vagotomy with gastrojejunostomy) Explanation in topic Dumping syndrome is characterized by all of the following except: (Sep 2007, 2010) a Colic b Tremors and giddiness c Hyperglycemia d Epigastric fullness Ans: c (Hyperglycemia) Features of early dumping syndrome: • Due to hypovolemia • Characterised by epigastric fullness, sweating, light headedness, tachycardia, colic and sometimes diarrhea Features of late dumping: • Due to reactive hypoglycemia • Characterised by tremor, faintness and prostration s que tion FMGE Stomach and Duodenum tahir99 - UnitedVRG 116 Nutshell Series for FMGE/DNB/NEET-PG—General Surgery 16 A posteriorly perforating ulcer in the pyloric antrum of the stomach is most likely to produce initial localized peritonitis or abscess formation in the following: (March 2003) a Omental bursa (lesser sac) b Greater sac 10 Curling’s ulcer are associated with: (March 2009) a Patient with gastrinoma b Head injuries c Burns d Analgesic overdosage Ans: c (Burns) 15 In gastric outlet obstruction in a peptic ulcer patient, the site of obstruction is most likely to be: (March 2009) a Antrum b Duodenum c Pylorus d Pyloric canal Ans b (1st part of duodenum) Hypochloremic alkalosis is seen in: (March 2008, 2010) a Achalasia cardia b Congenital hypertrophic pyloric stenosis c Ureterosigmoidostomy d Diarrhea Ans: b (Congenital hypertrophic pyloric stenosis) 14 All the following indicates early gastric cancer except (March 2009, 2010) a Involvement of mucosa b Involvement of mucosa and submucosa c Involvement of mucosa, submucosa and muscularis d Involvement of mucosa, submucosa and adjacent lymph nodes Ans c (Involvement of mucosa, submucosa and muscularis) • Early gastric cancer is involvement of mucosa and submucosa with or without lymph nodes (Sep 2006) Sister Joseph nodules are present at: a Umbilicus b Diaphragm c Lung d Liver Ans: a (Umbilicus) Which of the following plays a major role in the development of early dumping syndrome: (March 2006) a Vagolytic mechanism b Smaller stomach c Excessive food in the stomach d Large volume of hyperosmotic fluid in the intestine Ans: d (Large volume of hyperosmotic fluid in the intestine) 13 In case of hypertrophic pyloric stenosis, the metabolic disturbance is: (March 2010) a Respiratory alkalosis b Metabolic acidosis c Metabolic alkalosis with paradoxical aciduria d Metabolic alkalosis with alkaline urine Ans: c (Metabolic alkalosis with paradoxical aciduria) • The ratio of BAO : MAO= : normal • The ratio of BAO : MAO : decreased in ZES • Basal acid output in ZES is already high, so maximum acid output will not be so high compared to BAO Hence the ratio of BAO : MAO is reduced 12 Risk factor for development of gastric cancer: (March 2010) a Blood group O b Duodenal ulcer c Intestinal hyperplasia d Intestinal metaplasia type III Ans: d (Intestinal metaplasia type III) Normal Duodenal ulcer Gastric ulcer Zollinger-Ellison syndrome Peak acid output (after acid stimulation) Pentagastrin test (mmol/hr) 25–27 35–38 15 60% of maximal – acid output Basal acid output (mmol/hr) 11 The lowest recurrence of peptic ulcer is associated with: (March 2009) a Gastric resection b Vagotomy + drainage c Vagotomy + antrectomy d Highly selective vagotomy Ans: c (Vagotomy + antrectomy) e Explanation: Gastrinoma (Zollinger-Ellison syndrome) • Normal gastrin level < 150 pg/mL • Basal acid output: 15 m q/hr • Secretin stimulation—increases the gastrin secretion > 200 pg/mL • Fasting gastrin > 1000 pg/mL is highly suggestive tahir99 - UnitedVRG 117 Stomach and Duodenum 21 Which of the following plays a major role in Dumping syndrome? (Sep 2009) a Hypoglycemia b Glucagon 24 Sister Mary Joseph nodule is most commonly seen with: (March 2011) a Ovarian cancer b Stomach cancer c Colon cancer d Pancreatic cancer Ans: b (Stomach cancer) d 20 Which of the following produces hypochloremic alkalosis? (Sep 2009) a Pyloric stenosis b Cancer stomach c Achalasia cardia d iarrhea Ans a (Pyloric stenosis) 23 In pyloric stenosis, the following changes are seen: (March 2011) a Hypokalemic hyponatremic metabolic alkalosis b Hyperkalemia c Acidosis with hyponatremic alkalosis d Hyperchloremic acidosis Ans: a (Hypokalemic hyponatremic metabolic alkalosis) 19 Metabolic disturbance in pyloric stenosis: (March 2007) a Hyperchloremic metabolic acidosis b Hyperchloremic metabolic alkalosis c Hypochloremic metabolic acidosis d Hypochloremic metabolic alkalosis Ans: d (Hypochloremic metabolic alkalosis) 18 Cushing’s ulcers in stomach are due to: (March 2009) a Burns b Head injury c Stress d b and c Ans: d (b and c) 22 The morphological features of benign gastric ulcer are all, except: (Sep 2008) a Convergence of mucosal folds b Presence of peristalsis c Local aperistalsis d Healing tendency Ans: c (Local aperistalsis) Features of benign gastric ulcer on endoscopy: • Convergence of mucosal folds • Peristalsis around the ulcer is normal Features of malignant ulcer on endoscopy: • Loss of convergence of mucosal folds • Local aperistalsia • Ulcer > cm diameter • Ulcer on greater curvature • Ulcer base containing slough/necrotic tissue 17 Dumping syndrome is characterized by all, except: (Sep 2005) a Hyperglycemia b Numbness c Giddiness d None Ans c (Giddiness) c CCK d All the above Ans: a (Hypoglycemia) c Right subphrenic space d Hepatorenal space (pouch of Morrison) Ans: a (Lesser sac) tahir99 - UnitedVRG ... System 14 4 bd 12 1 bd bd b V Hirschsprung’s Disease 11 8 Meckel Diverticulum 11 8 Diverticular Disease 11 9 Polyps 11 9 Colonic Cancer 11 9 Percentages 12 0... Stomach 10 8 Histological Types 10 8 Gastric Lymphoma 11 1 Gastrointestinal Stromal Tumor (G Upper G Bleeding 11 2 Epithelial Polyps 11 3 Congenital Hypertrophic Pyloric Stenosis 11 3 Borchardt’s Triad 11 4... New Delhi 11 0002, India Phone: + 91- 11- 43574357 Fax: + 91- 11- 43574 314 Email: jaypee@jaypeebrothers.com Overseas Offices n is a r e s s Jaypee Brothers Medical Publishers Ltd The Bourse 11 1 South