MCQ - GOO, duodenal atresia, CHPS, Stress ulcers, Anatomy

Duodenal obstruction is distal to the ampulla of Vater, and infants present with bilious emesis in the neonatal periodQ.

Diamond-shaped duodenoduodenostomy is the treatment of choiceQ.

• Single bubble sign - Congenital Hypertrophic Pyloric StenosisQ
• Double bubble sign - Duodenal atresiaQ, Annular pancreas
• Triple bubble sign - Jejunal atresiaQ

• • Palpation of the pyloric tumor or olive in the epigastrium or right upper quadrant by a skilled examiner is pathognomonic for the diagnosis of HPSQ.
• • If the olive is palpated, no additional diagnostic testing is necessaryQ.

• Pyloric wall thickness of at least 4 mmQ
• Channel length of at least 17 mmQ

• −−String signQ: indicating a narrowed elongated pyloric canal that does not relax is seen
• −−Shoulder signQ: caused by the hypertrophied muscle indenting the antrum
• −−Double-track signQ: caused by the redundant mucosa

• Never a surgical emergency, although dehydration and electrolyte abnormalities may present a medical emergencyQ
• Ramstedt-Fredet pyloromyotomy (cutting across the abnormal pyloric musculatureQ while preserving the underlying mucosa). If the mucosa is inadvertently opened then feeding is delayed for 48 hoursQ

CA stomachQ

1st part of the duodenumQ

• Emptying the stomach with a nasogastric tube - instill 750 mL of saline, the patient is placed in sitting position, and 30 minutes later the nasogastric tube is aspirated, normally < 400 mL should remain in the stomach, and 90% of subjects have a residue of less than 200 mL.
• The finding of > 400 mL residual saline is consistent with a diagnosis of gastric outlet obstruction

• Truncal vagotomy and antrectomyQ is the ideal procedure
• The inflammation and scarring at duodenal bulb or previous proximal duodenal surgeries prevents safe performance of an antrectomy, in this setting truncal vagotomy with drainage (Gastrojejunostomy) is the preferred approachQ

• • Gastric alkalosis is most marked with vomiting due to pyloric stenosis or obstruction because the vomitus is acidic gastric juice onlyQ.
• • Vomiting in other conditions may involve a mixture of acid gastric loss and alkaline duodenal contentsQ and the acid-base situation that results is more variable

• Bezoars are collections of nondigestible materials.
• Four types of Bezoar: Phytobezoars (MC), Trichobezoars, Pharmacobezoar and Lactobezoar

Characterized by multiple, superficial (nonulcerating) erosions that begin in the proximal or acid-secreting portion of the stomach and progress distallyQ

Occur in the setting of central nervous system disease (Head trauma)Q

• Occurs as a result of thermal burn injury involving > 35% of BSAQ
• Increased acid secretion in Cushing’s ulcer but not in Curling’s ulcerQ

Linear gastric erosions in hiatal herniasQ

In stress (hypoxia, sepsis, or organ failure), mucosal ischemia is the main factor responsible for the breakdown of these normal defense mechanismsQ

• Organoaxial (two thirds): Torsion occurs along the stomach’s longitudinal axisQ
• Mesenteroaxial (one third): Torsion occurs along the vertical axisQ

• Seen in association with congenital asplenia and wandering spleenQ
• Usually mesenteroaxialQ

• Occur secondary to some anatomic abnormality, (Most commonly diaphragmatic hernia)Q
• Usually organoaxialQ

Epigastric pain + Inability to vomit + Inability to pass a nasogastric tube - characteristic feature of gastric volvulusQ

• Truncal vagotomy - Performed above the celiac and hepatic branches of the vagiQ
• Selective vagotomy - Performed below the celiac and hepatic branches of the vagiQ
• Highly selective vagotomy - Performed by dividing the crow’s feet to the proximal stomach while preserving the innervation of the antral and pyloric parts of stomachQ.

• Interstitial cells of Cajal (ICCs)Q
• Location: In bodyQ along the greater curvature

CMPE: Chief cells (44%) > Mucous cells (40%) > Parietal cells (13%) > Endocrine cells (3%)Q

• Parietal cells secrete Ghrelin, Intrinsic factor, Leptin and Acid. (GILA)Q
• Chief cells secrete pepsin and leptinQ

Muscularis mucosa is responsible for the rugaeQ

Submucosa

• Assumes normal asymmetric shape and position by the end of the 7th weekQ.
• During the 6th to 10th week as the stomach enlarges it also rotates 90 degrees in a clockwise direction

Submucosal gland found in the duodenumQ

Gherlin is secreted by oxyntic cells in the fundus of the stomachQ – it has orexigenic (appetite stimulating) propertiesQ

• • Motilin like effects on gastric motilityQ
• • Stimulates release of somatostatin and PPQ

Gastric cardia occurs in posterior cardia or fundusQ

• Extremely lax lower abdominal musculatureQ
• Dilated urinary tract including the bladderQ
• Bilateral undescended testesQ

Caused by cicatricial contraction of a saddle shaped ulcer at the lesser curvatureQ

Tea-pot stomach is caused by longitudinal shortening of gastric ulcer at the lesser curvature of stomach (stomach looks like tea-pot)Q

• For 1st or 2nd portion: Whipple procedureQ
• For 3rd or 4th portion: Segmental duodenal resectionQ

• Finney stricturoplasty is used for strictures > 10–15 cmQ.
• Heineke-Mikulicz stricturoplasty is appropriate strictures < 10 cmQ in length

• Antrectomy or distal gastrectomy • Removal of distal 1/3rd of stomachQ
• Hemigastrectmy • Removal of half of stomachQ
• Subtotal gastrectomy • Removal of 2/3rd of stomachQ
• Total gastrectomy • Removal of whole stomachQ