Giant Gastric ulcer

Q) Which of the following is true about giant gastric ulcer?

a) 70-80% of these ulcers  are malignant

b) By definition giant gastric ulcer is more than 1.5 cm in size

c) Medical therapy can heal 80% of  such ulcers

d) They are more common on the greater curvature and invade surrounding organs like spleen, liver etc

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Bleeding Peptic ulcer

Q) In a patient with a bleeding peptic ulcer, endoscopy is done. Which of the following findings on endoscopy predicts the highest rate of re bleed?

a) Non bleeding vessel

b) Adherent clot

c) Flat pigmented spot

d) Clean base ulcer

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a) Non bleeding vessel IIA - Out of the choices given

Bleeding peptic ulcer is mostly from the posterior surface of the lesion and can be sometimes lethal

Forrest classification is used to grade the risk of re bleeding in peptic ulcers.

According to the stigmata of recent bleed, the chances of re bleed increase.

Forrest Classification

Ia - Active Spurting

Ib-  Active oozing

IIa Non bleeding vessel             50% chance of rebleed

IIB Adherent clot

IIC Flat Pigmented spot

III Clean based ulcer

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Gastrinoma

Q) Regarding gastrinoma what is true? ( # Questions on Endocrine Surgery) 

a) All gastrinomas express SRS receptors

b) In 30 % of cases gastrinomas are not localized intra operatively

c) Levels of serum  gastrin more than 100pg/ml are strongly suggestive of gastrinoma

d) Angiography with secretin stimulation is required in all cases for localization of gastrinoma

 

Dumping Syndrome

Q) Which of the following is true about dumping syndrome

a) Somatostatin analogues are effective in controlling symptoms

b) Symptoms always include flushing and tachycardia 

c) Diarrhea is always part of dumping syndrome

d) Part of treatment includes combining solids with liquids in frequent small meals

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Complications of Billroth 2 surgery

Billroth 1 and 2

Q) What is true regarding complications of Billroth 2 surgery?

a) It has less complications than Billroth 1 surgery

b) Recurrent ulceration is more common in the afferent limb as compared to efferent limb.

c) Afferent loop obstruction is more common after Billroth 2 surgery

d) Billroth I operation is preferred in scarred duodenum

Answer c -

In Billroth 2 surgery, afferent limb obstruction is more common

In Billroth 1 reconstruction The remnant is anastomosed  to the duodenum

In Billroth 2 duodenum stump is closed and stomach is anastomosed to the jejunum limb

Advantages of Billroth 1 

  1. More Physiological as normal GI continuity is maintained
  2. No problem of afferent and efferent limb
  3. Future procedures like endoscopy and ERCP can be done
  4. Reduced chance of gastric carcinoma in remnant stomach as compared to Billroth 2  ( SKF page 682) 

In surgery for benign gastric ulcers, Billroth I reconstruction is the preferred choice.


Billroth II surgery has problems of

  1. Retained antrum syndrome
  2. Afferent loop obstruction
  3. Duodenal stump leak (1-3%)

Billroth 2 surgery is done when there is

1. Inadequate mobility of the duodenum

2. Scarring of duodenum

Complications of gastric surgery
Complications of gastrectomy

  1. Nutritional and weight loss - Iron deficiency, Copper deficiency, Vit B12 , Anemia
  2. Delayed gastric emptying
  3. Roux statsis- Seen in roux en y loops-  Pain, nausea, vomiting, abdominal bloating
  4. Cholelithiasis-  Higher incidence in roux en y reconstruction as compared to B1 and B 2 gastrectomy
  5. Recurrent ulceration

Complications of Billroth 2 surgery

  1. Dumping syndrome Dumping symptoms have been reported in up to 70% of Billroth II patients and up to 75% of patients after RYGBP
    for obesity.
  2. Afferent loop obstruction - It can be minimized by keeping the length of afferent loop less than 20 cm and using a retrocloic approach.
  3. Bile reflux gastritis - More common with billroth I and billroth 2 surgery, incidence is decreasing after the use roux en y anastomosis


Shackelford's Surgery of the Alimentary Tract, 2 Volume Set: Expert Consult - Online and Print

 

Q)  Billroth 1 gastrectomy all are  true except-

a) Normal anatomy of  duodenum is preserved

b) ERCP can still be performed

c) Avoiding efferent and afferent limb problem

d) No risk for gastric cancer because of decreased alkaline reflux

Answer