ABSITE Review Conference
Topic
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
Abdomen
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
H. Pylori is a helix shaped, microaerophilic 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.
Abdomen
The most common gastric polyp is:
A.
B.
C.
D.
E.
Adenomatous
Hyperplastic
Hamartomatous
Inflammatory
Heterotopic
Abdomen
Answer B.
Hyperplastic polyps are by far the
most common gastric polyp (7090%).
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 (1020%).
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.
B.
C.
D.
E.
Antral vascular ectasia
Abnormal gastric rugal folds
Ingested foreign material
An abnormal submucosal vessel
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.
B.
C.
D.
E.
Cytotoxic multidrug chemotherapy
Radiation therapy
Gastrectomy
Antibiotics
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.
B.
C.
D.
E.
Basal and stimulated gastric acid outputs
Octreotide scan
Fasting serum gastrin
Calcium stimulation test
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.
B.
C.
D.
Type II ulcers are the most common
Type IV ulcers occur near the GE junction
Type I ulcers have increased acid secretion
Type III ulcers are associated with decreased acid
secretion
E. Type I gastric ulcers are prepyloric
Abdomen
Answer 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
acid
Type IV- ulcers near the
gastroesophageal junction, not
associated with acid hypersecretion.
Abdomen
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.
B.
C.
D.
E.
Duodentomy, oversewing the ulcer, TV and pyloroplasty
Duodentomy, oversewing the ulcer
Truncal vagotomy and antrectomy with BI reconstruction
Truncal vagotomy and antrectomy with BII reconstruction
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.
B.
C.
D.
E.
Low fat, lactose free diet
Serotonin antagonists
Low carbohydrate, high fat diet
Octreotide
Creation of a reversed jejunal segment
Abdomen
Answer D.
Abdomen
Which of the following is true regarding postvagotomy
diarrhea?
A.
B.
C.
D.
It is effectively treated with octreotide.
It is improved with oral cholestyramine.
It is due to dumping syndrome.
It is best managed by creating a reversed jejunal
segment.
E. It does not respond to dietary interventions.
Abdomen
Answer B.
Abdomen
Complications of Ulcer Surgery
Early: Duodenal Stump Leak
Gastric Retention
Anastamotic Breakdown
Hemorrhage
Late: Recurrent Ulcer
[10% following V & P]
[2 - 3% following V & A]
Gastrocolic/Gastrojejunal Fistula
Dumping Syndrome - [1 - 2% of patients]
Alkaline Gastritis
Anemia [30% of patients, 5 years post-op]
Postvagotomy Diarrhea [5 - 10% of patients]
Chronic Gastroparesis
* may require a Roux-en-Y Esophagojejunostomy
Abdomen
The treatment for low grade early mucosa- associated
lymphoid tissue lymphoma is:
A.
B.
C.
D.
E.
Cytotoxic multidrug chemotherapy
Radiation therapy
Gastrectomy
Antibiotics
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.
B.
C.
D.
E.
Closing the abdomen
Distal pancreatectomy and splenectomy
Proximal pancreaticoduodenectomy
Blind proximal duodenotomy
Blind distal duodenotomy
Abdomen
Answer D.
Abdomen
The most accurate means of determining T and N staging of
gastric adenocarcinoma is:
A.
B.
C.
D.
E.
Triple phase helical CT
Diagnostic laparoscopy
EUS
MRI with gadolinium
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.
B.
C.
D.
E.
Number of positive nodes
Anatomic distribution of positive nodes
Proximity of positive nodes to the primary tumor
Immunohistochemical staining of positive nodes
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.
B.
C.
D.
E.
D1 resection
D2 resection
R0 resection
R1 resection
R2 resection
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
Abdomen
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 nodes
2 Left cardia lymph nodes
3 Lymph nodes along the lesser curvature
4 Lymph nodes along the greater curvature
4sa: lymph nodes along the short gastric vessels
4sb: lymph nodes along the left gastroepiploic vessels
4d: lymph nodes along the right gastroepiploic vessels
5 Suprapyloric lymph nodes
6 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 ligament
13 lymph nodes on the posterior surface of the head of the pancreas
14 lymph nodes at the root of the mesentery
14A lymph nodes along the superior mesenteric artery
14V 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.
B.
C.
D.
E.
H. pylori infection
Blood group O
Achlorydria
Li-Fraumeni syndome
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.
B.
C.
D.
E.
Radiation therapy
Total gastrectomy
Subtotal gastrectomy
Chemotherapy and radiation
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.
B.
C.
D.
E.
It is associated with hypoproteinemia.
It has a familial inheritance.
It is associated with CMV infections in children.
It increases the risk of malignancy.
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.
B.
C.
D.
E.
MRI
CT
US
Octreotide scan
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.
B.
C.
D.
E.
H. pylori serology
Urea breath test
Histologic biopsy
Rapid urease test
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.
B.
C.
D.
E.
The anterior and posterior vagal trunks are divided
The nerve of Grassi is spared
The anterior Laterjet nerve is divided
The crow’s feet to the antrum are spared
The celiac branch is divided
Abdomen
Answer D.
Abdomen
The most common metabolic disorder after gastric resection
is a deficiency of:
A.
B.
C.
D.
E.
Iron
Vitamin B12
Folate
Calcium
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.
B.
C.
D.
E.
A metastatic left axillary lymph node
A metastatic left supraclavicular lymph node
An ovarian mass from gastric metastasis
Umbilical metastasis suggesting carcinomatosis
An anterior nodule palpable on rectal examination
suggesting drop metastasis.
Abdomen
Answer C.
Abdomen
All of the following are associated with hypergastrinemia
EXCEPT:
A.
B.
C.
D.
E.
Retained gastric antrum
Hypothyroidism
Pernicious Anemia
Renal Insufficiency
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.