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116
M. L. Collins and O. T. Okusanya
The principles of treatment are as follows:
1. Control soilage.
(a) Drain widely, and in cases where repair cannot be
performed, place large bore drains near the defect.
Endoscopic stenting and endoluminal vacuums may
be useful adjuncts in these cases.
2. Debride devitalized tissue.
3. Perform a linear myotomy over the site of injury.
(a) Mucosal injury is often greater than injury to the
muscularis.
4. Perform a two-layered repair using absorbable suture in
the mucosa.
5. Buttress the repair with local tissue, pericardial fat,
pleura, or an intercostal muscle ap.
6. Extensive injuries and/or unstable patients may necessitate esophageal exclusion.
(a) The esophagus should be mobilized and stapled shut,
with placement of a nasogastric tube at the time of
exclusion.
(b) In patients with extensive injuries, consider place-
ment of a jejunal feeding tube at the time of index
operation.
Clean Kills
• Failure to properly diagnose the problem.
• Failure to discuss proper resuscitation of an unstable
patient enroute or just prior to operative intervention.
• Failure to institute prompt surgical intervention.
• Failure to get a follow-up study (repeat contrast esophagram with barium, or CT esophagram) in the setting of a
patient with a high index of suspicion for esophageal perforation but a negative initial water-soluble contrast
esophagram.
• Failure to use proper principals to repair perforation
(mucosal injury is typically larger than muscle injury;
debride devitalized tissue; mucosal closure followed by
muscle closure and wide drainage).
Words ofWisdom
This is one diagnosis where aggressive interventional treatment is warranted. Delays in surgical treatment, failure to
properly resuscitate the patient, and failure to discuss the
proper surgical principles can all lead to question failure.
Common Curveballs
• The patient continues to show a leak a day after properly
performed repair. Mention adjuncts (endoscopic stenting,
endoluminal vacuums) or return to OR for esophageal
exclusion.
• The diagnosis of esophageal perforation and the need for
acute surgical management will be made obvious, but the
question will be about proper resuscitative measures prior
to operation.
Bibliography
Jones WG 2nd, Ginsberg RJ. Esophageal perforation: a continuing
challenge. Ann Thorac Surg. 1992;53(3):534–43.
Kassem MM, Wallen JM.Esophageal perforations and tears StatPearls.
Last updated August 7, 2023. https://www.ncbi.nlm.nih.gov/books/
NBK532298/.
Sellke FW, Del Nido PJ, Swanson SJ. Sabiston and spencer sur-
gery of the chest. 9th ed. Elsevier; 2016. Sudarshan M, Cassivi
SD. Management of traumatic esophageal injuries. J Thorac Dis.
2019;11(Suppl 2):S172–6.
Esophageal Varices
DarshakThosani andAdamBodzin
38
Way Question May BeAsked?
A 60-year-old male presents to the emergency department
with multiple episodes of hematemesis. His past medical history is signicant for acid reux, pancreatitis, and
cirrhosis.
• Of note, the patient may be referred to you with the diagnosis of bleeding varices from another hospital, or simply
a patient with an upper gastrointestinal bleed.
How toAnswer?
1. Focused history and physical while simultaneously resus-
citating the patient (or you will have a great history on a
dead patient).
(a) Resuscitation:
• ABCs—airway, breathing, circulation
– Consider intubation for airway protection due
to encephalopathy or aspiration from massive
hematemesis.
– Multiple large-bore IV access.
• Labs (including coagulation parameters), type and
cross
• Transfuse with goals of (hemoglobin >7, platelet
>50K, INR <1.5)
• Consider nasogastric tube and gastric lavage if
unclear of source/etiology of bleeding.
(b) History:
• Alcohol use
D. Thosani (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: darshak.thosani@jefferson.edu
A. Bodzin
Division of Transplant Surgery, Department of Surgery,
Thomas Jefferson University Hospital, Philadelphia, PA, USA
e-mail: adam.bodzin@jefferson.edu
• Episodes of encephalopathy, bleeding varices
• History of pancreatitis
• History of peptic ulcer disease
• Viral hepatitis
• Other causes of chronic liver disease (primary
sclerosing cholangitis, primary biliary cirrhosis,
hemochromatosis, Wilson’s Disease)
(c) Physical Exam:
• Stigmata of liver disease
• Ascites
(d) Treatment:
• Decrease splanchnic circulation: Vasopressin
(0.4U/min) and Octreotide (50ug bolus +25ug/h)
• Consider non-selective beta-blockers if blood
pressure allows for it (Propranolol, Nadolol)
• Start antibiotics for spontaneous bacterial peritonitis (SBP) prophylaxis for 7 days (e.g.,
Ceftriaxone 1 gm every 24h)
• Consider Sengstaken-Blakemore tube for uncontrolled bleeding (must know proper insertion
technique)
• Once hemodynamically stable - endoscopy to
diagnose and treat—consider band ligation and
sclerotherapy
• If endoscopy fails, consider TIPS with goal to
decrease hepatic venous-portal gradient (HVPG)
to less than 12mmHg
• If TIPS is unavailable and one cannot temporize
with Sengstaken-Blakemore tube to transfer to
higher level of care, then consider a surgical procedure for uncontrolled bleeding
– Describe technique to perform a portosystemic
shunt.
Consider mesocaval shunt between inferior
vena cava and superior mesenteric vein.
This shunt does not complicate future liver
transplantation options as it does not involve
the porta hepatis.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_38
117
118
D. Thosani and A. Bodzin
– Consider gastroesophageal devascularization,
or esophageal transection (but only state this
option if prepared to describe in entirety)
Common Curveballs
• Child’s Class C (Bilirubin >3, albumin <2.8, severe ascites, severe encephalopathy, INR >2.3) will need to be
considered for liver transplantation
• Upper GI bleeding secondary to peptic ulcer disease,
esophagitis, gastric varices
• Patient will have had prior abdominal surgery
• Upper GI Bleeding will continue post-op (know how to
manage)
– Continue resuscitation, ultrasound to conrm patency
of portosystemic shunt, endoscopic ligation or sclerotherapy, continue pharmacological agents mentioned
above
• Asked to describe other shunting procedures
• Patient will become encephalopathic post-operatively
– Check CT/MRI to rule out intracranial lesion
– Start lactulose, rifaximin, re-evaluate surgical shunt
• Patient will develop hepatic failure or hepatorenal syndrome post-operatively
– Patient should be evaluated for liver transplantation
– Dialysis may be necessary and can be used as support-
ive measure until transplant available
– No role for shunts as treatment measure
• Patient will aspirate or perforate after balloon tamponade
– In case of aspiration, start antibiotics to cover
pneumonia
– Perforation can occur from misplaced Blakemore tube
or necrosis from balloon tamponade
– One can attempt conservative management with chest
tube as patient will likely be too unstable for an operative procedure (mortality high)
– Esophagectomy
• Patient with thrombosed splenic vein and bleeding gastric
varices (needs only a splenectomy)
Clean Kills
• Not resuscitating the patient rst
• Not being able to describe your surgical procedure
• Describing the Sugiura procedure (you do not want to do
something you have never done before and this is rarely
done in the USA)
• Rushing to the operating room
• Not performing EGD/trying sclerotherapy/banding
• Not knowing how to use Sengstaken-Blakemore tube
Bonus Points
• Management of esophageal varices that have not bled
– Small varices <5mm: screening EGD every year (for
ongoing liver injury) or every 2years (without ongoing
liver injury)
– Medium/large varices: non-selective beta blockers
and/or esophageal variceal band ligation (EVL)
If performing EVL, then need EGD every 1–4weeks
until eradication of varices then EGD every
6–12months
• Absolute contraindications to TIPS—heart failure, severe
pulmonary hypertension, severe tricuspid valve regurgitation, sepsis, and acute unrelieved biliary obstruction
– Controversial to TIPS for MELD>18
• Remember the biggest risk factor for mortality and early
rebleeding is the severity of liver disease
Words ofWisdom
Management of bleeding esophageal varices should be
treated like other forms of upper GI bleeding with prompt
diagnosis and resuscitation. These patients should be admitted to the ICU and should not be rushed off to surgery but
must have a surgical plan in place in case of uncontrolled
bleeding. Resuscitation, pharmacological agents, and endoscopic therapy are the primary forms of management for
acute esophageal variceal bleeding. Consider TIPS prior to
surgical shunts. Surgical approach to the treatment of uncontrolled esophageal variceal bleeding includes portosystemic
shunts, esophageal transection, gastroesophageal devascularization, and liver transplantation. Do not attempt to perform procedures (e.g., Sugiura procedure) if you have never
done them.
Bibliography
Boregowda U, Umapathy C, Halim N, Desai M, Nanjappa A, Arekapudi
S, Theethira T, Wong H, Roytman M, Saligram S.Update on the
management of gastrointestinal varices. World J Gastrointest
Pharmacol Ther. 2019;10(1):1–21. https://www.ncbi.nlm.nih.gov/
pmc/articles/PMC6347650/. Accessed 22 Aug 2023.
Fischer JE, Ellison EC, Upchurch GR, Galandiuk S, Gould JC,
Klimberg V, Henke P, Hochwald SN, Tiao GM.Fischer’s mastery of
surgery. 7th ed. Wolters Kluwer Health Adis (ESP); 2018.
Meseeha M, Attia M. Esophageal varices. Treasure Island,
FL: StatPearls; 2023. https://www.ncbi.nlm.nih.gov/books/
NBK448078/. Accessed 22 Aug 2023
Adult Gastroesophageal Reflux Disease
ElliusKwok
39
Way Question May BeAsked?
A 45-year-old male presents to your ofce with a history of
epigastric pain, choking at night, and recent onset of asthma.
How toAnswer?
• Remember, the goal is to ensure that you are NOT about
to perform a fundoplication on a patient with esophageal
dysmotility
• First, complete history including symptom relationship to
meals, tolerance of solids/liquids, alleviating factors
(loose clothing, caffeine cessation, trial of H2 blockers or
proton pump inhibitors (PPI))
• Second, complete physical exam including epigastric
masses and lymph node basins (examiners will usually
report that this exam will all be negative, but if you leave
out the exam, the patient will end up having a pronounced
supraclavicular node and the scenario will have changed
to esophageal cancer with obvious metastasis)
• Appropriate preoperative studies including full labs,
EKG, and chest X-ray
• Barium Upper GI to evaluate anatomy
– Look for reux, hernia, shortened esophagus, diver-
ticula, or motility disorders
• The next test should be an upper endoscopy to evaluate
the severity of the reux
– Stage I—erythema and edema
– Stage II—ulcerations
– Stage III—stricture
• The rest of the work-up must include:
– Manometry to evaluate for ineffective motility (will
affect your choice of anti-reux procedure), document
E. Kwok (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: Ellius.Kwok@jefferson.edu
the lower esophageal sphincter (LES) pressures, and
determine the location of the LES
– 24 h pH monitoring to document the relationship
between patient’s symptoms and reux, obtain a
DeMeester Score (>14.7 indicative of GERD), and
provide a baseline for post-operative evaluation of success of surgery
– A gastric emptying study should be added in any
patient with a history of signicant belching or bloating after meals and/or history of duodenal ulcer, since
a delay in gastric emptying contributes to 10% of
Nissen fundoplication failure
Surgical Treatment
• Remember the indications for surgery are:
– Failure of medical therapy
– Complications of reux disease
– Young age (relative indication)
• Procedure: (assuming normal motility) = Nissen
Fundoplication (today usually performed with minimally
invasive approach)
– Lithotomy position
– 5–6 ports
– Nissen performed over a bougie (54–56)
– Start dissection at gastrohepatic ligament
– Mobilize esophagus well into mediastinum
– Divide short gastric vessels down 1/3 along greater curve
– Posterior crural repair
– 3cm anterior wrap
– Take care not to injure the vagus nerve, stomach,
esophagus, or spleen
– Cannot make wrap too tight/ long or twist the stomach
when passing it around the esophagus
• Belsey, Dor, or Toupet can be performed in patients with
ineffective esophageal motility.
• Post-operative Upper GI with gastrogran prior to
feeding.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_39
119
120
E. Kwok
Common Curveballs
• The patient has a malignancy/Barrett’s esophagus/stricture on endoscopy (non-dilatable stricture = operative
treatment)
• The patient does not have classic manometry ndings
• Perforation during your procedure, by advancing bougie,
or post-operatively on Upper GI
• Perform primary repair and cover with wrap if perforation
is on the distal esophagus
• May attempt conservative management if perforation is
small and has minimal contamination
• The patient will present with a stricture where rst you
must rule out malignancy and dilate prior to any studies.
• The patient will have a “shortened esophagus” (be prepared to describe Collis gastroplasty)
• The patient will develop pneumothorax or bleeding from
the liver/spleen. During procedure
• The patient will have perforation of esophagus during
procedure or pre op work-up (change scenario)
• The fundoplication herniates into chest post-operatively
(poor hiatal closure, the surgeon did not mobilize the
esophagus enough)
• The fundoplication falls apart post-operatively (technical
failure)
• The patient has “gas bloat” syndrome post-operatively
(inadequate gastric emptying)
– This may improve with time
– Consider pyloroplasty or conversion to partial wrap
• The patient has difculty swallowing post-operatively
(surgeon made the fundoplication too tight)
Words ofWisdom
GERD affects 20–40% of the population and is largely due
to incompetence of the LES.Additional contributing factors
include presence of a hiatal hernia, delayed gastric emptying,
and decreased esophageal motility. Symptoms include heartburn, substernal chest pain, dysphagia, cough, increased salivation, and asthma-like symptoms. Diagnosis is based on
clinical suspicion and conrmed with 24h pH monitoring.
Additional testing includes barium swallow, EGD, and
manometry. Biopsies should be taken in patients with longstanding or refractory disease to rule out Barrett’s esophagus
or adenocarcinoma.
Treatment consists of lifestyle modications such as
weight loss, smaller meals, smoking sensation, avoiding
meals close to bedtime, and elevating the head of the bed. H2
blockers are effective in approximately 50% of patients. The
most successful medications are proton pump inhibitors.
Nissen fundoplication is reserved for those who are noncompliant with, or fail, medical therapy. 5–8 cm of intraabdominal esophagus are necessary to perform a successful
3–5cm fundoplication to prevent reux. The fundoplication
can be performed over a bougie to help prevent the wrap
from being too tight. If the esophagus is short and intraabdominal esophageal length is inadequate, a lengthening
procedure such as Collis gastroplasty should be performed.
A partial fundoplication (e.g., Dor, Toupet) should be considered for those patients with motility disorders to avoid
signicant dysphagia.
Bibliography
Clean Kills
• You forget to obtain Upper GI, EGD, or esophageal
manometry
• You cannot describe the fundoplication or forget to mention dividing the short gastric vessels
• You take patient to surgery right away without trying
medical therapy
• You do not take an adequate history and perform Nissen
fundoplication on a patient with achalasia
• Discussing endoscopic measures to treat Barrett’s (cryotherapy or photo-therapy)
• Discussing endoscopic measures to treat GERD
(“Plicator,” “Stretta,” or newly approved injectable agents)
El-Serag HB, Sweet S, Winchester CC, Dent J.Update on the epidemiol-
ogy of gastro-oesophageal reux disease: a systematic review. Gut.
2014;63(6):871–80. https://doi.org/10.1136/gutjnl- 2012- 304269.
Savarino E, Bredenoord AJ, Fox M, Pandolno JE, Roman S, Gyawali
CP, International Working Group for Disorders of Gastrointestinal
Motility and Function. Expert consensus document: advances
in the physiological assessment and diagnosis of GERD. Nat
Rev Gastroenterol Hepatol. 2017;14(11):665–76. https://doi.
org/10.1038/nrgastro.2017.130.
Khan M, Santana J, Donnellan C, Preston C, Moayyedi P. Medical
treatments in the short term management of reux oesophagitis. Cochrane Database Syst Rev. 2007;2:CD003244. https://doi.
org/10.1002/14651858.CD003244.pub2.
Katz PO, Gerson LB, Vela MF.Guidelines for the diagnosis and man-
agement of gastroesophageal reux disease. Am J Gastroenterol.
2013;108(3):308–29. https://doi.org/10.1038/ajg.2012.444.
Part IV
Duodenum
Duodenal Cancer
BenjaminDixson
40
Concept
Duodenal cancer will likely present as an incidentally found
mass in the duodenum on imaging, although patients may
also present with obstructions or bleeding. Be prepared to
describe your initial workup, staging, and surgical steps.
Keep in mind that location of the mass is a key factor. While
adenocarcinoma is one of the etiologies that can present as a
duodenal mass, other etiologies such as neuroendocrine
tumor, lymphoma, and GIST may be presented.
Way Question May BeAsked?
“A 60-year-old male, with a history of excessive red meat
intake and smoking, with weight loss was found to have duodenal mass (D3) on CT imaging concerning for malignancy.
CBC demonstrates hemoglobin of 8.2 from a baseline of 13
previously. What are your next steps?”
The case may also present a mass incidentally found on
imaging obtained for another reason, overt gastrointestinal
bleeding, colicky abdominal pain with associated nausea
and emesis from partial or complete obstruction, jaundice/
biliary obstruction, etc. Neuroendocrine tumors that are
productive may present with a wide variety of symptoms
depending on the substance produced (diarrhea, ushing,
hypoglycemia, gastric/duodenal ulcers, sweating, etc.)
(Snyder and Nguyen 2009).
How toAnswer?
History (Cameron and Cameron 2020)
• Risk factors
– Genetic
B. Dixson (*)
General Surgery, Christiana Care Health System,
Newark, DE, USA
Familial Adenomatous Polyposis (FAP)
Hereditary nonpolyposis colon cancer (HNPCC,
aka Lynch Syndrome)
Cystic Fibrosis
– Health Conditions
Celiac Disease
Crohn’s Disease
– Age/Gender
60–80years old
– Race
Black population
– Habits
Smoking
Alcohol
High salt
Red meats
• Abdominal pain
• Nausea and vomiting
• Weakness/Lethargy
• Anemia
• Dark stool
• Obstruction
• Jaundice
Physical Examination
• Rarely able to palpate abdominal mass
• Abdominal distention/tympany (in setting of duodenal
obstruction)
• Jaundice (in setting of biliary obstruction)
• Weight loss
Diagnostic Tests
• Full laboratory panel
– CBC: Anemia (bleeding mass)
– LFTs: Direct hyperbilirubinemia, transaminitis (bili-
ary obstruction)
– CEA: May be elevated if adenocarcinoma (not sensi-
tive or specic)
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
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124
B. Dixson
– Serum 5-HIAA and chromogranin A (may be elevated
if neuroendocrine tumor)
• Upper GI series
• Esophagogastroduodenoscopy (EGD), push enteroscopy
• Endoscopic ultrasound (EUS) with biopsy
• Staging CT scan of chest abdomen and pelvis with IV
contrast (to evaluate extent of locoregional and metastatic
disease)
• Can consider staging laparoscopy (separate trip to OR to rule
out carcinomatosis, liver/omental/peritoneal metastases)
Location ofTumor
• D2 or any involvement of the ampulla/pancreas should
have pancreaticoduodenectomy (Whipple procedure)
(Benson etal. 2024).
• D1, D3 or D4 may have pancreaticoduodenectomy but
can consider limited segmental resection in select cases
(<2cm tumor, antimesenteric border, absence of hereditary condition) (Benson etal. 2024).
Comments onSurgery
Intraoperative staging of the abdomen (mesentery, omentum,
peritoneum, etc.) should be performed.
Adequate lymphadenectomy should be performed (mini-
mum of eight lymph nodes) (Benson etal. 2024).
Pancreaticoduodenectomy (Whipple procedure) should
be considered for all duodenal malignancies, particularly if
the second portion of the duodenum, ampulla and/or pancreas are involved.
Key steps of pancreaticoduodenectomy (Sham et al.
2023):
1. Evaluate for resectability/metastasis
(a) Evaluate greater and lesser peritoneal sac. Enter
lesser sac (avoid injury to gastroepiploic vessels)
2. Resection
(a) Kocher maneuver
(b) Continue dissection toward the patient’s left until the
left renal vein is exposed
(c) Dissect out porta hepatis
(d) Gastroduodenal artery test clamping and transection
(e) Gastric antral transection
(f) Jejunal transection
(g) Cholecystectomy
(h) Pancreatic transection
3. Reconstruction
(a) Pancreaticojejunostomy anastomosis
(b) Hepaticojejunostomy anastomosis
(c) Gastrojejunostomy anastomosis
Limited segmental resection may be considered if limited
to rst, third, or fourth portion of duodenum (particularly
antimesenteric border) in absence of hereditary condition
(Benson etal. 2024).
Key steps of limited segmental resection:
1. Clear identication of tumor site.
2. Stapled transection proximal and distal (consider re-
excision if margin <5mm).
3. Excision of the portion of duodenum from its retroperito-
neal attachments.
4. Likely will need hand sewn anastomosis.
5. Lymph node evaluation and dissection is imperative due
to lower yield of lymph nodes sampled with limited segmental resection.
Consider obtaining a frozen section of margins intraoperatively if concerns about margins. If margins <5mm
on the frozen section, consider re-excision of the involved
margin.
Minimally invasive techniques may be considered by
experienced surgeons.
You can consider adjuvant and neoadjuvant treatments.
May perform gastrojejunostomy bypass (vs. decompressive G tube and feeding J tube) if unresectable for palliation.
Common Curveballs
• Patient has peritoneal metastases discovered intraopera-
tively.
• Patient has a postoperative leak.
• Patient has a postoperative anastomotic bleed.
• Patient is malnourished preoperatively.
• Pathology indicates lymphoma.
• Differentiating between resectable disease and border-
line/unresectable disease (similar to pancreatic cancer).
Clean Kills
• Incomplete workup and staging.
• Neglecting to evaluate for metastases prior to surgical
resection (staging imaging, staging laparoscopy, evalua-
tion at time of planned resection).
• Performing limited segmental resection of D2 tumor or
with involvement of the ampulla/pancreas.
• Not checking the margins of resection by frozen section.
40 Duodenal Cancer
125
Summary
Duodenal cancer is a relatively rare pathology encountered clinically; however its workup and management
are essential to understand for the boards. Appropriate
preoperative staging is a must in all cases of malignancy
and being able to describe a Whipple procedure concisely
yet thoroughly is key. You should have a solid understanding of how to help patients with unresectable disease (laparoscopic biopsy, chemo port placement, enteral
access, etc.).
Bibliography
Benson AB, Venook AP, Pederson K, et al. NCCN clinical practice
guidelines in oncology—small bowel adenocarcinoma. National
Comprehensive Cancer Network; 2024. https://www.nccn.org/pro-
fessionals/physician_gls/pdf/small_bowel.pdf
Cameron JL, Cameron AM.Management of small bowel tumors. In:
Current surgical therapy. 13th ed. Elsevier Health Sciences; 2020.
p.138–43. 978-0-323-64059-6.
Sham JG, Mahadey V, Pillarisetty VG. Major pancreatic resections
(surgical oncology/fellowship level). The SCORE Portal From the
Surgical Council on Resident Education; 2023. https://www.surgi-
calcore.org/modulecontent.aspx?id=1000394
Snyder B, Nguyen A.Small bowel tumors. In: How to win on the
American Board of Surgery Certifying Exam. Trafford Publishing;
2009. p.125–6. 978-1-4269-1582-6.
Gastric Outlet Obstruction
KirstenLung
41
Way Question May BeAsked?
A 70-year-old female presents to the Emergency Department
with progressive nausea, non-bilious vomiting, epigastric
pain, early satiety, abdominal distention, and weight loss.
Her past medical history is signicant for smoking and alcohol use disorder. On admission, she appears to have dry
mucous membranes and mild sinus tachycardia. CT imaging
is concerning for an obstructing mass in the gastric antrum.
How toAnswer?
Management
• Focused history and physical exam while simultaneously
resuscitating the patient
– Resuscitation:
ABCs—airway, breathing, circulation
• Consider intubation for airway protection due to aspiration from vomiting
Hypovolemia and metabolic derangements if having severe vomiting
• IV access
• Labs (basic metabolic panel, complete blood count, magnesium, phosphate, prealbumin, lactate)
• IV uids, electrolyte repletion
– History:
Benign versus malignant etiology of mechanical
obstruction and motility disorders
• Onset and spectrum of symptoms may suggest
one etiology over another
– Benign causes—early satiety and bloating
Peptic ulcer disease (NSAIDs versus H.
pylori etiology), polyps, ingestion of corro-
K. Lung (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: Kirsten.Lung@jefferson.edu
sive substances, anastomotic strictures,
inammatory bowel disease, eosinophilic
gastroenteritis, Bouveret syndrome (gallstone ileus via a biliary-enteric stula),
annular pancreas, pancreatitis, bezoars,
infection, percutaneous endoscopic gastrostomy tube migration, intramural hematoma,
gastric volvulus
– Malignant causes—pain, vomiting,
malnutrition
Gastric cancer, duodenal cancer, pancreatic
adenocarcinoma, locally advanced cholangiocarcinoma or gallbladder cancer, gastric
lymphoma, gastric carcinoid
Extrinsic compression from large local cancer (i.e., hepatocellular carcinoma, adrenocortical carcinoma)
– Motility Disorders—gastroparesis
Diabetes, prior viral illness, medications
(opiates), damage to vagus nerve, paraneo-
plastic or inltrative process (amyloidosis)
Age of presentation—duodenal atresia versus duodenal web versus hypertrophic pyloric stenosis in
neonates
Prior history of surgery
– Physical Exam:
Signs of chronic malnutrition
• Cachexia
• Volume depletion
• Dental erosions
Succussion splash
• Rocking patient back and forth while listening
over stomach for splashing
• Test is positive if splash present 3 or more hours
after drinking uids
Palpable thickened stomach with visible gastric
peristalsis through the skin
Palpable abdominal mass (hypertrophic pyloric stenosis in neonates)
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