1. The lesion pictured in the xray may be associated with dysphagia, regurgitation of food, and bad breath. All of the following techniques may be used for treatment EXCEPT

a.  Diverticulectomy and myotomy•b.  Myotomy alone•c.  Diverticulectomy alone•d.  Internal pharyngoesophageal myotomy•e.  Diverticulopexy with or without myotomy

• Answer CZenker’s pharyngoesophageal diverticulumPulsion false diverticulumTx: indicated in symptomatic patientsdiverticulectomy and cricopharyngeal myotomy to prevent recurrence

Diverticulopexy in elderly/high-risk patients

• L cervical incision• Retract SCM/carotid sheath laterally, • thyroid/trachea medially• Divide inferior thyroid artery• 40-Fr bougie in esophagus, dissect pouch at base• extramucosal esophagomyotomy in both directions (7-10 cm from base of pouch)• excise diverticulum with stapler if > 2 cm

Other esoph tics:• Midesophageal

• Traction• true diverticulum • caused by external inflammation (e.g. TB) that pulls out esophagus• new evidence suggest also may be from pulsion• more common on right

• Epiphrenic • distal esophagus• Pulsion• False• more common on right• Tx if symptomatic or > 3 cm• repair via L thoracotomy, diverticulectomy, esophagomyotomy

opposite side 

2. A 67-year-old man has had progressive dysphagia over the past 2 years. For the past 24 hours, he has been unable to tolerate anything by mouth. Shortly after eating, he has epigastric abdominal pain that is relieved by vomiting of undigested food. In addition, he has a 2-year history of burning epigastric and substernal chest pain following meals and during the night. These symptoms are improved with over-the-counter H2 blockers. His medical history is otherwise unremarkable. The plain abdominal x-ray and barium swallow shown are performed. The most appropriate management would be

a. Proton pump inhibitors

b. Percutaneous endoscopic gastrostomy placement

c. Reduction of hernia and open crural repair

d. Reduction of hernia, crural repair, and antireflux procedure

e. Watchful waiting

2. Answer DParaesophageal hernia, type II hiatal hernia, GE jxn okWorkup: esophogram, endoscopy, manometry, pH testing to evaluate extent of GERDTx: laparoscopic repair

Mobilize greater curvature and fundusDivide short gastricsExpose left crusReduce hernia contents into abdomen, transect sac at hiatusReapproximate crura Antireflux procedure: fundoplication

 Type I: sliding hernia, GE junction above diaphragm, tx if symptomatic Type III: I and II 

3. Which of the following statements about Barrett’s esophagus is NOT true?

a. Most patient who develop carcinoma in Barrett’s esophagus are men aged 55 to 60b. Patients with high-grade dysplasia should undergo esophagectomyc. Endoscopic surveillance effectively reduces the stage at presentation to stage II or lowerd. Barrett’s esophagus occurs in 10% to 15% of patients with symptoms of GERDe. Low-grade dysplasia should be treated with an antireflux procedure as well as antacids

3. Answer: EBarrett’s esophagus: PREMALIGNANTSquamous columnar epitheliumEsophagectomy for high-grade dysplasiaTx: antacids; antireflux procedure for symptomatic patients/not responsive to medsContinued endoscopic surveillance after surgery

4. Which of the following statements about highly selective vagotomy for treatment of a 35-year-old man with a peptic ulcer is NOT true?

a. The first 1 or 2 branches of the crow’s foot should be dividedb. Each vascular pedicle and its associated nerve to the lesser curve should be dividedc. 5 to 7 cm of esophagus is skeletonizedd. The criminal nerve of Grassi is preservede. The lesser curve may be oversewn

4. Answer: DHSV preserves vagal innervation of antrum so no drainage procedure required• Retract Anterior (left) and posterior (right) vagal trunks identified • Nerve of Latarjet retracted to right• Lesser curve dissected 7 cm from pylorus, divide branches of crow’s foot• Skeletonize 5-7 cm of esophagus proximal to GE jxn, dividing criminal nerve of Grassi• Devascularized lesser curve oversewn

5. A 70-year-old man with a history of chronic obstructive pulmonary disease present to the ED with diffuse abdominal pain and distention. Labs show a WBC of 14,000 with a left shift of 90%. CT confirms a small amount of pneumoperitoneum and mild small bowel dilation. At laparotomy, diffuse small bowel diverticulosis of the proximal jejunum is noted. The surgical procedure of choice would be

a. irrigation of peritoneal cavity and drainageb. jejunal resection and anastamosis of the perforated segmentc. jejunal resection and diverting ostomyd. jejunal resection of the entire segment of diverticulosise. closure of perforated diverticulum

5. Answer BSB tics usually asymptomaticTx for perforation: resect perforated segment and anastamosisIf perforation cannot be found, no resectionResection of all tics not indicated

6. A 35-year-old man develops severe diarrhea 3 days after an emergency appendectomy. He is admitted for severe hypovolemia. Stool assay for C. diff is positive and enteral metronidazole is initiated. Two days later he develops worsening diffuse abdominal pain and distention, respiratory failure requiring intubation and mechanical ventilatory support, and renal failure. After initial resuscitation, the next step in management should be

a. intravenous metronidazoleb. oral vancoc. intracolonic vancod. colonoscopic decompression and instillation of vancoe. emergency laparotomy

6. Answer ETx: subtotal colectomyIV/PO metronidazole, PO vanco

7.  Which of the following statements about short bowel syndrome is TRUE?

a. Gastrin levels are decreasedb. Preservation of ileocecal valve decreases the likelihood that

parenteral nutrition will be requiredc. Nephrolithiasis is due to hypercalcuriad. Jejunum is better able than ileum to adapt/increase

absorptive capacity after massive bowel resectione. Oral opioids should be avoided in treatment of diarrhea

7.  Answer BGastrin levels elevated from hypersecretion, leads to diarrheaNephrolithiasis from hyperoxaluria caused by increased

absorption in remaining SBProximal resection better tolerated as remaining ileum can

increase absorptive capacity better than jejunumDiarrhea also due to bile acid malabsorptionTreatment for diarrhea: fiber, opioids, H2 blockers, bile acid-

binders Short bowel syndrome<120 cm remaining bowel< 60 cm require TPN, unless ileocecal valve preserved, may be

ok with <45 cm

8. The initial treatment of most patients with bleeding esophageal varices should be

a. Intravenous pitressin and nitroglycerinb. Placement of a Sengstaken-Blakemore tubec. Emergency esophagoscopy with sclerotherapy or variceal

ligationd. Transjugular intrahepatic portosystemic shunt (TIPS)e. Intravenous octreotide

8. Answer E

Pitressin induces cardiac ischemia, which can be offset by nitroOctreotide is safer, acts by decreasing splanchnic blood flow

50 ug bolus, then 50 ug/h for 48-72 hours

The modified Sengstaken-Blakemore tube. Note the accessory nasogastric (N-G) tube for suctioning of secretions above the esophageal balloon and the two clamps, one secured with tape, to prevent inadvertent decompression of the gastric balloon.