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Core > Gastrointestinal: Luminal, Stomach > Flashcards

Gastrointestinal: Luminal, Stomach Flashcards

1
Q
A

Think malignant ulcerated stomach cancer

Note: This is the Carmen Meniscus sign.

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2
Q
A

Think benign gastric ulcer

Note: There is a Hampton’s line (red arrows).

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3
Q

Gastric ulcer that is wider than it is deep, with nodular edges, and gastric folds adjacent to the ulcer…

A

Think malignant ulcerated cancer

Note: Look for Carmen Meniscus sign (highly suggestive of cancer).

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4
Q

Gastric ulcer that is deeper than it is wide, with sharp contour, and gastric folds radiating to the ulcer…

A

Think benign gastric ulcer

Note: Look for Hampton’s line (highly suggestive of benign ulceration).

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5
Q

What is the most common mesenchymal tumor of the GI tract?

A

Gastrointestinal stromal tumor (GIST)

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6
Q

What is the most common location for GIST?

A

Stomach (70%)

Note: Duodenum is the second most common.

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7
Q

What age group do GISTs occur in?

A

Older pts (rare before age 40)

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8
Q

Gastrointestinal stromal tumors are associated with…

A
  • NF1
  • Carney’s triad
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9
Q

Is lymphadenopathy common in GIST?

A

No

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10
Q

Where is the most common location for GIST metastases?

A

Liver

Note: Metastases are very uncommon (which is why lymphadenopathy is uncommon).

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11
Q

Carney’s triad

A
  • Pulmonary chondroma
  • Extra adrenal pheochromocytoma
  • GIST
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12
Q

What is the most common gastric malignancy?

A

Adenocarcinoma (followed by lymphoma)

Note: Malignant GIST is very rare.

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13
Q

Risk factors for gastric adenocarcinoma

A
  • H. pylori infection
  • Older age
  • Pernicious anemia
  • Menetrier’s disease
  • Prior gastroenterostomy (old treatment for peptic ulcer disease)
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14
Q

Metastatic spread of gastric adenocarcinoma to the ovary…

A

Krukenberg tumor

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15
Q

Gastric adenocarcinoma with a left supraclavicular mass…

A

Think metastatic spread to a left supraclavicular lymph node (Virchow node)

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16
Q

Appearance of GIST vs gastric adenocarcinoma on imaging

A

GIST is usually smoothly marginated and exophytic

Gastric adenocarcinoma is usually large, ulcerated, and heterogeneous asymmetric wall thickening

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17
Q

What are the major types of gastric lymphoma?

A
  • Primary (MALT)
  • Secondary (systemic lymphoma)
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18
Q

What is the most common extra nodal site for non-Hodgkin lymphoma?

A

The stomach

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19
Q

Which gastric cancer is most likely to cause a gastric outlet obstruction?

A

Adenocarcinoma (if in the gastric antrum)

Note: Lymphoma rarely causes gastric outlet obstruction.

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20
Q

Major complication of chemotherapy treatment for gastric lymphoma

A

Gastric perforation

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21
Q

Classic imaging appearance of gastric lymphoma

A

Diffuse gastric wall thickening (>1 cm) without gastric outlet obstruction

Note: It often crosses the pylorus.

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22
Q

Stomach metastases are most likely to be from what primaries?

A
  • Melanoma
  • Breast
  • Lung

Note: Gastric metastases are very rare.

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23
Q

Linitis plastica

A

Diffuse infiltration of the gastric wall, creating a contracted stiffened appearance

Note: This is usually due to breast/lung metastases or gastric lymphoma.

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24
Q
A

Diffuse thickening of the gastric wall, suggestive of linitis plastica (think breast/lung mets or gastric lymphoma)

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25
Q

Multiple gastric ulcers with no duodenal ulcers…

A

Think chronic aspirin therapy

Note: Aspirin does not cause duodenal ulcers.

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26
Q

Multiple duodenal ulcers…

A

Think Zollinger-Ellison syndrome

Note: Most duodenal ulcers are solitary.

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27
Q

What is this gastric mucosal pattern called?

A

Areae gastricae (normal finding)

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28
Q

When does the normal areae gastricae mucosal pattern become enlarged?

A
  • Elderly pts
  • H. pylori infection
  • Focally enlarged next to an ulcer
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29
Q

Double contrast upper GI demonstrates absent areae gastricae…

A

Think atrophic gastritis

30
Q

Menetrier’s disease

A

Idiopathic gastropathy with regular regal thickening at the fundus (sparing the antrum)

31
Q

Complication of Menetrier’s disease

A

Hypoalbuminemia

32
Q

Gastric regal thickening in the fungus that spares the antrum…

A

Think Menetrier’s disease (an idiopathic gastropathy)

33
Q
A

Ram’s horn deformity (tapering of the gastric antrum, often seen in Crohns disease and other conditions)

34
Q

Differential for Ram’s Horn deformity (tubular tapering of the gastric antrum)

A
  • Scarring from peptic ulcers
  • Granulomatous disease (e.g. Crohns, sarcoid, tuberculosis, syphilis)
  • Scirrhous carcinoma
35
Q

What is the most common gastrointestinal location for sarcoidosis

A

Stomach

36
Q

What are the two major types of gastric volvulus?

A
  • Organoaxial (gastric antrum stays below the GE junction)
  • Mesenteroaxial (gastric antrum ends up above the GE junction)
37
Q

Which type of gastric volvulus is more common?

A

Organoaxial (gastric antrum remains below the GE junction)

38
Q

Which gastric volulus is more problematic and needs to be corrected?

A

Mesenteroaxial (gastric antrum ends up above the GE junction)

39
Q

Which type of gastric volvulus is more common in kids?

A

Mesenteroaxial (the problematic one that can cause obstruction/ischemia and needs to be fixed)

40
Q

Soft tissue mass posterior to the gastric fungus that appears to communicate with the gastric lumen…

A

Think gastric diverticulum

Note: This can easily be confused with an adrenal mass.

41
Q

Isolated gastric varices…

A

Think splenic vein thrombosis (e.g. pancreatitis or pancreatic cancer)

42
Q

Common complications of gastric banding

A
  • Stomal stenosis (most common)
  • Gastric band erosion
  • Band slippage
43
Q

Vomiting s/p gastric banding with upper GI demonstrating a dilated proximal gastric pouch…

A

Stomal stenosis (band is too tight)

Note: This is the most common complication of gastric banding.

44
Q

CT demonstrates that a gastric band is within the gastric lumen…

A

Gastric band erosion

45
Q
A

Gastric band slippage

Note: The gastric band should be oriented in the 2:00 position relative to the spine. If it is more horizontal than this, think slippage.

46
Q

What is the correct position for a gastric band?

A
  • 2:00 position relative to the spine
  • Phi angle between 5 and 60 degrees (angle between the spine and band)
47
Q

Billroth 1 procedure

A

Resection of the gastric pylorus with anastomosis of the proximal stomach to the duodenum

48
Q

Billroth 2 procedure

A

Partial gastrectomy with anastomosis of the proximal stomach to the jejunum

49
Q

Common indications for Billroth procedures

A
  • Gastric cancer
  • Gastric ulcers
  • Pyloric dysfunction (Billroth 1)
50
Q

Which is associated with more complications: Billroth 1 or Billroth 2?

A

Billroth 1 tends to more early postoperative complications (but less gastritis) than Billroth 2

51
Q

What are the 2 small bowel limbs created by a Billroth 2 procedure?

A
  • Afferent bilio-pancreatic limb
  • Efferent gastrojejunal “feeding” limb
52
Q

Complications of Billroth 2 procedure

A
  • Dumping syndrome
  • Afferent loop syndrome
  • Gastric cancer (increased risk 10-20 years after surgery)
53
Q

Roux-en-Y gastric bypass

A

Stomach is divided to create a small gastric pouch which attached to the jejunum. A jejunojejunal anastomosis is also created to connect the afferent limb to the efferent limb.

Note: The excluded stomach attaches and drains to the duodenum as normal.

54
Q

Afferent loop syndrome

A

Obstruction of the afferent loop (in Billroth 2, roux-en-Y, etc.) leading to an accumulation of secretions, bile, and pancreatic juice in the afferent limb. This can lead to bile duct dilatation and pancreatitis.

55
Q

What causes afferent loop syndrome?

A

Obstruction of the afferent loop:

  • Extrinsic causes (adhesions, internal hernia, neoplasm)
  • Intrinsic causes (radiation scarring, edema from a marginal ulcer)
56
Q

Which procedures may be complicated by afferent loop syndrome

A
  • Billroth 2
  • Roux-en-Y
  • Whipple
  • Partial pancreaticoduodenectomy
57
Q

Bilious vomiting with a remote history of a Billroth 2 procedure

A

Afferent loop syndrome (due to obstruction of the afferent loop)

58
Q

Postprandial diarrhea, nausea, and lightheadedness with history of recent Roux-en-Y gastric bypass…

A

Think dumping syndrome (due to rapid gastric emptying)

59
Q

Treatment for dumping syndrome secondary to Billroth 2 procedure

A

Conversion of Billroth 2 to Roux-en-Y gastric bypass

Note: Roux-en-Y also gets dumping syndrome, but usually only in the early postoperative period.

60
Q

Gastric fold thickening and filling defects seen in the stomach after a Billroth 1 or Billroth 2 procedure…

A

Think bile reflux gastritis

61
Q

Jejunogastric intussusception

A

A rare complication of gastro-jejunal anastomosis where the jejunum herniates into the stomach

Note: This can cause gastric obstruction.

62
Q

When do leaks tend to occur following bariatric surgeries?

A

Early postoperative (within 10 days)

63
Q

Upper GI series demonstrated a gastric bypass with contrast moving from the gastric pouch to the gastric remnant…

A

Gastro-gastric fistula

64
Q

Marginal ulcers

A

Peptic ulcers at or near a gastrojejunal anastomosis

65
Q

What is the most common location for a marginal ulcer?

A

Just distal to a gastrojejunal anastomosis (the small bowel is not used to stomach acid)

66
Q

Multiple giant marginal ulcers just distal to a gastrojejunal anastomosis…

A

Think chronic jejunal ischemia

67
Q

What are the three main places a small bowel obstruction could happen after Roux-en-Y gastric bypass?

A
  • Obstruction of the alimentary “roux” limb
  • Obstruction of the biliopancreatic limb (closed loop obstruction)
  • Obstruction below the jejunojejunal anastomosis
68
Q

Why is a small bowel obstruction of the biliopancreatic limb particularly dangerous?

A

This is automatically a closed loop obstruction (because the excluded gastric remnant is sewed shut)

69
Q

Small bowel obstruction s/p Roux-en-Y gastric bypass with dilatation of the gastric pouch and jejunal roux limb, but the biliopancreatic limb and excluded stomach remain decompressed…

A

Think obstruction of the alimentary “Roux” limb

Note: This is best seen on upper GI series.

70
Q

What are the two major types of Roux-en-Y gastric bypass?

A
  • Ante-colic (Roux limb passes anterior to the transverse colon)
  • Retro-colic (Roux limb passes posterior to the transverse colon)

Note: To create the retro-colic gastric bypass, the surgeon needs to create a small defect in the transverse mesocolon, which increases the risk of internal hernias later on.

71
Q

What are the major sites of internal hernia following Roux-en-Y gastric bypass?

A
  • Defect in the transverse mesocolon (for retro-colic gastric bypasses)
  • Mesenteric defect at the jejunojejunal anastomosis
  • Herniation behind the roux limb mesentery

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