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General Surgery > Stomach > Flashcards

Stomach Flashcards

1
Q

Cells in the fundus & secretions

A

Chief: pepsinogen
Parietal: HCL, intrinsic factor
Enterochromaffin-like cells: Histamine

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2
Q

Cells in pylorus & secretions

A

D cells: somatostatin
G cells: gastrin

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3
Q

Cells in duodenum & secretions

A

I cells: CCK (increase gallbladder & pancreas actions)

K cells: gastric inhibitory peptide (stimulate insulin production)

M cells: motilin (increase intestinal motility). erythromycin - motilin agonist

S cells: secretin (increase pancreas bicarb, decrease gastrin & HCL)

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4
Q

Blood supply to stomach

A

1) Celiac trunk
1a) Left gastric artery
1b) Splenic artery
1c) Common hepatic

2) Left gastric
2a) Eosophageal branches

3) Splenic
3a) Short gastric (supply fundus)
3b) Left gastroepiploic

4) Common hepatic
4a) Hepatic -> right gastric
4b) Gastroduodenal -> Right
gastroepiploic

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5
Q

The ligament of ___ is a suspensory ___ of the ___ that connects the ___ to ___

A

Treitz
suspensory muscle connecting DJ flexure to connective tissue surrounding celiac axis & SMA

*bleeding proximal to this ligament = UBGIT

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6
Q

Haemoptysis vs Haematemesis

A

Haemoptysis
- bloody expectorant from respi system
- pt experience sensation in their throat, blood is frothy & bright red

Haematemesis
- Vomited blood
- Fresh red blood = moderate to severe bleeds
- Coffee-ground vomitus = altered blood due to gastric acid, limited bleeding
- Usually melena can be observed

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7
Q

Types of melena

A

Fresh: jet black, tarry stool, non-particulate, almost liquid

Stale: black-grey, dull, can be particulate (could be bleed that has stopped)

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8
Q

Ddx of black stools

A

Iron stools - from consumption of iron supplement

  • Greenish on rubbing between fingers, particulate
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9
Q

Haematemesis can be due to ___ or ___ bleeds

A

variceal
non-variceal

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10
Q

Causes for variceal bleed

A

Chronic liver disease -> portal hypertension -> portosystemic shunting -> dilated oesophageal veins

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11
Q

Causes of non-variceal bleed

A

Peptic ulcer disease
Stress ulcer
Mallory-Weiss tear
Dieulafoy (AVM of gastric fundus)
Malignancy (gastric/oesophageal CA)
Gastric antral vascular ectasia

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12
Q

What can cause peptic ulcer disease?

A

H.pylori

Drugs: NSAIDs, antiplts, steroids (delay healing), TCM

Smoking

Others: Zollinger Ellison syndrome, hypergastrinemia, stress, head trauma, burns, alcohol

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13
Q

What causes mallory-weiss tear?

A

Violent retching following alcoholic binge

Longitudinal fissures occur in the mucosa of herniated stomach at GEJ

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14
Q

Suspect ___ in pts with BGIT without history of NSAIDs or alcohol abuse

A

Dieulafoy (AV malformation)

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15
Q

questions to ask to classify when assessing UBGIT

A

1) haematemesis vs haemoptysis
2) variceal vs non-variceal
3) quantify amt of bleeding
4) comorbidities

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16
Q

Classifying non-variceal UBGITs

A

1) oesophagus - MW tear, esophagitis, cancer, boerhaave
2) stomach - PUD, gastritis, cancer, dieulafoy
3) duodenum - PUD, lymphoma, periampullary cancers, trauma
4) others

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17
Q

For fluid resus, two large bore __ ___ should be inserted at antecubital fossa

A

18G IV cannula

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18
Q

Bloods to order in haemodynamically unstable pts

A

GXM
FBC
Urea/Cr/E - renal function (isolated uremia = UBGIT)
LFT
PT/PTT/INR
Troponin - risk of MI with severe blood loss
ABG/Lactate

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19
Q

__ tube should be inserted when pt having haematemesis UNLESS suspect ___

A

NG - prevent aspiration, allow gastric lavage prior to OGD

unless suspecting variceal bleed - NG tube will worsen bleed

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20
Q

Targets for fluid resus is to maintain ___, ___, ___

A

Hb >7 / >9 (IHD)
MAP: >60mmHg (perfuse end organs)
Urine output: >0.5ml/kg/hr

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21
Q

What is massive blood transfusion?

A

Transfusion of pt entire blood volume within 24 hrs

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22
Q

Complications of massive blood transfusion

A

Lethal triad: Acidosis, hypothermia, coaulopathy

Acute haemolytic transfusion reaction
Acute febrile non-haemolytic transfusion risk: from pt Abs attacking donor WBC/HLA antigens

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23
Q

Two veins in portosystemic anastomosis that leads to variceal bleeds

A

systemic: Oesophageal branch of azygos
portal: Left gastric veins

24
Q

Risk factors for variceal bleeding

A

Risk for development of varices: Hepatic venous pressure gradient >10mmHg

Risk of bleed: varices size, decompensated cirrhosis, endoscopic stigmata of recent haemorrhage

25
Q

Emergency management of severe variceal bleed is by ____ with a ___ tube that consists of ___

A

balloon tamponade

Sengstaken-Blakemore tube

gastric & oesophageal balloons + gastric/eosophageal aspiration openings

26
Q

Predictors of variceal haemorrhage

A

1) Site: GEJ
2) Size: Grade 1-3
3) Child’s score
4) Endoscopic stigmata of recent haemorrhage: red wale marks, cherry red spots, haematocystic spots, erythema
5) Previous haemorrhages

27
Q

Locations of peptic ulcers

A

Duodenum (75%)
Stomach - antrum (20%), lesser/greater curve
Oesophagus

Multiple sites = suspect ZES

28
Q

Gastric ulcer pain pattern vs duodenal ulcer pain pattern

A

Gastric: pain occurs after eating, pts tend to avoid food and lose weight

Duodenal: pain when hungry, relieved by food

29
Q

Protective mechanisms against ulcer formation

A

Bicarbonate, mucus secretion
Mucosal blood flow to remove protons
Epithelial regenerative capacity
Prostaglandins to maintain blood flow

30
Q

What are prostaglandins in the stomach impt for? How are they affected by NSAIDs?

A

NSAIDs impair prostaglandin synthesis

PG: increase bicarb & mucus secretion, promote blood flow, inhibit gastric acid secretion

31
Q

H. pylori effect on stomach

A

Inhibits antral D cells, decrease somatostatin -> increased gastrin -> increased HCL -> gastric metaplasia in duodenum

Decreased bicarb in duodenum + increased inflammation = duodenal ulcer

32
Q

Symptoms of dyspepsia

A

Ulcer-like dyspepsia: burning, gnawing, intermittent epigastric pain

Dysmotility-like dyspepsia: non-painful, bloating, belching, early satiety, N/V

Unspecified dyspepsia

33
Q

Clinical manifestation of perforated ulcer

A

Abdominal rigidity, involuntary guarding, generalised pain that worsens on movement

Fever, hypotension, tachycardia, sepsis

34
Q

Impt to order ___ when suspecting perforated ulcer

A

Erect chest X ray - detect free air under diaphragm

35
Q

Diagnostic method for H.pylori

A

Endoscopic biopsy for CLO (campylobacter-like organism) test: biopsy tissue placed in medium containing urea & phenol red. If H.pylori present to cleave urea, becomes ammonia and pH increase, phenol red change from yellow to red

36
Q

4 main complications for peptic ulcer disease

A

1) bleed
2) burst
3) block
4) burrow - ulcer penetrates into adjacent abdominal organs, leads to other diseases (eg. pancreatitis)

37
Q

Risk factors for gastric cancer

A

H.pylori/EBV infection
Environmental - smoking, diet (preserved food)
Genetic - family history, FAP/HNPCC, familial diffuse gastric cancer

PMH - Barrett’s, gastric polyps/ulcers, gastric resection, chronic atrophic gastritis

38
Q

Classification of gastric tumours

A

Boormann’s

Type 1: polypoid (tumour mostly intraluminal)
Type 2: excavating (ulcerated)
Type 3: ulcerative (tumour mostly in the wall)
Type 4: diffuse thickening/linitis plastica (entire thickness of stomach involved)

39
Q

Most common location of stomach for gastric cancer occurrence

A

Lesser curvature of the antropyloric region

40
Q

Most gastric cancers are ___. Subtypes are ___

A

adenocarcinomas

a) intestinal type
- usually elderly men
- papillary, tubular, mucinous
- atrophic gastritis -> severe intestinal metaplasia -> dysplasia
- less aggro
- haematogenous spread

b) diffuse type
- younger, females
- invasive, linitis plastica pattern (signet ring cells)
- late presentation, worse prognosis
- transmural, lymphatic spread

41
Q

Examples of non-adenocarcinomas of the stomach

A

gastric neuroendocrine tumours (carcinoids) -> from enterchromaffin like cells

lymphoma (MALT)

gastrointestinal stromal tumour (GIST)

leiomyoma/leiomyosarcoma

42
Q

Cx of gastric cancer

A

Bleeding
Gastric outlet obstruction
Intestinal obstruction (carcinomatosis peritonei)
Malnutrition
Perforation

43
Q

GOO presents as ____ in blood investigations

A

hypochloremic, hypokalaemic, metabolic alkalosis with paradoxical aciduria

44
Q

Lymphatic spread of GIT cancers result in enlarged __ node at ___

A

Virchow’s

Left supraclavicular region

45
Q

Modes of spread of gastric cancer

A

1) Local - pancreas, transverse colon, duodenum

2) Lymphatic - Virchow’s node, perigastric lymph node, para-aortic nodes

3) Haematogenous - lung, hepatosplenomegaly

4) Trans-coelomic - peritoneal seeding, Sister Mary Joseph nodule, Krukenburg tumour (ovary)

46
Q

___ is used to determine ___ of tumour invasion in gastric cancer, which is an important prognostic factor

A

Endoscopic ultrasound
depth of tumour invasion

*superior to CT in detecting depth

47
Q

Types of gastrectomies

A

Total - everything gone including cardia & pylorus

Distal - cardia preserved

Pylorus preserving - upper 1/3, pylorus, antrum preserved

Proximal - pylorus preserved

48
Q

Gastric reconstruction options

A

1) Billroth I (gastroduodenostomy)
2) Billroth II (gastrojejunostomy)
3) Roux-en-Y esophagojejunostomy
4) Double tract

49
Q

Signs of anastomotic leak post gastrectomy

A

TACHYCARDIA (early sign)

early leak - sepsis, contaminated drain discharge

50
Q

Late cx of gastrectomy

A

1) early satiety
2) Gastroesophageal reflux -> esophagitis
3) Dumping syndrome

51
Q

What is dumping syndrome?

A

Post gastrectomy, rapid gastric emptying

Hyperosmolar jejunal chyme -> draws water into lumen -> decreased blood volume (hypotension, tachycardia) + abdominal bloating (diarrhea)

Rapid glucose absorption -> reactive hyperinsulinemia -> hypoglycaemia

52
Q

Nutritional supplement requirements post gastrectomy

A

B12 (no more IF to bind)
Iron (no more conversion from Fe3 to Fe2 by gastric acid)

Vitamin D (fat malabsorption)

53
Q

Loop syndrome occurs when?

A

Billroth II (gastrojejunostomy)

Kinking, narrowing, adhesions of the jejunum causing mechanical obstruction

54
Q

Extranodal lymphoma most commonly occurs in ___

A

stomach

  1. marginal zone B cell lymphoma of mucosal associated lymphoid tissue (MALT)
  2. diffuse large B cell lymphoma
55
Q

Gastrointestinal stromal tumours are a type of ___. They are positive for ___ marker, and arises from ___.

A

soft tissue sarcoma of GI tract

CD117
interstitial cell of Cajal

56
Q

Risk factors for obesity

A

Genetics
Environment: diet, culture

57
Q

What are common complications of obesity?

A

T2DM, HTN, HLD, cardiovascular disease

GERD, cholelithiasis, asthma, depression, degenerative joint disease

General Surgery (13 decks)

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