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Fiser absite > Chapter 30 - Stomach > Flashcards

Chapter 30 - Stomach Flashcards

1
Q

What is the transit time of the stomach?

A

3-4h

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2
Q

What level of afferent sympathetic fibers sense gastroduodenal pain?

A

T5-10

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3
Q

What type of mucosa does the stomach have?

A

Simple columnar epithelium

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4
Q

What do the cardia glands secrete?

A

Mucus

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5
Q

What do Chief cells secrete? Location?

A

Pepsinogen; fundus and body

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6
Q

What do Parietal cells secrete? Location?

A

H+ and intrisic factor; fundus and body

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7
Q

What stimulates HCl release?

A

Gastrin, ACh, histamine

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8
Q

What mediator does ACh and gastrin work on to inc. HCl?

A

Phospholipase –> PIP –> DAG + IP3 –> inc. Ca, activates phosphorylase kinase

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9
Q

Histamine acts on what mediator to inc. HCl?

A

Adenylate cyclase –> cAMP –> protein kinase A

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10
Q

What are inhibitors of parietal cells?

A

Somatostatin, PGE1, secretin, CCK

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11
Q

What is the response to intrinsic factor?

A

Binds B12 and the complex is reabsorbed in the terminal ileum

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12
Q

G cells release what? Location?

A

Gastrin; Antrum and pylorus

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13
Q

G cells inhibited by? Stimulated by?

A

Inhibited by H+ in duodenum; stimulated by amino acids, ACh

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14
Q

D cell secrete what? Location?

A

Somatostatin; antrum and pylorus

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15
Q

Response to somatostatin in the stomach?

A

Inhibit gastrin and acid release

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16
Q

Brunner’s glands secrete what? Location?

A

Pepsinogen and alkaline mucus; duodenum

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17
Q

DDx for elevated acid and gastrin?

A

ZES, antral cell hyperplasia, retained antrum, renal failure, gastric outlet obstruction, short bowel syndrome

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18
Q

DDx for elevated gastrin and normal/decreased acid?

A

Pernicious anemia, chronic gastritis, gastric ca, postvagotomy, medical acid suppression

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19
Q

DDx for rapid gastric emptying?

A

1 previous surgery, ZES, ulcers

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20
Q

DDx for delayed gastric emptying?

A

Opiates, anticholinergics, myxedema, hyperglycemia, diabetes

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21
Q

Components of Billroth I?

A

Antrectomy with gastroduodenal anastamosis

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22
Q

Components of Billroth II?

A

Antrectomy with gastrojejunal anastamosis

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23
Q

What is a trichobezoar? Treatment?

A

Hair, hard to pull out; EGD inadequate, likely need gastrostomy and removal

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24
Q

What is a phytobezoar? Treatment?

A

Fiber, often in diabetics with poor gastric emptying; enzymes, EGD, diet changes

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25
Q

What is Dieulafoy’s ulcer?

A

Vascular malformation

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26
Q

What is Menetrier’s disease?

A

Mucous cell hyperplasia, increased rugal folds

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27
Q

Gastric volvulus is associated with what condition?

A

Type II hernia

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28
Q

Symptoms of gastric volvulus? Treatment?

A

Nausea without vomiting, severe pain; usually organoaxial volvulus; reduction and Nissen

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29
Q

What is a Mallory-Weiss tear? Presentation?

A

Secondary to forceful vomiting; hematemesis following severe retching

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30
Q

Diagnosis of Mallory-Weiss? Treatment?

A

EGD; tear usually near lesser curve of stomach, PPE, transfusion; if continued bleeding, may need gastrostomy and oversewing of the vessel

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31
Q

Effects of all forms of vagal denervation?

A

Increased liquid emptying; vagally mediated receptive relaxation is removed; results in increased gastric pressure that accelerates liquid emptying

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32
Q

Where is the denervation in truncal vagotomy? Effect on solid emptying?

A

Divides vagal trunks at level of esophagus; decreased emptying of solids

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33
Q

Where is the level of denervation in selective vagotomy? Effect on solid emptying?

A

Divides nerves of Latarjet; decreased emptying of solids

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34
Q

Where is the level of denervation in highly-selective vagotomy? Effect on solid emptying?

A

Divides individual fibers, preserves “crow’s foot”; normal emptying of solids

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35
Q

What are the gastric effects of truncal vagotomy?

A

Dec. acid output by 90%, increased gastrin, gastrin cell hyperplasia

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36
Q

What are the nongastric effects of truncal vagotomy?

A

Decreased exocrine pancreas function, decreased postprandial bile flow, increased gallbladder volumes, decreased release of vagally mediated hormones

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37
Q

What is the most common problem following vagotomy?

A

Diarrhea (30-50%), caused by sustained MMCs forcing bile acids into colon

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38
Q

Risk factors for upper GI bleed?

A

Previous UGI bleed, PUD, NSAIDs, smoking, liver disease, esophageal varices, splenic v thrombosis, sepsis, burn injuries, trauma, severe vomiting

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39
Q

Treatment for UGI bleed?

A

1st EGD; can potentially treat if due to bleeding ulcer; if pt hypotensive despite resuscitation, go to OR

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40
Q

Risk factors for rebleeding at time of EGD?

A

1 spurting blood vessel (60%), #2 visible blood vessel (40%), #3 diffuse oozing (30%)

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41
Q

Likely source of UGI bleed in liver failure patient? Treatment?

A

Bleeding from esophageal varices; EGD with sclerotherapy, TIPS, not OR

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42
Q

What is the cause of duodenal ulcers?

A

Increased acid production, decreased host defense

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43
Q

Most common location of duodenal ulcers?

A

1st part of duodenum, usually anterior

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44
Q

Most common presentation of anterior duodenal ulcers? Posterior?

A

Anterior: perforation, posterior: bleed

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45
Q

Treatment of duodenal ulcers?

A

H2 blockers, PPI, triple therapy for pts with H. pylori

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46
Q

Surgical indications for duodenal ulcer?

A

Perforation, protracted bleeding despite EGD therapy, obstruction, intractability despite medical therapy, inability to r/o cancer

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47
Q

Surgical options for duodenal ulcers?

A

Truncal vagotomy and pyloroplasty, truncal vagotomy and antrectomy with BI or BII

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48
Q

Ulcer surgery with lowest rate of recurrence?

A

Truncal vagotomy and antrectomy with BI/BII

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49
Q

Ulcer surgery with lowest rate of complications?

A

Proximal or highly selective vagotomy

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50
Q

What is the most frequent complication of duodenal ulcers?

A

Bleeding

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51
Q

Surgical options for bleeding duodenal ulcer?

A

Duodenostomy and GDA ligation (careful to avoid CBD), if pt was on PPI, needs surgical ulcer procedure

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52
Q

What is the initial treatment of choice for obstruction secondary to duodenal ulcers?

A

Serial dilation

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53
Q

Surgical options for duodenal ulcer causing obstruction?

A

Near ampulla: gastroj (BII, bypasses obstruction), antrectomy, truncal vagotomy; proximal to ampulla: antrectomy with ulcer excision, BII, truncal vagotomy

54
Q

% of patients with perforation that will have free air?

A

80%

55
Q

Treatment of perforation in elderly, high risk patients?

A

Possibility that high risk patients can be safely observed with UGI to make sure perforation has sealed

56
Q

Surgical option for perforated duodenal ulcer?

A

Graham patch and highly selective vagotomy (for pts on PPI); truncal vagotomy and pyloroplsty (include ulcer in pyloroplasty); truncal vagotomy and antrectomy with BI or BII (need to include ulcer)

57
Q

What defines intractability with duodenal ulcers?

A

> 3mo without relief on PPI or recurrence <1y after medical therapy; based on EGD findings, not symptoms

58
Q

Risk factors for gastric ulcers?

A

Male, tobacco, ETOH, NSAIDs, H. pylori, uremia, stress, steroids, chemo

59
Q

Most common cause of gastric ulcers?

A

Most (type I/IV) have normal acid secretion, due to abnormal mucosal defense

60
Q

% of gastric ulcers on lesser curve of stomach?

A

70-80%

61
Q

Where do biopsies for H. pylori need to be taken from?

A

Antrum

62
Q

What type of blood is associated with type I ulcers?

A

Type A

63
Q

What type of blood is associated with type II-IV ulcers?

A

Type O

64
Q

Indications for surgery with gastric ulcers?

A

Perforation, bleeding, obstruction, cannot exclude malignancy, intractability

65
Q

Location of type I gastric ulcer? Cause?

A

Lesser curvature; due to decreased mucosal protection

66
Q

Treatment of type I gastric ulcer?

A

Distal gastrectomy including ulcer with BI/BII

67
Q

Location of type II gastric ulcer? Cause?

A

Lesser curve and duodenal; high acid secretion

68
Q

Treatment of type II gastric ulcer?

A

Distal gastrectomy with BI/BII and truncal vagotomy

69
Q

Location of type III gastric ulcer? Cause?

A

Prepyloric; similar to duodena, high acid secretion

70
Q

Treatment for type III gastric ulcer?

A

Distal gastrectomy with BI/BII and truncal vagotomy

71
Q

Location of type IV? Cause?

A

Lesser curve high along cardia of stomach; decreased mucosal protection

72
Q

Treatment for type IV gastric ulcer?

A

Ulcer excision +/- vagotomy

73
Q

Location of type V gastric ulcer? Cause?

A

Anywhere; NSAID-related

74
Q

How many days after the event does stress gastritis occur?

A

3-5d

75
Q

Where is type A chronic gastritis located? Associated with what conditions?

A

Fundus; pernicious anemia, autoimmune disease

76
Q

Location of type B chronic gastritis? Associated conditions?

A

Antrum; H. pylori

77
Q

Symptoms associated with gastric cancer?

A

Pain unrelieved by eating, weight loss

78
Q

Where are the majority of gastric cancers located?

A

Antrum (40%)

79
Q

Risk factors for gastric cancer?

A

Adenomatous polyps, tobacco, previous gastric operations, intestinal metaplasia, atrophic gastritis, pernicious anemia, type A blood, nitrosamines

80
Q

Adenomatous polyps carry what % cancer risk? Treatment?

A

10-20% risk of cancer; endoscopic resection

81
Q

What is Krukenberg tumor?

A

Metastases to ovaries

82
Q

What is Virchow’s node?

A

Mets to supraclavicular node

83
Q

What is intestinal gastric cancer associated with?

A

High risk opulations, older men (rare in US); associated with chronic atrophy, dysplasia, blood invasion, glands on histology

84
Q

Characteristics of diffuse gastric cancer (linitis plastica)?

A

Low risk populations, women, lymphatic invasion, NO glands

85
Q

Surgical treatment of linitis plastica?

A

Total gastrectomy plus chemo

86
Q

Options for palliation for gastric cancer causing obstruction? Bleeding or pain?

A

Obstruction: stenting; bleeding/pain: XRT or palliative gastrectomy

87
Q

What is the most common benign gastric neoplasm?

A

Gastric leiomyomas (GIST)

88
Q

US findings of GIST?

A

Hypoechoic, smooth edges

89
Q

Treatment of GIST?

A

Resection; consider chemo if >5cm or 5-10 mitoses/HPF; need 1cm margins

90
Q

Gene mutation associated with GIST?

A

c-KIT

91
Q

Chemo used with GIST?

A

Gleevec (tyrosine kinase inhibitor)

92
Q

Treatment for gastric leiomyosarcoma?

A

En bloc resection

93
Q

What is the diagnosis of cancer with gastric leiomyosarcomas based on?

A

Mitoses/HPF (>5-10)

94
Q

Spread of leiomyosarcoma via what?

A

Hematogenous

95
Q

Symptoms of gastric lymphomas?

A

Ulcer symptoms

96
Q

Most common type of lymphoma of the stomach?

A

Non-Hodgkins

97
Q

Treatment for gastric lymphomas?

A

Chemo and XRT; surgery for complications

98
Q

Overall 5y survival rate of gastric lymphoma?

A

> 50%

99
Q

Mucosa-associated lymphoid tissue lymphoma (MALT) associated with what condition?

A

H. pylori infection

100
Q

Where are MALTs located?

A

Usually in GI, can also be in lung and Waldeyer’s ring

101
Q

Treatment for MALT?

A

Triple therapy abx for H. pylori and surveillance; if does not regress, need chemo (CHOP)

102
Q

Surgical eligibility for morbid obesity?

A

BMI >40, BMI >35 with comorbidities (DM, OSA, HTN, urinary stress incontinence, GERD, venous stasis ulcers, pseudotumor cerebri, joint pain)

103
Q

Operative mortality with surgery for morbid obesity?

A

1%

104
Q

Risk with roux-en-Y?

A

Marginal ulcers, leak, necrosis, B12 deficiency, iron-deficiency anemia, gallstones

105
Q

Procedure that should be performed with gastric bypass?

A

Cholecystectomy

106
Q

Failure rate of roux-en-y?

A

10-15% due to high carb snacking

107
Q

What is the most common cause of leak with roux-en-y? Signs?

A

Ischemia; tachycardia, tachypnea, pain, fever, elevated WBCs

108
Q

% of roux-en-y that develop marginal ulcers? Treatment?

A

10%; omeprazole

109
Q

Tx for stenosis following roux-en-y?

A

Dilation

110
Q

What are signs of obstruction following roux-en-y surgery?

A

Hiccups, large stomach bubble

111
Q

Why are jejunoileal bypass operations no longer done?

A

Associated with increased liver cirrhosis and kidney stones, osteoporosis

112
Q

What is the treatment for jejunoileal bypass when encountered?

A

Correction with roux-en-y

113
Q

What causes dumping syndrome post-gastrectomy?

A

From rapid entering of carbs into small bowel; can occur after gastrectomy, vagotomy, pyloroplasty

114
Q

What are the 2 phases of dumping syndrome?

A

Hyperosmotic load causes fluid shift into bowel (diarrhea, dizziness, hypotension); reactive increase in insulin and decrease in glucose (rarely occurs)

115
Q

Treatment for dumping syndrome?

A

Small, low-fat, low-carb, increased-protein meals; no liquids with meals, no lying down after meals

116
Q

Surgical options for dumping syndrome?

A

Rarely necessary; Conversion of BI or BII to Roux-en-y, oerations to increase gastric reservoir (jejunal pouch), or increase emptying time (reversed jejunal loop)

117
Q

What are symptoms of alkaline reflux gastritis?

A

Postprandial epigastric pain associated with n/v; pain not relieved with vomiting

118
Q

Diagnosis of alkaline reflux gastritis?

A

Evidence of bile reflux into stomach, histologic evidence of gastritis

119
Q

Treatment for alkaline reflux gastritis?

A

H2 blockers, cholestyramine, metoclopramide

120
Q

Surgical options for alkaline reflux gastritis?

A

Concersion of BI/BII to roux-en-y with afferent limb 60cm distal to original gastroj

121
Q

What is roux stasis? Diagnosis?

A

Stasis of chyme in roux limb due to loss of jejunal motility; EGD, emptying studies

122
Q

Treatment for roux stasis? Surgical options?

A

Metoclopramide, prokinetics; shorten roux limb to 40cm

123
Q

What is chronic gastric atony? Symptoms? Diagnosis?

A

Delayed gastric emptying after vagotomy; n/v, pain, early satiety; gastric emptying study

124
Q

Treatment for chronic gastric atony? Surgical options?

A

Metoclopramide, prokinetics; near-total gastrectomy with roux-en-y

125
Q

Treatment for duodenal stump blow-out?

A

place duodenostomy and drains

126
Q

What is blind-loop syndrome?

A

With BII or roux0en0y; pain, diarrhea, malabsorption, b12 deficiency, steatorrhea; caused by bacterial overgrowth and stasis in afferent limb

127
Q

Treatment for blind-loop syndrome?

A

Tetracycline, flagyl, reglan; reanastomosis with shorter (40cm) afferent limb

128
Q

What is afferent-loop obstruction?

A

With BII or roux-en-y; nonbilious vomiting, pain relieved with bilious emesis; ruq pain, steatorrhea; caused by obstruction of afferent limb

129
Q

Treatment of afferent-loop obstruction?

A

Blloon dilation may be possible; reanastomosis with shorter (40cm) afferent limb

130
Q

What is efferent-loop obstruction?

A

Symptoms of obstruction

131
Q

Treatment for efferent loop obstruction?

A

Dilation; find site of obstruction and relieve it

132
Q

What is postvagotomy diarrhea secondary to?

A

Nonconjugated bile salts in colon and sustained postprandial organized MMCs

Fiser absite (58 decks)

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