Chapter 30: Stomach Flashcards Preview

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Flashcards in Chapter 30: Stomach Deck (178):
1

Stomach transit time

3-4 hours

2

Where does stomach peristalsis occur?

Distal stomach (antrum)

3

How is gastroduodenal pain sensed

Through afferent sympathetic fibers T5-T10

4

Components of the celiac trunk

Left gastric
Common hepatic artery
Splenic artery

5

Branches of the splenic artery that supply the stomach

Left gastroepiploic and short gastric

6

Blood supply to the greater curvature

Right and left gastroepiploics, short gastrics

7

What is the right gastroepiploic a branch of?

Gastroduodenal artery

8

Blood supply of lesser curvature

Right and left gastrics

9

What is the right gastric a branch off?

The common hepatic artery

10

Blood supply of the pylorus

Gastroduodenal artery

11

Mucosa lining the stomach

Simple columnar epithelium

12

What do cardia glands secrete?

Mucus

13

Fundus and body glands

Chief cells
Parietal cells

14

Produces pepsinogen (1st enzyme in proteolysis)

Chief cells

15

Release hydrogen and intrinsic factor

Parietal cells

16

What stimulates parietal cells?

Acetylcholine (vagus nerve), gastrin (from G cells in antrum), and histamine (from mast cells) cause H+ release

17

What is the pathway of acetylcholine (vagus nerve) and gastrin?

Activates phospholipase (PIP -> DAG + IP3 + Increase Ca); Ca-calmodulin activates phosphorylase kinase -> H+ release

18

What is the pathway of histamine?

Activates adenylate cyclase -> cAMP -> activates protein kinase A -> increased H+ release

19

How do phosphorylase and protein kinase A work?

Phosphorylate H+/K+ ATPase to increase H+ secretion and K+ absorption

20

Blocks H+/K+ ATPase in parietal cell membrane (final pathway for H+ release)

Omeprazole

21

Inhibitors of parietal cells

Somatostatin, prostaglandins (PGE1), secretin, CCK

22

Binds B12 and the complex is reabsorbed in the terminal ileum

Intrinsic factor

23

Antrum and pylorus glands

Mucus and HCO3- secreting glands.
G cells (gastrin).
D cells (somatostatin)

24

Secreting glands - protect stomach

Mucus and HCO3- (Antrum and pylorus glands)

25

Release gastrin - reason why antrectomy is helpful for ulcer disease

G cells

26

What inhibits G cells?

H+ in duodenum

27

What stimulates G cells?

Amino acids, acetylcholine

28

Secrete somatostatin, inhibit gastrin and acid release

D cells

29

In duodenum; secrete alkaline mucus

Brunner's glands

30

Released with antral and duodenal acidification

Somatostain, CCK, and secretin

31

What are the causes of rapid gastric emptying?

Previous surgery (#1), ulcers

32

What are the causes of delayed gastric emptying?

Diabetes, opiates, anticholingerics, hypothyroidism

33

(Hair) - hard to pull out
Tx?

Trichobezoars
- Tx: EGD generally inadequate; likely need gastrostomy and removal

34

(fiber) - often in diabetics with poor gastric emptying
Tx?

Phytobezoars (fiber)

Tx: enzymes, EGD, diet changes

35

Vascular malformation; can bleed

Dieulafoy's ulcer

36

Mucous cell hyperplasia, increased rugal folds

Menetrier's disease

37

- Associated with type II (paraesophageal) hernia
- Nausea without vomiting; severe pain; usually organoaxial volvulus
Treatment?

Gastric volvulus

Tx: reduction and Nissen

38

- Secondary to forceful vomiting
- Presents as hematemesis following severe retching
- Bleeding often stops spontaneously

Mallory-Weiss tear

39

What type of volvulus is a gastric volvulus?

Organoaxial volvulus

40

Dx/Tx: Mallory Weiss Tear

EGD with hemo-clips; tear is usually on the lesser curvature (near GE junction)

41

Where is the Mallory Weiss Tear located?

Usually on the lesser curvature (near GE junction)

42

What if you have continued bleeding after EGD with hemo-clips for Mallory Weiss tear?

If continued bleeding, may need gastrostomy and oversewing of the vessel.

43

What is the physiologic effect of vagotomy?

Both truncal and proximal forms increase liquid emptying -> vaguely mediated receptive relaxation if removed (results in increased gastric pressure that accelerates liquid emptying)

44

Vagotomy:
Divides vagal trunks at the level of the esophagus; decreases emptying of solids

Truncal vagotomy

45

Vagotomy:
- highly selective
- divides individual fibers, preserves "crow's foot", normal emptying of solids

Proximal vagotomy

46

Emptying of solids: truncal vs proximal vagotomy

Truncal: decreased emptying of solids

Proximal: normal emptying of solids

47

How can you increase solid emptying with truncal vagotomy?

Addition of pyloroplasty to truncal vagotomy results in increased solid emptying.

48

Physiologic effects of truncal vagotomy
- Gastric effects
- Nongastric effects
- Diarrhea

- Gastric: decreased acid output by 90%, increased gastrin cell hyperplasia
- Nongastric: decreased exocrine pancreas function, decreased postprandial bile flow, increased gallbladder volumes, decreased release of vaguely mediated hormones
- Diarrhea: MC problem following vagotomy

49

MC common problem following vagotomy

Diarrhea (40%)

50

What causes diarrhea following vagotomy?

Caused by sustained MMCs (migrating motor complex) forcing bile acids into the colon

51

Name that vagotomy: both nerve trunks are divided at the level of the diaphragmatic hiatus

Truncal vagotomy

52

Name that vagotomy: division of the vagal fibers that supply the gastric funds. Branches to the antropyloric region of the stomach are not transected, and the hepatic and celiac divisions of the vagus nerves remain intact.

Proximal gastric vagotomy

53

Risk factors: upper gastroinestinal bleeding

Previous UGIB, PUD, NSAIDs, smoking, liver disease, esophageal varices, splenic vein thrombosis, sepsis, burn injuries, trauma, severe vomiting.

54

Dx/Tx: UGIB

EGD (confirm bleeding is from ulcer); can potentially treat with hemo-clips, Epi injection, cautery

55

Mgmt: UGIB with slow bleeding and having trouble localizing source

Tagged RBC scan

56

UGIB: biggest risk factor for rebleeding at the time of EGD

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

57

Highest risk factor for mortality with non-variceal UGIB

Continued or re-bleeding

58

Treatment: patient with liver failure is likely bleeding from esophageal varices, not an ulcer

EGD with variceal bands or sclerotherapy; TIPS if that fails

59

- From increased acid production and decreased defense
- Most common peptic ulcer; more common in men

Duodenal ulcers

60

Location of duodenal ulcers

Usually in 1st part of the duodenum; usually anterior.

61

Complications of duodenal ulcers:
- Anterior
- Posterior

- Anterior ulcers perforate
- Posterior ulcers bleed from gastroduodenal artery

62

Symptoms: epigastric pain radiating to the back; abates with eating but recurs 30 minutes after
- Dx/Tx?

Duodenal ulcer
- Dx: endoscopy
- Tx: PPI, triple therapy for H. pylori -> bismuth salts, amoxicillin, and metronidazole/tetracycline (BAM or BAT)

63

What has decreased incidence of surgery for ulcer?

Surgery for ulcer rarely indicated since PPIs

64

What do you need to rule out in patients with complicated ulcer disease?

Need to rule out gastrinoma

65

Gastric acid hyper secretion.
Peptic ulcers.
Gastrinoma.

Zollinger-Ellison Syndrome

66

Surgical indications for duodenal ulcer

Perforation. Protracted bleeding despite EGD therapy. Obstruction. Intractability despite medical therapy. Inability to rule out cancer. PPI with duodenal ulcer complication.

67

Duodenal ulcer: if patient has been on a PPI and has complications

If a patient has been on a PPI, an acid-reducing surgical procedure is required in addition to surgery for any complications

68

Surgical options (acid-reducing surgery) for duodenal ulcers

- Proximal vagotomy
- Truncal vagotomy and pyloroplasty
- Truncal vagotomy and antrectomy
- Reconstruction after antrectomy - Roux-en-Y gastro-jejunostomy (best)

69

Surgery duodenal ulcer: lowest rate of complications, no need for astral or pylorus procedure; 10-15% ulcer recurrence, 0.1% mortality

Proximal vagotomy

70

Ulcer recurrence / mortality after proximal vagotomy

- 10-15% ulcer recurrence
- 0.1% mortality

71

Ulcer recurrence / mortality after truncal vagotomy and pyloroplasty

- 5-10% ulcer recurrence
- 1% mortality

72

Ulcer recurrence / mortality after truncal vagotomy and antrectomy

- 1-2% ulcer recurrence (lowest rate of recurrence)
- 2% mortality

73

Why is roux-en-y gastro-jejunostomy the best procedure for reconstruction after antrectomy?

Less dumping syndrome and reflux gastritis compared to Bilroth I (gastro-duodenal anastomosis) and Billroth II (gastro-jejunal anastomosis)

74

Most frequent complication of duodenal ulcers

Bleeding (usually minor but can be life threatening)

75

Definition of major bleeding in duodenal ulcer

> 6 units of blood in 24 hours or patient remains hypotensive despite transfusion

76

Tx: bleeding from duodenal ulcer

EGD 1st - hemoclips , cauterize, Epi injection

77

Surgery: bleeding duodenal ulcers

Duodenotomy and gastroduodenal artery (GDA) ligation.
- Avoid hitting common bile duct (posterior) with GDA ligation
- If patient has been on a PPI, need acid-reducing surgery as well

78

Initial treatment of choice for obstruction from duodenal ulcer

PPI and serial dilation

79

Surgical options: duodenal ulcer obstruction

Antrectomy and truncal vagotomy (best); include ulcer in resection if it's located proximal to ampulla of Vater

80

What do you need to rule out in duodenal ulcer obstruction?

Need to biopsy area of resection to rule out CA

81

Duodenal ulcer perforation: % will have free air

80% will have free air

82

- patient usually have sudden epigastric pain; can have generalized peritonitis
- pain can radiate to the prevocalic gutters with dependent drainage of gastric content

Duodenal ulcer perforation

83

Tx: duodenal ulcer perforation

Graham patch (place momentum over the perforation)
- Also need acid-reducing surgery if the patient has been on a PPI

84

Definition of intractable duodenal ulcers

> 3 months without relief while on escalating doses of PPI

85

What is diagnosis of intractable duodenal ulcers based on?

Based in EGD mucosal findings, not symptoms

86

Tx: intractability of duodenal ulcers

Acid-reducing surgery

87

- Older men, slow healing
- 80% on lesser curvature of the stomach
- Symptoms: epigastric pain radiating to the back; relieved with eating but recurs 30 minutes later; melena or guaiac-positive stools

Gastric ulcers

88

Risk factors for gastric ulcer

Male, tobacco, ETOH, NSAIDs, H. pylori, uremia, stress (burns, sepsis, and trauma), steroids, chemotherapy

89

Where are most gastric ulcers located?

80% on lesser curvature of the stomach

90

What is difference in mortality between gastric and duodenal ulcer hemorrhage?

Hemorrhage is associated with higher mortality than duodenal ulcers.

91

Gastric ulcers: best test for H. pylori

Histiologic examination of biopsies from antrum

92

Test for H.pylori, detects urease released from H. pylori

CLO test (rapid urease test)

93

Type 1 Gastric ulcer

Lesser curve low along body of stomach; due to decreased mucosal protection

94

Type 2 gastric ulcer

2 ulcers (lesser curve and duodenal); similar to duodenal ulcer with high acid secretion

95

Type 3 gastric ulcer

pre-pyloric ulcer; similar to duodenal ulcer with high acid secretion

96

Type 4 gastric ulcer

Lesser curve high along cardia of stomach; decreased mucosal protection

97

Type 5 gastric ulcer

Ulcer associated with NSAIDS

98

What gastric ulcers are associated with decreased mucosal secretion?

Type 1 and 4

99

What gastric ulcers are similar to duodenal ulcer with high acid secretion?

Type 2 and 3

100

What type of gastric ulcer is associated with NSAIDS?

Type 5

101

Surgical indications for gastric ulcers

Perforation, bleeding not controlled with EGD, obstruction, cannot exclude malignancy, intractability (> 3 months without relief - based on mucosal findings)

102

Tx: gastric ulcer

Truncal vagotomy and antrectomy best for complications; try to include the ulcer with resection (extended antrectomy) - need separate ulcer excision if that is not possible (gastric ulcers are resected at time of surgery due to high risk of gastric CA)

103

What are poor options for surgical repair of gastric ulcers?

Omental patch and ligation of bleeding vessels are poor options for gastric ulcers due to high recurrence of symptoms and risk of gastric CA in the ulcer.

104

- Occurs 3-10 days after event; lesions appear in fundus first
- Tx: PPI
- EGD with cautery of specific bleeding point may be effective

Stress gastritis

105

Where do lesions in stress gastritis appear?

Lesions appear in fundus first

106

Chronic gastritis type: associated with pernicious anemia, autoimmune disease

Type A (fundus)

107

Chronic gastritis type: associated with H. pylori

Type B (antral)

108

Treatment Chronic Gastritis

PPI

109

Pain unrelieved by eating, weight loss

Gastric cancer

110

Where are 40% of gastric cancers located?

Antrum

111

Gastric cancer-related deaths in Japan

Accounts for 50% of cancer-related deaths in Japan

112

Dx: gastric cancer

EGD

113

Risk factors: gastric cancer

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

114

15% risk of gastric cancer.
- Tx: endoscopic resection

Adenomatous polpys

115

Gastric cancer metastases to ovaries

Krukenberg tumor

116

Gastric metastasis to supraclavicular node

Virchow's node

117

Increased in high-risk populations. Older men. Japan. Rare in United States

Surgical treatment: try to perform subtotal gastrectomy (need 10-cm margins)

Intestinal-type gastric CA

118

Low risk populations. Women. Most common type in the United States.
Diffuse lymphatic invasion, no glands.

Surgery: total gastrectomy bc of diffuse nature of linitis plastica

Diffuse gastric cancer

119

Prognosis: intestinal-type gastric CA vs diffuse gastric cancer

Less favorable prognosis than intestinal-type gastric CA (overall 5-YS - 25%)

120

Margins for intestinal-type gastric CA

need 10 cm margins

121

Chemotherapy for gastric cancer

Poor prognosis:
- 5 FU, doxorubicin, mitomycin C

122

Gastric cancer: management of metastatic disease outside area of resection

Contraindication to resection unless performing surgery for palliation.

123

When to consider palliation of gastric cancer?

- Obstruction - proximal lesions can be scented; distal lesions can be bypassed with gastrojejunostomy
- Low to moderate bleeding or pain - Tx: XRT

124

What if surgical management fails for palliation of gastric cancer (stents, gastrojejunostomy, XRT)?

If these fail, consider palliative gastrectomy for obstruction or bleeding.

125

Most common benign gastric neoplasm, although can be malignant

Symptoms: usually asymptomatic, but obstruction and bleeding can occur

Gastrointestinal stromal tumors (GISTs)

126

How do GISTs look on ultrasound?

Hypoechoic on ultrasound; smooth edges

127

Dx / Tx: GIST

Dx: biopsy - are C-KIT positive

Tx: resection with 1 cm margins; Chemotherapy with imatinib (Gleevac, tyrosine kinase inhibitor) if malignant

128

Chemotherapy for malignant GIST

Imatinib (Gleevax; tyrosine kinase inhibitor)

129

- Related to H. pylori infection
- Usually regresses after treatment for H. pylori

Mucosa-associated lymphoid tissue lymphoma (MALT lymphoma)

130

When are GIST considered malignant?

> 5 cm or > 5 mitoses / 50 HPF (high-powered field)

131

What will be positive in biopsy of GIST?

C-KIT

132

MC location of MALT lymphoma

Stomach

133

Treatment: MALT lymphoma

Triple-therapy antibiotics for H. pylori and surveillance.
If MALT does not regress, need XRT.

134

What if MALT lymphoma does not resolve with triple therapy antibiotics for H.pylori?

If MALT does not regress, need XRT

135

- Have ulcer symptoms
- Usually non-Hodgkin's lymphoma (B cell)
- Overall 5-year survival rate > 50%

Gastric lymphomas

136

MC location for extra-nodal gastric lympoma

Stomach

137

Dx: Gastric lymphoma

EGD with biopsy

138

Primary treatment modalities of gastric lymphoma

Chemotherapy and XRT are primary treatment modalities; surgery for complications

139

When is surgery indicated for gastric lymphoma?

Surgery possibly indicated only for stage 1 disease (tumor confined to stomach mucosa) and then only partial resection is indicated

140

Overall 5-year survival rate for gastric lymphoma

> 50%

141

Criteria for patient selection for bariatric surgery (need all 4)

- BMI > 40 kg/m^2 or BMI > 35 kg/m^2 with coexisting comorbidities
- Failure of nonsurgical methods of weight reduction
- Psychological stability
- Absence of drug or alcohol abuse

142

What type of obesity is worse prognosis in general population?

Central obesity

143

Operative mortality in morbid obesity

1%

144

What gets better are surgery for morbid obesity?

DM, cholesterol, sleep apnea, HTN, urinary incontinence, GERD, venous stasis ulcers, pseudotumor cerebri, joint pain, migraines, depressions, PCOS, NASH

145

- Better weight loss than just banding.
- Risk of marginal ulcers, leak, necrosis, B12 deficiency, IDA, gallstones
- Perform cholecystectomy during operation if stones present
- UGI on POD 2

Roux-en-Y gastric bypass

146

Failure rate of roux-en-y gastric bypass

10% failure rate due to high-carbohydrate snacking

147

What are the signs of a leak after roux-en-y gastric bypass?

- Ischemia: MCC leak
- Signs of leak: increased RR, increased HR, abdominal pain, fever, elevated WBCs

148

Dx / Tx: leak after roux-en-y gastric bypass

Dx: UGI

Tx: early leak (not contained) -> re-op; late leak (Weeks out from surgery, likely contained) -> percutaneous drain, antibiotics

149

Incidence of marginal ulcers after roux-en-y gastric bypass

Develop in 10%

Tx: PPI

150

Management of stenosis after roux-en-y gastric bypass

Usually responds to serial dilation

151

Complications of roux-en-y gastric bypass

- Leak
- Marginal ulcers
- Stenosis

152

MCC leak after roux-en-y gastric bypass

Ischemia

153

After roux-en-y gastric bypass:
- Hiccoughs, large stomach bubble
- Dx: AXR
- Tx: G-tube (gastrostomy tube)

Dilation of excluded stomach postop

154

s/p roux-en-y gastric bypass:
- nausea and vomiting, intermittent abodminal pain
- AXR shows dilated SB

Small bowel obstruction
- Surgical emergency

155

Why is SBO s/p roux-en-y gastric bypass a surgical emergency?

Due to the high risk of small bowel herniation, strangulation, infarction and subsequent necrosis.

- Tx: surgical exploration

156

- these operations are no longer done
- a/w liver cirrhosis, kidney stones, and osteoporosis (decreased calcium)
- need to correct these patients and perform roux-en-y gastric bypass if encountered

jejunoileal bypass

157

- can occur after gastrectomy or after vagotomy and pyloroplasty
- occurs form rapid entering of carbohydrates into the small bowel.
- can almost always be treated medically (and dietary changes)

Dumping syndrome

158

2 phases of dumping syndrome

- Hyperosmotic load causes fluid shift into bowel (hypotension, diarrhea, dizziness)
- hypoglycemia from reactive increase in insulin and decrease in glucose (2nd phase rarely occurs)

159

Tx: dumping syndrome

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

160

Surgical options for dumping syndrome (Rarely needed)

- Conversion of Billroth 1 or Billroth 2 to Roux-en-y gastrojejunostomy
- Operations to increase gastric reservoir (jejunal pouch) or increased emptying time (Reversed jejunal loop)

161

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

Alkaline reflux gastritis

162

Dx / Tx: alkaline reflux gastritis

Dx: evidence of bile reflux into the stomach; histologic evidence of gastritis

Tx: PPI, cholestyramine, metoclopramide

163

Surgical options for alkaline reflux gastritis

Conversion of Billroth 1 or Billroth 2 to Roux-en-Y gastrojejunostomy with afferent limb 60 cm distal to gastro jejunostomy

164

- Delayed gastric emptying
- Symptoms: n/v, pain, early satiety

Chronic gastric atony

165

Chronic gastric atony:
Dx / Tx / Surgical options

Dx: gastric emptying study

Tx: metoclopramide, prokinetics

Surgical option: near total gastrectomy with roux-en y

166

- Early satiety
- Actually want this for gastric bypass patients

Small gastric remnant

167

Small gastric remnant:
Dx / Tx / Surgical option

- Dx: EGD
- Tx: small meals
- Surgical option: jejunal pouch reconstruction

168

- With billroth 2 or roux-en-y; caused by poor motility
- Symptoms: pain, steatorrhea (bacterial beconjugation of bile), B12 deficiency (bacteria use it up), malabsorption

Blind-loop syndrome

169

What causes blind-loop syndrome with billroth 2 or roux-en-y?

Caused by bacterial overgrowth (E coli, GNRs) from stasis in afferent limb

170

Dx: blind-loop syndrome

EGD of afferent limb with aspirate and culture for organisms

171

Tx: blind loop syndrome

Tetracycline and flagyl, metoclopramide to improve motility

172

Surgical option: blind-loop syndrome

Re-anastomosis with shorter (40-cm) afferent limb to relieve obstruction

173

- Symptoms of obstruction - n/v, abdominal pain
- Dx: UGI, EGD
- Tx: balloon dilation
- Surgical option: find site of obstruction and relieve it

Efferent-loop obstruction

174

- Secondary to non-conjugated bile salts in the colon (osmotic diarrhea)
- Causes by sustained postprandial organized MMCs

Post-vagotomy diarrhea

175

Tx / Surgical option: post-vagotomy diarrhea

Tx: cholestyramine, octreotide

Surgical option: reversed interposition jejunal graft

176

What causes post-vagotomy diarrhea?

Reversed interposition jejunal graft

177

Management: duodenal stump blow-out

Place lateral duodenostomy tube and drains

178

Potential PEG complications

Insertion into the liver or colon