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Stomach 2 Flashcards

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1
Q

Hereditary diffuse gastric cancer is an inherited form of gastric CA, caused by what mutation?

A

E-cadherin mutation

***80% of these pts will develop gastric CA

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2
Q

Li Fraumeni syndrome is an AD syndrome caused by mutation what gene?

A

p53

**have risk of many malignancies, including gastric Ca

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3
Q

Hereditary non-polyposis colorectal cancer is AKA?

A

lynch syndrome

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4
Q

Lynch syndrome is a mutation in what?

A

assc w/ microsatellite instability

**also assc w/ increased risk of ovarian + gastric Ca

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5
Q

What is a micro-satellite?

A

lengths of DNA where 1 to 5 nucleotides motifs are repeated several times

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6
Q

What are some genes over-expressed in gastric Ca?

A

c-met

k-sam

c-erbB2

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7
Q

Pts with pernicious anemia are at increased risk of gastric Ca, what’s the defining feature of this dx?

A

achlorhydria

chief and parietal cells are destroyed by an autoimmune response

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8
Q

MOA of PPIs?

A

block H-K pump within the parietal cell

block all acid secretion in the stomach

***as a result pts develop hyper-gastrinemia

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9
Q

Few classification systems used to characterize gastric Ca?

A

Bormann classification–> uses macroscopic appearance, V types

Lauren classification–> separates gastric Ca into intestinal vs. diffuse type

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10
Q

What are some features of intestinal type gastric Ca?

A

arises in setting of a pre-cancerous condition; like gastric atrophy and intestinal metaplasia

M>W

incidence increases with age

mets via hematogenous spread

environmental causes involved

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11
Q

What are some features of diffuse type gastric Ca?

A

poorly differentiated, lacks glands

has tiny clusters of signet ring cells

W>M

younger age group affected

assc. w/blood type A

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12
Q

Diffuse type gastric Ca associated with what blood type?

A

type A

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13
Q

Better prognosis with intestinal or diffuse type gastric Ca?

A

intestinal type gastric Ca

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14
Q

Supraclavicular mets of gastric Ca called what?

A

Virchow’s nodes

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15
Q

What are Virchow’s nodes?

A

gastric Ca that has mets to supraclavicular nodes

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16
Q

What is a Sister Mary Joseph node?

A

gastric Ca that has mets to peri-umbilical area

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17
Q

Gastric Ca drop mets to ovaries called what?

A

Krukenberg tumors

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18
Q

Peritoneal gastric Ca mets felt on rectal exam called what?

A

Bloomer’s shelf

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19
Q

Most widely used staging system for gastric Ca?

A

TNM

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20
Q

In the TNM staging system for gastric Ca, how many nodes needs to be evaluated?

A

15

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21
Q

What’s the number of nodes that need to be evaluated in gastric Ca?

A

15

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22
Q

For gastric cancers of distal stomach, including the body and antrum, what operation do we perform?

A

distal gastrectomy

*distal margin should be proximal duodenum

frozen section should be performed prior to reconstruction

can do Bilroth I vs II

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23
Q

When performing gastrectomies for gastric Ca, how wide of a margin do we want?

A

at least 6 cm

studies have shown tumor spread as far as 5 cm

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24
Q

What surgery do we perform for proximal gastric Ca?

A

total gastrectomy w/Roux-en-y w/esophagojejunostomy

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25
When do we perform endoscopic resection of early gastric Ca?
tumor is limited to the mucosa there is NO lymphovascular invasion tumor is smaller than 2 cm there are no ulcers
26
Most recurrences of gastric cancer occur within what time frame?
3 yrs
27
Where does gastric Ca tend to spread to?
liver, lung, bone
28
MOst common site of lymphomas in the GI system>
stomach
29
Where do we see lymphomas most commonly in the GI system?
stomach
30
Share some facts about gastric lymphomas:
occur in older pts (6-7th decade) M>F usually occur in antrum 50% of pts will present with anemia
31
M0st common gastric lymphoma?
diffuse large B cell lymphoma (55%)
32
Most common gastric lymphomas?
diffuse large B cell (55%) gastric MALT lymphoma (40%) Burkitt's lymphoma (3%) mantle cell and follicular lymphoma (1%)
33
Risk factors for development of diffuse large B cell lymphoma??
h. pylori immunodeficiencies
34
Burkitt's lymphoma of stomach associated with what?
Epstein-barr virus
35
This type of gastric lymphoma is very aggressive, tends to affect younger pts, usually found in cardia of stomach;
Burkitt's lymphoma
36
Tx for gastric lymphoma?
surgery controversial most treated w/chemotherapy alone
37
Most common chemotherapy regimen for gastric lymphoma is?
CHOP cyclophosphamide doxorubicin vincristine prednisone
38
When is surgery for gastric lymphoma performed?
pts w/limited gastric disease pts w/recurrence of treatment failure pts w/complications like bleeding, obstruction, perforation
39
Gastric MALT lymphoma is usually preceded by what?
h-pylori associated gastritis
40
With this type of gastric lymphoma we see H. pylori involvement and increased NK-B activity;
gastric MALT lymphoma
41
Tx for gastric MALT lymphomas?
usually tx for h.pylori showed remission in 75% of pts
42
These gastric tumors derived from interstitial cells of Cajal:
GISTs
43
Where do we GISTs come from?
originate from interstitial cells of Cajal, pacemaker intestinal cells
44
Where do we commonly find GISts?
stomach small intestine colon
45
GISTs stain for what CD?
CD117 CD 34
46
C-kit (CD 117) proto-oncogene associated with what cancer?
GIST
47
What CD do GISTs express?
90% c-kit proto-oncogene for CD 117 80% for CD 34
48
Mainstay of tx for GISTs?
complete surgical excision
49
Demographics of GISTs?
usually pts >50 equal m/f ratio **Mostly develop de novo
50
How do pts with GISTs present?
bleeding, abdominal pain, discomfort
51
Why is long term follow up requires for GISTs?
recurrence can occur as late as 20 yrs
52
What are the most important risk factors for determining if a GIST is malignant?
tumor size >10 cm | >5 mitoses HPF
53
What is GLEEVEC?
imatinib used as adjuvant therapy for GISTs
54
MOA of imatinib?
tyrosine kinase inhibitor
55
What drug do we use for GISTs?
imatinib--> tyrosine kinase inhibitor
56
Most common locations for carcinoid tumors?
small intestine appendix rectum rarely stomach
57
What is Menetriere's disease?
rare acquired pre-malignant disease characerized by massive gastric folds in the body and fundus of stomach mucosa has a cobblestone or cerebriform appearance
58
Menetriere's dx is associated with what metabolic dernagements?
protein loss from stomach excessive mucus production achlorhydria
59
What causes Menetriere's dx?
cause unknown assc. w/cytmegalovirus in kids and h.pylori in adults
60
Tx for Menetriere's dx?
acid suppression ocreotide h. pylori eradication total gastrectomy for pts who have continued protein loss despite medical therapy
61
This is related to forceful vomiting and retching, that results in disruption of gastric mucosa on the lesser curve at GE junction;
mallory weiss tear
62
Overall mortality rate for Mallory Weiss tears?
3-4% highest in alcoholic pts with portal htn
63
How to manage a Mallory Weiss tear surgically?
most pts w/bleeding can be managed endoscopically surgery is rare; usually done via anterior gastrotomy, bleeding site is oversewn with 2-0 silk sutures
64
What is a DIeulafoy gastric lesion?
abnormally large, tortuous artery coursing thru the submucosa
65
What causes the bleeding seen in Dieulafoy gastric lesions?
you have large tortuous arteries coursing thru the submucosa pulsations of artery erode the mucosa artery is then exposed to gastric contents and bleeds **these lesions usually seen 6-10 cm from GE junction
66
Classic presentation of a bleeding Dieulafoy lesion?
sudden onset massive painless recurrent hematemesis w/hypotension
67
What causes gastric varices to develop?
can develop from splenic vein thrombosis causing htn can develop from portal htn
68
Gastric volvulus is uncommon and it can occur in two axes:
longitudinal axis; organoaxial (line drawn across lesser curve and greater curve) vertical axis; mesoaxial (line drawn from GE jxn to pylorus)
69
Difference between organoaxial and mesoaxial gastric volvulus?
organoaxial occur acutely, assc/ w diaphragmatic defect mesoaxial volvulus is partial < 180 degrees, its recurrent, not assc. w/diaphragmatic defect
70
Borchardt's triad with gastric volvulus?
sudden onset sever abd pain recurrent retching, minimal vomitus unable to pass an NG tube
71
Tx for acute gastric volvulus?
surgical emergency stomach is reduced and uncoiled thru a trans-abdominal approach
72
What are bezoars?
collections of non-digestable material usually vegetable material; phytobezoars trichobezoars; hair
73
What is gastrostomy performed for?
alimentation vs decompression
74
How is gastrostomy performed?
percutaneously (most common) open laparoscopic
75
Open techniques for gastrostomy tube placement?
Stamm method*** most common can be done open vs laparoscopic Witzel Janeway method
76
Complications of gastrostomy?
leakage w/peritonitis infection dislodgment aspiration pneumonia
77
What causes dumping syndrome?
caused by destruction or bypass of the pyloric sphincter
78
Early dumping syndrome?
abrupt delivery of a hyperosmolar load into the small bowel due to ablation of pylorus or decreased gastric compliance 15-30 mins after a meal pt becomes sweaty, weak, light headed, tachycardic
79
Late dumping syndrome?
2-3 hrs after a meal usually due to post-prandial hypoglycemia usually relieved by administration of sugar
80
Medical management of dumping syndrome?
``` dietary management somatostatin analogues (ocreotide) (100 micrograms subcutaneously twice daily) ```
81
How does ocreotide help in dumping syndrome?
helps ameliorate abnormal hormone pattern helps restore a fasting motility pattern
82
Greatest risk factors for stress gastritis?
prolonged ventilation >48 hrs coagulopathy
83
What causes late dumping syndrome seen 2-3 hrs after a meal?
rapid dumping of carbs into the intestines pts become hypoglycemic due to hyperinsulinemia as a result of carb load
84
What causes symptoms of late dumping syndrome?
carb load enters small intestine--> rapidly absorbed hyperinsulinemia causes hypoglycemia hypoglycemia triggers adrenal to make catecholamines--> tachycardia, tremulousness, sweating
85
Where do we find type 2 gastric ulcers on the Johnson classification?
gastric body + duodenum **assc w/acid
86
What is a Cameron's lesion?
chronic enteric blood loss from linear erosions at the level of the diaphragm within a hiatal hernia
87
A gastric emptying study is considered abnormal if what
if >60% of radiotracer is present in stomach at 2 hrs if >10% of radiotracer is present in stomach at 4 hrs
88
To maintain adequate stomach perfusion which arteries do we need to preserve?
1/4 arteries needs to be intact celiac artery supplies most of stomach (4 main arteries are left + right gastric, left + right gastroepiploic)
89
Left gastro-epipoloic comes off of what artery?
splenic
90
How do we treat a 3 cm perforated anterior duodenal ulcer?
ulcer too big to close primarily, too much tension jejunal serosal patch (Thal) should be used , less chance of a leak to optimize post-op healing, can do temp pyloroplasty with gastrojejunosotomy
91
GISTs stain for?
c-kit
92
How do GISTs spread?
hematogenously **Most commonly spread to liver and peritoneal surfaces
93
Where do GISTs spread to?
liver
94
Pts presenting with a Mallory-Weiss tear that resolve, when do you get repeat endoscopy?
not necessary
95
Gastrinomas AKA?
zollinger-ellison syndrome
96
How do diagnose a gastrinoma, Zollinger-Ellison syndrome?
secretin stimulation test measure baseline gastrin levels 2 units/kg of secretin are injected and gastrin levels measured at 5 min intervals for 30 mins gastrin level > 200 above basal level supports diagnosis
97
5 year survival of gastric Ca with no neoadjuvant therapy;
I: 88-94% II: 68-82% IIIA: 54%, IIIB: 36%, IIIC: 18% V: 4-5%
98
When do we see Curling ulcers?
seen after burns >30% TBSA
99
Benefits of diagnostic laparoscopy vs PET in looking for mets in advanced gastric CA?
PET misses 50% of mets diagnostic lap is better

Appendix (39 decks)

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