Flashcards in Stomach Deck (92):
What space lies behind the stomach?
Lesser sac; the pancreas lies behind the stomach
What is the opening into the lesser sac?
Foramen of Winslow
What are the folds of gastric mucosa called?
What do gastric parietal cells produce?
HCl; intrinsic factor
What do gastric chief cells produce?
What do mucous neck cells produce?
What do G cells produce?
Where are G cells located?
Antrum of stomach
What is pepsin?
Proteolytic enzyme that hydrolyzes peptide bonds
What is intrinsic factor?
Protein secreted by the parietal cells that combines with vitamin B12 and allows for absorption in the terminal ileum
What is GERD?
Excessive reflux of gastric contents into the esophagus
What is pyrosis?
Medical term for heartburn
What are the causes of GERD?
Decreased LES tone; decreased esophageal motility to clear refluxed fluid; gastric outlet obstruction; hiatal hernia
What are the signs and symptoms of GERD?
Heartburn, regurgitation, respiratory problems, aspiration pneumonia, substernal pain
What disease must be ruled out when the symptoms of GERD are present?
What tests are included in the workup of GERD?
EGD; UGI contrast study with esophagogram; 24-hour acid analysis; manometry; EKG; CXR
What is the medical treatment for GERD?
Small meals; PPIs; H2 blockers; elevation of head at night and no meals prior to sleeping
What are the indications for surgery with GERD?
Intractability; respiratory problems as a result of reflux and aspiration of gastric contents; severe esophageal injury
What is Barrett's esophagus?
Columnar metaplasia from the normal squamous epithelium as a result of chronic irritation from reflux
What is the major concern with Barrett's esophagus?
What type of cancer develops in Barrett's esophagus?
What percentage of patients with GERD develops Barrett's esophagus?
What percentage of patients with Barrett's esophagus will develop adenocarcinoma?
What is the treatment of Barrett's esophagus with dysplasia?
Nonsurgical: endoscopic mucosal resection and photodynamic therapy
Also: radiofrequency ablation, cryoablation
What is a Lap Nissen procedure?
360 degree fundoplication (2 cm long)
What is a Belsey mark IV procedure?
240-270 degree fundoplication performed through a thoracic approach
What is a Hill procedure?
Arcuate ligament repair (close large esophageal hiatus) and gastropexy to diaphragm
What is a Toupet procedure?
Incomplete (200 degree) posterior wrap often used with severe decreased esophageal motility
How does the Nissen wrap work?
1. Increasing LES tone
2. Elongating LES (3 cm)
3. Returning LES into abdominal cavity
In what percentage of patients with GERD does Lap Nissen work?
What are the post-operative complications of Lap Nissen?
Gas-bloat syndrome, stricture, dysphagia, spleen injury requiring splenectomy, esophageal perforation, pneumothorax
What is gas-bloat syndrome?
Inability to burp or vomit
What is the incidence of gastric cancer?
In US: 10/100,000
In Japan: 78/100,000
What are the associated risk factors for gastric cancer?
Diet (e.g. smoked meats, high nitrates, low fruits and vegetables, alcohol, tobacco).
Environment (e.g. high-risk area, poor SES, atrophic gastritis, male, type A blood, partial gastrectomy, pernicious anemia, polyps, H. pylori)
What is the average age at the time of discovery of gastric cancer?
> 60 years
What is the male:female ratio for gastric cancer?
Which blood type is associated with gastric cancer?
What are the symptoms of gastric cancer?
Weight loss, Emesis, Anorexia, Pain (epigastric), Obstruction, Nausea
What are the most common early symptoms of gastric cancer?
Mild epigastric discomfort and indigestion
What is the most common symptom of gastric cancer?
What are the signs of gastric cancer?
Anemia, melena, heme occult, epigastric mass (advanced), hepatomegaly, coffee-ground emesis, Blumer's shelf, Virchow's node, enlarged ovaries, axillary adenopathy
What does the patient with gastric cancer have if he or she has proximal colon distention?
Colonic obstruction by direct invasion (rare)
What is the symptom of proximal gastric cancer?
What is a Blumer's shelf?
Solid peritoneal deposit anterior to the rectum, forming a "shelf", palpated on rectal exam
What is a Virchow's node?
Metastatic gastric cancer to the nodes in the left supraclavicular fossa
What is a Sister Mary Joseph's sign?
Periumbilical lymph node gastric cancer metastases.
Presents as periumbilical mass.
What is a Krukenberg's tumor?
Gastric cancer (or other adenocarcinoma) that has metastasized to the ovary
What is "Irish's" node?
Left axillary adenopathy from gastric cancer metastasis
What is a surveillance laboratory finding in gastric cancer?
CEA elevated in 30% of cases (if positive, useful for post-operative surveillance)
What is the initial workup for gastric cancer?
EGD with biopsy; endoscopic U/S (evaluate level of invasion); abdominal and pelvic CT (metastases); CXR; labs
What is the histology in gastric cancer?
What is the differential diagnosis for gastric tumors?
Adenocarcinoma, leiomyoma, leimyosarcoma, lymphoma, carcinoid, ectopic pancreatic tissue, gastrinoma, benign gastric ulcer, polyp
What are the 2 histologic types of gastric cancer?
1. Intestinal (glands)
2. Diffuse (no glands)
What is the morphology of gastric cancer?
Are gastric cancers more common on the lesser or greater curvatures?
What is more common, proximal or distal gastric cancer?
Which morphologic type is named after a "leather bottle"?
Linitus plastica: the entire stomach is involved and looks thickened
How do gastric adenocarcinomas metastasize?
Hematogenously and lymphatically
Which patients with gastric cancer are non-operative?
1. Distant metastasis (e.g. liver)
2. Peritoneal implants
What is the role of laparoscopy in gastric cancer?
To rule out peritoneal implants and to evaluate for liver metastasis
What is the genetic alteration seen in over 50% of patients with gastric cancer?
What is the treatment for gastric cancer?
Surgical resection with wide (> 5 cm checked by frozen section) margins and lymph node dissection
What operation is performed for a gastric tumor in the antrum?
Distal subtotal gastrectomy
What operation is performed for a gastric tumor in the mid body?
What operation is performed for a proximal gastric tumor?
What is a subtotal gastrectomy?
75% of stomach removed
What is a total gastrectomy?
Stomach is removed and a Roux-en-Y limb is sewn to the esophagus
What type of anastomosis is used in a gastrectomy?
Billroth II or Roux-en-Y (never Billroth I)
When should a splenectomy be performed for gastric cancer?
When the tumor directly invaded the spleen or splenic hilum or with splenic hilar adenopathy
In the treatment of gastric cancer, what is an extended lymph node dissection?
Usually D1 (perigastric nodes) and D2 (splenic artery, hepatic artery, anterior mesocolon, anterior pancreas, and crural nodes)
What percentage of patients with gastric cancer are inoperable at presentation?
What is the adjuvant treatment for gastric cancer?
Stages II and III: post-op chemotherapy and radiation
What is the 5-year survival rate for gastric cancer?
Why is it though that post-operative survival of gastric cancer is so much higher in Japan?
Aggressive screening and capturing early
What is a GIST?
GastroIntestinal Stromal Tumor
What was GIST originally known as?
What is the cell of origin in GIST?
Interstitial cells of Cajal
Where are GISTs found?
GI tract, most commonly in stomach and small bowel
What are the symptoms of GIST?
GI bleed, occult GI bleed, abdominal pain, abdominal mass, nausea, distention
How is GIST diagnosed?
CT, EGD, colonoscopy
How are distant metastases of GISTs diagnosed?
What is the tumor marker for GIST?
C-KIT (CD117 antigen)
What is the treatment for GIST?
Resect with negative margins, +/- chemo
Is there a need for lymph node dissection in GIST?
What is the chemotherapy for metastatic or advanced GIST?
Imatinib (tyrosine kinase inhibitor)
What is MALToma?
Mucosal-Associated Lymphoproliferative Tissue
What is the most common site for MALToma?
What is the causative agent in MALToma?
What is the medical treatment for MALToma?
Non-surgical: Treat for H. pylori; chemo/XRT in refractory cases
What is gastric volvulus?
Twisting of the stomach
What are the symptoms of gastric volvulus?
1. Distention of epigastrium
2. Cannot pass an NGT
3. Emesis followed by inability to vomit