STOMACH Flashcards
(151 cards)
1
Q
What does GIST look like?
A
submucosal gastric mass w/ central necrosis
2
Q
GIST arises from…?
A
interstitial cells of Cajal
3
Q
Stains for GIST
A
c-kit (CD-117) and CD-34
4
Q
GIST mets to where?
A
heme spread -> commonly spread to liver + peritoneal surfaces
5
Q
Gastric carcinoids arise from what cells?
A
enterochromaffin cells
6
Q
3 types of gastric carcinoids + mgmt?
A
- 2/2 atrophic gastritis/pernicious anemia (MC), low malignant potential -> local excision if <2cm + antrectomy
- 2/2 ZES -> less aggressive, typically complete regression after antrectomy
- sporadic, greatest malignant potential
7
Q
Anatomical changes of stomach w/ hypergastrinemia 2/2 ZES vs. atrophic gastritis
A
ZES -> hypertrophic mucosa
atrophic gastritis -> lack of rugal folds
8
Q
Most common Cx of gastric ulcer
A
perforation
9
Q
Factors that predict MALT lymphoma Tx failure after H.pylori eradication
A
- transmural tumor excision
- nodal involvement
- transformation into large-cell phenotype
- T(11;18)
- nuclear BCL-10 expression
10
Q
Gastric ulcers mostly found where on stomach?
A
lesser curvature
11
Q
Dyspepsia + failure PPI mgmt… next step?
A
- upper endoscopy + mucosal biopsy (to r/o H.pylori)
- if ulcer, need all 4 quadrant biopsy of ulcer margin
- if H.pylori, treat, then re-eval after 2-3 months
12
Q
Rate of bleeding detected by: angiography
A
> 0.5-1 cc/min
13
Q
Rate of bleeding detected by: 99mtechnetium (Tc)-labeled RBC scan
A
0.04-0.1 cc/min, but have higher rate of inaccuracy dx location of bleed compared to angio
14
Q
Surface epithelial cells of stomach secrete…?
A
mucus + bicarb (to maintain neutral pH 7.0 in gastric surface cell microenviro)
15
Q
absolute C/I to PEG placement (6)
A
- massive ascites (impairs tract formation and healing -> fluid leak and increase risk infection)
- uncorrectable coagulopathy
- peritonitis
- severe malnutrition
- gastric outlet obstruction (bc unable to pass endoscope into stomach)
- life expectancy <30d
16
Q
Is hiatal hernia C/I for PEG placement?
A
no - makes placement difficult, but insufflation will allow stomach to be closely approx with abdominal wall
17
Q
Characteristic of GIST w/ high malignant potential? Mgmt?
A
- > 5cm and <10cm with >5 mitoses/hpf (49-85% mortality)
- may benefit from adjuvant imatinib
18
Q
Characteristic of GIST w/ low-mod malignant potential?
A
- 2-5cm w/ >5 mitoses/hpf, or
- >10cm with <5 mitoses/hpf
19
Q
Cameron’s lesion
A
source of chronic blood loss 2/2 mechanically induced linear erosions at level of diaphragm within hiatal hernia; needs operative mgmt
20
Q
Borchardt triad
A
- severe epigastric pain
- inability to vomit
- inability to pass NGT
-> think acute gastric volvulus (emergent surgery)
21
Q
Gastrinoma triangle borders? Associated with?
A
- ZES (gastrinoma) associated with MEN1
- jxn CD/CBD + jxn head/neck of pancreas + jxn 2nd/3rd duodenum
22
Q
Reconstructive techniques following total gastrectomy
A
- RNY esophagojejunostomy
- RNY w/ pouch
- RNY w/ pouch w/ interposition
23
Q
Non-ulcerogenic causes of hypergastrinemia
A
nl to low gastric acid secretion
- atrophic gastritis
- pernicious anemia
- hx vagotomy
- renal failure
- short-gut syndrome
24
Q
Ulcerogenic causes of hypergastrinemia
A
excess gastric acid secretion
- antral G-cell hyperplasia or hyperfunction
- gastric outlet obstruction
- retained excluded gastric antrum
- ZES
25
Mgmt gastric volvulus in poor surgical candidate
endoscopic decompression + single or double PEG (2-pt fixation to prevent re-volvulizing)
26
MC complication of vagotomy; tx?
diarrhea; Tx: PO cholestyramine
27
Highest risk re-bleeding if see this on EGD gastric ulcer
actively bleeding or visible vessel (even if not bleeding)
28
Types of gastric ulcer 2/2 high acid secretion
Type 2 + 3
29
Types of gastric ulcer 2/2 poor mucosal protection
Type 1 + 4
30
Type of gastric ulcer 2/2 NSAID use
5
31
Virchow's node
supraclavicular node associated with gastric CA mets
32
Sister Mary Joseph node
periumbilical node
33
Most sensitive test H.pylori
Ab test
34
Best test to document resolution of H.pylori
urease breath test
35
When use imatinib for GIST?
- tumors >5cm
- >5 mitoses per hpf
- metastatic
36
Gastric volvulus associated with what type of hernia?
paraesophageal
37
Criminal nerve of DeGrassi
if did not divide all of celiac plexus (right vagus) -> will cause persistent hyperacid state
38
DeMeester Score based on...?
ambulatory pH testing:
- total % time GERD with pH <4
- total % time GERD upright
- total % time GERD supine
- # reflux episodes >5min
39
w/u GERD
1. barium swallow
2. EGD (biopsy if needed)
3. pH testing
4. esophageal manometry: esp important if considering doing Nissan; need normal motility
40
Peri-op difficulty ventilating pt during Nissen procedure... think? Tx?
capnothorax (CO2 leaking into chest); tx: need more enlarge tear into chest
41
When do Collis gastroplasty?
if during paraesophageal hernia repair and cannot get enough mobilization of esophagus... then need to do this esophageal lengthening procedure
42
Sxs dumping syndrome
after eating -> tachycardia, diaphoresis, flushing, dizziness
43
Mechanism of early vs. late dumping syndrome
```
early = due to abrupt osmolar load to small bowel
late = due to rapid carb load leading to insulin surge + hypoglycemia
```
44
If had Bilroth or RNY, and present with sxs concerning for SBO... mgmt?
emergent surgery - high risk rupture
45
T-stage gastric CA
```
T1A = lamina propria or muscularis mucosa
T1B = submucosa
T2 = muscularis propria
T3 = subserosa
T4 = through serosa, into adjacent structures
```
46
N-stage gastric CA
```
N1 = 1-2
N2 = 3-6
N3 = >6
```
47
When need staging laparoscopy for gastric CA?
>T1B if CRT or surgery being considered bc occult mets
48
If splenic vessels involved in gastric CA... unresectable?
no, can resect + splenectomy
49
Unresectable gastric CA (4)
- lap staging finds peritoneal involvement
- distant mets
- root of mesentery or periaortic nodal disease seen on biopsy
- encasement of any vascular structure (not including splenic)
50
When do neoadjuvant for gastric CA?
>/= T3 or LN positive based of EUS
51
w/u staging gastric CA
CT A/C/P
EUS w/ FNA
laparoscopy
52
Margins and # nodes for gastric CA resection?
>4-6cm margins (bc known to have wide lateral spread); 15 nodes
53
Nodal stations of gastric CA
```
D1 = 1-6 stations (perigastric nodes along greater/lesser curve)
D2 = 1-6, and 7-11 station (included common hepatic, celiac, and splenic... essentially down to aorta)
```
54
Hx Bilroth 2 + intermittent abdominal pain that relieves w/ emesis + megaloblastic anemia... dx?
afferent limb syndrome
55
Role of PPI in H.pylori treatment
relief - does NOT reduce healing time
56
Gastric vs. duodenal ulcers... risk of malignancy?
gastric >> duodenal (hence why to biopsy ALL gastric ulcers)
57
ZES triad
gastric acid hypersecretion + peptic ulcer disease + gastrinoma
58
Young pt w/ perf gastric ulcer... suspect?
ZES
59
Repair mgmt of large perf anterior duodenal ulcer
Thal patch (jejunal serosal repair) - less recurrent leak than w/ omental patch; cannot close primarily bc tension
+/- temp pyloroplasty + gastroJ reconstruction (to optimize healing)
60
Uncontrolled bleeding from duodenal ulcer... suspect?
posterior ulcer -> erosion to GDA
61
Best study of choice for suspected recurrent hiatal hernia
upper GI (detail to size, type of recurrence, location of GE jxn, etc)
62
What is gastric tonometry used for?
measure luminal PCO2, with thought that luminal = mucosal PCO2, which can be used to calculate mucosal pH - monitor tissue perfusion in critical pts
63
Why not use PPI w/ antacids or H2-blockers?
bc PPIs require acidic environment to be activated
64
What is afferent loop syndrome (aka. blind loop syndrome)?
mechanical issue where afferent loop becomes partially or completely obstructed
65
Afferent loop syndrome MC associated with what surgery?
antecolic Billroth II loop reconstructions with long (>30cm) afferent limb
66
Mgmt afferent loop syndrome
surgery (billroth II -> RNY)
67
Bile reflux gastritis 2/2 to...? Results in what histology?
exposure of gastric mucosa to bile, panc secretions, and duodenal contents -> intestinalization of gastric glands w/ inflammation
68
Bile reflux gastritis MC seen after what surgery?
Billroth II bc defective pyloric channel
69
EGD instrumentation: flexible endoscope
for investigating stomach to navigate its curvature and to retroflex
70
EGD instrumentation: double-channel
for foreign object retrieval bc dx + therapeutic instruments can be passed thru scope
71
EGD instrumentation: esophageal overtube
to protect esophageal mucosa and upper airway when pulling foreign body out of GI tract
72
EGD instrumentation: forceps
to retrieve flat objects
73
Recurrent ulcer disease s/p selective vagotomy... think?
incomplete posterior vagotomy - criminal nerve of Grassi
74
Presentation of MALToma in small bowel
can present w/ obstructive sxs -> need resection + H.pylori treatement
75
RF for gastric polyps
atrophic gastritis, H.pylori
76
MC type gastric polyp
hyperplastic polyp
77
Malignant potential in fundic polyp?
NO.
78
Pt s/p lap gastric banding, presenting with erythema and port tenderness... high concern for...?
band erosion into stomach
79
Dx gastric band c/b band erosion
upper endoscopy
80
Gastric ulcer associated with large hiatal hernias?
Cameron ulcer
81
Type of gastric ulcer associated with active or occult duodenal ulcer?
Type 2
82
NSAID effect on gastrum?
decreases mucus secretion -> Type V ulcer
83
Parietal cells stimulated to secrete acid by...?
1. ACh (via vagus nerve)
2. gastrin (G-cells)
3. histamine (enterochromaffin-like cells)
84
How does properly placed gastric band appear on plain film?
~45 degree upward angle from horizontal
85
Gastric varices typically found where on stomach?
Cardia
86
What is: Dieulafoy lesion?
vascular malformation along lesser curve (within 6cm of GE jxn); 2/2 erosion of gastric mucosa overlying submucosal vessels -> life-threatening arterial hemorrhage
*if not bleeding, often mistaken as normal mucosa on EGD
87
What is: watermelon stomach?
gastric antral vascular ectasia - series of dilated vessels appearing as longitudinal linear red streaks on antrum mucosa
88
Typical presentation of gastric antral vascular ectasia?
persistent Fe-deficiency anemia from occult blood loss (hemorrhage rare)
89
Sleeve gastrectomy has higher incidence of what Cx compared to RNY gastric bypass?
- leak
- esophageal reflux (as high as 30%)
- durability of sleeve beyond 5-yrs is unknown
90
Sleeve gastrectomy has lower incidence of...? compared to RNY gastric bypass?
- lower overall Cx rate
| - lower incidence post-op malnutrition
91
Sleeve gastrectomy vs. RNYGB in curing T2DM?
same - ~40% cured within 1 year for both
92
MCC upper GI bleeding
peptic ulcer disease
93
Mgmt unresectable GIST (c-kit mutation pos)
imatinib (400mg/day, unless KIT exon9 mutation, then 800mg/day) -> repeat staging in 6-mo -> 60% pts will be able to receive R0 resection -> stay on imatinib for 24-36mo
94
MC side effect imatinib
edema, fluid retention
95
Fxn of interstitial cells of Cajal
neural pacemaker cells responsible for smooth muscle activity in GI tract
96
Fundic gastric polyps associated with...?
- PPI use
| - FAP
97
In young pt with multiple fundic gastric polyps on endoscopy, suspect...?
FAP - need work-up
98
Hyperplastic polyps associated with...?
- H-pylori infection
| - chronic gastritis
99
Surveillance after gastric adenomatous polyp removal
endoscopy 6-12mo
100
Endoscopic surveillance for Vanek tumors (inflammatory fibroid polyp)
none - no malignant potential
101
Pt presenting with pain, dysphagia, N/V 12-mo s/p gastric bypass think...
marginal ulcer
102
Risk factors for development of marginal ulcers s/p gastric bypass
- smoking**
- larger gastric pouch (>6cm long, >5cm wide)
- NSAIDs
- alcohol
103
MALT is what kind of lymphoma?
B-cell lymphoma
104
Bloody NG aspirate (not coffee ground) predicts what findings on endoscopy?
high-risk findings (active bleeding site, visible vessel, adherent clot)
105
What is the Blatchford score?
helps identify need for endoscopic intervention
106
What Blatchford score indicates 50% risk of needing endoscopic intervention
6+
107
Indication for vagotomy in treatment of PUD
only for complicated PUD in pts with active tobacco smoking, NSAID use, or intolerance to NSAID
108
Epidemiology for proximal vs. distal gastric cancers
Proximal: M>F 2:1; H.pylori is protective/risk-lowering
Distal: black > white; association with H.pylori
109
Size of gastric ulcer to consider surgical mgmt
>2cm
110
Dx for gastroparesis
gastric emptying scintigraphy
111
Mgmt asymptomatic Type 3 paraesophageal hernia in elderly pt
observation
112
Best imaging to assess effectiveness of Heller myotomy
timed barium esophagram
113
Persistent dysphagia (and delayed barium esophagram) s/p myotomy... need to do...?
esophageal manometry w/ amyl nitrite challenge - to differentiate incomplete myotomy vs. obstruction due to wrap too tight - amyl nitrite will relax incomplete myotomy
114
If determine via manometry s/p myotomy that wrap is too tight... need to do what imaging to determine next mgmt?
EGD - if fixed obstruction requires surgical reintervention (slipped fundoplication) vs. pneumatic dilation
115
Siewert classification of EGJ adenoCA
I: distal esophagus; located within 1-5cm above EGJ
II: true cardia CA; 1cm above to 2cm below EGJ
III: gastric; between 2-5cm distal to EGJ (although may enrouch to distal esophagus)
116
Mgmt EGJ cancers
complete macro and microscopic tumor resection
117
Mgmt GIST (dependent on size)
local surgical excision with neg margins (LN mets rare so NO LN resection) - +/- imatinib therapy
=/<5cm - laparoscopic wedge resection
>5cm - require laparotomy
<1cm may be observed with repeat EGD in 1-yr
118
Mgmt perforated duodenal ulcer 2/2 complicated PUD - HDS
truncal vagotomy + antrectomy (lower recurrence rate than highly selective vagotomy + gastroJ)
119
When do Belsey-Mark IV procedure?
when not enough fundus for fundiplication - rarely done anymore. (can also do collis gastroplasty)
120
Incomplete vagotomy more common Cx in truncal vs. highly selective vagotomy?
highly selective vagotomy
121
Mgmt unstable pt presenting with prepyloric gastric ulcer
biopsy, omental patch repair, washout
122
Mgmt sporadic type III gastric carcinoid tumor
```
(elevated urine 5-HIAA, normal gastrin level)
gastric resection (may be partial) + regional lymphadenectomy
```
123
Mgmt alkaline (bile) reflux gastritis
medical mgmt for symptom relief, but if intractable, then conversion previous gastric surgery -> RNY
124
What should be done surgically to avoid bile reflux gastritis?
Make Roux limb at least 45cm long
125
Origin of right gastroepiploic artery?
GDA artery (off common hepatic artery)
126
Origina of right gastric artery?
common hepatic artery (after GDA branches off)
127
Origin of left gastroepiploic artery?
Splenic artery
128
If have AD mutation in CDH1, then need...?
prophylactic gastrectomy between age 18-40 ... also high risk breast CA
129
How many biopsies needed for accurate >95% ulcer for CA?
7
130
Physical Exam findings for metastatic gastric CA (6)
- Virchows node
- Sister Mary node
- Krunkenberg node
- Blumer shelf (nodes in pouch of Douglas)
- Irish node (axillary node)
- Trousseau syndrome
131
Surgical resection for gastric cancer
R0 resection + omentectomy + regional LN dissection
132
Resection for proximal vs. distal gastric cancer
Proximal - total gastrectomy (bc less reflux and other complications compared to subtotal)
Distal - subtotal
133
Mgmt gastroparesis refractory to dietary modifications and medical mgmt
Gastric pacemaker or pyloroplasty (feeding tube or TPN only if nutrition state is critical or if all other options have failed)
134
SE metoclopramide
- prolonged QT
| - tardive dyskinesia
135
Which type of vagotomy requires pyloroplasty (drainage procedure)?
Truncal vagotomy
136
Where is laparoscopic adjustable gastric band placed anatomically?
@ proximal stomach
137
Pt with recurrent UGI bleed s/p first attempt EGD control... next step?
repeat EGD - 25% pts will fail, but no increase in mortality for pts that go for second attempt at endo
138
If recurrent UGI bleeding after second attempt EGD control... next step?
angiogram with embolization
139
What is the Roux limb?
intestinal segment following surgery that is the primary recipient of food
140
Anatomical RF for developing afferent loop syndrome?
afferent limb >30-40cm + anastomosis to gastric remnant in antecolic fashion
141
Duodenal stump rupture after gastrectomy due to... what reasons?
- inadequate duodenal stump closure
- obstruction of afferent loop
- local pancreatitis
- poor surgical technique
142
MC pattern of inflammation associated with H.pylori infection
mild-to-mod inflammation in ALL regions of stomach (most with this pattern do not develop PUD)
143
Three major patterns of inflam response associated with H.pylori
1. mild-to-mod inflam in all regions of stomach
2. high acid output + devel of duo and prepyloric ulcers
3. predom body of stomach - gastric atrophy, hypergastrin, precursor for gastric cancer
144
Pts with duodenal ulcer tend to have what level of bicarb secretion?
lower basal and stimulatory duodenal bicarb section -> hence, impairment of mucosal defense -> prone to ulcers
145
MOA erythromycin as promotility agent
Acts on motilin receptors located on SM in GI tract
146
Dx gastric band erosion
Upper endoscopy
147
Mgmt kinking of tubing that connects gastric band to subQ port (unable to add/remove fluid)
Exploration of port and tubing under local anesthesia
148
Tx H.pylori
PPI + 2 Abx (amoxicillin, metronidazole, tetracycline, clarithromycin)
149
RF development of gastric adenoCA
- smoking, alcohol
- pernicious anemia
- EBV infection
- iron and tin manufacturing
- high nitrogen foods (smoked)
- Type A blood type
- previous H.pylori infection, chronic gastritis -> development of pilots
150
MCC gastroparesis (#1, #2, #3)
```
MC: idiopathic
#2: DM
#3: cavalry injuries (ie. s/p Nissen)
```
151
MC site extranodal lymphoma
Stomach
