STOMACH

Question 1

Layers of the Stomach

Answer 1

MUCOSA - first and innermost layer

SUBMUCOSA - 2nd layer

• rich in branching blood vessels, lymphatics, collagen, various inflammatory cells, and nerve fibers
• Meissner’s autonomic submucosal plexus
• gives strength to GI anastomoses

MUSCULARIS EXTERNA (muscularis propria) - 3rd layer
-consists of an incomplete inner oblique layer
-a complete middle circular layer (continuous with the esophageal circular muscle and the circular muscle of the pylorus)
-a complete outer longitudinal layer (continuous with the longitudinal layer of the esophagus and
duodenum)
-Auerbach’s myenteric plexus
-interstitial cells of Cajal (ICC)
-specialized pacemaker cells

SEROSA (visceral peritoneum)

• last and outermost layer
• provides significant tensile strength to gastric anastomoses
• when tumors originating in the mucosa penetrate and breach the serosa, microscopic or gross peritoneal metastases are common, presumably from shedding of tumor cells that would not have occurred if the serosa had not been penetrated

Question 2

Innervation of the Stomach

Answer 2

Parasympathetic: vagus nerve (CN X)
Sympathetic: celiac plexus (T5-T12)

Question 3

Opening into the lesser sac

Answer 3

Foramen of Winslow

Question 4

Parietal cells

Answer 4

HCl

IF

Question 5

Chief cells

Answer 5

pepsinogen

Question 6

Mucous neck cells

Answer 6

bicarbonate

mucus

Question 7

G cells

Answer 7

gastrin

Question 8

Location of G cells

Answer 8

antrum

Question 9

Pepsin

Answer 9

Proteolytic enzyme that hydrolyzes peptide bonds

Question 10

Protein secreted by the parietal cells that combines with vitamin B12 and allows
for absorption in the terminal ileum

Answer 10

Intrinsic Factor (IF)

Question 11

GERD

Answer 11

Excessive reflux of gastric contents into the esophagus, “heartburn or pyrosis”

Question 12

Branch that the POSTERIOR VAGUS sends to the posterior FUNDUS

Answer 12

Criminal nerve of Grassi

Question 13

Heartburn

Answer 13

substernal burning type discomfort

beginning in the epigastrium and radiating upward

often aggravated by meals, spicy or fatty foods, chocolate, alcohol, and coffee

can be worse in the supine position

Question 14

Effortless return of acid or bitter gastric contents into the chest, pharynx, or mouth

Answer 14

Regurgitation

Question 15

GERD management

Answer 15

Small meals

PPIs (proton-pump inhibitors) or H2 blockers

Elevation of head at night and no meals prior to sleeping

Question 16

GERD indications for surgery

Answer 16

Intractability (failure of medical treatment)

Respiratory problems as a result of reflux and aspiration of gastric contents (e.g., pneumonia)

Severe esophageal injury (e.g., ulcers, hemorrhage, stricture, w/w/o Barrett’s
esophagus)

Question 17

COLUMNAR METAPLASIA from the normal squamous epithelium as a result of chronic irritation from reflux

Answer 17

Barrett’s esophagus

Question 18

Cancer develops in Barrett’s esophagus

Answer 18

Adenocarcinoma

Question 19

360 fundoplication—2 cm long (laparoscopically)

Answer 19

Lap Nissen

Question 20

240 to 270 fundoplication performed through a thoracic approach

Answer 20

Belsey Mark IV

Question 21

Arcuate ligament repair (close large esophageal hiatus) and gastropexy to diaphragm (suture stomach to diaphragm)

Answer 21

Hill

Question 22

Incomplete (around 200) posterior wrap (laparoscopic) often used with severe decreased esophageal motility

Answer 22

Toupet

Question 23

Nissen wrap

Answer 23

Work by improving the lower
esophageal sphincter:
1. Increasing LES tone
2. Elongating LES ~3 cm
3. Returning LES into abdominal cavity

Question 24

Nissen wrap

Answer 24

Work by improving the lower
esophageal sphincter:
1. Increasing LES tone
2. Elongating LES ~3 cm
3. Returning LES into abdominal cavity

Question 25

Postoperative complications of Lap Nissen

Answer 25

1. Gas-bloat syndrome 2. Stricture 3. Dysphagia 4. Spleen injury requiring splenectomy 5. Esophageal perforation 6. Pneumothorax

Question 26

Gas-bloat syndrome

Answer 26

Inability to burp or vomit

Question 27

Gastric Cancer associated risk factors

Answer 27

Diet—smoked meats, high nitrates, low fruits and vegetables, alcohol, tobacco Environment—raised in high-risk area, poor socioeconomic status, atrophic gastritis, MALE gender, blood type A, previous partial gastrectomy, pernicious anemia, polyps, Helicobacter pylori

Question 28

Gastric cancer symptoms

Answer 28

``` Weight loss Emesis Anorexia Pain/epigastric discomfort Obstruction Nausea ```

Question 29

Most common early symptoms of gastric cancer

Answer 29

Mild epigastric discomfort and indigestion

Question 30

Symptom of PROXIMAL gastric cancer

Answer 30

Dysphagia (gastroesophageal | junction/cardia)

Question 31

Blumer’s shelf

Answer 31

Solid peritoneal deposit anterior to the rectum, forming a “shelf,” palpated on RECTAL examination

Question 32

Virchow's nodes

Answer 32

Metastatic gastric cancer to the nodes in the LEFT SUPRACLAVICULAR FOSSA

Question 33

Sister Mary Joseph’s | sign

Answer 33

PERIUMBILICAL lymph node gastric cancer metastases presents as periumbilical mass

Question 34

Krukenberg's tumor

Answer 34

Gastric cancer (or other adenocarcinoma) that has metastasized to the OVARY

Question 35

Irish node

Answer 35

LEFT AXILLARY adenopathy from gastric cancer | metastasis

Question 36

Differential Diagnosis for gastric tumors

Answer 36

``` Adenocarcinoma leiomyoma leiomyosarcoma lymphoma carcinoid ectopic pancreatic tissue gastrinoma benign gastric ulcer polyp ```