Blood supply to greater curvature
R and L gastroepiploic arteries
Blood supply to lesser curvature
R and L gastric arteries
Blood supply to pylorus
Blood supply to fundus
short gastric arteries
Celiac trunk branches
Secrete HCl and intrinsic factor (needed for B12 absorption) into gastric lumen. Secrete bicarb into venous circulation and into protective gastric mucosa. Located in body and fundus
Secrete pepsinogen (digest protein). Located in fundus and body
Secrete gastrin. Located in antrum
Gastrin secreting cells are also found in duodenum and pancreas
Parietal cells are stimulated by what?
Gastrin, histamine, vagus nerve
What inhibits bicarb secretion into protective mucus by pareital cells?
NSAIDs, alpha blockers, alcohol, acetazolamide
What type of ulcer perforation will not show free air on KUB?
Posterior perf of duodenal ulcer = no free air because retroperitoneal
What is another complication of PUD besides bleeding or rupture?
Gastric outlet obstruction
Zollinger Ellison Syndrome
20% are associated with MEN1. Fasting serum gastrin > `1000 is diagnostic. Secretin stimulation test shows paradoxical rise in gastrin.
Preferred H. pylori tx
PPI, clarithromycin, amoxicillin x 14 days
Surgery for PUD, duodenal ulcer
Only if refrax to med tx or if hemorrhage/obstruction/perf. Can do highly selective vagotomy, taking out branches going to the lesser curvature of stomach.
Surgery for PUD, gastric ulcer
Depending on location: antrectomy, highly selective vagotomy, subtotal gastrectomy with R-enY
Early dumping syndrome (a postgastrectomy syndrome)
Within 15 min of eating- rapid emptying of food into small bowel. Food is hyperosmolar, so fluid rapidly shifts from plasma into the small bowel -> hypotension. Presents with pain, diarrhea, nausea, tachycardia. Manage by eating small frequent meals and avoid high sugar content foods. Usu resolves 7-12 weeks.
Late dumping syndrome (a postgastrectomy syndrome)
Hyperglycemia after meal -> insulin response -> hypoglycemia 2-3 hrs after meal. Present with dizziness, fatigue, diaphoresis, weakness. Tx is similar to early dumping syndrome.
Post vagotomy diarrhea
Usually self-limited, tx symptomatically e.g. with loperamide.
Alkaline reflux gastritis (a postgastrectomy syndrome)
Must rule out recurrent ulcer before diagnosing this. Presentation: chronic abd pain, bilious vomiting. Tx: R-en-Y gastrojejunostomy. Recurrence may occur after this procedure.
Afferent loop syndrome (a postgastrectomy syndrome)
Obstruction of afferent limb following gastrojejunostomy. Present: RUQ pain after meal, steatorrhea, bilious vomiting, anemia; majority present in first week post-op. Dx with UGI series (afferent loop devoid of contrast). Tx: endoscopic balloon dilation or surgical revision.
Complications of chronic gastritis
Gastric atrophy. Gastric metaplasia. Pernicious anemia 2/2 parietal cell atrophy -> no IF
Causes of gastritis
Gastric reflux (e.g. pancreatic secretions), NSAIDs, alcohol, H pylori, Ischemia, nicotine, steroids (long term use)
Causes of upper GI hemorrhage
Mallory Weiss tear, varices, gastritis, AVM, peptic ulcer
Indications for bariatric surgery
BMI > 40 or BMI > 35 + comorbidities
Vertical banded gastroplasty
Partitioning of stomach into small proximal pouch and more distal pouch. Results in earlier satiety signal tot hypothalamus, delayed gastric emptying. Advantage is that it does not interrupt anatomy of GI tract
Roux-en-Y gastric bypass
Bypassed: stomach, duodenum, and proximal jejunum. Jejunum transected 15 cm past ligament of Treitz and attached to antrum
Torsion of stomach, usu along long axis. Often assoc with paraesophageal hernia. May be acute but more often chronic. Presents with intermittent severe epigastric pain/distention + inability to vomit. Dx: upper GI contrast study. Tx: surgical repair of accompanying hernia plus gastropexy (fix stomach to ant ab wall), gastric resection if necrosis occurred.
Majority of malignant stomach tumors are..?
Risk factors for gastric adenocarcinoma
FAP, chronic atrophic gastritis, H pylori infection, post-partial gastrectomy, pernicious anemia, diet high in nitrates, smoking
Types of gastric adenocarcinoma
Polyploid, ulcerative, superficial spreading (best prog), linitis plastica (very poor prog)
Met to ovaries, most commonly from gastric adenocarcinoma but can be from elsewhere such as breast
Met to pelvic cul-de-sac (felt on DRE)
Met to LN palpable in L supraclavicular fossa
Best method for dx of gastric adenocarcinoma
Upper GI endoscopy
Gastric cancer staging
What is the second most common type of gastric malignancy?
Gastric lymphoma (includes but not limited to mucosa associated lymphoid tissue-MALT- lymphoma)
What group is at increased risk of gastric lymphoma?
Tx of gastric lymphoma
Low grade: tx for H pylori. High grade MALT or non-MALT lymphoma: rads/chemo. Resection only if bleeding or perf.
Most are leiomyosarcomas. Tx is surgical resection.
Gastric leiomyosarcoma, pulmonary chondromas, extra-adnreal paraganglioma. Syndrome seen in women under 40.
Benign tumors of stomach (10% of stomach tumors overall)
Adenomatous polyps, lipomas, ectopic pancreas, Menetrier''s disease, bezoars, Dieulafoy's lesion
Adenomatous polyps of stomach
Only type of stomach polyp with malignant potential. Bx lesions > 5 mm.
Do not need to biopsy, usu just found incidentally in endoscopy
Rare. Often presents as "umbilicated dimple." Bx to exclude malignancy.
Autoimmune dz causing hypertrophic gastritis -> protein-losing enteropathy. Enlarged, tortuous rugae. Can lead to gastric cancer or ulcer. Tx: anticholinergics, H2 blockers to reduce protein loss; protein rich diet; tx ulcer/cancers if present; severe dz may require gastrectomy.
Concretions of nondigestible matter that accumulate in stomach, may develop after gastric surgery. Sx are similar to those of gastric outlet obstruction (early satiety, vomiting etc.) Tx: proteolytic enzymes (papain), endoscopic fragmentation, surgical removal.
Developmental malformation of a tortuous arteriole in the stomach that erodse and bleeds. Presents with massive, recurrent, painless hematemesis. Dx: endoscopy. Tx: endoscopic sclerosing tx or electrocautery; wedge resection.