30 Stomach Flashcards
1
Q
Risk factors for UGI Bleed?
A
Previous UGI bleed Peptic ulcer disease NSAID use Smoking Liver disease Esophageal varices Splenic vein thrombosis Sepsis Burn injuries Trauma Severe vomiting
2
Q
How to you diagnose/treat an UGI bleed?
A
EGD
Treat with hemo-clips, Epi injections, cautery
3
Q
On EGD, you find no stigmata of hemorrhage and a clean ulcer base: how do you proceed?
A
Biopsy of antral mucosa for H. Pylori
OP tx with Omprazole and Abx
4
Q
On EGD, you find stigmata of bleeding: how do you proceed?
A
Endoscopic hemostasis methods (hemo-clips, Epi injections, cautery)
Biopsy of antral mucosa
Examine for further bleeding
5
Q
What are the stigmata of bleeding for an UGI bleed?
A
Active bleeding
Oozing
Adherent clog
Visible vessel
6
Q
After initial treatment of bleeding on EGD, you now have cessation of bleeding: how do you proceed?
A
IP observation
Omeprazole and Abx
7
Q
After initial treatment of bleeding on EGD, you now have recurrent bleeding: how do you proceed?
(Or you cannot perform endoscopic therapy and/or patient is hemodynamically unstable?)
A
Operative treatment
IP recovery
Omeprazole and Abx for H. pylori
8
Q
UGI bleed with slow bleeding causing difficulty localizing the source - how do you proceed?
A
Tagged RBC scan
9
Q
What are the biggest risk factors for rebleeding at the time of EGD for UGI bleed?
A
Spurting blood vessel (60%)
Visible blood vessel (40%)
Diffusion oozing (30%)
10
Q
Greatest risk factor for mortality with non-variceal UGI bleed?
A
Continued or recurrent bleeding
11
Q
Liver failure patient presents with UGI bleed - what is likely cause? How do you proceed?
A
Esophageal varices (NOT ulcer) EGD with variceal bands or sclerotherapy If that fails - TIPS
12
Q
Cause of duodenal ulcers?
A
Increased acid production and decreased mucosal defences
13
Q
What is the most common site for peptic uclers? More common m/f?
A
Duodenal ulcers
Males
14
Q
Most likely site for duodenal ulcers?
A
1st part of the duodenum (remember they are related to acid)
Usually anterior
15
Q
Complications related to anterior duodenal ulcers?
A
Perforation
16
Q
Complications related to posterior duodenal ulcers?
A
Bleeding (from gastroduodenal artery)
17
Q
Symptoms of a duodenal ulcer?
A
Epigastric pain radiation to the back
Abates with eating, but reoccurs after 30min
18
Q
Diagnosis for duodenal ulcer?
A
EGD
19
Q
Treatment for duodenal ulcer?
A
PPI (omeprazole)
Triple therapy for H. Pylori (bismuth salts, amoxicillin, metronidazole/tetracycline)
20
Q
Define Zolinger-Ellison syndrome
A
Gastrinoma, gastric acid hypersecretion, multiple peptic ulcers
Suspect in patient with multiple ulcers that does not respond to PPI treatment
21
Q
Surgical indications in duodenal ulcers?
A
Perforation
Protracted bleeding (despite EGD therapy)
Obstruction
Intractability despite medical therapy
Inability to rule out cancer (ulcer remains despite treatment)
22
Q
In addition to surgical repair for complications, what must you do for patients with complicated duodenal ulcers that develop complications while on PPIs?
A
Acid-reducing surgical proceedure
23
Q
What are the surgical options for duodenal ulcers?
A
Acid-reducing surgery:
- Proximal vagotomy
- Truncal vagotomy and pyloroplast
- Truncal vagotomy and antrectomy
- Reconstruction after antrectomy -> Roux-en-Y gastro-jejunostomy
24
Q
Duodenal ulcer surgery - recurrence and mortality?
Proximal vagotomy
A
10-15% ulcer recurrence
0.1% mortality
Bonus - lowest complication rate, no need for antral or pylorus procedure (maintains pyloric function)
25
Duodenal ulcer surgery - recurrence and mortality?
| Truncal vagotomy and pyloroplasty
5-10% ulcer recurrence
| 1% mortality
26
Duodenal ulcer surgery - recurrence and mortality?
| Truncal vagotomy and antrectomy
1-2% ulcer recurrence (best)
2% mortality
Requires reconstruction of GIT
27
Methods of reconstruction after Truncal vagotomy and antrectomy?
```
Roux-en-Y gastro-jejunostomy (best)
Billroth I (gastro-duodenal anastomosis)
Billroth II (gastro-jejunal anastomosis)
```
28
Why is a Roux-en-Y gastro-jejunostomy better than the Billroth procedures?
Less dumping syndrome and reflex gastritis
29
What is the most frequent complication of duodenal ulcers?
Bleeding
| Generally minor, but can be life threatening
30
What qualifies as a major bleed?
>6 units of blood in 24 hours or patient remains hypotensive despite transfusion
31
Initial treatment of duodenal ulcer bleed?
EGD - hemoclips, cauterize and EPI injection
32
Surgical intervention of duodenal ulcer bleed?
Duodenotomy and gastroduodenal artery (GDA) ligation
33
What do you need to avoid when GDA ligation?
Common bile duct (posterior)
34
What is the initial treatment for obstruction related to duodenal ulcer?
PPIs and serial dilation
35
Surgical intervention for duodenal ulcer obstruction?
Antrectomy and truncal vagotomy
| Do bx to rule out cancer
36
When you do have to include the duodenal ulcer in surgical treatment for obstruction?
When it is proximal to the ampulla of Vater
37
What percentage of duodenal ulcer perforations will have free air?
80%
38
Symptoms of a duodenal ulcer perforation?
Sudden, sharp epigastric pain
Generalized peritonitis
Pain can radiate to pericolic gutters with dependent drainage of gastric content
39
Surgical treatment of duodenal ulcer perforation?
Graham patch (omentum placed over perforation) and acid-reducing surgery (if patient had been on a PPI)
40
How do you define intractability related to duodenal ulcers?
> 3 months without relieft while on escalating does of PPI; based on EGD findings
41
Treatment of intractable duodenal ulcers?
Acid-reducing surgery
42
Risk factors for gastric ulcers?
```
Male
Tobacco
ETOH
NSAIDs
H. pylori
Uremia
Stress (burns, sepsis, trauma)
Steroids
Chemotherapy
```
43
Most common location of gastric ulcer?
Lesser curvature of the stomach (80%)
44
Which UGI bleed has greater mortality - gastric ulcer or duodenal ulcer?
Gastric ulcer
45
Symptoms of gastric ulcers?
Epigastric pain radiating to the back
Relieved by eating but reoccurs 30 minutes later (maybe - some say worsened by eating, others say no effect)
Melena or guaiac-positive stools
46
Best test for H. Pylori?
Histiologic examination of biopsies from antrum
47
What is the CLO test?
Rapid urease test
| Non-invasive test for H. pylori - detects the urease it releases
48
Type I gastric ulcer?
Lesser curve, low along body of stomach
| Due to decreased mucosal protection
49
Type II gastric ulcer?
Two ulcers - lesser curve and duodenal
| Associated with high acid secretion
50
Type III gastric ulcer?
Pre-pyloric ulcer
| Associated with high acid secretion
51
Type IV gastric ulcer?
Lesser curve, high along cardia of stomach
| Decreased mucosal protection
52
Type V gastric ulcer?
Associated with NSAID use
53
Which gastric ulcers are associated with decreased mucosal protection? What is the difference?
Types I and IV
I - low on lesser curve (body)
IV - high on lesser curve (cardia)
54
Which gastric ulcers are associated with high acid secretion? What is the difference?
Types II and III
II - Two ulcers - lesser curve and duodenal
III - Pre-pyloric
55
What are the indications for surgical intervention for gastric ulcers?
```
Perforation
Bleeding not controlled with EGD
Obstruction
Cannot exclude malignancy
Intractability (>3 months without relief - based on EGD)
```
56
What is the surgical treatment for gastric ulcer complications?
Truncal vagotomy and antrectomy
| Include the ulcer - extended antrectomy OR separate ulcer excision
57
Why do you have to resect a gastric ulcer at time of surgical intervention?
Associated high risk of gastric cancer
58
Stomach transit time
3-4 hours
59
Location of peristalsis in stomach?
Distal stomach (antrum) only
60
Carries sensation of gastroduodenal pain?
Afferent sympathetic fibers T5-10
61
Branches of the celiac trunk
Left gastric
Common hepatic artery
Splenic artery
Left gastroepiploic and short gastrics (from splenic artery)
62
Blood supply to greater curvature of stomach
Right and left gastroepiploics
Short gastrics
Right gastroepiploic is a branch of the gastroduodenal artery
63
Blood supply to the lesser curvature of stomach
Right and left gastrics
| Right gastric is a branch off the common hepatic artery
64
Blood supply to the pylorus
Gastroduodenal artery
65
Mucosa of the stomach
Lined with simple columnar epithelium
66
Cardia glands
Mucus secreting
67
Fundus and body glands
Chief cells
| Parietal cells
68
What do parietal cells release?
H+ and intrinsic factor
69
Stimulation for H+ release from parietal cells?
Acetylcholine (vagus nerve)
Gastrin (From G cells in antrum)
Histamine (from mast cells)
70
Secondary messengers for acetylecholine in parietal cells?
Phospholipase (PIP --> DAG + IP3 to increase Ca)
Ca-calmodulin activates phosphorylase kinase -->
phosphorylates H+/K+ ATPase to increase H+ secretion and K+ absorption
71
Secondary messengers for Gastrin in parietal cells?
Phospholipase (PIP --> DAG + IP3 to increase Ca)
Ca-calmodulin activates phosphorylase kinase -->
phosphorylates H+/K+ ATPase to increase H+ secretion and K+ absorption
72
Secondary messengers for histamine in parietal cells?
Activates adenylate cyclase --> cAMP --> activates protein kinase A --> phosphorylates H+/K+ ATPase to increase H+ secretion and K+ absorption
73
MOA of Omeprazole
Blocks H+/K+ATPase in parietal cell membrane
| Final pathway for H+ release
74
Inhibitors of parietal cells
Somatostatin
Prostaglandin (PGE1)
Secretin
CCK
75
Effect of intrinsic factor
Binds B12 and the complex is reabsorbed in the terminal ileum
76
Antrum and pylorus glands
Mucus glands
HCO3 glands
G cells
D cells
77
Activity of G cells
Located in antrum
Release gastrin
Inhibited by H+ in duodenum
Stimulated by AA, acetylcholine
78
Activity of D cells
Secrete somatostatin
| Inhibit gastrin and acid release
79
Brunner's glands
Located in duodenum
| Secrete alkaline mucus
80
Stimulation for release of somatostatin, CCK, secretin
Released with antral and duodenal acidification
81
Causes for rapid gastric emptying
Previous surgery*
| Ulcers
82
Causes for delayed gastric emptying
Diabetes
Opiates
Anticholinergics
Hypothyroidism
83
Trichobezoars
Hair - hard to pull out
| Tx: EGD generally inadequate; likely will need gastrostomy and removal
84
Dieulafoy's ulcer
Vascular malformation
| Can bleed
85
Menetrier's disease
Mucous cell hyperplasia
| Increased rugal folds
86
Gastric volvulus
Associated with type II (paraesophegeal) hernia
Nausea without vomiting, severe pain
Usually organoaxial volvulus
Tx: reduction and nissen
87
Mallory-Weiss tear
Secondary to forceful vomiting
Presents as hematemesis following severe retching
Mucosal tear
Bleeding often stops spontaneously
Dx/Tx: EGD with hemo-clips
Tear is usually on lesser curvature, near GE junction
If continued bleeding - gastrostomy and oversewing of the vessel
88
Physiologic changes due to vagotomy
Increased liquid emptying --> vagally mediated receptive relaxation is removed
Results in increased gastric pressure that accelerates liquid emptying
89
Truncal vagotomy
Divides vagal trunks at level of esophagus
| Decreased emptying of solids
90
Proximal vagotomy
AKA highly selective vagotomy
Divides individual fibers - preserves crow's foot
Normal emptying of solids
91
Physiologic changes when a pylorplasty is added to truncal vagotomy
Increased solid emptying
92
Gastric effects of truncal vagotomy
Decreased acid output by 90%
Increased gastrin secretion
Gastrin cell hyperplasia
93
Nongastric effects of truncal vagotomy
Decreased exocrine panreas function
Decreased postprandial bile flow
Increased gallbladder volumes
Decreased release of vagally mediated hormones
94
Most common problem following vagotomy?
Diarrhea
| Caused by sustained MMCs (migrating motor complex) forcing bile acids into the colon
95
What is the cause if ulcer recurs?
Missed criminal nerve of Grassi
| Branch of Rt vagus nerve - provides stimulation to the gastric cardia
96
Heineke-Mikulicz pylorplasty
Longitudinal incision of the pyloric sphincter followed by a transverse closure
97
Stress gastritis
Occurs 3-10 days after event
Lesions appear in the fundus first
Tx: PPI
EGD with cautery of specific bleeding points may be effective
98
Chronic gastritis - type A
Fundus
| Associated with pernicious anemia, autoimmune disease
99
Chronic gastritis - type B
Antral
| Associated with H. pylori
100
Treatment for chronic gastritis
PPI
101
Symptoms of gastric cancer
Pain unrelieved by eating
| Weight loss
102
Diagnosis of gastric cancer
EGD
103
Risk factors for gastric cancer
```
Adenomatous polyps
Tobacco
Previous gastric operations
Intestinal metaplasia
Atrophic gastritis
Pernicious anemia
Type A blood
Nitrosamines
```
104
Adenomatous polyps - gastric
15% risk of cancer
| Tx: endoscopic resection
105
Krukenberg tumor
Metastases to ovaries
106
Virchow's nodes
Metastases to supraclavicular node
107
Intestinal-type gastric cancer
Increased in high-risk populations
Older men
Japan (rare in US)
Tx: subtotal gastrectomy (need 10cm margins)
108
Diffuse gastric cancer
```
AKA linitis plastica
Low-risk populations, Women, Most common in US
Diffuse lymphatic invasion - no glands
Less favorable prognosis (5-YS 25%)
Tx: total gastrectomy
```
109
Chemotherapy for gastric cancer
Poor response
| 5-FU, doxorubicin, mitomycin C
110
Palliation of gastric cancer
```
Obstruction:
- Proximal lesion - stenting
- Distal lesion - bypass with gastrojejunostomy
Low to moderate bleeding/pain - tx: XRT
Fail --> palliative gastrectomy
```
111
Gastrointestinal stromal tumors (GIST) of stomach
```
Most common benign gastric tumor - can be malignant
Sx: asymptomatic, obstruction, bleeding
Dx: US - hypoechoic, smooth edges
- Biopsy - C-KIT positive
Tx: Resection with 1cm margin
Chemotherapy - Imatinib (for malignant)
```
112
Indicators of malignancy in GIST tumors
>5cm
| >5 mitoses/50 HPF
113
Imatinib
Gleevec
Tyrosine kinase inhibitor
Used to treat malignant GIST tumors
114
Muscosa-associated lymphoid tissue lymphoma (MALT lymphoma) of stomach
Related to H. pylori infection
Regress after tx for H. pylori (triple-therapy abx)
If MALT does not regress - XRT
115
Gastric lymphoma
Ulcer symptoms
Stomach is the most-common location for extra-nodal lymphoma
Usually non-Hodgkin's lymphoma (B-cell)
Dx: EGD with biopsy
Tx: Chemotherapy, XRT
Sx: Partial resection for stage I disease (confined to stomach mucosa)
116
Criteria for patient selection for bariatric surgery (need all 4)
BMI >40 (or BMI >35 with coexisting comorbidities)
Failure of nonsurgical methods of weight reduction
Psychological stability
Absence of drug and alcohol abuse
117
What gets better after bariatric surgery?
```
Diabetes
Cholesterol
Sleep apnea
HTN
Urinary incontinence
GERD
Venous stasis ulcer
Pseudotumor cerebri
Joint pain
Migraines
Depression
Polycystic ovarian syndrome
nonalcoholic fatty liver disease
```
118
Complications of Roux-en-Y gastric bypass
Marginal ulcers
Leak
Necrosis
B12 deficiency (intrinsic factor needs acidic environment to bind B12)
Iron-deficiency anemia (bypasses duodenum where iron is absorbed)
Gallstones (from rapid weight loss)
119
What do 10% of Roux-en-Y bypass patients fail?
High-carbohydrate snacking
120
What is the most common cause of leak in Roux-en-Y bypass?
Ischemia
121
Signs of leak after roux-en-Y bypass?
```
Increased respiratory rate
Increased heart rate
Abdominal pain
Fever
Elevated WBCs
```
122
S/P Roux-en-Y bypass - Treatment of marginal ulcers
Occur in 10%
| PPI
123
S/P Roux-en-Y bypass - Treatment of stenosis
Response to serial dilation
124
S/P Roux-en-Y bypass - Dilation of excluded stomach post-op
Hiccups, large stomach bubble
Dx: AXR
Tx: Gastrostomy tube
125
S/P Roux-en-Y bypass - Small bowel obstruction
Nausea, vomiting, intermittent abdominal pain
Dx: AXR (small bowel dilation
Surgical emergency due to risk of small bowel herniation (internal hernia), strangulation, infarction and necrosis
Tx: surgical exploration
126
Jejunoileal bypass
Operation is no longer done
Associated with liver cirrhosis, kidney stones, osteoporosis (decreased calcium)
Need to correct these patients and perform Roux-en-Y gastric bypass if ileojejunal bypass is encountered
127
Post-gastrectomy complication: Dumping syndrome
Rapid entry of carbohydrates into the small bowel
2 phases - hyperosmotic load (fluid shift into bowel); hypoglycemia
Tx: small, low-fat, low-carb, high-protein meals; no liquid with meals; no lying down after meals; octretide
Sx: Conversion of BRI/BRII to R-Y gastrojejunostomy; increase gastric reservoir (jejunal pouch) or increase empthing time (reversed jejunal loop)
128
Phases of dumping syndrome
Phase 1 - hyperosmotic load causes fluid shift into bowel - hypotension, diarrhea, dizziness
Phase 2 - hypoglycemia from reactive increase in insulin and decrease in glucose
129
Post-gastrectomy complication: Alkaline reflux gastritis
Postprandial epigastric pain associated with N/V; pain does not improve with vomiting.
Dx: bile reflux in stomach; gastritis
Tx: PPI, cholestyramine, metoclopramide
Sx: Conversion of BRI/BRII to RY gastrojejunostomy with afferent limb 60cm distal to gastrojejunostomy
130
Post-gastrectomy complication: treated with PPI, cholestyramine, metoclopramide
Alkaline reflux gastritis
131
Post-gastrectomy complication: Chronic gastric atony
```
Delayed gastric emptying
sx: nausea, vomiting, pain, early satiety
Dx: gastric emptying study
Tx: metoclopramide, prokinetics
Sx: near-total gastrectomy with RY
```
132
Post-gastrectomy complication: Treated with metoclopramide, prokinetics
Chronic gastric atony
133
Post-gastrectomy complication: Small gastric remnant
Early satiety
Dx: EGD
Tx: Small meals
Sx: Jejunal pouch construction
134
Post-gastrectomy complication: Blind-loop syndrome
BRII or RY - poor motility
Sx: pain, steatorrhea, B12 deficiency, malabsorption
Caused by bacterial overgrowth (E.coli, GNR) from stasis in afferent limb
Dx: EGD of afferent limb with aspirate/cultures
Tx: tetracycline & flagyl, metoclopramide
Sx: Re-anastomosis with shorter (40cm) afferent limb
135
Post-gastrectomy complication: Treated with Tetracycline & Flagyl, Metoclopramide
Blind-loop syndrome
136
Post-gastrectomy complication: Afferent-loop obstruction
BRII or RY - mechanical obstruction of afferent limb
Sx: RUQ pain, seatorrhea, nonbilious vomiting, pain relived with bilious emesis
Due to long afferent limb
Dx: CT scan
Tx: Balloon dilation
Sx: Re-anastomosis with shorter (40cm) afferent limb
137
Post-gastrectomy complication: Efferent-loop obstruction
Symptoms of obstruction - nausea, vomiting, abdominal pain
Dx: UGI, EGD
Tx: balloon dilation
Sx: Find site of obstruction and relieve it
138
Post-gastrectomy complication: Post-vagotomy diarrhea
Secondary to non-conjugated bile salts in the colon (osmotic diarrhea)
Caused by sustained postprandial organized MMCs
Tx: cholestyramine, octreotide
Sx: reversed interposition jejunal graft
139
Post-gastrectomy complication: Duodenal stump blow-out
Place lateral duodenostomy tube and drinas
140
PEG complications
Insertion into liver or colon
