30 Stomach Flashcards
Risk factors for UGI Bleed?
Previous UGI bleed Peptic ulcer disease NSAID use Smoking Liver disease Esophageal varices Splenic vein thrombosis Sepsis Burn injuries Trauma Severe vomiting
How to you diagnose/treat an UGI bleed?
EGD
Treat with hemo-clips, Epi injections, cautery
On EGD, you find no stigmata of hemorrhage and a clean ulcer base: how do you proceed?
Biopsy of antral mucosa for H. Pylori
OP tx with Omprazole and Abx
On EGD, you find stigmata of bleeding: how do you proceed?
Endoscopic hemostasis methods (hemo-clips, Epi injections, cautery)
Biopsy of antral mucosa
Examine for further bleeding
What are the stigmata of bleeding for an UGI bleed?
Active bleeding
Oozing
Adherent clog
Visible vessel
After initial treatment of bleeding on EGD, you now have cessation of bleeding: how do you proceed?
IP observation
Omeprazole and Abx
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?)
Operative treatment
IP recovery
Omeprazole and Abx for H. pylori
UGI bleed with slow bleeding causing difficulty localizing the source - how do you proceed?
Tagged RBC scan
What are the biggest risk factors for rebleeding at the time of EGD for UGI bleed?
Spurting blood vessel (60%)
Visible blood vessel (40%)
Diffusion oozing (30%)
Greatest risk factor for mortality with non-variceal UGI bleed?
Continued or recurrent bleeding
Liver failure patient presents with UGI bleed - what is likely cause? How do you proceed?
Esophageal varices (NOT ulcer) EGD with variceal bands or sclerotherapy If that fails - TIPS
Cause of duodenal ulcers?
Increased acid production and decreased mucosal defences
What is the most common site for peptic uclers? More common m/f?
Duodenal ulcers
Males
Most likely site for duodenal ulcers?
1st part of the duodenum (remember they are related to acid)
Usually anterior
Complications related to anterior duodenal ulcers?
Perforation
Complications related to posterior duodenal ulcers?
Bleeding (from gastroduodenal artery)
Symptoms of a duodenal ulcer?
Epigastric pain radiation to the back
Abates with eating, but reoccurs after 30min
Diagnosis for duodenal ulcer?
EGD
Treatment for duodenal ulcer?
PPI (omeprazole)
Triple therapy for H. Pylori (bismuth salts, amoxicillin, metronidazole/tetracycline)
Define Zolinger-Ellison syndrome
Gastrinoma, gastric acid hypersecretion, multiple peptic ulcers
Suspect in patient with multiple ulcers that does not respond to PPI treatment
Surgical indications in duodenal ulcers?
Perforation
Protracted bleeding (despite EGD therapy)
Obstruction
Intractability despite medical therapy
Inability to rule out cancer (ulcer remains despite treatment)
In addition to surgical repair for complications, what must you do for patients with complicated duodenal ulcers that develop complications while on PPIs?
Acid-reducing surgical proceedure
What are the surgical options for duodenal ulcers?
Acid-reducing surgery:
- Proximal vagotomy
- Truncal vagotomy and pyloroplast
- Truncal vagotomy and antrectomy
- Reconstruction after antrectomy -> Roux-en-Y gastro-jejunostomy
Duodenal ulcer surgery - recurrence and mortality?
Proximal vagotomy
10-15% ulcer recurrence
0.1% mortality
Bonus - lowest complication rate, no need for antral or pylorus procedure (maintains pyloric function)
Duodenal ulcer surgery - recurrence and mortality?
Truncal vagotomy and pyloroplasty
5-10% ulcer recurrence
1% mortality
Duodenal ulcer surgery - recurrence and mortality?
Truncal vagotomy and antrectomy
1-2% ulcer recurrence (best)
2% mortality
Requires reconstruction of GIT
Methods of reconstruction after Truncal vagotomy and antrectomy?
Roux-en-Y gastro-jejunostomy (best) Billroth I (gastro-duodenal anastomosis) Billroth II (gastro-jejunal anastomosis)
Why is a Roux-en-Y gastro-jejunostomy better than the Billroth procedures?
Less dumping syndrome and reflex gastritis
What is the most frequent complication of duodenal ulcers?
Bleeding
Generally minor, but can be life threatening
What qualifies as a major bleed?
> 6 units of blood in 24 hours or patient remains hypotensive despite transfusion
Initial treatment of duodenal ulcer bleed?
EGD - hemoclips, cauterize and EPI injection
Surgical intervention of duodenal ulcer bleed?
Duodenotomy and gastroduodenal artery (GDA) ligation
What do you need to avoid when GDA ligation?
Common bile duct (posterior)
What is the initial treatment for obstruction related to duodenal ulcer?
PPIs and serial dilation
Surgical intervention for duodenal ulcer obstruction?
Antrectomy and truncal vagotomy
Do bx to rule out cancer
When you do have to include the duodenal ulcer in surgical treatment for obstruction?
When it is proximal to the ampulla of Vater
What percentage of duodenal ulcer perforations will have free air?
80%
Symptoms of a duodenal ulcer perforation?
Sudden, sharp epigastric pain
Generalized peritonitis
Pain can radiate to pericolic gutters with dependent drainage of gastric content
Surgical treatment of duodenal ulcer perforation?
Graham patch (omentum placed over perforation) and acid-reducing surgery (if patient had been on a PPI)
How do you define intractability related to duodenal ulcers?
> 3 months without relieft while on escalating does of PPI; based on EGD findings
Treatment of intractable duodenal ulcers?
Acid-reducing surgery
Risk factors for gastric ulcers?
Male Tobacco ETOH NSAIDs H. pylori Uremia Stress (burns, sepsis, trauma) Steroids Chemotherapy
Most common location of gastric ulcer?
Lesser curvature of the stomach (80%)
Which UGI bleed has greater mortality - gastric ulcer or duodenal ulcer?
Gastric ulcer
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
Best test for H. Pylori?
Histiologic examination of biopsies from antrum
What is the CLO test?
Rapid urease test
Non-invasive test for H. pylori - detects the urease it releases
Type I gastric ulcer?
Lesser curve, low along body of stomach
Due to decreased mucosal protection
Type II gastric ulcer?
Two ulcers - lesser curve and duodenal
Associated with high acid secretion
Type III gastric ulcer?
Pre-pyloric ulcer
Associated with high acid secretion
Type IV gastric ulcer?
Lesser curve, high along cardia of stomach
Decreased mucosal protection
Type V gastric ulcer?
Associated with NSAID use
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)
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
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)
What is the surgical treatment for gastric ulcer complications?
Truncal vagotomy and antrectomy
Include the ulcer - extended antrectomy OR separate ulcer excision
Why do you have to resect a gastric ulcer at time of surgical intervention?
Associated high risk of gastric cancer
Stomach transit time
3-4 hours
Location of peristalsis in stomach?
Distal stomach (antrum) only
Carries sensation of gastroduodenal pain?
Afferent sympathetic fibers T5-10
Branches of the celiac trunk
Left gastric
Common hepatic artery
Splenic artery
Left gastroepiploic and short gastrics (from splenic artery)
Blood supply to greater curvature of stomach
Right and left gastroepiploics
Short gastrics
Right gastroepiploic is a branch of the gastroduodenal artery
Blood supply to the lesser curvature of stomach
Right and left gastrics
Right gastric is a branch off the common hepatic artery
Blood supply to the pylorus
Gastroduodenal artery
Mucosa of the stomach
Lined with simple columnar epithelium
Cardia glands
Mucus secreting
Fundus and body glands
Chief cells
Parietal cells
What do parietal cells release?
H+ and intrinsic factor
Stimulation for H+ release from parietal cells?
Acetylcholine (vagus nerve)
Gastrin (From G cells in antrum)
Histamine (from mast cells)
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
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
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
MOA of Omeprazole
Blocks H+/K+ATPase in parietal cell membrane
Final pathway for H+ release
Inhibitors of parietal cells
Somatostatin
Prostaglandin (PGE1)
Secretin
CCK
Effect of intrinsic factor
Binds B12 and the complex is reabsorbed in the terminal ileum
Antrum and pylorus glands
Mucus glands
HCO3 glands
G cells
D cells
Activity of G cells
Located in antrum
Release gastrin
Inhibited by H+ in duodenum
Stimulated by AA, acetylcholine
Activity of D cells
Secrete somatostatin
Inhibit gastrin and acid release
Brunner’s glands
Located in duodenum
Secrete alkaline mucus
Stimulation for release of somatostatin, CCK, secretin
Released with antral and duodenal acidification
Causes for rapid gastric emptying
Previous surgery*
Ulcers
Causes for delayed gastric emptying
Diabetes
Opiates
Anticholinergics
Hypothyroidism
Trichobezoars
Hair - hard to pull out
Tx: EGD generally inadequate; likely will need gastrostomy and removal
Dieulafoy’s ulcer
Vascular malformation
Can bleed
Menetrier’s disease
Mucous cell hyperplasia
Increased rugal folds
Gastric volvulus
Associated with type II (paraesophegeal) hernia
Nausea without vomiting, severe pain
Usually organoaxial volvulus
Tx: reduction and nissen
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
Physiologic changes due to vagotomy
Increased liquid emptying –> vagally mediated receptive relaxation is removed
Results in increased gastric pressure that accelerates liquid emptying
Truncal vagotomy
Divides vagal trunks at level of esophagus
Decreased emptying of solids
Proximal vagotomy
AKA highly selective vagotomy
Divides individual fibers - preserves crow’s foot
Normal emptying of solids
Physiologic changes when a pylorplasty is added to truncal vagotomy
Increased solid emptying
Gastric effects of truncal vagotomy
Decreased acid output by 90%
Increased gastrin secretion
Gastrin cell hyperplasia
Nongastric effects of truncal vagotomy
Decreased exocrine panreas function
Decreased postprandial bile flow
Increased gallbladder volumes
Decreased release of vagally mediated hormones
Most common problem following vagotomy?
Diarrhea
Caused by sustained MMCs (migrating motor complex) forcing bile acids into the colon
What is the cause if ulcer recurs?
Missed criminal nerve of Grassi
Branch of Rt vagus nerve - provides stimulation to the gastric cardia
Heineke-Mikulicz pylorplasty
Longitudinal incision of the pyloric sphincter followed by a transverse closure
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
Chronic gastritis - type A
Fundus
Associated with pernicious anemia, autoimmune disease
Chronic gastritis - type B
Antral
Associated with H. pylori
Treatment for chronic gastritis
PPI
Symptoms of gastric cancer
Pain unrelieved by eating
Weight loss
Diagnosis of gastric cancer
EGD
Risk factors for gastric cancer
Adenomatous polyps Tobacco Previous gastric operations Intestinal metaplasia Atrophic gastritis Pernicious anemia Type A blood Nitrosamines
Adenomatous polyps - gastric
15% risk of cancer
Tx: endoscopic resection
Krukenberg tumor
Metastases to ovaries
Virchow’s nodes
Metastases to supraclavicular node
Intestinal-type gastric cancer
Increased in high-risk populations
Older men
Japan (rare in US)
Tx: subtotal gastrectomy (need 10cm margins)
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
Chemotherapy for gastric cancer
Poor response
5-FU, doxorubicin, mitomycin C
Palliation of gastric cancer
Obstruction: - Proximal lesion - stenting - Distal lesion - bypass with gastrojejunostomy Low to moderate bleeding/pain - tx: XRT Fail --> palliative gastrectomy
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)
Indicators of malignancy in GIST tumors
> 5cm
>5 mitoses/50 HPF
Imatinib
Gleevec
Tyrosine kinase inhibitor
Used to treat malignant GIST tumors
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
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)
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
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
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)
What do 10% of Roux-en-Y bypass patients fail?
High-carbohydrate snacking
What is the most common cause of leak in Roux-en-Y bypass?
Ischemia
Signs of leak after roux-en-Y bypass?
Increased respiratory rate Increased heart rate Abdominal pain Fever Elevated WBCs
S/P Roux-en-Y bypass - Treatment of marginal ulcers
Occur in 10%
PPI
S/P Roux-en-Y bypass - Treatment of stenosis
Response to serial dilation
S/P Roux-en-Y bypass - Dilation of excluded stomach post-op
Hiccups, large stomach bubble
Dx: AXR
Tx: Gastrostomy tube
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
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
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)
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
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
Post-gastrectomy complication: treated with PPI, cholestyramine, metoclopramide
Alkaline reflux gastritis
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
Post-gastrectomy complication: Treated with metoclopramide, prokinetics
Chronic gastric atony
Post-gastrectomy complication: Small gastric remnant
Early satiety
Dx: EGD
Tx: Small meals
Sx: Jejunal pouch construction
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
Post-gastrectomy complication: Treated with Tetracycline & Flagyl, Metoclopramide
Blind-loop syndrome
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
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
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
Post-gastrectomy complication: Duodenal stump blow-out
Place lateral duodenostomy tube and drinas
PEG complications
Insertion into liver or colon
