3.02 General Surgery - Gastric Disease Flashcards
What are the subtypes of gastric cancer? Indicate the most common.
- adenocarcinoma arising from gastric mucosa (most common, ~90%)
- connective tissue malignancy
- lymphoid malignancy
- neuroendocrine malignancy
What are the risk factors for gastric cancer?
- male gender
- Helicobacter pylori infection
- increasing age
- smoking
- alcohol consumption
- salt in diet
- low fibre diet
- positive family history
What is the most important modifiable risk factor identified in developing gastric cancer?
Helicobacter pylori infection - a gram negative helical bacterium.
Produces urease enzyme, breaking down urea into CO2 and ammonia. The ammonia neutralises stomach acid, allowing bacterium to create an alkaline microenvironment in the stomach.
It sets of a cycle of repeated damage to epithelial cells, leading to inflammation, ulceration and gastric neoplasia.
What are the clinical features of gastric cancer?
- dyspepsia (non-response to PPI)
- dysphagia
- early satiety
- vomiting
- malena
OE an epigastric mass may be palpable in advanced disease; Troisier sign is the presence of a palpable left supraclavicular node (Virchow node) and is considered a sign of metastatic abdominal malignancy.
Other signs of metastatic disease include hepatomegatly, ascites, jaundice or acanthosis nigricans.
What are the differentials to gastric cancer?
As symptoms are non-specific, causes could include diagnoses such as peptic ulcer disease, GORD, gallstone disease and pancreatic cancer.
How is suspected gastric cancer investigated?
- FBC and LFTs
- urgent upper GI endoscopy
- biopsy of suspected gastric malignancies
For staging all patients need a CT CAB and staging laparoscopy.
What is the curative treatment of gastric cancer?
Surgery with peri-operative chemotherapy.
Proximal gastric cancers treated via total gastrectomy.
Distal gastric cancers (antrum / pylorus) treated via subtotal gastrectomy.
What are the complications of gastrectomy?
- mortality
- anastomotic leak
- dumping syndrome
- vitamin B12 deficiency*
*Patients need 3-monthly vitamin B12 injections.
What is the palliative treatment of gastric cancer?
Most pts offered a palliative approach due to extend of disease at time of presentation.
- chemotherapy
- best supportive care
- stenting
- palliative surgery
What are the main complications of gastric cancer?
- gastric outlet obstruction
- iron deficiency anaemia
- perforation
- malnutrition
- death
What is a hiatus hernia?
The protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus of the diaphragm.
The stomach is the most commonly involved organ, however the small bowel, colon and mesentery can also herniate through.
Describe
a) sliding hiatus hernia
b) para-oesophageal hernia
a) the GOJ, abdominal part of the oesophagus and cardia of the stomach ‘slides’ upwards through the oesophageal diaphragmatic hiatus into the thorax. (80%)
b) an upward movement of the gastric fundus to lie beside a normally positioned GOJ, creating a ‘bubble’ of stomach in the thorax. (20%)
What are the risk factors for hiatus hernia?
- age related loss of diaphragmatic tone
- increasing intrabdominal pressure
- increased size of diaphragmatic hiatus
- pregnancy
- obesity
- ascites
What are the clinical features of hiatus hernia?
- asymptomatic (most common)
- GOR symptoms (treatment-resistant)
- vomiting and weight loss
- bleeding
- anaemia
- hiccups or palpations
- swallowing difficulties
What are the differentials of hiatus hernia?
- cardiac chest pain
- gastric or pancreatic cancer
- GORD
How is suspected hiatus hernia investigated?
Oesophagogastroduodenoscopy (OGD) showing upward displacement of gastro-oesophageal junction.
How is hiatus hernia managed?
- PPI
- weight loss
- alteration of diet
- smoking cessation
- reduce alcohol intake
Surgical management considered in patients who are persistently symptomatic despite conservative measures or when there is nutrition failure due to gastric outlet obstruction.
Surgical options include fundoplication and cruroplasty.
What are the complications of hiatus hernia surgery?
- recurrence of hernia
- abdominal bloating
- dysphagia (esp. if fundoplication too tight; requires revision surgery)
- fundal necrosis (if supply by left gastric artery and short gastric vessels are disrupted)
What are the complications of hiatus hernia?
- incarceration
- strangulation
- gastric volvulus (stomach twists leading to obstruction of gastric passage and tissue necrosis; requires prompt surgical intervention)
Gastric volvulus presents with Borchadt’s triad:
- severe epigastric pain
- retching without vomiting
- inability to pass an NG tube
What is a peptic ulcer?
A break in the lining of the gastrointestinal tract, extending through to the muscularis mucosa.
Where is peptic ulceration most commonly seen?
- lesser curvature of the proximal stomach
- first part of the duodenum
What are the causes of peptic ulcers?
- Helicobacter pylori infection
- NSAID use
These disrupt the surface mucous secretion and HCO3- ion release, causing imbalance of the factors that protect the mucosa of the stomach and duodenum.
What are the risk factors for peptic ulceration?
- Helicobacter pylori infection
- prolonged NSAID use
- corticosteroid use
- gastric bypass surgery
What are the features of peptic ulcer disease?
- asymptomatic (~70%)
- epigastric or retrosternal pain
- nausea
- bloating
- post-prandial discomfort*
- early satiety
*gastric ulcer pain exacerbated by eating; duodenal ulcer pain alleviated by eating.
NICE guidelines suggest that an urgent referral for oesophagogastroduodenoscopy (OGD) should be done for patients presenting with:
- new-onset dysphagia
- age >55yrs with weight loss and upper abdominal pain, reflux or dyspepsia
- new onset dyspepsia not responding to PPI treatment
How is suspected peptic ulcer disease investigated?
- endoscopy finding; biopsy
- FBC to assess for potential anaemia
- non-invasive H. pylori testing
OGD if red-flag or ongoing symptoms.
How is peptic ulcer disease managed?
- smoking cessation
- weight loss
- reduction in alcohol consumption
- advise on avoidance or cessation of NSAIDs
Medical management:
- PPI (e.g. omeprazole)
- PPI + 2x abx (H. pylori infection)
What are the main complication of gastric ulcer disease?
- perforation
- haemorrhage
- pyloric stenosis
