Abdominal Surgery- Stomach Flashcards
Peptic Ulcer Disease (PUD)
the presence of one or more ulcerative lesions in the stomach or lining of the duodenum.
PUD risk factors
- Chronic gastritis caused by H. pylori, a curved, flagellated gram-negative rod
- Duodenal ulcers: up to 90% are due to H. pylori infection
- Gastric ulcers: up to 80% are due to H. pylori infection
- Long-term use of NSAIDs
- Long-term use of NSAIDs plus glucocorticoids
- Smoking
- Chronic alcohol consumption
- Rare risk factors:
- Zollinger-Ellison syndrome (can result in duodenal ulcer)
Zollinger-Ellison syndrome
- gastrin-secreting neuroendocrine tumor that is most often localized to the duodenum and pancreas.
- part of multiple endocrine neoplasia (MEN) syndrome]
- elevated serum gastrin and low gastric pH
PUD Pathophysiology
- Helicobacter pylori gastritis: increased acid secretion, decreased protective factors/mucus production
- NSAIDs inhibit COX-1 and COX-2 → decrease in PGE2 (normally decreases gastric acid secretion and increases HCO3- and mucus secretion) → gastric mucosa erosions
PUD clinical features for both gastric and duodenal
∼ 70% of patients with PUD are asymptomatic
- Dyspepsia: postprandial heaviness, early satiety, and gnawing, aching or burning epigastric pain
- Pain relief with antacids
- Potential signs of internal bleeding (anemia, hematemesis, melena)
- Stool sample positive for occult blood
PUD Clinical signs for gastric ulcers
Pain increases shortly after eating →weight loss
nocturnal pain in 30-40% patients
PUD clinical features for duodenal ulcers
- pain increases 2–5 hours after eating
- Pain on an empty stomach (hunger pain) that is relieved with food intake → weight gain
- nocturnal pain 50-80% patients
Stress Ulcer
Acute damage to the gastric mucosa, resulting from increased levels of endogenousglucocorticoids and decreased blood flow to the stomach.
- Causes: polytrauma, major surgery, SIRS, kidney failure, etc.
- Types
- Curling ulcer:
- Cushing ulcer:
Curling Ulcer
severe burns → decreased plasma volume → decreased gastric blood flow → hypoxic tissue injury of stomach surface epithelium → weakening of the normal mucosal barrier
Cushing Ulcer
In patients with brain injury, increased vagal stimulation leads to increased production of stomach acid via acetylcholine release.
Nonulcer dyspepsia:
Symptoms including bloating, nausea, and belching persisting ≥ 3 months without organic cause
(synonym: functional dyspepsia)
PUD Diagnostic Approach
- ≤ 60 years of age without alarm features: Urea breath test for H. pylori
- > 60 years of age or presence of ≥ 1 alarm features: EGD with biopsies and rapid urease testing for H. pylori
- Negative for H. pylori infection and NSAID intake; trial therapy unsuccessful
- Measure serum gastrin level at baseline and after secretin stimulation test: high levels in gastrinoma (Zollinger-Ellison syndrome)
PUD Alarm Features
- Certain symptoms: progressive dysphagia, painful swallowing (odynophagia), and/or persistent vomiting
- Signs of active GI bleeding (e.g., melena, unexplained iron-deficiency anemia)
- Signs of malignancy (e.g., unintended weight loss, lymphadenopathy, palpable mass)
- Family history of upper GI malignancy in a first-degree relative
- Jaundice
PUD EGD
- MOst Accurate Test
- Biopsy samples from:
- Edge and base of the ulcer (essential to rule out malignancy)
- Helicobacter pylori testing
- If active bleeding, EGD can be performed for diagnosis and subsequent hemostasis treatment (electrocautery)
PUD Tx
H. Pylori Positive
eradication therapy (with antibiotics and a PPI) and supportive treatment → continue PPIs for 4–8 weeks → follow-up
PUD tx
h. pylori negative
medical acid suppression (with a PPI) and supportive treatment for 4–8 weeks → follow-up
PUD Supportive treatment
Discontinue NSAIDs
Restrict alcohol use/smoking/emotional stress
Avoid eating before bedtime
PUD Surgical Treatment
surgical intervention is rarely needed.
- Indications
- Refractory syndromes despite appropriate medical treatment
- If cancer is suspected
- Complications that cannot be treated endoscopically
- Partial gastrectomy (Billroth I/II)
PUD Complications
- Bleeding (posterior ulcers)
- Perforation (anterior ulcers)
- Subhepatic abcess
- Gastric Outlet Obstruction
- Fistula Formation
- Malignant Transformation
- Postgastrectomy Syndromes
Subhepatic Abscess
- Etiology: may result from a perforated duodenal or gastric ulcer
- Clinical presentation: fever and vomiting
- Diagnosis: subhepatic gas on abdominal x-ray
Gastric Outlet Obstruction
condition of obstruction of the pyloric channel or duodenum
- Etiology
- Malignancy (most common)
- Acute PUD → inflammation and edema
- Chronic PUD → scarring and fibrosis
Gastric outlet obstruction clinical findings
- Postprandial, nonbilious vomiting
- Succussion splash
- Early satiety
- Weight loss
Gastric outlet obstruction diagnosis
- Upper endoscopy (confirmatory test): identification of the gastric pathology
- Laboratory tests: hypokalemic hypochloremic metabolic alkalosis
Malignant Transformation of PUD
- Gastric ulcers: high malignant potential (progression to cancer in 5–10% of cases) → malignancy should be ruled out with biopsy
- Duodenal ulcers: usually benign
Gastric Cancer Risk Factors
Exogenous
- Diet rich in nitrates and/or salts
- Nicotine use
- Low socioeconomic status
Endogenous
- Atrophic gastritis
- H. pylori infection
- Gastric ulcers
- Partial gastrectomy
Gastric Cancer Clinical findings
Gastric cancer is often asymptomatic.
- General signs
- Weight loss
- Chronic iron deficiency anemia; fatigue
- Gastrointestinal signs
- Abdominal pain
- Early satiety
- Nausea or vomiting
- Acute gastric bleeding (hematemesis or melena)
- Late stage gastric cancer
- Gastric outlet obstruction
- Hepatomegaly, ascites
- Virchow’s node
- Sister Mary Joseph’s node
- Malignant acanthosis nigricans
Malignant acanthosis nigricans
Presents as verrucous or papulous, hyperpigmented, pruritic skin lesions with rapid growth. Mainly affects the neck, genital area, and axillae.
Virchow’s node
left supraclavicular adenopathy, located where the thoracic duct joins the subclavian vein at the venous angle.
Sister Mary Joseph’s node
umbilical node indicating metastasis from a gastrointestinal or abdominopelvic malignancy
Krukenberg tumor
an ovarian malignancy comprised of signet ring cells that has metastasized from a primary site, most commonly the stomach
Gastric Cancer Pathology
- Adenocarcinoma (90% of cases)
- Signet ring cell carcinoma
- Multiple signet ring cells = round cells filled with mucin, with a flat nucleus in the cell periphery
Gastric Cancer Tx
- Endoscopic resection
- Trastuzumab is indicated for HER2+ gastric adenocarcinomas
- Surgery
- Radical gastrectomy and lymphadenectomy (operative standard)
- Roux-en-Y gastric bypass
Postgastrectomy Maldigestion
- Iron deficiency → supplement iron
- Pernicious anemia due to lack of intrinsic factor, usually produced by gastric parietal cells → supplement vitamin B12
Postgastrectomy:
Small intestinal Bacterial Overgrowth
Clinical Features/ Diagnosis
- diarrhea,
- steatorrhea,
- weight loss,
- malabsorption (e.g., deficiency of vitamin B12, A, E, D, zinc, and iron)
Diagnostics
- Positive lactulose breath test
Postgastrectomy:
Small intestinal Bacterial Overgrowth
Definition: bacterial overgrowth within the small intestine
Causes
- Anatomic abnormalities: blind loop syndrome
Pathophysiology:
- bacterial overgrowth → bacteria deconjugate bile acids, increase vitamin B12 turnover, and produce increased amounts of vitamin K and folic acid
Treatment: antibiotics and parenteral supplementation
Dumping Syndrome
- rapid gastric emptying due to either defective gastric reservoir function or pyloric emptying mechanism, or anomalous postsurgery gastric motor function.
- Early dumping
- rapid emptying of undiluted chyme into the small intestine caused by a dysfunctional or bypassed pyloric sphincter
Dumping Syndrome
Clincal Features
- Appears within 15–30 minutes after ingestion of a meal
- Nausea,
- vomiting,
- diarrhea, and
- cramps,
- vasomotor symptoms such as sweating, flushing, and palpitations
Dumping Syndrome Managment
- Dietary modifications: Small meals that include a combination of complex carbohydrates and foods rich in protein and fat to cover protein and energy requirements are preferable.
- 30–60 min of rest in the supine position after meals
Mucosa-Associated Lymphoid Tissue (MALT) lymphoma
- is a B-cell non-Hodgkin lymphoma (NHL) that typically affects elderly patients in the 7th and 8th decades.
- Gastric MALTomas are frequently associated with Helicobacter pylori (H. pylori) infection
- nongastric MALTomas are rather associated with autoimmune conditions
MALT Lymphoma Clinical Features
- Gastric MALTomas
- Abdominal pain
- Melena, hematemesis, potentially anemia
- weight loss
- Non-gastric MALTomas:
- Salivary MALToma: parotid enlargement
Gastric MALToma
- First-line: H. pylori eradication therapy
- If H. pylori eradication therapy fails → radiotherapy or chemotherapy
