ABSITE Review - Stomach Flashcards
What is the approximate transit stomach time?
3-4 hours
Does peristalsis occurs in the stomach?
Only in distal stomach
What is the blood supply of the stomach?
Lesser curvature - right (common hepatic artery) and left gastric (celiac trunk)
Greater curvature - right (GDA) and left gastroepiploic artery (splenic artery), short gastric (splenic artery)
What the epithelium of the stomach mucosa?
Simple columnar
What are the glands in the cardia?
Mucus secreting
What are the glands in the fundus and body of the stomach?
Chief and parietal cells
What are the three stimulators for HCL secretion?
ACh, gastrin, histamine
What is the first enzyme in proteolysis?
pepsinogen
What is released by the parietal cells?
H+ and intrinsic factor
How differs the mechanism for HCl release of histamine vs ACh/gastrin?
Histamine acts on adenylate cyclase –> cAMP –> protein kinase A to increase HCl
Ach/Gastrin act on phospholipase –> PIP –> DAG + IP3 to increase Ca; activates phosphorylase kinase –> increase HCl production
What is the main inhibitor of the H/K ATPase in parietal cell?
Omeprazole
What are the inhibitors of the parietal cells?
Somatostatin, PGE1, secretin, CCK
What is the function of intrinsic factor?
Binds B12 and the complex is reabsorbed in the terminal ileum
What are the glands in the antrum and pylorus of the stomach?
Mucus and HCO3 screting glands, G cells, D cells
Where are the Brunner’s glands? What they secrete?
They are in the duodenum; they secrete pepsinogen and alkaline mucus
What are the causes of increase acid and gastrin?
ZES, antral cell hyperplasia, retained antrum, renal failure, gastric outlet obstruction, short bowel syndrome
What are the causes of increase gastrin but normal/low acid?
Pernicious anemia, chronic gastritis, gastric CA, postvagotomy, medical acid suppression
What are some causes of rapid gastric emptying?
Previous surgery (#1), ZES, ulcers
What are some causes of delayed gastric emptying?
Opiates, anticholinergics, myxedema, hyperglycemia, diabetes
What is a Billroth I?
Antrectomy with gastroduodenal anastomosis
What is a Billroth II?
Antrectomy with gastrojejunal anastomosis
What is the disavantage of a Billroth I and II vs RNY gastrojejunostomy?
Increase marginal ulceration and diarrhea
What is the Dieulafoy’s ulcer?
Vascular malformation
What is Menetrier disease?
Mucous cell hyperplasia, increase rugal folds
What is the cause of a Mallory Weiss tear? What is the treatment?
Forceful vomiting - presents as hematemesis following severe retching
Tx - EGD, tear is usually in lesser curvature (near GEJ), PPI, transfusion
If continued bleeding, may need gastrostomy and oversewing of the vessel.
What occurs in term of gastric emptying with vagal denervation?
All forms increase liquid emptying
What is a truncal vagotomy vs a selective vagotomy?
Truncal vagotomy - divides the vagal trunks at the level of the esophagus
Selective vagotomy - divides nerves of Latarjet
What is a highly selective (proximal) vagotomy?
Divides individual fibers, preserves “crow’s foot”
What is the difference on gastric emptying between a complete and highly selective vagotomy?
Complete vagotomy (truncal or selective) - decrease emptying of solids Highly selective vagotomy - normal emptying of solids
What is the MC problem following a vagotomy?
Diarrhea - caused by sustained MMCs forcing bile acids into the colon
What are some risk factors of UGI bleeding?
Previous UGI bleed, PUD, NSAID use, smoking, liver disease, esophageal varices, splenic vein thrombosis, sepsis, burn injuries, trauma, severe vomiting
What is the most important predictor of continued or recurrent UGI bleed?
Bleeding at the time of EGD
What is the next step in a patient with UGI bleeding and hypotension despite resuscitation?
go to OR
If you are having trouble localizing the bleeding source, what is the next step?
Tagged RBC scan
What are the three biggest risk factors for rebleeding at the time of EGD?
#1 Spurting blood vessel (60% chance of rebleed) #2 Visible blood vessel (40% chance of rebleed) #3 Diffuse oozing (30% chance of rebleed)
What is the most frequent ulcer and where it is located?
Duodenal ulcer; more common in men
Usually 1st part of duodenum; usually anterior
What is the MC complication of anterior and posterior duodenal ulcers?
Anterior - perforate
Posterior - Bleed from GDA
What is the triple therapy for H. pylori?
Bismuth salts, amoxicillin, metronidazole/tetracycline (BAM or BAT)
What are the surgical indications for PUD?
Perforation, Protacted bleeding despite EGD therapy, Obstruction, Intractability, Inability to rule out cancer
What are the surgical options for duodenal ulcers?
Truncal vagotomy and pyloroplasty
Truncal vagotomy and antrectomy with Billroth I or II - BEST surgery for preventon of recurrence
Proximal or highly selective vagotomy - lowest rate of complications
What is the MOST frequent complication of duodenal ulcers?
Bleeding
What is consider major bleeding?
> 6 units of blood in 24 hours or patient remains hypotensive despite transfusion
How many sutures are needed to ligate the GDA?
Three - Proximal and distal brnches of GDA + transverse pancreatic branch
What is the conservative and surgical options for obstruction secondary to duodenal ulcer?
Serial dilation
If near ampulla of Vater or removing ulcer is difficult –> Billroth II, antrectomy, and truncal vagotomy
If proximal to ampulla of Vater –> antrectomy (with ulcer excision) with Billroth II and truncal vagotomy
What is consider intractability?
> 3 months without relief while on H-pump inhibitor therapy or recurrence >1 year after medical therapy based on EGD not symptoms
What is the test of choice for ZES?
Secretin stimulation test causes high gastrin level
What pancreatic tumor size can be enucleated?
< 2cm
What are the riks factors for gastric ulcers?
Male, tobacco, ETOH, NSAIDs, H. pylori, uremia, stress (burns, sepsis and trauma), steroids, chemotherapy
What is the CLO test?
Detects urease released from H. pylori
What type of ulcers are associated with type A and O blood?
Type A blood - type I ulcers
Type O blood - type II-IV ulcers
What are the 5 types of gastric ulcers and what is the treatment for each of them?
Type I - lesser curve along the body of stomach; due to increase mucosal protection
Tx: distal gastrectomy including ulcer with billroth I or II +/- vagotomy
Type II - 2 ulcers (lesser curve and duodenal); high acid secretion
Tx: distal gastrectomy including ulcer with billroth I or II and truncal vagotomy
Type III - prepyloric ulcer; high acid secretion, increase bleeding
Tx: distal gastrectomy including ulcer with billroth I or II and truncal vagotomy
Type IV - lesser curve high along cardia of stomach; increase risk of bleeding due to decrease mucosal protection
Tx: ulcer excision +/- highly selective vagotomy or truncal vagotomy and pyloroplasty
Type V - ulcer associated with NSAIDs
What is chronic gastritis type A and B?
Type A (fundus) - associated with pernicious anemia, autoimmune disease Type B (antral) - associated with H. pylori
Where are most of gastric cancers located?
Antrum - 40%
What are risk factors for gastric cancer?
adenomatous polyps, tobacco, previous, gastric operations, intestinal metaplasia, atrophic gastritis, pernicious anemia, type A blood, nitrosamines
What is the Krukenberg tumor?
Metastases to ovaries
What is the Virchow’s node?
Metastases to supraclavicular node
What is the treatment for stage I gastric cancer?
Subtotal gastrectomy (need 5cm margins)
What is linitis plastica? What is the treatment?
Diffuse gastric cancer due to lymphatic invasion
Tx: Total gastrectomy if no metastatic disease
What is the MC benign gastric tumor?
GIST tumors or leiomyoma
How are GIST diagnosed and treated?
Dx - Hypoechoic on US, smooth edges, biopsy
Tx: resection with 1cm margins, consider chemotherapy if >5cm or >5-10 mitoses/HPF
What chemo agent can be give to GIST patients and why?
Gleevec (TK inhibitor) because most are C-KIT positive.
How are the leiomyosarcomas diagnosed and how can they spread?
Cancer diagnosis based on mitosis/HPF (>5-10 associated with increase risk of metastases)
Hematogenous spread
What is the ogan most commonly involved in extranodal lymphoma?
Stomach
What agent is MALT lymphoma related to? What is the treatment?
H. pylori
Tx - usually regresses after treatment for H. pylori, triple therapy antibiotics and surveillance
If MALT does not regress, need chemotherapy (CHOP)
What are the criteria for bariatric surgery?
BMI > 40 BMI > 35 with coexisting comorbidities Failure of nonsurgical methods of weight reduction Psychological stability Absence of drug and alcohol abuse
What are the risk of a roux-en-Y gastric bypass?
Marginal ulcers, leak, necrosis, B12 deficiency (IF needs acidic environment to bind B12), iron deficiency anemia (bypass duodenum, when Fe absorbed), gallstones (from rapid weight loss)
What is the MCC of leak in a RNY gastric bypass?
Ischemia
What is dumping syndrome?
Occurs from rapid entering of CHO into the small bowel
What are the 2 phases of dumping syndrome?
Hyperosmotic load causes fluid shift into bowel (diarrhea, dizziness, hypotension)
Reactive increase in insulin and decrease in glucose (2nd phase rarely occurs)
What is the treatment for dumping syndrome?
Small, low-fat, low-CHO, increased-protein meals; no liquids with meals, no lying down after meals
