Alimentary Tract - Stomach Flashcards

Question

Describe complications of PUD operaiton: dumping syndrome

Answer 1

Rapid passage of hypertonic food bolus from stomach into the small intestine causes extracellular to intraluminal fluid shifts, causing intestinal distension, nausea, vomiting, crampy abdominal pain, palpitations, tachycardia, diaphoresis, flushing, dizziness as a result of autonomic stimulation and hormone release. Early symptoms usually occur 20–30 minutes after eating. Late dumping is due to the rapid delivery of carbohydrates to the intestines triggering hyperglycemia and resultant hyperinsulinemia which can then precipitate severe hypoglycemia. The catecholamine response causes lightheadedness, tachycardia, diaphoresis, and sometimes altered mental status. To prevent this, patients should avoid large carbohydrate heavy meals and avoid having liquids with meals. Some patients require octreotide. In some cases Roux-en-Y reconstruction is necessary.

Answer 2

Due to obstruction of the afferent loop, causing distension, abdominal pain and cramps, reflux of intestinal contents into the stomach, and bilious emesis. Blind loop syndrome can result from bacterial overgrowth causing vitamin B12 deficiency. Acute complete occlusion is a surgical emergency putting the bowel at risk of ischemia and perforation. Diagnosis can be obtained via upper endoscopy with inability to visualize the afferent loop. Correction involves Roux-en-Y reconstruction with shorter afferent loop.

Answer 3

Less common. Presents with abdominal pain, bilious emesis, distension. Diagnosed via upper GI contrast study with lack of contrast transit. Requires surgical correction as it is usually due to internal herniation of the efferent loop or adhesive disease (form of SBO).

Answer 4

Due to reflux of bile into the stomach. Can be diagnosed clinically or via endoscopy or HIDA scan. More common in V + A with Billroth II reconstruction. Bile acid sequestrants such as cholestyramine may help but Roux-en-Y conversion may be required.

Answer 5

Due to gastric atony, but most rule out metabolic, neurogenic, and anatomic causes. Seen more commonly in truncal or selective vagotomies. Usually affects emptying of food only, not liquids. Can be treated with metoclopramide, erythromycin, or resection in severe cases.

Answer 6

Due to exposure of gastric G-cells to alkaline duodenal secretions, causing acid hypersecretion and recurrent ulceration at the anastomosis. Can be treated with PPIs or surgical resection of gastric remnant with hyperplastic G-cells or vagotomy.

Answer 7

Can be due to bile acid or fat malabsorption, bacterial overgrowth, or dumping syndrome. Usually treated medically.

Answer 8

Small perforations can be closed primarily with an omental patch. Perforations \>1 cm should be repaired with a Graham patch in which a piece of omentum is sutured in place over the perforation. Some surgeons perform acid-reducing procedures in stable patients.

Answer 9

The most common bleeding vessel is the gastroduodenal artery from a posterior ulcer. The vessel should be oversewn and a Heineke-Mikulicz pyloroplasty performed. The duodenum is opened longitudinally across the pylorus, the vessel is oversewn with a three-point stitch, and the duodenotomy is closed transversely.

Answer 10

Usually requires vagotomy and antrectomy with gastrojejunostomy. Cancer must be ruled out as the underlying cause.

Answer 11

* D1: perigastric nodes along lesser/greater curvature (stations 1-6, N1) * D2: D1 plus nodes along left gastric artery, common hepatic artery, celiac trunk, splenic hilum, and splenic artery (stations 7-11, N2) * D3: D2 plus nodes along the hepatoduodenal ligament near porta hepatis, retropancreatic space, and along the root of the SMA/SMV extending to vessels of the transverse mesocolon (stations 12-15, N3). * D3 - often described as including peri-aortic nodes AND LNs along porta hepatis/root of the mesentery. * D4: D3 plus peri-aortic LNs (station 16)

Answer 12

* men, 70s, Asian * diets w/ salt and smoked meats, nitrates * smokers * H pylori * hereditary diffuse gastric ca, FAP, Li-Fraumeni, HNPCC * pernicious anemia * large polyps

Answer 13

* constant epigastric pain unaffected by food * fatigue, weight loss, early satiety * dysphagia if proximal * obstruction if distal * iron deficiency anemia, unlikely frank hematemesis * non-healing gastric ulcers

Answer 14

Number. N-stage is based on number.

Answer 15

15 is accurate, 30 is recommended

Answer 16

D1 vs D2. Western studies show higher mortality w/ D2 w/o benefit. Japanese studies show increased recurrence-free survival w/o increased morbidity. Prefer D2 at high-volume centers.

Answer 17

Adjuvant chemo/XRT shows increased survival

Answer 18

PUD, GERD, DGE, biliary dysfunction (e.g., cholecystitis, cholangitis, biliary dyskinesia), pancreatitis, pancreatic neoplasm, MI or dysrhythmia, hepatitis, gastric outlet obstruction, perforation, mesenteric ischemia, IBD, viral or bacterial gastritis/enteritis, SBP, AAA, constipation, diverticulosis/diverticulitis.

Answer 19

Endoscopy w/ EUS and biopsy

Answer 20

* CT abd/pelvis required for mets and can help with T/N staging. * EUS is superior for T staging and possible nodal involvement (N), and is recommended if no M1 disease is present on CT (NCCN guidelines) * Perform FNA of suspicious nodes as it increases staging accuracy. * PET/CT is clinically indicated or recommended by multidisciplinary board.

Answer 21

* Resection is based on location: distal gastrectomy is appropriate for distal tumors including body and antrum; proximal transection at incisura w/ 6-cm margins, distal transection point is proximal duodenum w/ 2-cm margins; reconstruction w/ Billroth II vs. Roux-en-Y * Tumors of gastric body require total gastrectomy w/ Roux-en-Y. * For proximal tumors of cardia or fundus - prefer total gastrectomy, some advocate for proximal gastrectomy. * D2 nodal dissection should be attempted if technically capable.

Answer 22

* Prognosis is poor; some studies quote 3- to 5-month median survival. * Asymptomatic unresectable patients may opt for chemotherapy; triple therapy with 5FU, cisplatin, and anthracycline-based compound (epirubicin) is recommended; for those with increased age or comorbidities, dual or single agent therapy is appropriate. * Symptomatic unresectable patients may be resected for palliation of symptoms; endoscopic stent placement is also an option.

Answer 23

* Per NCCN guidelines: all stages require H&P q3–6 months for 1-2 years, q6–12 months for 3–5 years, annually thereafter w/ CBC and CMP prn. * For endoscopic resection: endoscopy q6 months for 1 year, annually for 3 years thereafter; for partial gastrectomy, EGD as clinically indicated * For pathologic stage II or greater: CT chest/abd/pelvis q6–12 months for 2 years, annually for up to 5 years; consider PET/CT on individual patient basis or provider preference; CT C/A/P as needed if lower than stage II.

Answer 24

* Recurrence rates range from 40–80% and most occur within the first 3 years. * Peritoneal dissemination occurs ~54% vs. locoregional recurrence at 38–45%. * Locoregional recurrence is typically at anastomotic site, gastric bed or regional LNs; hematogenous spread can occur, commonly to liver, lung or bone.

Answer 25

Perioperative chemotherapy is given in the neoadjuvant setting in contrast to adjuvant therapy that consists of chemotherapy plus radiation. Common chemotherapy regimen consists of: Epirubicin, Cisplatin and 5-Fluorouracil.