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A1-G Surg Note Stomach > Benign Gastric Ulcer > Flashcards

Benign Gastric Ulcer Flashcards

1
Q

What is a benign gastric ulcer?

A

macroscopic wound in the surface of the stomach that extends into the submucosa or muscularis propria and rarely to the serosa

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2
Q

How do benign gastric ulcers generally form?

A

mucosal defect that remains unrepaired

deepens due to an imbalance between gastric mucosal defenses and aggressive luminal forces, primarily acid and pepsin.

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3
Q

What are some rapid causes of gastric ulcers related to drug use or stress?

A

NSAIDs
aspirin
cocaine use
severe stress

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4
Q

What are the most common causes of gastric ulcers?

A

Helicobacter pylori infection
NSAID (aspirin)
smoking
physiologic or psychological stress

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5
Q

How do microscopic defects in the gastric mucosa heal?

A

repaired by rapid restitution

1-surface epithelial cells (SECs) reconstitute an intact layer
2-Mucus acts as a bandage over the denuded mucosa
3-mucosal blood flow is augmented during this process

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6
Q

What role do prostaglandins play in gastric ulcer healing?

A

help facilitate mucosal blood flow and healing of the gastric mucosa.

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7
Q

How do NSAIDs and aspirin affect the formation of gastric ulcers?

A

block prostaglandin production, which interferes with the mucosal defenses

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8
Q

How does smoking affect gastric ulcer formation?

A

decreases mucosal blood flow

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9
Q

What effect does Helicobacter pylori infection have on the stomach?

A

-chronic mucosal inflammation
-primes the lamina propria with inflammatory cells
-interferes with acid and gastrin secretion

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10
Q

How does severe physiologic or psychological stress contribute to gastric ulcer formation?

A

-interfere with mucosal blood flow
-gastric motility
-acid secretion

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11
Q

Where do Type 1 gastric ulcers typically occur?

A

at or near the angularis incisura on the lesser curvature of the stomach

where the parietal cell containing body transitions to the gastric antrum > (locus minoris resistentiae)

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12
Q

What is the association of Type 2 gastric ulcers

A

occur in the distal stomach and are associated with duodenal ulcer disease, either active or chronic.

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13
Q

Where do Type 3 gastric ulcers occur, and how are they treated?

A

in the prepyloric region

treated similarly to duodenal ulcers, with truncal vagotomy being part of the surgical treatment

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14
Q

Where do Type 4 gastric ulcers occur and what is their surgical implication?

A

occur high on the lesser curvature near the gastroesophageal junction.

Excision may get close to the esophagus, requiring a Roux reconstruction (Csendes operation).

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15
Q

What are Type 5 gastric ulcers, and what is their typical treatment?

A

drug-induced

typically occur toward the greater curvature.

They are usually treated with simple wedge resection.

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16
Q

Type of Ulcer , Location and Acid

A

Type 1 : on the lesser curvature, at the incisura, and not associated with acid hypersecretion.

Type 2 : in the body of the stomach and incisura, and are associated with duodenal ulcers (active or healed). They are associated with acid hypersecretion

Type 3 : occur in the prepyloric region and associated with acid hypersecretion.

Type 4 : high on the lesser curvature, near the GEJ, and not associated with acid hypersecretion.

Type 5 : occur anywhere , medication-induced. They are not associated with acid hypersecretion.

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17
Q

What must be done if a gastric ulcer is not excised during surgery?

A

it must be biopsied to rule out cancer.

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18
Q

When is formal gastric resection with anastomosis avoided?

A

in unstable patients.

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19
Q

What should be assessed during surgery before embarking on gastric ulcer resection?

A

Before resection, it is prudent to assess whether the ulcer involves the

1-pancreas
2-portal triad
3-celiac artery or its branches.

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20
Q

What is the treatment of choice for low-risk patients with distal gastric ulcers (types 2 and 3)?

A

Distal gastrectomy

with Truncal Vagotomy (for types 2 and 3)

without Truncal vagotomy (for type 1)

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21
Q

What are the two common types of reconstruction after distal gastrectomy for gastric ulcer?

A

Billroth 1 gastroduodenostomy
or Billroth 2 gastrojejunostomy.

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22
Q

When is a Billroth 2 gastrojejunostomy preferred?

A

when there is concomitant duodenal ulcer disease
(e.g., type 2 gastric ulcers).

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23
Q

What is the preferred reconstruction technique for patients with small gastric remnants when the gastrojejunostomy is close to the gastroesophageal junction?

A

Roux-en-Y reconstruction is preferred when the gastrojejunostomy is close to the gastroesophageal junction with small gastric remnants

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24
Q

What procedure is recommended for low-risk patients with high gastric ulcers (type 4)?

A

distal subtotal gastrectomy with in-continuity excision of the high lesser curvature ulcer and Roux-en-Y esophagogastrojejunostomy (Csendes procedure) is recommended if resection encroaches on the gastric cardia.

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25
Q

What procedure is used for type 5 gastric ulcers?

A

Simple wedge resection is a good option

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26
Q

What are the challenges with simple wedge resection for certain gastric ulcer types?

A

difficult to perform for
-prepyloric ulcers (types 2 and 3)
-juxtacardial ulcers (type 4)
-ulcers on the lesser curvature.

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27
Q

What is the next step if a gastric ulcer is diagnosed during endoscopy?

A

The gastric ulcer is aggressively biopsied to rule out gastric cancer, and if benign,

the patient is treated with acid suppression and elimination of causative factors such as H. pylori, NSAIDs, or smoking.

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28
Q

What is an alternative to distal gastric resection for type 2 and 3 gastric ulcers that are left in situ?

A

Truncal vagotomy and gastrojejunostomy (with ulcer biopsy) may be a reasonable alternativ

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29
Q

What is the Kelling-Madlener operation?

A

involves distal gastrectomy without ulcer excision (but with ulcer biopsy), typically considered for type 4 gastric ulcers

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30
Q

Pauchet procedure

A

limited distal gastric resection and lesser curvature extension

can be performed, with reconstruction by gastrojejunostomy (Billroth 2 or Roux)

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31
Q

How long after the initial diagnosis is an upper endoscopy repeated, and why?

A

repeated in 2 to 3 months to document ulcer healing and perform a repeat biopsy to ensure the ulcer is not malignant.

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32
Q

What is the expected outcome if Helicobacter pylori is eradicated, NSAIDs and aspirin are stopped, and smoking is eliminated?

A

If these factors are addressed, almost all gastric ulcers will heal with a 2- to 3-month course of proton pump inhibitor therapy, and recurrence or nonhealing is unusual.

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33
Q

What is crucial for optimal results after surgery for gastric ulcer?

A

For optimal results, it is crucial to document the absence of Helicobacter pylori infection, NSAID use, and smoking after surgery.

34
Q

Which patients should receive long-term acid-suppressive medication after surgery for gastric ulcer?

A

who require long-term NSAIDs or aspirin after surgery for gastric ulcer should receive long-term acid-suppressive medication.

35
Q

What type of medication may be considered for patients with ulcers requiring NSAIDs?

A

Selective COX-2 inhibitors may be considered because they have a lower risk of causing peptic ulceration.

36
Q

What is the most common indication for operation in benign gastric ulcer?

A

The most common indication for operation in benign gastric ulcer is perforation

37
Q

What imaging techniques are used to diagnose gastric ulcer perforation?

A

-CT > free intraperitoneal air and fluid

-water-soluble oral contrast > extravasation from the stomach.

-Upright chest radiography > free air under the diaphragm, may be absent in 20% of patients.

38
Q

What is the initial management for patients with perforated gastric ulcers?

A

-fluid resuscitation with 1 to 2 liters of isotonic fluid due to intravascular volume depletion
-Administration of IV antibiotics (cefazolin and fluconazole)
-Careful insertion of an NG tube for gastric decompression.

39
Q

When is nonoperative treatment considered for gastric ulcer perforation?

A

Nonoperative treatment is considered if the patient is clinically stable, without signs of sepsis, and there is good radiologic evidence that the perforation has sealed.

40
Q

What surgical steps are taken to manage gastric ulcer perforation?

A

-copious irrigation of the peritoneal cavity (5-10 Liters)
-inspection of the anterior and posterior (open lesser Sac) surfaces of the stomach
-and if no perforation is found, the greater or lesser curvatures are inspected
-If the perforation is found, it is either patched with an omental (Graham) patch or resected.

41
Q

What is the treatment for a perforated gastric ulcer in hemodynamically unstable patients?

A

perforated gastric ulcer is biopsied
closed, either with a Graham (omental) patch or wedge resection

42
Q

What is the treatment for low-risk, hemodynamically stable patients with perforated gastric ulcers?

A

Definitive operations, such as distal gastrectomy or vagotomy and drainage, are considered.

Vagotomy is considered for type 2 and type 3 ulcers.

43
Q

What is the approach for giant (> 2 cm) perforated gastric ulcers?

A

may require resection

or if resection is hazardous,

closure may be achieved by anastomosing the perforation to a Roux limb (mucosa to mucosa).

44
Q

How is the repair of a gastric ulcer tested after surgery?

A

with air insufflation and methylene blue via the NG tube before abdominal closure.

45
Q

What is the postoperative management after surgery for perforated gastric ulcer?

A

-continuing antibiotics until the patient is fever-free with a normal WBC count
-performing a gastrografin swallow before initiating a liquid diet
-managing any leakage without surgery if adequately drained and the patient is stable

46
Q

What should be done if there is leakage at the repair site after surgery?

A

If leakage occurs and the patient is stable, it is managed without surgery.

If the patient is not doing well, early reoperation is necessary to achieve adequate drainage and establish enteral access for decompression and feeding. Gastrostomy and Jejunostomy

47
Q

What is the most common cause of GI bleeding in hospitalized patients?

A

The most common cause of GI bleeding in hospitalized patients is peptic ulcer.

48
Q

What risk assessment tool is used to predict the likelihood of life-threatening ulcer bleeding?

A

The Rockall score is used to assess the risk of life-threatening ulcer bleeding

49
Q

Rockall score

A

PIC

50
Q

What are the risk levels associated with Rockall scores of 0-1 and 9-11?

A

score of 0-1 are very unlikely to have life-threatening GI hemorrhage

scores of 9-11 are at high risk of succumbing to the bleed.

51
Q

What are the common presentations of patients at high risk of bleeding gastric ulcers?

A

High-risk patients often present with hematemesis, hypotension, or require multiple units of blood transfusion

52
Q

What endoscopic findings indicate high risk during urgent upper endoscopy for a bleeding gastric ulcer?

A

High-risk endoscopic features include active bleeding or a visible vessel in the ulcer base

53
Q

What is the primary endoscopic treatment for a bleeding gastric ulcer?

A

Endoscopic hemotherapy, which includes cautery, injection of epinephrine, and application of clips.

54
Q

What should be considered if endoscopic therapy fails to control bleeding?

A

If endoscopic therapy fails, angiography with possible embolization or operation should be considered.

55
Q

What criteria make a patient a candidate for surgery for bleeding gastric ulcer?

A

include patients who have been transfused with multiple units of blood,
have recurrent or refractory hemorrhagic shock
or have ulcer erosion into a large artery such as the left gastric or splenic artery

56
Q

What is the appropriate surgical approach for high-risk or hemodynamically unstable patients with bleeding gastric ulcer

A

Biopsy and oversewing of the bleeding ulcer is the appropriate operation for high-risk or hemodynamically unstable patients

57
Q

What surgical option is recommended for bleeding ulcers on the greater curvature or free wall of the proximal stomach?

A

Wedge resection should be considered for these locations

58
Q

When should formal resection be considered for bleeding gastric ulcers?

A

Formal resection should be reserved for good-risk, hemodynamically stable patients

59
Q

What is the most common cause of gastric outlet obstruction in adult patients?

A

is cancer (pancreatic, duodenal, or gastric).

60
Q

What should the surgeon consider when operating on a patient with obstructing distal gastric ulcer

A

must consider whether the patient might have malignant obstruction, as misdiagnosis, although rare, is a real possibility

61
Q

What is the classic operation for obstructing gastric ulcer?

A

The classic operation for obstructing gastric ulcer is vagotomy and distal gastrectomy

62
Q

What is an acceptable alternative to vagotomy and distal gastrectomy for obstructing gastric ulcer?

A

Vagotomy and gastrojejunostomy may be an acceptable alternative to vagotomy and distal gastrectomy.

63
Q

Why might vagotomy and gastrojejunostomy be preferred in certain cases?

A

Vagotomy and gastrojejunostomy

have a lower operative mortality risk, and the gastrojejunostomy is potentially reversible if gastric outlet patency can be maintained

64
Q

What is the advantage of distal gastrectomy over gastrojejunostomy in treating obstructing gastric ulcer?

A

Distal gastrectomy confirms the absence of cancer, which is a significant advantage over gastrojejunostomy.

65
Q

Why is vagotomy recommended in cases of obstructing gastric ulcers?

A

Vagotomy is recommended because obstructing gastric ulcers are likely to be Johnson type 2 or type 3 lesions, which are associated with acid hypersecretion

66
Q

What important questions should a surgeon consider before operating on a nonhealing gastric ulcer?

A

-whether the ulcer might be cancerous
-if the patient is noncompliant
-if there is unrecognized gastric stasis or enterogastric reflux
-if there are undiscovered factors in ulcer pathogenesis

67
Q

What is the appropriate surgical approach if operation for nonhealing gastric ulcer is necessary?

A

The ulcer should be excised either through distal gastrectomy or wedge resection to exclude cancer and resect the vulnerable part of the stomach.

68
Q

What additional procedure should be performed if a distal gastrectomy is done for nonhealing gastric ulcer?

A

Vagotomy should be added for type 2 and type 3 gastric ulcers when performing a distal gastrectomy.

69
Q

What additional procedure should be performed if the ulcer is excised with wedge resection?

A

If the ulcer is wedged out, vagotomy and drainage should be added

70
Q

What are marginal ulcers, and where do they occur?

A

occur at or near the gastroenterostomy, and they can occur on either side of the anastomosis

71
Q

What causes marginal ulcers on the distal side of the anastomosis?

A

caused by acid/peptic injury to small bowel mucosa, which lacks adequate defense against unbuffered gastric juice

72
Q

Why are marginal ulcers more common in Roux gastrojejunostomy than in Billroth 2 anastomosis?

A

In Roux gastrojejunostomy, the anastomosis is devoid of the buffering effects of duodenal contents, which help protect the Billroth 2 anastomosis

73
Q

What are the common causes of proximal marginal ulcers?

A

caused by ischemia, stasis, foreign bodies (suture), bile reflux, or recurrent ulcers.

74
Q

What is the medical treatment for marginal ulcers?

A

same as for gastric ulcers:

acid suppression, eradication of Helicobacter pylori, elimination of NSAIDs, and smoking cessation

75
Q

What are the indications for surgery in marginal ulcers?

A

Indications for surgery in marginal ulcers are

perforation, bleeding, obstruction, and intractability.

76
Q

How should perforated marginal ulcers be treated in high-risk or unstable patients?

A

Perforated marginal ulcers in high-risk or unstable patients should be treated with simple patch closure.

77
Q

How are stable, low-risk patients with perforated gastrojejunostomy after distal gastric resection treated?

A

These patients are treated with resection of the anastomotic region (segmental jejunal resection with additional gastrectomy), and the addition of truncal vagotomy may be considered.

78
Q

What reconstruction options are recommended if the remaining gastric remnant is 30% or less after resection?

A

Roux gastrojejunostomy is recommended to avoid bile reflux esophagitis if the remaining gastric remnant is 30% or less

79
Q

What reconstruction options are recommended if the remaining gastric remnant is larger than 30% after resection?

A

Billroth 1 or Billroth 2 reconstruction is recommended to minimize the recurrence of marginal ulceration

80
Q

What is the recommended treatment for bleeding marginal ulcers?

A

managed without surgery using endoscopic hemostatic techniques or angiographic embolization.

Surgery may be necessary if the ulcer erodes into a major vessel.

gastroenterotomy and transluminal oversewing of the bleeding vessel may prove adequate

resection of the anastomotic region may be expeditious and safer.

81
Q

What is the treatment for marginal ulcers associated with obstruction or intractability?

A

Elective resection of the anastomosis, followed by Roux or Billroth reconstruction, is recommended depending on how close the anastomosis is to the gastroesophageal junction.

A1-G Surg Note Stomach (11 decks)

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