Chapter 30 - Stomach Flashcards
1
Q
What is the transit time of the stomach?
A
3-4h
2
Q
What level of afferent sympathetic fibers sense gastroduodenal pain?
A
T5-10
3
Q
What type of mucosa does the stomach have?
A
Simple columnar epithelium
4
Q
What do the cardia glands secrete?
A
Mucus
5
Q
What do Chief cells secrete? Location?
A
Pepsinogen; fundus and body
6
Q
What do Parietal cells secrete? Location?
A
H+ and intrisic factor; fundus and body
7
Q
What stimulates HCl release?
A
Gastrin, ACh, histamine
8
Q
What mediator does ACh and gastrin work on to inc. HCl?
A
Phospholipase –> PIP –> DAG + IP3 –> inc. Ca, activates phosphorylase kinase
9
Q
Histamine acts on what mediator to inc. HCl?
A
Adenylate cyclase –> cAMP –> protein kinase A
10
Q
What are inhibitors of parietal cells?
A
Somatostatin, PGE1, secretin, CCK
11
Q
What is the response to intrinsic factor?
A
Binds B12 and the complex is reabsorbed in the terminal ileum
12
Q
G cells release what? Location?
A
Gastrin; Antrum and pylorus
13
Q
G cells inhibited by? Stimulated by?
A
Inhibited by H+ in duodenum; stimulated by amino acids, ACh
14
Q
D cell secrete what? Location?
A
Somatostatin; antrum and pylorus
15
Q
Response to somatostatin in the stomach?
A
Inhibit gastrin and acid release
16
Q
Brunner’s glands secrete what? Location?
A
Pepsinogen and alkaline mucus; duodenum
17
Q
DDx for elevated acid and gastrin?
A
ZES, antral cell hyperplasia, retained antrum, renal failure, gastric outlet obstruction, short bowel syndrome
18
Q
DDx for elevated gastrin and normal/decreased acid?
A
Pernicious anemia, chronic gastritis, gastric ca, postvagotomy, medical acid suppression
19
Q
DDx for rapid gastric emptying?
A
1 previous surgery, ZES, ulcers
20
Q
DDx for delayed gastric emptying?
A
Opiates, anticholinergics, myxedema, hyperglycemia, diabetes
21
Q
Components of Billroth I?
A
Antrectomy with gastroduodenal anastamosis
22
Q
Components of Billroth II?
A
Antrectomy with gastrojejunal anastamosis
23
Q
What is a trichobezoar? Treatment?
A
Hair, hard to pull out; EGD inadequate, likely need gastrostomy and removal
24
Q
What is a phytobezoar? Treatment?
A
Fiber, often in diabetics with poor gastric emptying; enzymes, EGD, diet changes
25
What is Dieulafoy's ulcer?
Vascular malformation
26
What is Menetrier's disease?
Mucous cell hyperplasia, increased rugal folds
27
Gastric volvulus is associated with what condition?
Type II hernia
28
Symptoms of gastric volvulus? Treatment?
Nausea without vomiting, severe pain; usually organoaxial volvulus; reduction and Nissen
29
What is a Mallory-Weiss tear? Presentation?
Secondary to forceful vomiting; hematemesis following severe retching
30
Diagnosis of Mallory-Weiss? Treatment?
EGD; tear usually near lesser curve of stomach, PPE, transfusion; if continued bleeding, may need gastrostomy and oversewing of the vessel
31
Effects of all forms of vagal denervation?
Increased liquid emptying; vagally mediated receptive relaxation is removed; results in increased gastric pressure that accelerates liquid emptying
32
Where is the denervation in truncal vagotomy? Effect on solid emptying?
Divides vagal trunks at level of esophagus; decreased emptying of solids
33
Where is the level of denervation in selective vagotomy? Effect on solid emptying?
Divides nerves of Latarjet; decreased emptying of solids
34
Where is the level of denervation in highly-selective vagotomy? Effect on solid emptying?
Divides individual fibers, preserves "crow's foot"; normal emptying of solids
35
What are the gastric effects of truncal vagotomy?
Dec. acid output by 90%, increased gastrin, gastrin cell hyperplasia
36
What are the nongastric effects of truncal vagotomy?
Decreased exocrine pancreas function, decreased postprandial bile flow, increased gallbladder volumes, decreased release of vagally mediated hormones
37
What is the most common problem following vagotomy?
Diarrhea (30-50%), caused by sustained MMCs forcing bile acids into colon
38
Risk factors for upper GI bleed?
Previous UGI bleed, PUD, NSAIDs, smoking, liver disease, esophageal varices, splenic v thrombosis, sepsis, burn injuries, trauma, severe vomiting
39
Treatment for UGI bleed?
1st EGD; can potentially treat if due to bleeding ulcer; if pt hypotensive despite resuscitation, go to OR
40
Risk factors for rebleeding at time of EGD?
#1 spurting blood vessel (60%), #2 visible blood vessel (40%), #3 diffuse oozing (30%)
41
Likely source of UGI bleed in liver failure patient? Treatment?
Bleeding from esophageal varices; EGD with sclerotherapy, TIPS, not OR
42
What is the cause of duodenal ulcers?
Increased acid production, decreased host defense
43
Most common location of duodenal ulcers?
1st part of duodenum, usually anterior
44
Most common presentation of anterior duodenal ulcers? Posterior?
Anterior: perforation, posterior: bleed
45
Treatment of duodenal ulcers?
H2 blockers, PPI, triple therapy for pts with H. pylori
46
Surgical indications for duodenal ulcer?
Perforation, protracted bleeding despite EGD therapy, obstruction, intractability despite medical therapy, inability to r/o cancer
47
Surgical options for duodenal ulcers?
Truncal vagotomy and pyloroplasty, truncal vagotomy and antrectomy with BI or BII
48
Ulcer surgery with lowest rate of recurrence?
Truncal vagotomy and antrectomy with BI/BII
49
Ulcer surgery with lowest rate of complications?
Proximal or highly selective vagotomy
50
What is the most frequent complication of duodenal ulcers?
Bleeding
51
Surgical options for bleeding duodenal ulcer?
Duodenostomy and GDA ligation (careful to avoid CBD), if pt was on PPI, needs surgical ulcer procedure
52
What is the initial treatment of choice for obstruction secondary to duodenal ulcers?
Serial dilation
53
Surgical options for duodenal ulcer causing obstruction?
Near ampulla: gastroj (BII, bypasses obstruction), antrectomy, truncal vagotomy; proximal to ampulla: antrectomy with ulcer excision, BII, truncal vagotomy
54
% of patients with perforation that will have free air?
80%
55
Treatment of perforation in elderly, high risk patients?
Possibility that high risk patients can be safely observed with UGI to make sure perforation has sealed
56
Surgical option for perforated duodenal ulcer?
Graham patch and highly selective vagotomy (for pts on PPI); truncal vagotomy and pyloroplsty (include ulcer in pyloroplasty); truncal vagotomy and antrectomy with BI or BII (need to include ulcer)
57
What defines intractability with duodenal ulcers?
>3mo without relief on PPI or recurrence <1y after medical therapy; based on EGD findings, not symptoms
58
Risk factors for gastric ulcers?
Male, tobacco, ETOH, NSAIDs, H. pylori, uremia, stress, steroids, chemo
59
Most common cause of gastric ulcers?
Most (type I/IV) have normal acid secretion, due to abnormal mucosal defense
60
% of gastric ulcers on lesser curve of stomach?
70-80%
61
Where do biopsies for H. pylori need to be taken from?
Antrum
62
What type of blood is associated with type I ulcers?
Type A
63
What type of blood is associated with type II-IV ulcers?
Type O
64
Indications for surgery with gastric ulcers?
Perforation, bleeding, obstruction, cannot exclude malignancy, intractability
65
Location of type I gastric ulcer? Cause?
Lesser curvature; due to decreased mucosal protection
66
Treatment of type I gastric ulcer?
Distal gastrectomy including ulcer with BI/BII
67
Location of type II gastric ulcer? Cause?
Lesser curve and duodenal; high acid secretion
68
Treatment of type II gastric ulcer?
Distal gastrectomy with BI/BII and truncal vagotomy
69
Location of type III gastric ulcer? Cause?
Prepyloric; similar to duodena, high acid secretion
70
Treatment for type III gastric ulcer?
Distal gastrectomy with BI/BII and truncal vagotomy
71
Location of type IV? Cause?
Lesser curve high along cardia of stomach; decreased mucosal protection
72
Treatment for type IV gastric ulcer?
Ulcer excision +/- vagotomy
73
Location of type V gastric ulcer? Cause?
Anywhere; NSAID-related
74
How many days after the event does stress gastritis occur?
3-5d
75
Where is type A chronic gastritis located? Associated with what conditions?
Fundus; pernicious anemia, autoimmune disease
76
Location of type B chronic gastritis? Associated conditions?
Antrum; H. pylori
77
Symptoms associated with gastric cancer?
Pain unrelieved by eating, weight loss
78
Where are the majority of gastric cancers located?
Antrum (40%)
79
Risk factors for gastric cancer?
Adenomatous polyps, tobacco, previous gastric operations, intestinal metaplasia, atrophic gastritis, pernicious anemia, type A blood, nitrosamines
80
Adenomatous polyps carry what % cancer risk? Treatment?
10-20% risk of cancer; endoscopic resection
81
What is Krukenberg tumor?
Metastases to ovaries
82
What is Virchow's node?
Mets to supraclavicular node
83
What is intestinal gastric cancer associated with?
High risk opulations, older men (rare in US); associated with chronic atrophy, dysplasia, blood invasion, glands on histology
84
Characteristics of diffuse gastric cancer (linitis plastica)?
Low risk populations, women, lymphatic invasion, NO glands
85
Surgical treatment of linitis plastica?
Total gastrectomy plus chemo
86
Options for palliation for gastric cancer causing obstruction? Bleeding or pain?
Obstruction: stenting; bleeding/pain: XRT or palliative gastrectomy
87
What is the most common benign gastric neoplasm?
Gastric leiomyomas (GIST)
88
US findings of GIST?
Hypoechoic, smooth edges
89
Treatment of GIST?
Resection; consider chemo if >5cm or 5-10 mitoses/HPF; need 1cm margins
90
Gene mutation associated with GIST?
c-KIT
91
Chemo used with GIST?
Gleevec (tyrosine kinase inhibitor)
92
Treatment for gastric leiomyosarcoma?
En bloc resection
93
What is the diagnosis of cancer with gastric leiomyosarcomas based on?
Mitoses/HPF (>5-10)
94
Spread of leiomyosarcoma via what?
Hematogenous
95
Symptoms of gastric lymphomas?
Ulcer symptoms
96
Most common type of lymphoma of the stomach?
Non-Hodgkins
97
Treatment for gastric lymphomas?
Chemo and XRT; surgery for complications
98
Overall 5y survival rate of gastric lymphoma?
>50%
99
Mucosa-associated lymphoid tissue lymphoma (MALT) associated with what condition?
H. pylori infection
100
Where are MALTs located?
Usually in GI, can also be in lung and Waldeyer's ring
101
Treatment for MALT?
Triple therapy abx for H. pylori and surveillance; if does not regress, need chemo (CHOP)
102
Surgical eligibility for morbid obesity?
BMI >40, BMI >35 with comorbidities (DM, OSA, HTN, urinary stress incontinence, GERD, venous stasis ulcers, pseudotumor cerebri, joint pain)
103
Operative mortality with surgery for morbid obesity?
1%
104
Risk with roux-en-Y?
Marginal ulcers, leak, necrosis, B12 deficiency, iron-deficiency anemia, gallstones
105
Procedure that should be performed with gastric bypass?
Cholecystectomy
106
Failure rate of roux-en-y?
10-15% due to high carb snacking
107
What is the most common cause of leak with roux-en-y? Signs?
Ischemia; tachycardia, tachypnea, pain, fever, elevated WBCs
108
% of roux-en-y that develop marginal ulcers? Treatment?
10%; omeprazole
109
Tx for stenosis following roux-en-y?
Dilation
110
What are signs of obstruction following roux-en-y surgery?
Hiccups, large stomach bubble
111
Why are jejunoileal bypass operations no longer done?
Associated with increased liver cirrhosis and kidney stones, osteoporosis
112
What is the treatment for jejunoileal bypass when encountered?
Correction with roux-en-y
113
What causes dumping syndrome post-gastrectomy?
From rapid entering of carbs into small bowel; can occur after gastrectomy, vagotomy, pyloroplasty
114
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 (rarely occurs)
115
Treatment for dumping syndrome?
Small, low-fat, low-carb, increased-protein meals; no liquids with meals, no lying down after meals
116
Surgical options for dumping syndrome?
Rarely necessary; Conversion of BI or BII to Roux-en-y, oerations to increase gastric reservoir (jejunal pouch), or increase emptying time (reversed jejunal loop)
117
What are symptoms of alkaline reflux gastritis?
Postprandial epigastric pain associated with n/v; pain not relieved with vomiting
118
Diagnosis of alkaline reflux gastritis?
Evidence of bile reflux into stomach, histologic evidence of gastritis
119
Treatment for alkaline reflux gastritis?
H2 blockers, cholestyramine, metoclopramide
120
Surgical options for alkaline reflux gastritis?
Concersion of BI/BII to roux-en-y with afferent limb 60cm distal to original gastroj
121
What is roux stasis? Diagnosis?
Stasis of chyme in roux limb due to loss of jejunal motility; EGD, emptying studies
122
Treatment for roux stasis? Surgical options?
Metoclopramide, prokinetics; shorten roux limb to 40cm
123
What is chronic gastric atony? Symptoms? Diagnosis?
Delayed gastric emptying after vagotomy; n/v, pain, early satiety; gastric emptying study
124
Treatment for chronic gastric atony? Surgical options?
Metoclopramide, prokinetics; near-total gastrectomy with roux-en-y
125
Treatment for duodenal stump blow-out?
place duodenostomy and drains
126
What is blind-loop syndrome?
With BII or roux0en0y; pain, diarrhea, malabsorption, b12 deficiency, steatorrhea; caused by bacterial overgrowth and stasis in afferent limb
127
Treatment for blind-loop syndrome?
Tetracycline, flagyl, reglan; reanastomosis with shorter (40cm) afferent limb
128
What is afferent-loop obstruction?
With BII or roux-en-y; nonbilious vomiting, pain relieved with bilious emesis; ruq pain, steatorrhea; caused by obstruction of afferent limb
129
Treatment of afferent-loop obstruction?
Blloon dilation may be possible; reanastomosis with shorter (40cm) afferent limb
130
What is efferent-loop obstruction?
Symptoms of obstruction
131
Treatment for efferent loop obstruction?
Dilation; find site of obstruction and relieve it
132
What is postvagotomy diarrhea secondary to?
Nonconjugated bile salts in colon and sustained postprandial organized MMCs
