Chapter 30: Stomach Flashcards
1
Q
Stomach transit time
A
3-4 hours
2
Q
Where does stomach peristalsis occur?
A
Distal stomach (antrum)
3
Q
How is gastroduodenal pain sensed
A
Through afferent sympathetic fibers T5-T10
4
Q
Components of the celiac trunk
A
Left gastric
Common hepatic artery
Splenic artery
5
Q
Branches of the splenic artery that supply the stomach
A
Left gastroepiploic and short gastric
6
Q
Blood supply to the greater curvature
A
Right and left gastroepiploics, short gastrics
7
Q
What is the right gastroepiploic a branch of?
A
Gastroduodenal artery
8
Q
Blood supply of lesser curvature
A
Right and left gastrics
9
Q
What is the right gastric a branch off?
A
The common hepatic artery
10
Q
Blood supply of the pylorus
A
Gastroduodenal artery
11
Q
Mucosa lining the stomach
A
Simple columnar epithelium
12
Q
What do cardia glands secrete?
A
Mucus
13
Q
Fundus and body glands
A
Chief cells
Parietal cells
14
Q
Produces pepsinogen (1st enzyme in proteolysis)
A
Chief cells
15
Q
Release hydrogen and intrinsic factor
A
Parietal cells
16
Q
What stimulates parietal cells?
A
Acetylcholine (vagus nerve), gastrin (from G cells in antrum), and histamine (from mast cells) cause H+ release
17
Q
What is the pathway of acetylcholine (vagus nerve) and gastrin?
A
Activates phospholipase (PIP -> DAG + IP3 + Increase Ca); Ca-calmodulin activates phosphorylase kinase -> H+ release
18
Q
What is the pathway of histamine?
A
Activates adenylate cyclase -> cAMP -> activates protein kinase A -> increased H+ release
19
Q
How do phosphorylase and protein kinase A work?
A
Phosphorylate H+/K+ ATPase to increase H+ secretion and K+ absorption
20
Q
Blocks H+/K+ ATPase in parietal cell membrane (final pathway for H+ release)
A
Omeprazole
21
Q
Inhibitors of parietal cells
A
Somatostatin, prostaglandins (PGE1), secretin, CCK
22
Q
Binds B12 and the complex is reabsorbed in the terminal ileum
A
Intrinsic factor
23
Q
Antrum and pylorus glands
A
Mucus and HCO3- secreting glands. G cells (gastrin). D cells (somatostatin)
24
Q
Secreting glands - protect stomach
A
Mucus and HCO3- (Antrum and pylorus glands)
25
Release gastrin - reason why antrectomy is helpful for ulcer disease
G cells
26
What inhibits G cells?
H+ in duodenum
27
What stimulates G cells?
Amino acids, acetylcholine
28
Secrete somatostatin, inhibit gastrin and acid release
D cells
29
In duodenum; secrete alkaline mucus
Brunner's glands
30
Released with antral and duodenal acidification
Somatostain, CCK, and secretin
31
What are the causes of rapid gastric emptying?
Previous surgery (#1), ulcers
32
What are the causes of delayed gastric emptying?
Diabetes, opiates, anticholingerics, hypothyroidism
33
(Hair) - hard to pull out
| Tx?
Trichobezoars
| - Tx: EGD generally inadequate; likely need gastrostomy and removal
34
(fiber) - often in diabetics with poor gastric emptying
| Tx?
Phytobezoars (fiber)
Tx: enzymes, EGD, diet changes
35
Vascular malformation; can bleed
Dieulafoy's ulcer
36
Mucous cell hyperplasia, increased rugal folds
Menetrier's disease
37
- Associated with type II (paraesophageal) hernia
- Nausea without vomiting; severe pain; usually organoaxial volvulus
Treatment?
Gastric volvulus
Tx: reduction and Nissen
38
- Secondary to forceful vomiting
- Presents as hematemesis following severe retching
- Bleeding often stops spontaneously
Mallory-Weiss tear
39
What type of volvulus is a gastric volvulus?
Organoaxial volvulus
40
Dx/Tx: Mallory Weiss Tear
EGD with hemo-clips; tear is usually on the lesser curvature (near GE junction)
41
Where is the Mallory Weiss Tear located?
Usually on the lesser curvature (near GE junction)
42
What if you have continued bleeding after EGD with hemo-clips for Mallory Weiss tear?
If continued bleeding, may need gastrostomy and oversewing of the vessel.
43
What is the physiologic effect of vagotomy?
Both truncal and proximal forms increase liquid emptying -> vaguely mediated receptive relaxation if removed (results in increased gastric pressure that accelerates liquid emptying)
44
Vagotomy:
| Divides vagal trunks at the level of the esophagus; decreases emptying of solids
Truncal vagotomy
45
Vagotomy:
- highly selective
- divides individual fibers, preserves "crow's foot", normal emptying of solids
Proximal vagotomy
46
Emptying of solids: truncal vs proximal vagotomy
Truncal: decreased emptying of solids
Proximal: normal emptying of solids
47
How can you increase solid emptying with truncal vagotomy?
Addition of pyloroplasty to truncal vagotomy results in increased solid emptying.
48
Physiologic effects of truncal vagotomy
- Gastric effects
- Nongastric effects
- Diarrhea
- Gastric: decreased acid output by 90%, increased gastrin cell hyperplasia
- Nongastric: decreased exocrine pancreas function, decreased postprandial bile flow, increased gallbladder volumes, decreased release of vaguely mediated hormones
- Diarrhea: MC problem following vagotomy
49
MC common problem following vagotomy
Diarrhea (40%)
50
What causes diarrhea following vagotomy?
Caused by sustained MMCs (migrating motor complex) forcing bile acids into the colon
51
Name that vagotomy: both nerve trunks are divided at the level of the diaphragmatic hiatus
Truncal vagotomy
52
Name that vagotomy: division of the vagal fibers that supply the gastric funds. Branches to the antropyloric region of the stomach are not transected, and the hepatic and celiac divisions of the vagus nerves remain intact.
Proximal gastric vagotomy
53
Risk factors: upper gastroinestinal bleeding
Previous UGIB, PUD, NSAIDs, smoking, liver disease, esophageal varices, splenic vein thrombosis, sepsis, burn injuries, trauma, severe vomiting.
54
Dx/Tx: UGIB
EGD (confirm bleeding is from ulcer); can potentially treat with hemo-clips, Epi injection, cautery
55
Mgmt: UGIB with slow bleeding and having trouble localizing source
Tagged RBC scan
56
UGIB: biggest risk factor 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)
```
57
Highest risk factor for mortality with non-variceal UGIB
Continued or re-bleeding
58
Treatment: patient with liver failure is likely bleeding from esophageal varices, not an ulcer
EGD with variceal bands or sclerotherapy; TIPS if that fails
59
- From increased acid production and decreased defense
| - Most common peptic ulcer; more common in men
Duodenal ulcers
60
Location of duodenal ulcers
Usually in 1st part of the duodenum; usually anterior.
61
Complications of duodenal ulcers:
- Anterior
- Posterior
- Anterior ulcers perforate
| - Posterior ulcers bleed from gastroduodenal artery
62
Symptoms: epigastric pain radiating to the back; abates with eating but recurs 30 minutes after
- Dx/Tx?
Duodenal ulcer
- Dx: endoscopy
- Tx: PPI, triple therapy for H. pylori -> bismuth salts, amoxicillin, and metronidazole/tetracycline (BAM or BAT)
63
What has decreased incidence of surgery for ulcer?
Surgery for ulcer rarely indicated since PPIs
64
What do you need to rule out in patients with complicated ulcer disease?
Need to rule out gastrinoma
65
Gastric acid hyper secretion.
Peptic ulcers.
Gastrinoma.
Zollinger-Ellison Syndrome
66
Surgical indications for duodenal ulcer
Perforation. Protracted bleeding despite EGD therapy. Obstruction. Intractability despite medical therapy. Inability to rule out cancer. PPI with duodenal ulcer complication.
67
Duodenal ulcer: if patient has been on a PPI and has complications
If a patient has been on a PPI, an acid-reducing surgical procedure is required in addition to surgery for any complications
68
Surgical options (acid-reducing surgery) for duodenal ulcers
- Proximal vagotomy
- Truncal vagotomy and pyloroplasty
- Truncal vagotomy and antrectomy
- Reconstruction after antrectomy - Roux-en-Y gastro-jejunostomy (best)
69
Surgery duodenal ulcer: lowest rate of complications, no need for astral or pylorus procedure; 10-15% ulcer recurrence, 0.1% mortality
Proximal vagotomy
70
Ulcer recurrence / mortality after proximal vagotomy
- 10-15% ulcer recurrence
| - 0.1% mortality
71
Ulcer recurrence / mortality after truncal vagotomy and pyloroplasty
- 5-10% ulcer recurrence
| - 1% mortality
72
Ulcer recurrence / mortality after truncal vagotomy and antrectomy
- 1-2% ulcer recurrence (lowest rate of recurrence)
| - 2% mortality
73
Why is roux-en-y gastro-jejunostomy the best procedure for reconstruction after antrectomy?
Less dumping syndrome and reflux gastritis compared to Bilroth I (gastro-duodenal anastomosis) and Billroth II (gastro-jejunal anastomosis)
74
Most frequent complication of duodenal ulcers
Bleeding (usually minor but can be life threatening)
75
Definition of major bleeding in duodenal ulcer
> 6 units of blood in 24 hours or patient remains hypotensive despite transfusion
76
Tx: bleeding from duodenal ulcer
EGD 1st - hemoclips , cauterize, Epi injection
77
Surgery: bleeding duodenal ulcers
Duodenotomy and gastroduodenal artery (GDA) ligation.
- Avoid hitting common bile duct (posterior) with GDA ligation
- If patient has been on a PPI, need acid-reducing surgery as well
78
Initial treatment of choice for obstruction from duodenal ulcer
PPI and serial dilation
79
Surgical options: duodenal ulcer obstruction
Antrectomy and truncal vagotomy (best); include ulcer in resection if it's located proximal to ampulla of Vater
80
What do you need to rule out in duodenal ulcer obstruction?
Need to biopsy area of resection to rule out CA
81
Duodenal ulcer perforation: % will have free air
80% will have free air
82
- patient usually have sudden epigastric pain; can have generalized peritonitis
- pain can radiate to the prevocalic gutters with dependent drainage of gastric content
Duodenal ulcer perforation
83
Tx: duodenal ulcer perforation
```
Graham patch (place momentum over the perforation)
- Also need acid-reducing surgery if the patient has been on a PPI
```
84
Definition of intractable duodenal ulcers
> 3 months without relief while on escalating doses of PPI
85
What is diagnosis of intractable duodenal ulcers based on?
Based in EGD mucosal findings, not symptoms
86
Tx: intractability of duodenal ulcers
Acid-reducing surgery
87
- Older men, slow healing
- 80% on lesser curvature of the stomach
- Symptoms: epigastric pain radiating to the back; relieved with eating but recurs 30 minutes later; melena or guaiac-positive stools
Gastric ulcers
88
Risk factors for gastric ulcer
Male, tobacco, ETOH, NSAIDs, H. pylori, uremia, stress (burns, sepsis, and trauma), steroids, chemotherapy
89
Where are most gastric ulcers located?
80% on lesser curvature of the stomach
90
What is difference in mortality between gastric and duodenal ulcer hemorrhage?
Hemorrhage is associated with higher mortality than duodenal ulcers.
91
Gastric ulcers: best test for H. pylori
Histiologic examination of biopsies from antrum
92
Test for H.pylori, detects urease released from H. pylori
CLO test (rapid urease test)
93
Type 1 Gastric ulcer
Lesser curve low along body of stomach; due to decreased mucosal protection
94
Type 2 gastric ulcer
2 ulcers (lesser curve and duodenal); similar to duodenal ulcer with high acid secretion
95
Type 3 gastric ulcer
pre-pyloric ulcer; similar to duodenal ulcer with high acid secretion
96
Type 4 gastric ulcer
Lesser curve high along cardia of stomach; decreased mucosal protection
97
Type 5 gastric ulcer
Ulcer associated with NSAIDS
98
What gastric ulcers are associated with decreased mucosal secretion?
Type 1 and 4
99
What gastric ulcers are similar to duodenal ulcer with high acid secretion?
Type 2 and 3
100
What type of gastric ulcer is associated with NSAIDS?
Type 5
101
Surgical indications for gastric ulcers
Perforation, bleeding not controlled with EGD, obstruction, cannot exclude malignancy, intractability (> 3 months without relief - based on mucosal findings)
102
Tx: gastric ulcer
Truncal vagotomy and antrectomy best for complications; try to include the ulcer with resection (extended antrectomy) - need separate ulcer excision if that is not possible (gastric ulcers are resected at time of surgery due to high risk of gastric CA)
103
What are poor options for surgical repair of gastric ulcers?
Omental patch and ligation of bleeding vessels are poor options for gastric ulcers due to high recurrence of symptoms and risk of gastric CA in the ulcer.
104
- Occurs 3-10 days after event; lesions appear in fundus first
- Tx: PPI
- EGD with cautery of specific bleeding point may be effective
Stress gastritis
105
Where do lesions in stress gastritis appear?
Lesions appear in fundus first
106
Chronic gastritis type: associated with pernicious anemia, autoimmune disease
Type A (fundus)
107
Chronic gastritis type: associated with H. pylori
Type B (antral)
108
Treatment Chronic Gastritis
PPI
109
Pain unrelieved by eating, weight loss
Gastric cancer
110
Where are 40% of gastric cancers located?
Antrum
111
Gastric cancer-related deaths in Japan
Accounts for 50% of cancer-related deaths in Japan
112
Dx: gastric cancer
EGD
113
Risk factors: gastric cancer
Adenomatous polyps, tobacco, previous gastric operations, intestinal metaplasia, atrophic gastritis, pernicious anemia, type A blood, nitrosamines
114
15% risk of gastric cancer.
| - Tx: endoscopic resection
Adenomatous polpys
115
Gastric cancer metastases to ovaries
Krukenberg tumor
116
Gastric metastasis to supraclavicular node
Virchow's node
117
Increased in high-risk populations. Older men. Japan. Rare in United States
Surgical treatment: try to perform subtotal gastrectomy (need 10-cm margins)
Intestinal-type gastric CA
118
Low risk populations. Women. Most common type in the United States.
Diffuse lymphatic invasion, no glands.
Surgery: total gastrectomy bc of diffuse nature of linitis plastica
Diffuse gastric cancer
119
Prognosis: intestinal-type gastric CA vs diffuse gastric cancer
Less favorable prognosis than intestinal-type gastric CA (overall 5-YS - 25%)
120
Margins for intestinal-type gastric CA
need 10 cm margins
121
Chemotherapy for gastric cancer
Poor prognosis:
| - 5 FU, doxorubicin, mitomycin C
122
Gastric cancer: management of metastatic disease outside area of resection
Contraindication to resection unless performing surgery for palliation.
123
When to consider palliation of gastric cancer?
- Obstruction - proximal lesions can be scented; distal lesions can be bypassed with gastrojejunostomy
- Low to moderate bleeding or pain - Tx: XRT
124
What if surgical management fails for palliation of gastric cancer (stents, gastrojejunostomy, XRT)?
If these fail, consider palliative gastrectomy for obstruction or bleeding.
125
Most common benign gastric neoplasm, although can be malignant
Symptoms: usually asymptomatic, but obstruction and bleeding can occur
Gastrointestinal stromal tumors (GISTs)
126
How do GISTs look on ultrasound?
Hypoechoic on ultrasound; smooth edges
127
Dx / Tx: GIST
Dx: biopsy - are C-KIT positive
Tx: resection with 1 cm margins; Chemotherapy with imatinib (Gleevac, tyrosine kinase inhibitor) if malignant
128
Chemotherapy for malignant GIST
Imatinib (Gleevax; tyrosine kinase inhibitor)
129
- Related to H. pylori infection
| - Usually regresses after treatment for H. pylori
Mucosa-associated lymphoid tissue lymphoma (MALT lymphoma)
130
When are GIST considered malignant?
> 5 cm or > 5 mitoses / 50 HPF (high-powered field)
131
What will be positive in biopsy of GIST?
C-KIT
132
MC location of MALT lymphoma
Stomach
133
Treatment: MALT lymphoma
Triple-therapy antibiotics for H. pylori and surveillance.
| If MALT does not regress, need XRT.
134
What if MALT lymphoma does not resolve with triple therapy antibiotics for H.pylori?
If MALT does not regress, need XRT
135
- Have ulcer symptoms
- Usually non-Hodgkin's lymphoma (B cell)
- Overall 5-year survival rate > 50%
Gastric lymphomas
136
MC location for extra-nodal gastric lympoma
Stomach
137
Dx: Gastric lymphoma
EGD with biopsy
138
Primary treatment modalities of gastric lymphoma
Chemotherapy and XRT are primary treatment modalities; surgery for complications
139
When is surgery indicated for gastric lymphoma?
Surgery possibly indicated only for stage 1 disease (tumor confined to stomach mucosa) and then only partial resection is indicated
140
Overall 5-year survival rate for gastric lymphoma
> 50%
141
Criteria for patient selection for bariatric surgery (need all 4)
- BMI > 40 kg/m^2 or BMI > 35 kg/m^2 with coexisting comorbidities
- Failure of nonsurgical methods of weight reduction
- Psychological stability
- Absence of drug or alcohol abuse
142
What type of obesity is worse prognosis in general population?
Central obesity
143
Operative mortality in morbid obesity
1%
144
What gets better are surgery for morbid obesity?
DM, cholesterol, sleep apnea, HTN, urinary incontinence, GERD, venous stasis ulcers, pseudotumor cerebri, joint pain, migraines, depressions, PCOS, NASH
145
- Better weight loss than just banding.
- Risk of marginal ulcers, leak, necrosis, B12 deficiency, IDA, gallstones
- Perform cholecystectomy during operation if stones present
- UGI on POD 2
Roux-en-Y gastric bypass
146
Failure rate of roux-en-y gastric bypass
10% failure rate due to high-carbohydrate snacking
147
What are the signs of a leak after roux-en-y gastric bypass?
- Ischemia: MCC leak
| - Signs of leak: increased RR, increased HR, abdominal pain, fever, elevated WBCs
148
Dx / Tx: leak after roux-en-y gastric bypass
Dx: UGI
Tx: early leak (not contained) -> re-op; late leak (Weeks out from surgery, likely contained) -> percutaneous drain, antibiotics
149
Incidence of marginal ulcers after roux-en-y gastric bypass
Develop in 10%
Tx: PPI
150
Management of stenosis after roux-en-y gastric bypass
Usually responds to serial dilation
151
Complications of roux-en-y gastric bypass
- Leak
- Marginal ulcers
- Stenosis
152
MCC leak after roux-en-y gastric bypass
Ischemia
153
After roux-en-y gastric bypass:
- Hiccoughs, large stomach bubble
- Dx: AXR
- Tx: G-tube (gastrostomy tube)
Dilation of excluded stomach postop
154
s/p roux-en-y gastric bypass:
- nausea and vomiting, intermittent abodminal pain
- AXR shows dilated SB
Small bowel obstruction
| - Surgical emergency
155
Why is SBO s/p roux-en-y gastric bypass a surgical emergency?
Due to the high risk of small bowel herniation, strangulation, infarction and subsequent necrosis.
- Tx: surgical exploration
156
- these operations are no longer done
- a/w liver cirrhosis, kidney stones, and osteoporosis (decreased calcium)
- need to correct these patients and perform roux-en-y gastric bypass if encountered
jejunoileal bypass
157
- can occur after gastrectomy or after vagotomy and pyloroplasty
- occurs form rapid entering of carbohydrates into the small bowel.
- can almost always be treated medically (and dietary changes)
Dumping syndrome
158
2 phases of dumping syndrome
- Hyperosmotic load causes fluid shift into bowel (hypotension, diarrhea, dizziness)
- hypoglycemia from reactive increase in insulin and decrease in glucose (2nd phase rarely occurs)
159
Tx: dumping syndrome
Small, low-fat, low-carb, high-protein meals; no liquids with meals, no lying down after meals; octreotide
160
Surgical options for dumping syndrome (Rarely needed)
- Conversion of Billroth 1 or Billroth 2 to Roux-en-y gastrojejunostomy
- Operations to increase gastric reservoir (jejunal pouch) or increased emptying time (Reversed jejunal loop)
161
postprandial epigastric pain associated with n/v; pain not relieved with vomiting
Alkaline reflux gastritis
162
Dx / Tx: alkaline reflux gastritis
Dx: evidence of bile reflux into the stomach; histologic evidence of gastritis
Tx: PPI, cholestyramine, metoclopramide
163
Surgical options for alkaline reflux gastritis
Conversion of Billroth 1 or Billroth 2 to Roux-en-Y gastrojejunostomy with afferent limb 60 cm distal to gastro jejunostomy
164
- Delayed gastric emptying
| - Symptoms: n/v, pain, early satiety
Chronic gastric atony
165
Chronic gastric atony:
| Dx / Tx / Surgical options
Dx: gastric emptying study
Tx: metoclopramide, prokinetics
Surgical option: near total gastrectomy with roux-en y
166
- Early satiety
| - Actually want this for gastric bypass patients
Small gastric remnant
167
Small gastric remnant:
| Dx / Tx / Surgical option
- Dx: EGD
- Tx: small meals
- Surgical option: jejunal pouch reconstruction
168
- With billroth 2 or roux-en-y; caused by poor motility
| - Symptoms: pain, steatorrhea (bacterial beconjugation of bile), B12 deficiency (bacteria use it up), malabsorption
Blind-loop syndrome
169
What causes blind-loop syndrome with billroth 2 or roux-en-y?
Caused by bacterial overgrowth (E coli, GNRs) from stasis in afferent limb
170
Dx: blind-loop syndrome
EGD of afferent limb with aspirate and culture for organisms
171
Tx: blind loop syndrome
Tetracycline and flagyl, metoclopramide to improve motility
172
Surgical option: blind-loop syndrome
Re-anastomosis with shorter (40-cm) afferent limb to relieve obstruction
173
- Symptoms of obstruction - n/v, abdominal pain
- Dx: UGI, EGD
- Tx: balloon dilation
- Surgical option: find site of obstruction and relieve it
Efferent-loop obstruction
174
- Secondary to non-conjugated bile salts in the colon (osmotic diarrhea)
- Causes by sustained postprandial organized MMCs
Post-vagotomy diarrhea
175
Tx / Surgical option: post-vagotomy diarrhea
Tx: cholestyramine, octreotide
Surgical option: reversed interposition jejunal graft
176
What causes post-vagotomy diarrhea?
Reversed interposition jejunal graft
177
Management: duodenal stump blow-out
Place lateral duodenostomy tube and drains
178
Potential PEG complications
Insertion into the liver or colon
