Fiser ABSITE Ch. 30 Stomach Flashcards
What is the stomach transit time?
3-4 hours
Where does peristalsis occur in the stomach?
only in the distal stomach
What are the branches of the Celiac trunk?
left gastric, common hepatic, splenic
Left gastroepiploic and short gastrics are branches of what artery?
splenic
What is the blood supply of the greater curvature of the stomach?
right and left gastroepiploics, short gastrics
What is the blood supply of the lesser curvature of the stomach?
right and left gastrics
The right gastric is a branch of what artery?
common hepatic
What is the blood supply of the pylorus?
gastroduodenal artery
What is the mucosa of the stomach lined with?
simple columnar epithelium
What is the first enzyme in proteolysis and what cell secretes it?
Pepsinogen, secreted by chief cells
What do the parietal cells secrete?
H+ and intrinsic factor
What 2 things do Brunner’s glands in the duodenum secrete?
pepsinogen and alkaline mucus
Antrectomy with gastroduodenal anastomosis?
Billroth I
Antrectomy with gastrojejunal anastomosis?
Billroth II
____ ulcer is a vascular malformation in the stomach
Dieulafoy’s
____ disease is mucous cell hyperplasia, increased rugal folds of the stomach.
Menetrier’s
What is the tx for gastric volvulus?
reductiona and Nissen
Associated with type II (paraesophageal) hernia _ Nausea without vomiting; severe pain.
Gastric volvulus
Where is the tear usually located in a Mallory-Weiss tear?
near lesser curvature of the stomach near GE junction
What is the result of a vagotomy
vagal denervation all forms increase liquid emptying -> vagally mediated receptive relaxation is removed, results in increased gastric pressure that accelerates liquid emptying
In complete vagotomy (truncal or selective) there is decreased emptying of solids. In highly selective vagotomy there is normal emptying of solids. Addition of what procedure to either results in increased solid emptying?
Pyloroplasty
What is the most common problem following vagotomy (30-50%)?
diarrhea
Upper GI bleed and having trouble localizing source with EGD. What can be done next?
tagged RBC scan
What is the biggest risk factor for rebleeding of an upper GI bleed at the time of EGD?
spurting blood vessel
In a pt with liver failure, what is the most likely source of an upper GI bleed?
esophageal varices
What is the tx for a bleeding esophageal varices?
EGD with sclerotherapy or TIPS, not OR
What location of duodenal ulcers usually perforate? what location bleed from GDA?
anterior ulcers perforate, posterior ulcers bleed from GDA
Describe the incision and closure of a Heineke-Mikulicz pyloroplasty.
longitudunal incision of the plyloric sphincter followed by a transverse closure
What is the most frequent complication of duodenal ulcers?
bleeding
The 1st surgical option for bleeding duodenal ulcer is duodenstomy and what? what if the pt has been on PPI therapy?
GDA ligation; truncal vagotomy and pyloroplasty
With GDA ligation for bleeding duodenal ulcer, it is important to avoid hitting what structure?
common bile duct
What is the initial treatment of choice for obstruction due to duodenal ulcer?
serial dilation
Pt on H-pump inhibitor develops a perforated duodenal ulcer. What is the best surgical option? what if they were not on H-pump inhibitor?
Graham patch and highly selective vagotomy; just do Graham patch and place on omeprazole
What is the test for Zollinger-Ellison Syndrome?
Secretin test results in high gastrin level
In Zollinger-Ellison syndrome, what size tumors can be enucleated?
Less than 2 cm
What is the most common location for gastric ulcers? and the most common cause?
lesser curvature; decreased mucosal defense (normal acid secretion)
Hemorrhage is associated with higher mortality in duodenal or gastric ulcers?
gastric
What location in the stomach is the bx for H. pylori taken?
antrum
List the locations of gastric ulcers types I-V
Type I - lesser curve along body of stomach; Type II - 2 ulcers, lesser curve and duodenal; Type III - pre pyloric; Type IV - lesser curve high along cardia of stomach; Type V - associated with NSAIDs
What is the timing after event for stress gastritis?
3-10 days after event
Chronic gastritis has types A and B what is their location and what are they associated with?
Type A (fundus) - associated with pernicious anemia, autoimmune disease; Type B (antral) - associated with H. pylori
Where are 40% of gastric cancers located?
antrum
What is the difference in the pain with gastric cancer vs gastric ulcer?
gastric ulcer pain is relived by eating but recurs 30 min later
What blood type is a risk factor for gastric cancer?
type A
What is Krukenberg tumor?
gastric cancer with mets to ovaries
What is Virchow’s nodes?
gastric cancer with metastases to supraclavicular nodes
What size margins in subtotal gastrectomy for gastric cancer?
5 cm
What is diffuse gastric cancer called?
linitis plastica
What is the surgical tx for linitis plastica?
total gastrectomy
In palliation for gastric cancer, proximal obstruction can be treated with what? and distal?
proximal can be stented, distal lesions can be bypassed with gastrojejunostomy
What is the most common benign gastric neoplasm? aka?
gastric leiomyomas, also called gist tumors
What is the chemotherapy agent and MOA for gastric leiomyomas?
Gleevec (tyrosine kinase inhibitor)
What is the proto-oncogene are most gastric leiomyomas positive for?
c-kit (CD117)
What route does gastric leiomyosarcoma spread?
hematogenous
What is the tx for mucosa associated lymphoid tissue lymphoma (MALT lymphoma)? and if it does not regress?
Triple therapy abx for H. pylori; CHOP
What are the surgical eligibility criteria for bariatric surgery?
BMI >40 kg or BMI >35 kg with coexisting comorbiditiies
What is the medical and surgical tx for dumping syndrome?
octreotide may be effective. Surgery is rarely needed but includes converting a billroth I or II to a roux-en-Y gastrojejunostomy. Or increasing the gastric reserve with a jejunal pouch or increasing emptying type with a reversed jejunal loop
What is the dietary tx for dumping syndrome?
small, low-fat, low-carb, increased-protein meals; no liquids with meals; no lying down after meals
What are two surgical options for treating dumping syndrome after gastrectomy?
conversion of billroth I or billroth II to Roux-en-Y gastrojejunostomy; operations to increase gastric reservoir (jejunal pouch) or increase emptying time (reversed jejunal loop)
After a gastrectomy there is postprandial epigastric pain associated with N/V; pain not relived with vomiting. Evidence of bile reflux into stomach and histologic evidence of gastritis. Dx?
Alkaline reflux gastritis
What are 3 medical options for the tx of alkaline reflux gastritis after gastrectomy?
H2 blockers, cholestyramine, metoclopramide
What is the surgical option for treating alkaline reflux gastritis after gastrectomy?
Conversion of Billroth I or Billroth II to Roux-en-Y gastrojejunostomy with afferent limb 60 cm distal to original gastrojejunostomy
In roux-en-y which limb is the roux limb? Which is the afferent limb?
The roux limb goes from the gastrojejunostomy to the jejunojenuostomy. The afferent limb is the portion of duodenum and jejunum feeding the jejunojenunostomy.
What is the cause of roux stasis?
stasis of chyme in Roux limb due to loss of jejunal motility.
How do you dx Roux stasis?
EGD, emptying studies
What are 2 treatment options for Roux stasis?
metoclopramide/prokinetics; shorten Roux limb to 40 cm
What is caused by delayed gastric emptying after vagotomy?
chronic gastric atony
What is the surgical treatment for chronic gastric atony after gastrecomy?
near total gastrectomy with Roux-en-Y
What is the surgical option for small gastric remnant and early satiety after gastrectomy?
jejunal pouch reconstruction
After Billroth II or Roux-en-Y, symptoms include pain, diarrhea, malabsorption, B12 deficiency, steatorrhea. Caused by bacterial overgrowth and stasis in affarent limb.
Blind-loop syndrome
What is the medical and surgical treatment options for blind-loop syndrome?
tetracycline, Flagyl, metoclopramide; reanastomosis with shorter (40 cm) afferent limb
