Gastric Adeno Carcinoma And Peptic Ulcer

Question 1

Zollinger Ellison syndrome

Answer 1

Hypergastrinemia: Gastrinomas are commonly seen
in the small intestine or pancreas o increased gastrin secretion o leads to massive secretion of acid and pepsin.
x Increased acid secretion o inactivation of pancreatic enzymes and bile salts o leading to malabsorption and diarrhea. Stomach shows increase in the number of parietal cells.
x Multiple and recurrent peptic ulcers in the duodenum, stomach and/or jejunum.

Question 2

Meckel diverticulum

Answer 2

Meckel diverticulum is the most common type of true diverticula of GI tract and occurs in the ileum.
Meckel diverticulitis: Symptoms mimic acute appendicitis. Rule of 2s: It is used to remember characteristics of Meckel diverticulae.
x Occur in about 2% of the population.
x Generally present within 2 feet of the ileocecal valve.
x ~ 2 inches long (varies from 2 to 15 cm)

Two times common in males than in females.
x Most often symptomatic by age 2.

MORPHOLOGY
x Single and always lies on the antimesenteric side of the bowel (Fig. 18.13).
x True diverticulum: The wall consists of mucosa, submucosa and muscularis propria and has its own blood supply.
x Lining of epithelium resembles that of normal small intes- tine, but ectopic pancreatic or gastric tissue is common. Heterotopic gastric mucosa may lead to peptic ulceration of adjacent small intestinal mucosa and present with bleeding, or perforation.
Complications

Meckel diverticulum: Bleeding is the most common complication.
x Severe hemorrhage: Develops if the diverticulum con- tains acid-secreting gastric epithelium with peptic ulceration o maroon colored painless bleeding per rectum.
x Meckel’s diverticulitis: Develops secondary to peptic ulcerations or obstruction of the orifice of the diverticula and symptoms appear similar to acute appendicitis.
x Intestinal obstruction: Results from intussusception, volvulus, adhesions or the presence of a tumor or ectopic or enteroliths.

Question 3

Peptic, ulcer, location

Answer 3

Duodenum is to stomach=4:1

Question 4

Damaging forces of stomach

Answer 4

Hydrochloric acid
Pepsinogen

Question 5

Defensive forces of stomach

Answer 5

1 mucus
2 bicarbonate
3 intra cellular tight junctions
4 regeneration of epithelium
5 Prostaglandins
6 adequate oxygen and nutrients
7 removal of toxic metabolic byproducts

Question 6

Pathogenesis of peptic ulcer

Answer 6

1 H pylori
2 nsaids
3 cigarette smoking
4 alcohol
5 stress
Y Zollinger Ellison syndrome
7 increase in Cortico steroids

Question 7

Kissing ulcers

Answer 7

Anterior and posterior wall of duodenum

Question 8

Most common malignancy of stomach

Answer 8

Adenocarcinoma

Question 9

Dietary carcinogens

Answer 9

Nitroso and benzo compounds
Salt and smoking food
Preservatives

Question 10

Cancer reduction foods

Answer 10

Green leafy vegetables
Citrus foods
Antioxidant
Fibre

Question 11

Familial gastric cancer gene

Answer 11

Loss of function of tumor suppressor gene CDH1
Cell adhesion protein E cadherin reduce

Question 12

Sporadic intestinal type genes involved

Answer 12

Beta catenin
TP53
Bax
Wnt pathway

Question 13

Signet ring cells present in intestinal/diffuse type

Answer 13

Diffuse type

Question 14

Better prognosis: intestinal / diffuse

Answer 14

Intestinal

Question 15

Linitis plastica

Answer 15

Leather bottle like appearance -
Flattened rugal folds, thickening of the wall
Loss of distensibilitynarrou lumen seen in stomach cancer
In diffuse or infiltrative adenocarcinoma

Question 16

Symptoms of stomach cancer

Answer 16

Heart burn
Stomach pain
Blood in stool
Bloating
Loss of appetite
Indigestion

Question 17

Types of spread of gastric can er

Answer 17

Direct)mc)→ submucosa → muscularis → serosa
Lymph node → left supra clavicular node C Virchow ) node – sister Mary Joseph node
Hematogenous spread
Visceral → krukenberg tumor

Question 18

Sister Mary Joseph node

Answer 18

Palpable lymph mode at umbilical region
Shows advanced stage of cancer.

Question 19

Lauren classification of Aden carcinoma

Answer 19

1. Intestinal type → with intestinal metaplasia
2. Diffuse or infiltrating → linitis plastica

Question 20

Based on macroscopic growth pattern, types of adenocarcinoma

Answer 20

1. Exophytic
2. Flat / depressed
3. Excavated with deep erosive crater

Question 21

Based on depth of invasion, types of Aden carcinoma

Answer 21

1. Early gastric carcinoma:- limited to mucosa and submucosa
2. Advanced gastric carcinoma I- extend below submucosa into muscular layer

Question 22

Site of gastric carcinoma

Answer 22

1.pylorus,antrum :- 60%
2.cardia: 25%
3. Body & fundus:- 15 - 25%
Lesser curvature more often involved than greater curvature

Question 23

How signet sing cell are formed

Answer 23

Loss of e-cadherin which makes them dis cohesive and cannot form glands
Abundant mucin pushes nucleus to periphery

Question 24

Metastasis to ovary

Answer 24

Krukenberg tumor

Question 25

Troiser sign

Answer 25

Palpable left supra clavicular lymph node

Question 26

Trousseaus syndrome

Answer 26

Migrating thrombophlebitis

Question 27

How chronic H pylori infection cause carcinoma stomach

Answer 27

Chronic H pylori infection -
Gastric atrophy-
Decrease acid secretion-
Promote bacterial growth which convert nitrate to nitrite(carcinogenic)
Mucosal atrophy-
Intestinal metaplasia
Carcinoma stomach

Question 28

In familial gastric cancer there is loss of function mutation in

Answer 28

CDH1 tumor suppressor genes

Question 29

In sporadic gastric carcinoma cases there is

Answer 29

Loss of function in CDH1, p53
Increased in WNT pathway and beta catenin
BRCA 2 mutation