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MBBS Surgery > Gastro > Flashcards

Gastro Flashcards

1
Q

Gastric CA RF

A

Modifiable

  • lifestyle: diet (preserved, smoke, nitrosamine), smoking
  • low SES
  • chronic gastritis, prev H pylori, barrett esophagus
  • prev OGD: polyp
  • prev stomach lymphoma
  • smoking
  • obesity
  • atrophic gastritis
  • pernicious anemia
  • Menetrier dz (hypertrophic gastropathy)

Non modifiable

  • age >50
  • gender: males
  • previous gastric resection (partial gastrectomy with bile reflux)
  • type A blood
  • family history
  • familial diffuse gastric cancer (e-cadherin, CDH 1)
  • FAP (Apc gene), HNPCC/ Lynch syndrome, BRCA1/2, PJS, Li-Fraumeni syndrome
  • common variable immune deficiency (CVID)

protective factors: aspirin, fresh fruits/ vegetables, vit C

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2
Q

Forrest classification

A 
Acute hemorrhage
Ia: spurting
Ib oozing
Signs of recent hemorrhage
IIa: non bleeding visible vessel
IIb: adherent clot
IIc: flat pigmented spot
no active bleed:
III: clean ulcer base
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3
Q

Prognostication for acute UGI bleed

A 
Rockall
Blatchford
AIMS 65
- Albumin <30
- INR >1.5
- Mental state GCS<14
- SBP <90
- age >65
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4
Q

CLO positive?

  • treatment of H pylori
  • test for eradication
A

Clostridium like organism: urease producing org that cleaves urea to ammonia and HCO3, decreasing the PH (yellow > red)

H pylori tx: TRIPLE THERAPY

  • amoxicillin (1g BD) 2w
  • clarithromycin (500mg BD) 2w
  • omeprazole 6w

sub amox for metronidazole only in penicillin allergic individuals

BISMUTH QUAD THERPAY

  • omeprazole 20mg BD
  • bismuth subsalicylate (120mg QDS)
  • 2 Abu: metronidazole 400mg BD + tetracycline 500mg QDS

ERADICATION TESTS

  • urea breath test
  • fecal antigen test
  • OGD >4w after completion of abx therapy (PPI withheld 1-2w prior to testing)
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5
Q

Indications for repeat endoscopy for gastric ulcers

A

surveillance endoscopy after 12w of antisecretory therapy if gastric ulcer with

  • symptoms despite med therapy
  • unclear etiology
  • giant ulcer >2cm
  • presented with bleeding
  • RF for gastric ca
  • first endoscopic shows suspicious ulcer
  • biopsies not taken in first endoscopy
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6
Q

Definition of orthostatic hypotension

A

a decrease in the systolic blood pressure of more than 20 mmHg and/or an increase in heart rate of 20 beats per minute when moving from recumbency to standing

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7
Q

ddx UGBIT

A 
variceal - GEJ
non variceal
- eso: mallory weiss
- gastric: PUD, gastritis, dieulafoy
- duodenum: duodenitis, aorto-enteric fistula
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8
Q

classes of shock

A

I: <15%
II: 15-30%: resting tachycardia, urine output 20-30, decreased pulse pressure, orthostatic hypotension
III: 30-40%: resting hypotension, anxious, urine 5-15, tachypnea
IV: >40%: negligible urine output, confused lethargic

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9
Q

Indications for emergency OGD

- role of OGD

A
  1. shock/ hemodynamic instability
  2. active BGIT (hemetemesis, fresh Malena)
  3. suspected variceal bleed

diagnostic - confirm UGBIT, identify source of bleed, biopsy (clo + 6 bites for gastric ulcer)

therapeutic: stop bleed
prognostic: forest classification

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10
Q

Types of gas used to scopes and differences

A

types of gas infused

  • CO2: need more vol to distend bowel but body can resorb
  • air (more nitrogen): not absorbed by mucosa, helps distend bowel with less volume, but more problems if perforated bowel - cannot be resorbed by body
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11
Q

complications of OGD

A 
Anesthetic risk
- sedation: resp depression
- CVS risk - ami, cva
Procedural related risk
- bleeding and perforation
- failure of endoscopic hemostasis
- failure of complete scope
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12
Q

Mgx of rebleeding of UGBIT

A

repeat OGD and endoscopic hemostasis

if fail:

  • surgery
  • radio: CTMA or mesenteric angiogram KIV embolisation
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13
Q

Prognostication for UGBIT

A

Rockall score
Blatchford scoring
AIMS 65: albumin <30, INR >1.5, Mental status <14, SBP<90, age>65

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14
Q

Hepatic venous pressure gradient

  • normal value
  • risk of variceal devt
  • risk of variceal bleed
A

n: 1-5mmhg
devt: >10mmhg
bleed/ ascites: >12

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15
Q

What is Zollinger Ellison syndrome?

  • how to diagnose
  • how to mgx?
A

hyper secretion of gastric acid due to a gastrinoma (rare cause of PUD)

triad of: recurrent PUD in unusual locations, massive gastric acid hyper secretion, gastrinoma

dx: high fasting serum gastrin levels with high acid secretion
mgx: PPI + sx

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16
Q

Endoscopic methods of stopping bleeding

A
  • injection of adrenaline 1:10,000 dilute to 10ml (cx: perforation, bleed, necrosis, arrhythmia)
  • coagulation (heater probe - thermal/ argon plasma)
  • haemostatic clipping (endocrine clip), hemospray

dual modality

17
Q

sx management of duodenal ulcers

A
  1. truncal vagotomy with pyloroplasty
  2. truncal vagotomy with antrectomy and bilroth 1/2
  3. highly selective vagotomy
18
Q

options for gastric ulcer bleeding refractory to endoscopic therapy

A

transcatheter arterial embolisation (TAE)

surgical: oversewing of bleeding vessels/ wedge excision of ulcer

DU posterior: GD artery

19
Q

Causes of pneumoperitoneum

A

suggestive of perforated viscus: GU, DU, appendix, GB

20
Q

sx mgx of perf gastric/ duodenal ulcer

A

Duodenal:
lap omental patch repair
peritoneal debridement/washout
H pylori eradication

Gastric:
wedge excision - TRO CA
if perf too big > gastrectomy (bilroth II) or serial patch/ mental patching

21
Q

mgx of gastric outlet obstruction

A

correct volume/ electolytes
NG suction
IV antisecretory agents

OGD
endoscopic hydrostatic balloon dilatation

surgical if recurrent/ refractory after endo balloon
- antrectomy with bilroth I/II reconstruction

22
Q

OGD classification of gastric cancer

A 
Borrmann classification
I: polypoid/ protruded type
II-V: depressed type
2 ulcerative
3 infiltrative ulcerative
4 diffuse infiltrative aka linitis plastica (signet ring cells)
5 can't be classified
23
Q

Classification of biopsy findings in gastric ca

A

Adenocarcinoma (Lauren classification)
- intestinal (expanding): elderly male, distal stomach, GOO, hematogenous spread
> papillary
> tubular
> mucinous
- diffuse (infiltrative): signet cell, younger, female, proximal stomach, transmural and lymphatic spread with early mets, CDH1 mutation (E-cadherin)

Non-adenoCA

  • gastric neuroendocrine tumour (carcinoid)
  • gastric lymphoma
  • gastrointestinal stomal tumour
24
Q

what are signet ring cells

A

large cytoplasmic mucin vacuoles and peripherally displaced crescent shaped nuclei

25
Q

what is carcinoid syndrome?

A

due to release of vasoactive substances into systemic circulation
Characterized by cutaneous flushing, sweating, bronchospasm, colicky abdominal pain, diarrhoea, right-sided cardiac valvular fibrosis

suggestive of mets, if localised in GIT should not have systemic effects due to first pass from liver

26
Q

What are carcinoids?

A

gastric neuroendocrine tumour
derived from: enterochromaffin like cells in gastric mucosa
due to: hypergastrinoma (Zollinger-Ellison syndrome, MEN 1)

look for carcinoid syn - mets

27
Q

What is gastric lymphoma

A

B cell lymphoma - extra nodal MALT type (mucosal Assoc lymphoid tissue)

  • lymphocytes in gastric mucosa
  • etiology: H pylori chronic gastritis, trisomy 3
28
Q

What is GIST?
how to tx
are they malignant?

A

gastrointestinal stromal tumour

from: interstitial cells of cajal
etiology: c-KIT (gain of function mutation), PDGFRA (plt derived growth factor receptor alpha) mutation

c-KIT positive (95%): treat with imatinib (Tyrosine kinase inhibitors)

3/4 benign
indicators of malignancy:
- size > 10cm
- mitotic index >5/10hpf
- site (extra gastric position)
29
Q

lab results of iron deficiency anemia

A

low ferritin, low serum fe, high transferrin, high TIBC

30
Q

examples of paraneoplastic syndromes

A
  • trousseau syndrome (migratory thrombophlebitis)
  • DVT
  • leser trelat sign (acute seborrheic keratosis)
31
Q

signs of peritoneal seeding of gastric cancer

A
  • ascites (peritoneal carinomatosis), may present as small bowel obstruction
  • sister Mary Joseph nodule
  • krukenburg tumour
  • fullness in pelvic cul-de-sac (blumer shelf) on DRE
32
Q

Classification of esophagogastric junction tumours (adenoCA)

A

Siewert classification
I: distal eso (1-5cm above gastric cardia)
II: 1cm above to 2cm below gastric cardia
III: subcardial, 2-5cm below gastric cardia

33
Q

Curative mgx of gastric ca

A

Early Ca: endoscopic mucosal resection or endoscopic submucosal dissection

patient optimisation: nutrition support
neoadjuvant chemo

  1. wide resection (>6cm margins): partial, subtotal and total gastrectomy
  2. resection of LN and involved structures (D2 lymphadenectomy)
  3. re-establish GI continuity (reconstruction: bilrothI Gastroduodenostomy)/II (gastrojejunostomy), roux en y)
  4. adjuvant chemo
34
Q

what is the difference between total, subtotal and partial gastrectomy

A

total: excision of whole stomach, 1st part duodenum, distal eso and all vessels (RGA, LGA, RGeA, LGeA, short gastric arteries)
subtotal: leaves proximal part of stomach for anastomosis to jejunum and has better residual reservoir function. keeps short gastric arteries
partial: distal stomach + RGA + RGeA

35
Q

Complications of gastrectomy

A

Early

  • bleed/ infection
  • injury to surrounding organs
  • anastomotic leak (d5-7)
  • duodenal stump blowout (d5-7)

Late

  • early satiety
  • dumping syndromes (early/ late)
  • nutritional deficiency (loss of intrinsic factor - b12, less gastric acid to convert Fe3 to Fe2, less iron absorption into terminal ileum
  • loop syndromes
  • retained antrum syndrome
  • intestinal hurry
  • biliary reflux into stomach
  • recurrence of gastric ca
36
Q

Gastric ca tumour markers

A

CEA and CA125

37
Q

Gastric cell types and secretions

A 
Parietal cells: HCL, intrinsic factor
Chief cells: pepsinogen, gastric lipase
G cells: Gastrin
ECL cells: histamine
Mucus neck cells: mucus and HCO3
D cells: somatostatin

antrum: G cells
body: parietal cells

38
Q

Evidence of trans-coelomic spread (peritoneal seeding)

A
  • ascites/ SBO (peritoneal carcinomatosis)
  • umbilical infiltration (sister Mary Joseph)
  • enlarged ovaries (krukenburg tumor)
    Fullness in pelvic cul-de-sac (blumer shelf)
39
Q

gene mutations in

  • HNPCC
  • FAP
  • PJS
  • Li-Fraumeni
A
  • HNPCC: DNA mismatch repair genes (MLH1, MSH2, MSH6, PMS2) or EPCAM gene
  • FAP: APC gene
  • PJS: STK1
  • Li-Fraumeni: TP53

MBBS Surgery (18 decks)

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