General - gastric Flashcards
What is a peptic ulcer?
Break in the lining of the GI tract, extending through to the muscularis mucosae layer of the bowel wall
Endoscopic diagnosis
Most often located on the lesser curvature of the proximal stomach or the first part of the duodenum
List risk factors for peptic ulcer disease
NSAIDs
H. pylori
Smoking
Corticosteroid use
Massive physiological stress
Describe the pathophysiology of peptic ulcers
Normal gastrointestinal mucosa is protected by numerous defensive mechanisms – surface mucous secretion & HCO3- ion release
In PUD – imbalance between factors that protect the mucosa of the stomach and duodenum & factors that cause damage to it
List clinical features of PUD
Epigastric/retrosternal pain
Nausea, bloating, post-prandial discomfort, early satiety
Presentation with complications – bleeding, perforation, gastric outlet obstruction
Zollinger-ellison syndrome
Triad of:
1) Severe peptic ulcer disease
2) Gastric acid hypersecretion
3) Gastrinoma
Characteristic finding = fasting gastrin level of >1000 pg/ml
PUD investigations
FBC
Non-invasive H. pylori testing – C13 urea breath test, serum antibodies to H. pylori and stool antigen test
OGD required in red flag symptoms, older patients or those with ongoing symptoms
Endoscopy – any peptic ulceration seen can be biopsied which will be sent for histology & for rapid urease test
PUD conservative management
Any patient with suspected/confirmed PUD should be given lifestyle advice to reduce symptoms – smoking cessation, weight loss & reduction in alcohol consumption, avoidance of NSAIDs
PPI for 4-8 weeks to reduce acid production
Patients with a positive H. pylori should be started on triple therapy
Persistence of symptoms post-PPI +/- eradication therapy warrants further work-up – urgent OGD to exclude any malignancy
PUD surgical management
Rare
Severe/relapsing disease – partial gastrectomy/selective vagotomy
PUD complications
Perforation
Haemorrhage
Pyloric stenosis
Gastric cancer
5th most common cancer globally, mostly due to patients presenting with advanced disease
Majority arise from the gastric mucosa as adenocarcinomas
Gastric cancer risk factors
Male
H pylori infection
Increasing age
Smoking
Alcohol consumption
Gastric cancer clinical features
Dyspepsia, dysphagia, early satiety, vomiting or melaena
Examination – epigastric mass may be felt in late stage disease, Troisier sign (palpable left supraclavicular node)
Metastatic disease – hepatomegaly, ascites, jaundice or acanthosis nigricans (hyperpigmentation of the skin creases)
Gastric cancer investigations
Lab tests – urgent bloods: FBC, LFTs
Imaging – urgent upper GI endoscopy
Biopsies should be sent for:
- Histology: classification and grading of any neoplasia
- CLO test: presence of H. pylori
- HER2/neu protein expression: allow targeted monoclonal therapies if present
CT chest-abdomen-pelvis and a staging laparoscopy
Gastric cancer curative treatment
Mainstay of curative treatment is surgery
- Proximal gastric cancers = total gastrectomy
- Distal gastric cancers = subtotal gastrectomy
Most commonly used method in reconstructing the alimentary anatomy is the Roux-en-Y reconstruction as it gives the best functional result
Patients with early tumours may be offered an endoscopic mucosal resection
Gastrectomy complications
Death
Anastomotic leak
Re-operation
Dumping syndrome
Vitamin B12 deficiency
Gastric cancers palliative management
Most patients will only be offered palliative care due to the extent of disease at time of presentation
- Chemotherapy
- Best supportive care
- Stenting
Palliative surgery can be used when stenting fails/is not available
Gastric cancers complications
Gastric outlet obstruction
Iron-deficiency anaemia
Perforation
Malnutrition
Hiatus hernia
Describes the protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus (typically the stomach)
Hiatus hernia classification
Classified into two subtypes:
- Sliding hiatus hernia – GOJ, the abdominal part of the oesophagus and frequently the cardia of the stomach move or slide upwards through the diaphragmatic hiatus into the thorax
- Rolling/para-oesophageal hernia – upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ, which creates a bubble of stomach in the thorax (true hernia with a peritoneal sac)
Hiatus hernia risk factors
Age
Increasing intrabdominal pressures
Increased size of diaphragmatic hiatus
Pregnancy, obesity & ascites
Hiatus hernias clinical features
Vast majority are completely asymptomatic
GORD symptoms – burning epigastric pain, made worse by lying flat
Other symptoms – vomiting, weight loss, bleeding, anaemia, hiccups, palpitations, swallowing difficulties
In large hiatus hernia – bowel sounds may be auscultated within the chest
Hiatus hernia investigations
Oesophagogastroduodenoscopy = gold standard investigation, showing upward displacement of the GOJ
Can also be diagnosed incidentally either on a CT or MRI
Hiatus hernia conservative management
PPI
Weight loss, alteration of diet, sleeping with head of the bed raised
Smoking cessation, reduction in alcohol intake should be advised
Hiatus hernia surgical management
Indicated when:
- Remaining symptomatic
- Increased risk of strangulation/volvulus
- Nutritional failure
Two aspects of surgery:
1) Cruroplasty – hernia is reduced from the thorax into the abdomen & the hiatus reapproximated to the appropriate size
2) Fundoplication – gastric fundus is wrapped around the lower oesophagus and stitched in place
Hiatus hernia surgery complications
Recurrence of the hernia
Abdominal bloating
Dysphagia
Fundal necrosis
Hiatus hernia complications
Prone to incarceration and strangulation
Gastric volvulus can occur – stomach twists on itself by 180 degrees, present with Borchardt’s triad:
1) Severe epigastric pain
2) Retching without vomiting
3) Inability to pass an NG tube
