hematemesis Flashcards
What lies anterior to the surface of the stomach?
left lateral segment of the liver
What attaches the stomach to the transverse colon?
gastrocolic omentum
What does the gastro-hepatic ligament attach?
the lesser omentum attaches the lesser curvature to the liver
after subtotal gastrectomy where the right & left gastric arteries & the right & left gstro-epiploic arteries are ligated, what supplies the rest of the stomach?
short gastric arteries
What is the main stimulus for gastrin secretion?
meals -> gastric distention
stimulates secretion of HCL
pH <3 inhibits its secretion, alkaline environment stimulates its secretion
somatostatin inhibits it
What should u ask in history taking of a patient presenting with hematemesis with suspected gastric cancer?
- weight loss
- decreased food intake
- anorexia
- early satiety
- abdominal pain
- nausea & vomiting
- bloating
- dysphagia
What will be found on physical examination of patient that has suspected gastric cancer?
- chronic occult blood loss
- Virchow’s node (left supraclavicular)
- abdominal mass
- Krukenberg’s tumor of the ovary
- Sister Joseph’s nodule (umbilical mass in subcutaneous tissue)
- malignant ascites
- Blumer shelf (pouch of douglas)
- Trousseau’s syndrome (thrombophlebitis)
- Acanthosis nigricans
- peripheral neuropathy
- cachexia
What is the first step that should be preformed in order to diagnose the cause of hematemesis?
1- esophagogastrodudonoscopy + biopsy
if afraid of obstruction you can start with upper abdominal series
2- CT -> to detect metastases
last step before operation -> laparoscopy
What are the 2 modules of investigation that we can use to diagnose & take a biopsy?
EGD
EUS
What are the 3 most common primary malignant gastric neoplasms?
adenocarcinoma 95%
lymphoma 4%
malignant GIST 1%
Hematogenous metastasis to the stomach is more likely to occur from?
Melanoma
Breast
Who is more commonly diagnosed with gastric cancer?
elderly
if young -> diffuse, large, aggressive, poorly differentiated, LINTIS PLASTICA
What is the pathogenesis of gastric cancer?
aggregating factor (ex H.pylori) -> chronic superficial gastritis -> atrophic gastritis -> intestinal metaplasia -> dysplasia -> cancer
an E-cadherin gene is associated with?
LINTIS PLASTICA
(diffuse gastric cancer)
consider prophylactic total gastrectomy
Menetrier disease is a risk factor for?
adenocarcinoma
What is the gold standard for monitoring patients with hereditary risk of developing gastric carcinoma?
EGD
What are the types of presentation of gastric cancer?
- polypoid -> doesn’t ulcerate
- fungating -> can ulcerate
- ulcerative -> ulcer within mass
- scirrhous -> linitis plastica (entire thickness & large area)
Where does the majority of gastric cancers develop?
distal stomach
What is the classification of gastric polyps?
- BENIGN GASTRIC POLYPS:
neoplastic (adenoma) or nonneoplastic (hyperplastic, inflammatory, or hamartomatous) - LARGE HYPERPLASTIC POLYPS (>2cm):
harbors dysplasia or carcinoma in situ
associated with chronic inflammation - GASTRIC ADENOMAS
premalignant
patients with FAP (familial adenomatous polyposis) are at 10 times higher risk of developing adenocarcinoma
needs screening (EGD) - POLYPS >1cm
remove to confirm diagnosis & eliminate risk of malignant degeneration
if associated with FAP -> periodic screening - FUNDIC GLAND POLYPS
benign lesions associated with PPI use
doesn’t require excision, regular surveillance, or cessation of therapy
What is the most common precursor for intestinal subtype gastric cancer?
ATROPHIC GASTRITIS
more in older age groups
H. pylori is involved in its pathogenesis
What is the only curative treatment for gastric cancer?
RADICAL SUBTOTAL GASTRECTOMY -> R0 resection
proximal, distal, & radial margins should be atleast 5cm (freeze & send to pathology)
EN-BLOC RESECTION
How many lymph nodes are required for proper staging of gastric cancer?
15 or more
How does the reconstruction of the bowel continuity occur after the radical subtotal gastrectomy?
Billroth II OR Roux-en-Y Gastro-jejunostomy
How is proximal gastric cancer treated?
total gastrectomy
When is neoadjuvant therapy indicated?
in Stage 3 & above
- 5-FU, Cisplatin & docetaxel
Radiotherapy is useful in which stages?
stage II & III
When is endoscopic mucosal resection (EMR) indicated?
curative in early gastric cancer
- in differentiated mucosal cancer <2cm without ulceration, is node negative, & confined to mucosa (seen by EUS)
What is the prognosis of gastric cancer?
Stage I -> 75%
Stage II -> 50%
Stage III -> 25%
What is the most common site for primary GI lymphoma & what is the most common type?
STOMACH in the antrum
95% is non-hodgkin
responds well to chemotherapy
what is the cause behind low-grade MALT?
chronic gastritis from H.pylori
How does high grade MALToma present?
like gastric cancer:
- weight loss
- decreased food intake
- anorexia
- early satiety
- abdominal pain
- nausea & vomiting
- bloating
- dysphagia
How is MALToma treated?
chemotherapy & radiotherapy
CHOP
cyclophosphamide, hydroxydaunomycin, oncovin (vincristine), prednisone
Which tumor arises from the interstitial cells of Cajal?
GIST
- epithelial cell stromal type more common than cellular spindle type
- any lesion >1cm behaves like malignancy
Which type of gastric cancer expresses C-KIT?
GIST
How is GIST treated?
- leiomyoma -> enucleation
- GIST or leiomyosarcoma -> resection with negative margins
- Imatinib -> chemo of choice
What type of gastric cancer arises from ECL cells?
GASTRIC CARCINOID (neuroendocrine tumor) Somatostatin analogs are used to control symptoms (octreotide, sandostatin)
how is leiomyoma managed?
- <2cm or asymptomatic (benign) -> obserce or enucleate
- >2cm or symptomatic (malignant) -> wedge resection
