Stomach Flashcards
1
Q
Part of the stomach important for HCl secretion
A
Cardia
2
Q
Part of the stomach with a crucial role in capacitance by undergoing receptive relaxation
A
Fundus
3
Q
Part of the stomach spanning the cardiac orifice to the incisura angularis
A
Body
4
Q
Part of the stomach spanning the incisura angularis to the Pylorus
A
Antrum
5
Q
Site of the autonomic pacemaker responsible for initiating gastric motor activity
A
Fundus
6
Q
Blood supply of the Lesser curvature and roots from the aorta
A
Celiac trunk > Left gastric artery
Celiac trunk > Common hepatic artery > Right gastric artery
7
Q
Blood supply to Greater curvature and roots from the aorta
A
Celiac trunk > Splenic artery > Left gastroepiploic artery
Celiac trunk > Common hepatic artery > Gastroduodenal artery > Right gastroepiploic artery
8
Q
Blood supply of the fundus
A
Celiac trunk > Splenic artery > Short gastric arteries
9
Q
Venous drainage of the Right side of the stomach
A
Right and Left gastric veins > Portal vein
Right gastroepiploic vein > Superior mesenteric vein > Portal vein
10
Q
Venous drainage of the Left side of the stomach
A
Short gastric vein and Left gastroepiploic vein > Splenic vein > Portal vein
11
Q
4 sites of lymphatic drainage of the stomach
A
1) Superior gastric LN
2) Supra-pyloric LN
3) Infra-pyloric LN
4) Pancreaticosplenic LN
12
Q
Anterior surface of the stomach is innervated by:
A
Parasympathetic:
Left vagal trunk > Hepatic branch
13
Q
Posterior surface of the stomach is innervated by:
A
Parasympathetic:
Right vagal trunk > Celiac branch
14
Q
Sympathetic innervation of the stomach
A
Celiac plexus (T5-T10)
15
Q
Cell in the gastric lining responsible for acid secretion via H+/K-ATPase pump (proton pump)
A
Parietal cell (Oxyntic cells)
16
Q
Hormones that stimulate parietal cell acid secretion
A
Acetylcholine
Gastrin
Histamine
17
Q
Up to how many arteries can be ligated during gastric surgery
A
2
Stomach has a rich anastomotic vascular network,
18
Q
Nerve that supplies the posterior fundus, and is easily missed during highly selective or truncal vagotomy
A
Criminal nerve of Grassi
19
Q
Layers of the stomach lining (innermost to outermost)
A
Mucosa > Submucosa > Muscularis propria > Serosa
20
Q
Layer of the stomach lining that contains the Meissner autonomic plexus
A
Submucosa
21
Q
Specific layers of the Muscularis Propria
A
Inner Oblique layer
Middle Circular layer
Outer Longitudinal layer
22
Q
Interstitial pacemaker cells of the stomach. Found in the muscularis propria
A
Interstitial cells of Cajal
23
Q
Layer of the stomach lining that contains the Auerbach Myenteric plexus
A
Muscularis Propria
24
Q
Stomach cell that that secretes Pepsinogen, Gastric lipase, and Leptin
A
Chief (Zympgenic) cells
25
Stomach cell that that secretes Histamine
Enterochromaffin-like cells
26
Stomach cell that that secretes Serotonin
Enterochromaffin cells
27
Stomach cell that that contains bicarbonate and serves as a protective mucus later
Surface mucous cells
28
Stomach cell that that secretes Gastrin
G-cells
29
Stomach cell that that secretes Somatostatin
D-cells
30
Hormone that inhibits Acid secretion
Somatostatin
SomatoSTOP acid secretion
31
Most serious complication of EGD
Esophageal perforation
32
Gold standard diagnostic test for H. Pylori
Histologic examination of antral mucosal biopsy
33
Gold standard test to confirm H. Pylori eradication
Urease breath test
34
Imbalance in acid and mucosal defense that leads to Focal defects in the gastric/duodenal mucosa that extend into the submucosa or deeper
Peptic Ulcer Disease
35
Peptic Ulcer Classification:
Type I: Antral + Lesser curvature (most common)
Type II: Antral + Duodenal
Type III: Pre-pyloric
Type IV: Upper lesser curvature
Type V: NSAIDs induced
36
Peptic Ulcer Types that are associated with Acid Hypersecretion
Type II (Antrum + Duodenum)
Type III (Pre-pyloric)
37
Peptic Ulcer Types that are associated with Normal or Low acid output
Type I (Antral + Lesser curvature)
Type IV (Upper lesser curvature)
38
Gastric vs Duodenal Ulcer
Usual location
Gastric ulcer: Incisura
Duodenal ulcer: D1 (w/in 3cm from pylorus)
39
Gastric vs Duodenal Ulcer
Age group
Gastric ulcer: Older age group
Duodenal ulcer: younger age group
40
Gastric vs Duodenal Ulcer
Sex Predilection
Gastric ulcer: M1:F1
Duodenal ulcer:
M2:F1
41
Gastric vs Duodenal Ulcer
Pain in relation to meals
Gastric ulcer: Pain during meals, worsens with food
Duodenal ulcer: Pain 2-3 hours after meal; relieved by food
42
Gastric vs Duodenal Ulcer
Pain in relation to sleep
Gastric ulcer: does not awaken patient
Duodenal ulcer: Awakens patient from sleep
43
Gastric vs Duodenal Ulcer:
Risk of malignancy
Gastric ulcer: Common (should be biopsied)
Duodenal ulcer: Extremely rare
44
Gastric vs Duodenal Ulcer
Usual etiology
BOTH Gastric and Duodenal ulcer: NSAIDs/H. Pylori infection
45
Gastric vs Duodenal Ulcer
Pathophysiology
Gastric ulcer: Decreased gastric cytoprotection; Normal or decreased Gastric acid production
Duodenal ulcer: increased gastric acid production, decreased bicarbonate secretion
46
Gastric vs Duodenal Ulcer
Goal of management
Gastric ulcer: Gastrectomy, biopsy
Duodenal ulcer: Decrease acid production (vagotomy)
47
Complications of both Gastric and Duodenal ulcers
- Melena
- Coffee ground emesis
- Penetrating ulcer
- Perforation
- Gastric outlet obstruction
48
First line management for peptic ulcer disease
Empiric treatment with Proton pump inhibitors
49
Indications for EGD in PUD
- Patients >45 yo
- With alarm symptoms: weight loss, bleeding, recurrent vomiting, anemia, dysphagia
50
Indications for Surgery in PUD
- Persistent bleeding after endoscopic therapy
- Significant hemorrhage > 4 u in 24 hrs
- Elderly with comorbidities
- Ulcers at posterior duodenal bulb, high lesser curvature
- High risk of rebleeding on endoscopic findings
51
Classification system for Endoscopic findings and rebleeding risk in PUD
Forrest Classification
52
53
Forrest Classification of Rebleeding
Grade Ia - active pulsatile bleeding
Grade Ib - active nonpulsatile bleeding
Grade IIa - nonbleeding, visible vessel
Grade IIb - adherent clot
Grade IIc - black dot
Grade III - no signs of recent bleeding
53
Presenting symptom of gastric outlet obstruction (complication of PUD)
Nonbilious vomiting
leads to profound hypokalemic, hypochloremic metabolic alkalosis
54
H. pylori eradication:
PPI Triple therapy
OCA
Omeprazole (PPI)
Clarithromycin 500mg BID
Amoxicillin 1000mg BID
10-14 days
Repeat EGD w/wo biopsy in 6-8 weeks
55
Surgery for gastric outlet obstruction related to PUD
Vagotomy and Antrectomy (V&A)
Vagotomy and Pyloroplasty
56
Surgical management of Gastric/Duodenal PUD if with:
Bleeding
Gastric: Oversew and Biopsy, Vagotomy + Drainage, Distal gastrectomy
Duodenal: Oversew,
Oversew + Drainage,
V&A
57
Surgical management of Gastric/Duodenal PUD if with:
Perforation
Gastric:
1. Biopsy and patch
2. Wedge excision, V&D
3. Distal gastrectomy
Duodenal:
1. Patch
2. Patch + Highly selective vagotomy
3. Patch + V&D
58
Surgical management of Gastric/Duodenal PUD if with:
Obstruction
Gastric:
1. Biopsy + Highly selective vagotomy + Gastrojejunostomy
Duodenal:
1. Highly selective vagotomy + Gastrojejunostomy
59
Most common complication of PUD
Bleeding
- Melena
- Hematemesis
- Hematochezia
60
Complication of PUD that presents as an Acute Abdomen
Perforation
61
Complication of PUD that presents as triad of Abdominal pain, Distention, and Vomiting
Gastric Outlet Obstruction
62
Gastric Outlet obstruction in PUD can lead to the following electrolyte imbalance
Hypokalemic Hypochloremic Metabolic Alkalosis
63
Perforation in Duodenal and Gastric ulcer: usual involvement
Gastric ulcer: Left hepatic lobe
Duodenal Ulcer: Pancreas (posteriorly)
64
Initial nonoperative management for Bleeding in PUD
- Sliding NPO
- IV PPI
- Endoscopic treatment: Epinephrine or cautery
65
Indications for Surgery in PUD Bleeding
- Persistent bleeding after endoscopic management
- Significant hemorrhage (>4 u/24h)
- Elderly with comorbidities
- Ulcers in the Posterior duodenal bulb or Gastric lesser curvature
- High chance of rebleeding (enlarged vessel)
66
Surgical management in Perforation of PUD
- Emergency Exploration
- Omental Patch + Biopsy
67
Surgical Management in Gastric Outlet Obstruction in PUD
- Emergency Exploration
- Selective Vagotomy + Gastrojejunostomy + Biopsy
68
Post Gastrectomy syndrome caused by destruction of the pyloric sphincter --causing abrupt delivery of hyperosmolar load (chyme) to the small intestines
Dumping Syndrome
(e.g. post gastrojejunostomies, pyloroplasty)
69
Classifications of Dumping Syndrome
Early Dumping (15-30 min postprandial)
Late dumping (2-3 hrs)
70
Early dumping syndrome presentation
Shock-like symptoms (sweating, tachycardia, lightheadedness) followed by Diarrhea
71
Late Dumping syndrome presentation
Hypoglycemic symptoms (Hunger, shaking, dizziness, sweating)
- Hyperinsulinemia causing reactive hypoglycemia
72
Nonoperative management of Early and Late dumping syndrome
Early dumping: Octreotide, Saline, Recumbency
Late dumping: Glucose administration, Alpha-glucosidase inhibitors
73
Surgical management of Early and Late dumping syndrome
Conversion to Roux-en-Y Anastomosis
73
Postgastrectomy syndrome most associated with Billroth II Gastrojejunostomies
Alkaline Reflux Gastroenteritis
74
Triad of Alkaline Reflux Gastroenteritis
1. Constant epigastric pain (no association with meals)
2. Nausea
3. Bilious emesis (no relief of pain)
Billroth II --> Bilious Emesis
75
Endoscopic findings of Alkaline Reflux Gastroenteritis
Inflamed, beefy red, friable gastric mucosa (liquefactive necrosis)
76
Surgical management of Alkaline Reflux Gastroenteritis
Creation of a Long limb Roux-en-Y Gastrojejunostomy
77
Postgastrectomy syndrome that results from functional obstruction and altered motility in gastric remnant due to disruption of propagation of pacesetter potentials
in the Roux limb from the proximal duodenum
Roux Stasis syndrome
78
Clinical presentation of Roux Stasis syndrome
Abdominal Pain
Nausea and Vomiting
Aggravated by eating
79
Upper GI Series findings for Roux Stasis syndrome
Delayed gastric emptying
80
Management of Roux stasis syndrome (non-operative and operative)
Non-operative: Promotility agents
Operative: Near-total or Total gastrectomy to remove atonic stomach
81
A surgical Afferent and Efferent loop is formed during what type of Gastrojejunostomy
Billroth II
82
Afferent Loop syndrome pathophysiology
- Duodenal stump blowout
- Acute bowel kink
- Volvulus
- Internal herniation
83
Efferent loop pathophysiology
- Intermittent obstruction of efferent limb of gastrojejunostomy
- internal herniation of distal intestine behind efferent limb
84
Manifestations of Afferent Loop syndrome
Acute form: Severe abdominal pain with nonbilious emesis
Chronic form: RUQ pain with bilious emesis not mixed with food
85
Bacterial overgrowth and bile salt deconjugation may cause the following condition in afferent loop syndrome
Blind loop syndrome
- Stateorrhea
- Vit B12 deficiency
- Vit B9 (folate) deficiency
- Iron deficiency
86
Manifestations of Efferent Loop syndrome
Abdominal pain and bilious emesis 8mos to years after surgery
87
Diagnosis of Afferent Limb syndrome
CT Scan showing dilated Afferent limb
88
Diagnosis of Efferent limb syndrome
Upper GI Series showing small bowel obstruction
89
Management of Afferent syndrome
- Conversion to Roux-en-Y anastomosis OR
- Creation of jejunojejunostomy
90
Management of Efferent syndrome
Prompt surgical intervention of internal hernia
91
Premalignant lesion of the stomach associated with protein-losing enteropathy and hypocholrydia. Patho: Large rugal folds sparing the antrum
Menetrier Disease (Hypertrophic Gastropathy)
92
An Elderly woman, known case of SLE, presents with chronic GI Blood loss. Endoscopy of the stomach shows dilated mucosal blood vessels in distal stomach and portal gastropathy
Watermelon Stomach (Gastric Antral Vascular Ectasia)
93
48/M With intermittent UGIB, on endoscopy shows pulsating large tortuous submucosal artery on a base of normal gastric mucosa
Dieulafoy Lesion
94
95% of cancers of the stomach are of this type
ADenocarcinoma
95
Histologic classification system for Gastric Adenocarcinomas
Lauren Classification
96
Lauren Classification: 2 Types of Gastric Adenocarcinoma
Intestinal Type
Diffuse Type
97
Lauren Classification: 4 Factors considered in classifying Gastric AdenoCAs:
H-E-L-P
Histology
Epidemiology
Location
Prognosis
98
Lauren Classification:
Histology of Intestinal Type vs Diffuse Type
Intestinal Type: well-delineated, well-differentiated glandular structures
Diffuse type: Poorly-differentiated small cells growing diffusely into gastric wall. No glands.
99
Lauren Classification:
Epidemiology of Intestinal Type vs Diffuse Type
Intestinal Type: Less-developed, High-risk populations, Environmental exposures
Diffuse type: Younger, associated with genetics
100
Lauren Classification:
Location of Intestinal Type vs Diffuse Type
Intestinal type: Distal stomach, ulcerative
Diffuse type: Cardia of stomach
101
Lauren Classification:
Prognosis of Intestinal Type vs Diffuse Type
Intestinal type: Long precancerous phase, better prognosis
Diffuse type: Worse prognosis, Linitis Plastica lesion (leather bottle): extensive infiltration of entire stomach (leather bottle)
102
Morphology of Gastric Ca:
Bulk of tumor mass is in the wall of the stomach, involves entire stomach
Scirrhous (linitis plastica)
103
Morphology of Gastric Ca: Bulk of tumor mass in the wall of stomach
Ulcerated
104
Morphology of Gastric Ca: Bulk of tumor mass is intraluminal, non-ulcerating
Polypoid
105
Morphology of Gastric Ca: Bulk of tumor mass is intraluminal, Ulcerated
Fungating
106
Metastatic Gastric Ca reaching the ovaries
Krukenberg tumor
107
Metastatic Gastric Ca manifesting as axillary lymphadenopathy
Irish node
108
Metastatic Gastric Ca manifesting as left supraclavicular lymphadenopathy
Virchow node
109
Metastatic Gastric Ca manifesting as periumbilical lymph node
Sister mary joseph nodule
110
Metastatic Gastric Ca manifesting as solid peritoneal deposit anterior to the rectum. Forms a shelf palpated on DRE
Blumer shelf
111
Biomarker used for postoperative surveillance of Gastric cancer
CEA
112
Gold standard in the diagnosis of Gastric Cancer
Upper endoscopy (EGD) + Biopsy
113
Most frequently used diagnostic tool for staging of Gastric Ca (Liver involvement, regional or distal lymphadenopathy, invasion)
Abdominal/pelvic CT with oral and IV Contrast
114
Tumor staging for Gastric AdenoCa
Tx - Tumor cannot be assessed
T0 - No evidence of primary tumor
T1 - Lamina Propria (T1a) or Submucosa (T1b)
T2 - Muscularis mucosae
T3 - Adventitia
T4 - Serosa (T4a) or Adjacent structure (T4b)
115
Lymph Node staging for Gastric AdenoCa
Nx - Lymph nodes cannot be assessed
N0 - No nodal metastasis
N1 - 1-2 regional LN
N2 - 3-6 regional LN
N3 - 7-15 regional LN (N3a), 16++ (N3b)
116
Metastasis Staging for Gastric AdenoCa
Mx - Distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis
117
Surgical management for Tumors < 2cm
Endoscopic Mucosal resection
118
Cancerous lesions located in the mid-stomach, linitis plastica, or Metetrier disease are managed with:
Radical Total Gastrectomy
119
Cancers in the distal antrum are managed with:
Distal Subtotal Gastrectomy + Billroth II / Roux-en-Y reconstruction
120
Over 95% of Gastric lymphomas are:
Hodgkin/Non-Hodgkin
Non-Hodgkin type
121
Risk factors for Gastric Lymphoma
> Inflammatory Bowel Disease
> HIV Infection
> H. Pylori infection
> Gene mutations
> Transplant related immunosuppression
122
Type of Lymphoma: Primary/ Secondary/ Tertiary
Histologic confirmation of lymphoma without evidence of peripheral lymphadenopathy or hepatosplenomegaly
Primary Lymphoma
123
Type of Lymphoma: Primary/ Secondary/ Tertiary
A recurrence in the stomach after treatment of Lymphoma
Tertiary
124
Type of Lymphoma: Primary/ Secondary/ Tertiary
Involvement of the stomach by a diffuse lymphoma elsewhere
Secondary
125
Gastric lymphomas are usually of the B-cell type, thought to arise from:
Mucosa Associated Lymphoid Tissue (MALT)
126
Low-Grade MALT Lymphoma pathophysiology:
MALT can arise in the stomach in response to chronic inflammation (H. pylori infection)
127
High grade lymphoma pathophysiology:
Inactivation of p53 tumor suppressor gene (--)
C-MYC proto-oncogene mutation (++)
128
Low-Grade MALT Lymphoma management:
Nonsurgical.
> H. pylori eradication (first-line treatment)
> followed by second course H. Pylori eradication + external beam radiation therapy for persistent lesions
> Advanced lesions: H. pylori eradication, external beam radiation, chemo, endoscopic surveillance
129
High-Grade Lymphoma management:
Chemoradiation for most
Surgery IF: urgent, tumor complications (acute hemorrhage, obstruction), failure to respond to chemoradiation
130
Most common mesenchymal tumor of the GI Tract
Gastrointestinal Stromal Tumor (GIST)
131
GIST arises from what cells of the GI Tract
Interstitial cells of Cajal
132
Proteins expressed by GIST
KIT protein and CD-34
133
Clinical manifestation of GIST
Usually asymptomatic.
Bleeding, Early satiety, abdominal pain, abdominal distention, abdominal fullness
134
Clinical manifestations of Gastric Lymphoma
Nonspecific upper GI symptoms.
Abdominal pain, anorexia, nausea, vomiting, weight loss (!)
135
Tumor markers used to diagnose GIST
c-KIT (CD117) and CD 34
136
First-line treatment of GIST
Complete surgical resection with negative margins.
Wide margins and extensive lymphadenectomy is not necessary.
137
Oral Chemotherapy given for GIST for KIT receptor inhibition
Imatinib (Gleevec)
138
Gastric Carcinoids pathophysiology
Arise from enterochromaffin cells. Follows the sequence of hyperplasia-dysplasia-neoplasia
139
Gastric Carcinoid Type that is usually associated with Zollinger-Ellison syndrome and found almost exclusively in patients with MEN-type 1 syndrome
Type II Gastric Carcinoid
140
Most common Gastric carcinoid type, associated with Atrophic gastritis, presumably autoimmune, usually affects women, often benign course
Type I Gastric Carcinoid
141
Carcinoid tumor of sporadic form, no hypergastrinemia, more common in men, worst prognosis
Type III Gastric Carcinoid
