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SURGERY > Stomach > Flashcards

Stomach Flashcards

1
Q

Part of the stomach important for HCl secretion

A

Cardia

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2
Q

Part of the stomach with a crucial role in capacitance by undergoing receptive relaxation

A

Fundus

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3
Q

Part of the stomach spanning the cardiac orifice to the incisura angularis

A

Body

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4
Q

Part of the stomach spanning the incisura angularis to the Pylorus

A

Antrum

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5
Q

Site of the autonomic pacemaker responsible for initiating gastric motor activity

A

Fundus

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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

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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

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8
Q

Blood supply of the fundus

A

Celiac trunk > Splenic artery > Short gastric arteries

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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

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10
Q

Venous drainage of the Left side of the stomach

A

Short gastric vein and Left gastroepiploic vein > Splenic vein > Portal vein

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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

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12
Q

Anterior surface of the stomach is innervated by:

A

Parasympathetic:

Left vagal trunk > Hepatic branch

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13
Q

Posterior surface of the stomach is innervated by:

A

Parasympathetic:

Right vagal trunk > Celiac branch

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14
Q

Sympathetic innervation of the stomach

A

Celiac plexus (T5-T10)

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15
Q

Cell in the gastric lining responsible for acid secretion via H+/K-ATPase pump (proton pump)

A

Parietal cell (Oxyntic cells)

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16
Q

Hormones that stimulate parietal cell acid secretion

A

Acetylcholine
Gastrin
Histamine

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17
Q

Up to how many arteries can be ligated during gastric surgery

A

2

Stomach has a rich anastomotic vascular network,

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18
Q

Nerve that supplies the posterior fundus, and is easily missed during highly selective or truncal vagotomy

A

Criminal nerve of Grassi

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19
Q

Layers of the stomach lining (innermost to outermost)

A

Mucosa > Submucosa > Muscularis propria > Serosa

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20
Q

Layer of the stomach lining that contains the Meissner autonomic plexus

A

Submucosa

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21
Q

Specific layers of the Muscularis Propria

A

Inner Oblique layer
Middle Circular layer
Outer Longitudinal layer

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22
Q

Interstitial pacemaker cells of the stomach. Found in the muscularis propria

A

Interstitial cells of Cajal

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23
Q

Layer of the stomach lining that contains the Auerbach Myenteric plexus

A

Muscularis Propria

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24
Q

Stomach cell that that secretes Pepsinogen, Gastric lipase, and Leptin

A

Chief (Zympgenic) cells

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25
Q

Stomach cell that that secretes Histamine

A

Enterochromaffin-like cells

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26
Q

Stomach cell that that secretes Serotonin

A

Enterochromaffin cells

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27
Q

Stomach cell that that contains bicarbonate and serves as a protective mucus later

A

Surface mucous cells

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28
Q

Stomach cell that that secretes Gastrin

A

G-cells

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29
Q

Stomach cell that that secretes Somatostatin

A

D-cells

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30
Q

Hormone that inhibits Acid secretion

A

Somatostatin

SomatoSTOP acid secretion

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31
Q

Most serious complication of EGD

A

Esophageal perforation

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32
Q

Gold standard diagnostic test for H. Pylori

A

Histologic examination of antral mucosal biopsy

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33
Q

Gold standard test to confirm H. Pylori eradication

A

Urease breath test

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34
Q

Imbalance in acid and mucosal defense that leads to Focal defects in the gastric/duodenal mucosa that extend into the submucosa or deeper

A

Peptic Ulcer Disease

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35
Q

Peptic Ulcer Classification:

A

Type I: Antral + Lesser curvature (most common)

Type II: Antral + Duodenal

Type III: Pre-pyloric

Type IV: Upper lesser curvature

Type V: NSAIDs induced

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36
Q

Peptic Ulcer Types that are associated with Acid Hypersecretion

A

Type II (Antrum + Duodenum)

Type III (Pre-pyloric)

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37
Q

Peptic Ulcer Types that are associated with Normal or Low acid output

A

Type I (Antral + Lesser curvature)

Type IV (Upper lesser curvature)

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38
Q

Gastric vs Duodenal Ulcer

Usual location

A

Gastric ulcer: Incisura

Duodenal ulcer: D1 (w/in 3cm from pylorus)

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39
Q

Gastric vs Duodenal Ulcer

Age group

A

Gastric ulcer: Older age group

Duodenal ulcer: younger age group

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40
Q

Gastric vs Duodenal Ulcer

Sex Predilection

A

Gastric ulcer: M1:F1

Duodenal ulcer:
M2:F1

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41
Q

Gastric vs Duodenal Ulcer

Pain in relation to meals

A

Gastric ulcer: Pain during meals, worsens with food

Duodenal ulcer: Pain 2-3 hours after meal; relieved by food

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42
Q

Gastric vs Duodenal Ulcer

Pain in relation to sleep

A

Gastric ulcer: does not awaken patient

Duodenal ulcer: Awakens patient from sleep

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43
Q

Gastric vs Duodenal Ulcer:

Risk of malignancy

A

Gastric ulcer: Common (should be biopsied)

Duodenal ulcer: Extremely rare

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44
Q

Gastric vs Duodenal Ulcer

Usual etiology

A

BOTH Gastric and Duodenal ulcer: NSAIDs/H. Pylori infection

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45
Q

Gastric vs Duodenal Ulcer

Pathophysiology

A

Gastric ulcer: Decreased gastric cytoprotection; Normal or decreased Gastric acid production

Duodenal ulcer: increased gastric acid production, decreased bicarbonate secretion

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46
Q

Gastric vs Duodenal Ulcer

Goal of management

A

Gastric ulcer: Gastrectomy, biopsy

Duodenal ulcer: Decrease acid production (vagotomy)

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47
Q

Complications of both Gastric and Duodenal ulcers

A
  • Melena
  • Coffee ground emesis
  • Penetrating ulcer
  • Perforation
  • Gastric outlet obstruction
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48
Q

First line management for peptic ulcer disease

A

Empiric treatment with Proton pump inhibitors

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49
Q

Indications for EGD in PUD

A
  • Patients >45 yo
  • With alarm symptoms: weight loss, bleeding, recurrent vomiting, anemia, dysphagia
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50
Q

Indications for Surgery in PUD

A
  • 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
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51
Q

Classification system for Endoscopic findings and rebleeding risk in PUD

A

Forrest Classification

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52
Q
A
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53
Q

Forrest Classification of Rebleeding

A

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

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53
Q

Presenting symptom of gastric outlet obstruction (complication of PUD)

A

Nonbilious vomiting

leads to profound hypokalemic, hypochloremic metabolic alkalosis

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54
Q

H. pylori eradication:

PPI Triple therapy

A

OCA

Omeprazole (PPI)
Clarithromycin 500mg BID
Amoxicillin 1000mg BID

10-14 days
Repeat EGD w/wo biopsy in 6-8 weeks

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55
Q

Surgery for gastric outlet obstruction related to PUD

A

Vagotomy and Antrectomy (V&A)

Vagotomy and Pyloroplasty

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56
Q

Surgical management of Gastric/Duodenal PUD if with:

Bleeding

A

Gastric: Oversew and Biopsy, Vagotomy + Drainage, Distal gastrectomy

Duodenal: Oversew,
Oversew + Drainage,
V&A

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57
Q

Surgical management of Gastric/Duodenal PUD if with:

Perforation

A

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
Q

Surgical management of Gastric/Duodenal PUD if with:

Obstruction

A

Gastric:
1. Biopsy + Highly selective vagotomy + Gastrojejunostomy

Duodenal:
1. Highly selective vagotomy + Gastrojejunostomy

59
Q

Most common complication of PUD

A

Bleeding

  • Melena
  • Hematemesis
  • Hematochezia
60
Q

Complication of PUD that presents as an Acute Abdomen

A

Perforation

61
Q

Complication of PUD that presents as triad of Abdominal pain, Distention, and Vomiting

A

Gastric Outlet Obstruction

62
Q

Gastric Outlet obstruction in PUD can lead to the following electrolyte imbalance

A

Hypokalemic Hypochloremic Metabolic Alkalosis

63
Q

Perforation in Duodenal and Gastric ulcer: usual involvement

A

Gastric ulcer: Left hepatic lobe

Duodenal Ulcer: Pancreas (posteriorly)

64
Q

Initial nonoperative management for Bleeding in PUD

A
  • Sliding NPO
  • IV PPI
  • Endoscopic treatment: Epinephrine or cautery
65
Q

Indications for Surgery in PUD Bleeding

A
  • 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
Q

Surgical management in Perforation of PUD

A
  • Emergency Exploration
  • Omental Patch + Biopsy
67
Q

Surgical Management in Gastric Outlet Obstruction in PUD

A
  • Emergency Exploration
  • Selective Vagotomy + Gastrojejunostomy + Biopsy
68
Q

Post Gastrectomy syndrome caused by destruction of the pyloric sphincter –causing abrupt delivery of hyperosmolar load (chyme) to the small intestines

A

Dumping Syndrome

(e.g. post gastrojejunostomies, pyloroplasty)

69
Q

Classifications of Dumping Syndrome

A

Early Dumping (15-30 min postprandial)

Late dumping (2-3 hrs)

70
Q

Early dumping syndrome presentation

A

Shock-like symptoms (sweating, tachycardia, lightheadedness) followed by Diarrhea

71
Q

Late Dumping syndrome presentation

A

Hypoglycemic symptoms (Hunger, shaking, dizziness, sweating)

  • Hyperinsulinemia causing reactive hypoglycemia
72
Q

Nonoperative management of Early and Late dumping syndrome

A

Early dumping: Octreotide, Saline, Recumbency

Late dumping: Glucose administration, Alpha-glucosidase inhibitors

73
Q

Surgical management of Early and Late dumping syndrome

A

Conversion to Roux-en-Y Anastomosis

73
Q

Postgastrectomy syndrome most associated with Billroth II Gastrojejunostomies

A

Alkaline Reflux Gastroenteritis

74
Q

Triad of Alkaline Reflux Gastroenteritis

A
  1. Constant epigastric pain (no association with meals)
  2. Nausea
  3. Bilious emesis (no relief of pain)

Billroth II –> Bilious Emesis

75
Q

Endoscopic findings of Alkaline Reflux Gastroenteritis

A

Inflamed, beefy red, friable gastric mucosa (liquefactive necrosis)

76
Q

Surgical management of Alkaline Reflux Gastroenteritis

A

Creation of a Long limb Roux-en-Y Gastrojejunostomy

77
Q

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

A

Roux Stasis syndrome

78
Q

Clinical presentation of Roux Stasis syndrome

A

Abdominal Pain
Nausea and Vomiting
Aggravated by eating

79
Q

Upper GI Series findings for Roux Stasis syndrome

A

Delayed gastric emptying

80
Q

Management of Roux stasis syndrome (non-operative and operative)

A

Non-operative: Promotility agents

Operative: Near-total or Total gastrectomy to remove atonic stomach

81
Q

A surgical Afferent and Efferent loop is formed during what type of Gastrojejunostomy

A

Billroth II

82
Q

Afferent Loop syndrome pathophysiology

A
  • Duodenal stump blowout
  • Acute bowel kink
  • Volvulus
  • Internal herniation
83
Q

Efferent loop pathophysiology

A
  • Intermittent obstruction of efferent limb of gastrojejunostomy
  • internal herniation of distal intestine behind efferent limb
84
Q

Manifestations of Afferent Loop syndrome

A

Acute form: Severe abdominal pain with nonbilious emesis

Chronic form: RUQ pain with bilious emesis not mixed with food

85
Q

Bacterial overgrowth and bile salt deconjugation may cause the following condition in afferent loop syndrome

A

Blind loop syndrome
- Stateorrhea
- Vit B12 deficiency
- Vit B9 (folate) deficiency
- Iron deficiency

86
Q

Manifestations of Efferent Loop syndrome

A

Abdominal pain and bilious emesis 8mos to years after surgery

87
Q

Diagnosis of Afferent Limb syndrome

A

CT Scan showing dilated Afferent limb

88
Q

Diagnosis of Efferent limb syndrome

A

Upper GI Series showing small bowel obstruction

89
Q

Management of Afferent syndrome

A
  • Conversion to Roux-en-Y anastomosis OR
  • Creation of jejunojejunostomy
90
Q

Management of Efferent syndrome

A

Prompt surgical intervention of internal hernia

91
Q

Premalignant lesion of the stomach associated with protein-losing enteropathy and hypocholrydia. Patho: Large rugal folds sparing the antrum

A

Menetrier Disease (Hypertrophic Gastropathy)

92
Q

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

A

Watermelon Stomach (Gastric Antral Vascular Ectasia)

93
Q

48/M With intermittent UGIB, on endoscopy shows pulsating large tortuous submucosal artery on a base of normal gastric mucosa

A

Dieulafoy Lesion

94
Q

95% of cancers of the stomach are of this type

A

ADenocarcinoma

95
Q

Histologic classification system for Gastric Adenocarcinomas

A

Lauren Classification

96
Q

Lauren Classification: 2 Types of Gastric Adenocarcinoma

A

Intestinal Type
Diffuse Type

97
Q

Lauren Classification: 4 Factors considered in classifying Gastric AdenoCAs:

A

H-E-L-P

Histology
Epidemiology
Location
Prognosis

98
Q

Lauren Classification:

Histology of Intestinal Type vs Diffuse Type

A

Intestinal Type: well-delineated, well-differentiated glandular structures

Diffuse type: Poorly-differentiated small cells growing diffusely into gastric wall. No glands.

99
Q

Lauren Classification:

Epidemiology of Intestinal Type vs Diffuse Type

A

Intestinal Type: Less-developed, High-risk populations, Environmental exposures

Diffuse type: Younger, associated with genetics

100
Q

Lauren Classification:

Location of Intestinal Type vs Diffuse Type

A

Intestinal type: Distal stomach, ulcerative

Diffuse type: Cardia of stomach

101
Q

Lauren Classification:

Prognosis of Intestinal Type vs Diffuse Type

A

Intestinal type: Long precancerous phase, better prognosis

Diffuse type: Worse prognosis, Linitis Plastica lesion (leather bottle): extensive infiltration of entire stomach (leather bottle)

102
Q

Morphology of Gastric Ca:
Bulk of tumor mass is in the wall of the stomach, involves entire stomach

A

Scirrhous (linitis plastica)

103
Q

Morphology of Gastric Ca: Bulk of tumor mass in the wall of stomach

A

Ulcerated

104
Q

Morphology of Gastric Ca: Bulk of tumor mass is intraluminal, non-ulcerating

A

Polypoid

105
Q

Morphology of Gastric Ca: Bulk of tumor mass is intraluminal, Ulcerated

A

Fungating

106
Q

Metastatic Gastric Ca reaching the ovaries

A

Krukenberg tumor

107
Q

Metastatic Gastric Ca manifesting as axillary lymphadenopathy

A

Irish node

108
Q

Metastatic Gastric Ca manifesting as left supraclavicular lymphadenopathy

A

Virchow node

109
Q

Metastatic Gastric Ca manifesting as periumbilical lymph node

A

Sister mary joseph nodule

110
Q

Metastatic Gastric Ca manifesting as solid peritoneal deposit anterior to the rectum. Forms a shelf palpated on DRE

A

Blumer shelf

111
Q

Biomarker used for postoperative surveillance of Gastric cancer

A

CEA

112
Q

Gold standard in the diagnosis of Gastric Cancer

A

Upper endoscopy (EGD) + Biopsy

113
Q

Most frequently used diagnostic tool for staging of Gastric Ca (Liver involvement, regional or distal lymphadenopathy, invasion)

A

Abdominal/pelvic CT with oral and IV Contrast

114
Q

Tumor staging for Gastric AdenoCa

A

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
Q

Lymph Node staging for Gastric AdenoCa

A

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
Q

Metastasis Staging for Gastric AdenoCa

A

Mx - Distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis

117
Q

Surgical management for Tumors < 2cm

A

Endoscopic Mucosal resection

118
Q

Cancerous lesions located in the mid-stomach, linitis plastica, or Metetrier disease are managed with:

A

Radical Total Gastrectomy

119
Q

Cancers in the distal antrum are managed with:

A

Distal Subtotal Gastrectomy + Billroth II / Roux-en-Y reconstruction

120
Q

Over 95% of Gastric lymphomas are:

Hodgkin/Non-Hodgkin

A

Non-Hodgkin type

121
Q

Risk factors for Gastric Lymphoma

A

> Inflammatory Bowel Disease
HIV Infection
H. Pylori infection
Gene mutations
Transplant related immunosuppression

122
Q

Type of Lymphoma: Primary/ Secondary/ Tertiary

Histologic confirmation of lymphoma without evidence of peripheral lymphadenopathy or hepatosplenomegaly

A

Primary Lymphoma

123
Q

Type of Lymphoma: Primary/ Secondary/ Tertiary

A recurrence in the stomach after treatment of Lymphoma

A

Tertiary

124
Q

Type of Lymphoma: Primary/ Secondary/ Tertiary

Involvement of the stomach by a diffuse lymphoma elsewhere

A

Secondary

125
Q

Gastric lymphomas are usually of the B-cell type, thought to arise from:

A

Mucosa Associated Lymphoid Tissue (MALT)

126
Q

Low-Grade MALT Lymphoma pathophysiology:

A

MALT can arise in the stomach in response to chronic inflammation (H. pylori infection)

127
Q

High grade lymphoma pathophysiology:

A

Inactivation of p53 tumor suppressor gene (–)

C-MYC proto-oncogene mutation (++)

128
Q

Low-Grade MALT Lymphoma management:

A

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
Q

High-Grade Lymphoma management:

A

Chemoradiation for most

Surgery IF: urgent, tumor complications (acute hemorrhage, obstruction), failure to respond to chemoradiation

130
Q

Most common mesenchymal tumor of the GI Tract

A

Gastrointestinal Stromal Tumor (GIST)

131
Q

GIST arises from what cells of the GI Tract

A

Interstitial cells of Cajal

132
Q

Proteins expressed by GIST

A

KIT protein and CD-34

133
Q

Clinical manifestation of GIST

A

Usually asymptomatic.

Bleeding, Early satiety, abdominal pain, abdominal distention, abdominal fullness

134
Q

Clinical manifestations of Gastric Lymphoma

A

Nonspecific upper GI symptoms.

Abdominal pain, anorexia, nausea, vomiting, weight loss (!)

135
Q

Tumor markers used to diagnose GIST

A

c-KIT (CD117) and CD 34

136
Q

First-line treatment of GIST

A

Complete surgical resection with negative margins.

Wide margins and extensive lymphadenectomy is not necessary.

137
Q

Oral Chemotherapy given for GIST for KIT receptor inhibition

A

Imatinib (Gleevec)

138
Q

Gastric Carcinoids pathophysiology

A

Arise from enterochromaffin cells. Follows the sequence of hyperplasia-dysplasia-neoplasia

139
Q

Gastric Carcinoid Type that is usually associated with Zollinger-Ellison syndrome and found almost exclusively in patients with MEN-type 1 syndrome

A

Type II Gastric Carcinoid

140
Q

Most common Gastric carcinoid type, associated with Atrophic gastritis, presumably autoimmune, usually affects women, often benign course

A

Type I Gastric Carcinoid

141
Q

Carcinoid tumor of sporadic form, no hypergastrinemia, more common in men, worst prognosis

A

Type III Gastric Carcinoid

SURGERY (13 decks)

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