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Stomach Flashcards

1
Q

Bezoars are indigestible collection of material in the GI tract; what’s the most common bezoars?

A

Phytobezoars (plant-based)

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2
Q

Good sampling technique for taking samples of suspected gastric ulcers?

A

Get at least 8 specimens from core and edges of the ulcer

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3
Q

5 types of gastric ulcers?

A
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4
Q

Forest classification of ulcers and risk of re-bleeding;

A
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5
Q

Location of gastric Ca and surgical management ;

A
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6
Q

For gastric adenoCa, what’s an appropriate surgical margin?

A

5 cm

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7
Q

Siewart classification of GEJ ca;

A
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8
Q

Left and right vagus branches:

A

Left Vagus Anterior—> gives rise to hepatic branch, then branches to give nerve of latarjet which innervates pylorus

Right Vagus Posterior—> gives off the criminal nerve of grassi (innervates cardia), continues until it joins the celiac plexus

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9
Q

In a truncal vagotomy where do we transect the vagus?

A

Distal esophagus, 4 cm proximal to GEJ

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10
Q

In a selective vagotomy where do we transect the vagus?

A

Division occurs below the celiac and hepatic branches

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11
Q

Where do we divide the vagus in a highly selective vagotomy?

A

Transecting the distal crow’s feet

Preserving nerve of Latarjet

A drainage procedure is not necessary

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12
Q

Tx of trichobezoars?

A

Gastrotomy and removal (laparotomy or laparoscopy)

EGD not good at removing bezoars

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13
Q

Tx of gastric lymphomas?

A

Low grade—-> abx (usually assc w/ h. Pylori)

High grade—> chemo/radiation

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14
Q

Why is severe malnutrition a relative contraindication to PEG placement?

A

The tract won’t heal

Can result in leakage

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15
Q

Treatment for retained gastric antrum after antrectomy, vagotomy and Billroth II?

A

Completion surgical removal of the antrum

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16
Q

WHat procedure for morbid obesity performed in the 1970s led to a high rate of cirrhosis?

A

Jejunal-ileal bypass

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17
Q

Afferent v efferent loop syndromes;

A

Efferent loop syndrome; less common, GOO due to kinking of the efferent limb, the jejunal limb will herniate posterior to the anastomosis
TX—> operative reduction and closing the space so it can’t herniate anymore

Afferent loop syndrome; more common, often due to excessive length of the afferent limb, can see vomiting when high pressures eventually back up into the stomach
TX—-> operative, can convert to B1 or Roux-en-Y

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18
Q

A smooth submucosa mass found in the stomach most likely represents what kind of lesion?

A

GIST
Tx—-> wedge resection

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19
Q

90% of GISTs demonstrate what mutation?

A

C-KIT (CD 117) mutation

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20
Q

GISTs are known to originate from what type of cells?

A

Interstitial cells of Cajal

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21
Q

What do we do with high risk GISTs?

A

> 5 cm, or >5 mitoses/HPF
Or unresectable disease need to be treated with imatinib

We don;t perform lymph node dissections for GISTs because they spread hematogenously

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22
Q

3 types of gastric carcinoids and their treatment;

A
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23
Q

What nerve roots does the anterior vagus give?

A

Left anterior

Gives off hepatic division and anterior nerves of Latarjet

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24
Q

What nerve root does the posterior vagus give?

A

Criminal nerve of grassi

Celiac branch

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25
Q

Sxs of slipped gastric banding?

A

Abd pain, early satiety, nausea

The band needs to lie so that the Phi angle is between 4-58 degrees

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26
Q

What do parietal cells secrete?

A

HCL and IF

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27
Q

MOst common mineral deficiency in bariatric patients?

A

Vit D

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28
Q

What are essential vitamins that bariatric pts need to take?

A

Vit D
Vit B12
Fe

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29
Q

B1 v B2 v Roux-en-y:

A
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30
Q

Why do pts with afferent loop syndrome have megaloblastic anemia?

A

Partial obstruction of the afferent limb causes biliary/pancreatic secretions to accumulate

This leads to epigastric discomfort until the secretions can be forced into the stomach leading to biliary emesis and improvement of symptoms

This chronic stasis in the afferent limb also leads to bacterial overgrowth, the bacteria then bind to Vit B12 and the body can’t absorb it—> megaloblastic anemia

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31
Q

Tx for afferent loop syndrome?

A

Convert BII to a Roux-en-y

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32
Q

Erosion of a gastric band into the stomach presents how?

A

Usually with abd pain and port-site infection

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33
Q

What does gastrin do?

A

Made by G-cells of the gastric antrum

Main regulator of the gastric phase of acid secretion once food is eaten

Stimulates acid secretion by stimulating enterochromaffin like cells to make histamine

Histamine then binds to H2 receptors of parietal cells—> acid secretion

34
Q

Linear mucosal or submucosal lacerations near GE junction?

A

Mallory Weiss tears
Tx is EGD

35
Q

Where are G cells located?

A

Antrum

Make gastrin, which stimulates parietal cells to make HCL via histamine release

36
Q

What do chief cells make?

A

Pepsinogen

Found in body/fundus

37
Q

MC type of bezoar”

A

Phytobezoars (plant based)

38
Q

MC of recurrent ulcers after truncal vagotomy?

A

Failure to identify and transect the criminal nerve of grassi from the posterior vagus

39
Q

MC of recurrent ulcers after truncal vagotomy?

A

Failure to identify and transect the criminal nerve of grassi from the posterior vagus

40
Q

First branch off of the posterior vagus?

A

Criminal nerve of grassi

41
Q

First branch off of the posterior vagus?

A

Criminal nerve of grassi

42
Q

Hepatic vagus branch comes off of what vagus nerve?

A

Anterior

43
Q

Hepatic vagus branch comes off of what vagus nerve?

A

Anterior

44
Q

Celiac branch comes off of what vagus n?

A

Posterior

45
Q

Tx of afferent loops syndrome?

A

Surgical

Convert to a Roux-en-y

46
Q

Where do we find gastrin secreting G cells in the stomach?

A

Antrum

47
Q

Gastric lymphoma:

A

Usually presents with vague GI sxs

Anemia is common

Tx is usually chemo

Non-hodkins lymphoma; no B symptoms seen

48
Q

Tx of gastric carcinoid?

A

<2 cm—> endoscopic resection with surveillance

> 2 cm—-> antrectomy

49
Q

Chronic afferent limb obstructions causes megaloblasetic anemia; how?

A

Bacterial overgrowth causing B12 malabsorption

50
Q

Tx of mucosa-associated lymphoid tissue lymphoma?

A

Abx

Assc w/ h. Pylori

51
Q

Gastric mucosal associated lymphoma tissue is associated with?

A

H.pylori

Path shows small cells that express B cell markers; CD 19, CD 20, CD 22

Tx is abx

52
Q

What happens if MALT lymphoma is still present after abx eradication therapy?

A

MALTs that have t11;18 and H. Pylori positive, these pts don’t usually respond to abx eradication

In these cases; radiation is the next tx option

53
Q

What surgical margin needed for gastric ca?

A

5 cm

54
Q

Tx for a cancer >5 cm distal to the GEJ?

A

Total gastrectomy

You need 5 cm margins with gastric ca

55
Q

What do we do for gastric cancers that T2 N0 MO or higher?

A

Neoadjuvant chemo then surgery

56
Q

Initial tx of Phytobezoars?

A

Chemical dissolution

57
Q

Fundic gland polyps?

A

Assc with PPIs

Benign

No surveillance needed if no hx of polyposis syndromes

58
Q

The anterior vagus gives rise to:

A

The hepatic branch

59
Q

Where do we perform a truncal vagotomy?

A

Distal esophagus, 4 cm proximal to GEJ

60
Q

What bariatric procedure performed in the 1970s had a high rate of cirrhosis?

A

Jejunoileal bypass

61
Q

Efferent loop syndrome?

A

Rare

Occurs 2/2 kinking of efferent jejunal limb, sometimes the limb herniates posterior the anastomosis

Sxs; abd pain, nausea/bilious vomiting,

Half of cases occur within first month

Tx is surgical—-> reducing the herniated efferent limb and closing the retro-anastomotic space

62
Q

Two branches off of the anterior vagus nerve?

A

Hepatic branch

Anterior nerve of Latarjet

63
Q

These tumors originate from the interstitial cells of Cajal:

A

GISTS

Submucosa gastric masses

64
Q

90% of GISTs have what mutation?

A

C-kit mutation (CD 117)

65
Q

Treatment of GISTs?

A

Resection
Dont spread via lymph nodes; so R0 resection all that is needed

High risk features; >5 mitoses/hpf or >5 cm should receive imatinib

Unresectable tumors or those with distant spread should also get imatinib

66
Q

How do we diagnose an eroded gastric band?

A

Endoscopy

67
Q

Cameron ulcer?

A

Linear mucosal erosions caused by para-esophageal hernias

Usually on lesser curve

68
Q

B1 defiency?

A

Thiamine deficiency

Causes wet/dry beriberi

Wet—> tachy, heart failure, respiratory sxs

Dry—> neurological sxs

69
Q

B1 defiency?

A

Thiamine deficiency

Causes wet/dry beriberi

Wet—> tachy, heart failure, respiratory sxs

Dry—> neurological sxs

70
Q

Barretts esophagus causes what ca?

A

Adenocarcinoma

71
Q

Fundic vs hyperplastic gastric polyps;

A

70% of gastric polyps are Fundic or hyperplastic

Fundic assc with PPI use ; no malignant potential (unless hx of FAP)

Hyperplastic polyps have increased risk of gastric Ca

If solitary and >0.5 cm and removed, yearly endoscopy needed

If multiple, need biopsy around the polyps too, usually assc with chronic inflammation, h. Pylori

72
Q

What aberrant artery can sometimes be injured when dissecting in the pars flaccida, gastrohepatic ligament?

A

A replaced left hepatic coming off the left gastric artery

73
Q

Fundic gland polyps?

A

Benign

Assc with PPI use

No further imaging necessary

74
Q

What’s transected in a selective vagotomy?

A

The anterior and posterior nerves of latarjet are cut only after the hepatic and celiac branches are given off

Need a pylorus draining procedure b/c pylorus is denervated

75
Q

Indications for stress ulcer prophylaxis;

A

Mech vent >48 hrs
TBI
Traumatic spinal cord injury
Severe burn (>20% TBSA)
Coagulopathy

76
Q

CDH1 carriers?

A

Predisposed to hereditary diffuse gastric cancer at an early age

Recommendation is for prophylactic gastrectomy between 18-30

77
Q

Contraindications to PEG

A

Severe malnutrition
Coagulopathy
Hemodynamic instability
Esophageal obstruction

78
Q

Tx of bile reflux after B1 or B2?

A

Lifestyle modifications

If these fail; convert to Roux-en-y with 40 cm afferent limb

79
Q

Jejunum-ileal bypass done in the 1970s had higher rates of?

A

Cirrhosis

80
Q

Gastric GISTs

A

Arise from interstitial cells of cajal; stain for c-kit
Usually submucosal masses
Do not spread via lymphatics

Can be low risk <2 cm, or high risk > 5 cm
Mitotic rate also important distinction (>5 or > 10/50 HPF)

For high risk GISts, can downsize with neoadjuvant imatinib if C-kit + and then can resect; neoadjuvant therapy helps downsize and preserve organ during surgery; adjuvant imatinib also usually given if high risk

81
Q

Most effective bariatric procedure for curing diabetes?

A

Biliopancreatic diversion with duodenal switch

82
Q

Most common type of sarcoma seen in the GI tract;

A

GIST

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