Stomach Flashcards

Question

NSAID Use

Answer 1

NSAID use is the highest risk factor for causing peptic ulcer bleeding. Higher than H. Pylori

Answer 2

Newest studies show the following ulcer size larger than 2 cm, hypotension, initial hemoglobin less than 10 mg/dL, fresh blood in the stomach, visible vessel, active bleeding. Greatest risk factor = visible vessel.

Answer 3

Indicated if on PPI/treated for H. Pylori and going to the OR, AND for any Billroth procedures Type II or III ulcers only, located distal to incisura angularis All type of Vagotomy increase liquid emptying  vagally mediated receptive relaxation is removed (results in increased gastric pressure that accelerates liquid emptying) All forms of vagotomy result in an increase in gastrin and gastrin cell hyperplasia Truncal vagotomy - Ant and post vagus above GE junction divided 4-5 cm above EGJ - Causes delayed gastric emptying  gastroparesis - MC problem is diarrhea 2/2 to sustained MMC forcing bile acids to colon - Dumping syndrome - Causes gallstones - Decreases emptying of solids  from pyloric constriction - Requires pyloroplasty or antrectomy to increase emptying of solids Selective vagotomy - Divides the nerves of laterjet (innervates antrum) - Spares the branches to liver and small intestine by dividing distal to these branches, this decreases risk of dumping syndrome, diarrhea and gallstone formation - Need to make sure to divide posterior criminal nerve of grassi (Off of right (posterior) vagus), unlike truncal - Decreases Emptying of solids - Requires pyloroplasty or antrectomy to increase emptying of solids Highly selective vagotomy (proximal vagotomy) - Divides the nerves of Letarjet but preserves Crow’s foot (supplies pylorus) Preserves the celiac, hepatic branches - Does not require drainage procedure - Normal emptying of solids, increased emptying of liquids - Decreased risk of dumping syndrome Other alterations caused by truncal vagotomy - Gastric effects – decrease acid output by 90%, increase gastrin, gastrin cell hyperplasia - Nongastric effects – decreases exocrine pancreas function, decrease postprandial bile flow, increase gallbladder volume, decrease release of vagally mediated hormones - Post vagotomy Diarrhea 40% - The most common problem following truncal vagotomy. Caused by sustained migrating motor complex forcing bile acids to the colon. Tx: Initial treatment = Cholestyramine treatment of choice. or very rarely  interposition of reversed jejunal segment

Answer 4

H. pylori - Helix shaped, gram negative rod - Reduces number of antrum D cell  Decrease somatoastatin release increases gastrin increases acid level - Produces urease  splits urea into ammonia and bicarb allows H. pylori bacteria to survive in acidic environment Tx: (Triple therapy) PPI + Clarithyromycin + amoxicillin/flagyl (7-10 days) Refractory ulcers – (USE DIFFERENT ABX THAN BEFORE) (Quadruple therapy) PPI, Flagyl, tetracycline/doxycycline, bismuth salt Allergic to PCN – flagyl, PPI, and clarithromycin 4-6 weeks After treatment, all patients need confirmatory tests with urease breath test (Best)

Answer 5

Triple therapy: PPI + Clarithromycin + Amoxicillin/Flagyl for 7-10 days.

Answer 6

Negligible risk of cancer, but associated with PPI use.

Answer 7

-3-10 days after event (multiple trauma, burns, complicated post) -Lesions appear in fundus first -> can progress to ulcers Tx: PPI

Answer 8

UGIB but can’t find source (too much blood or food) angiography Lower rates of GI Bleeding with PPI vs H2 blocker Prophylaxis only for high risk: - Coagulopathy INR > 1.5, platelets < 50k - Mechanical vent > 48 hours - History of GIB or GI ulcer in the last year - Traumatic brain injury or spinal cord injury - Severe Burn > 35%

Answer 9

Fundic gland polyp – MC gastric polyp Associated with PPI (biggest association) Can be associated with FAP Risk of cancer is negligible Not associated with H. Pylori Often regress after stopping PPI If polyps > 1 cm or > 20 in number then stop PPI. If not, don’t need to do anything Don’t need to remove all polyps If >20 polyps should think of FAP  if it is from FAP  resect all polyps  perform colonoscopy

Answer 10

caused by H. Pylori infection !!!!! Associated with atrophic gastritis Has malignant potential 2% cancer risk Tx: remove ALL polyps > 0.5 cm and H. Pylori treatment

Answer 11

Adenomatous polyp in stomach Occur in the setting of Chronic atrophic gastritis Can be related to H. pylori infection Can be sporadic or associated with FAP Has the highest risk of cancer Definite CA risk for polyps > 2 cm (50%) Tx: endoscopic resection of ALL polyps and H. Pylori treatment

Answer 12

Gastric CA MC site: antrum 90% are adenocarcinoma RF: #1 H. Pylori, HNPCC, EBV, adenomatous polyps, atrophic gastritis, pernicious anemia, achlorhydria, blood type A. BRCA2,

Answer 13

Stage with: - Endoscopy WITH EUS + FNA (Best for T and N), - CT chest/abd/pelv (best for resectability and mets). - PET-CT is optional but very useful for mets -Staging laparoscopy: NCCN recommends laparoscopic staging with peritoneal washing for clinical stage > T1b tumors if chemoradiation or surgery being considered (not needed if known metastasis and undergoing definitive chemoradiation or palliative options)

Answer 14

Have CDH1 mutation. Need Prophylactic total gastrectomy for CDH1 carriers between 18-41. Need 5 cm margins Women with CDH1= inc risk of breast cancer

Answer 15

Adenocarcinoma: Intestinal type gastric CA – MC type. 5 YS 25% - Path shows glands and goblet cells - Most often seen in the setting of atrophic gastritis (H. Pylori, autoimmune gastritis) – MC related to environment Adenocarcinoma: Diffuse Gastric CA (linitis plastica). 5YS 10% - Diffuse connective tissue invasion. Early lymphatic spread - NO GLANDS - Less favorable prognosis. Usually beyond resection at time of Dx

Answer 16

All GE junction tumors need esophagectomy Siewart classification of EGJ adenocarcinoma that is 5 cm proximal and distal to EGJ * Type I - 1-5 cm proximal to EGJ: Ivor Lewis (preferred b/c need to take mediastinal LN) and PROXIMAL gastrectomy with gastric pullup with thoracic esophagogastrostomy * Type II - 1 cm proximal to 2 cm distal to EGJ: Transhiatal proximal gastrectomy and esophagectomy * Type III – 2 -5 cm distal to EGJ: Treated like gastric cancer: Transhiatal TOTAL gastrectomy and esophagectomy

Answer 17

Splenic invasion: resect stomach + splenectomy Chemo - 5FU, leucovorin and oxaliplatin = MC used = FOLFOX - cisplatin + capecitabine + epiribucin used in trials - Trustuzumab used for Her-2 expression only -Neoadjuvant therapy: cT2 or higher and any N Early gastric cancer = Tis or T1a (lamina propria or muscularis mucosa): You have two options: - 1. Straight to Gastrectomy with D1. No adjuvant chemo/radiation unless node positive - 2. Endoscopic mucosal resection only IF T1a < 2 cm, no lymphovascular invasion, mod-well differentiated, no ulceration Locoregional advanced gastric cancer (resectable) = T1b (submucosa) or greater - All patients with locally advanced cancer need a diagnostic laparoscopy with peritoneal washing PRIOR to neoadjuvant chemo to rule out mets - T1b (submucosa) N0: straight to surgery (Need D2 lymphadenectomy), no neoadjuvant therapy - T2 (muscularis propia) or greater or any N: Neoadjuvant chemo then surgery is preferred then post op chemo-radiation Locoregional advanced gastric cancer but unresectable: chemotherapy or chemoradiotherapy Metastatic: non-op unless palliative D1 LN 1-6 – perigastric D1+ - resect all D1 and as many D2 that seem likely to harbor CA, without need for splenectomy or pancreatectomy D2 LN 7-11 – nodes near common hepatic, left gastric, celiac, and splenic hilum D3 LN 12-16– Portahepatis and aortic nodes Treatment: For tumors > T1b or any N - Total gastrectomy with RNY esophagojejunostomy for proximal 1/3 tumors - Distal gastrectomy with RnY gastroJ or Bilroth II for distal 2/3 - Never do Bilroth I for distal gastric CA b/c duodenal recurrence can obstruct - D2 Resection is current guideline without routine splenectomy or pancreatectomy unless they are grossly affected then must take en bloc - All need 5 cm margins unless its diffuse CA then it is 8 cm - Need at least 15 LN for staging - Post op chemo-radiation for all T2, T3, T4 or node positive - Stage IV: with bleeding/obstruction -> palliative total gastrectomy provides good palliation - Mets to outside area of resection: unresectable, palliation - For patients with (small volume, limited peritoneal disease (unresectable really) you can increase survival with cytoreductive surgery and HIPIC -Lymph node dissection: -NCCN recommendation is for R0 resection with at least D1 or modified D2 lymph node dissection -D1 dissection = removal of N1 nodes (perigastric nodes along greater/lesser curve, stations 1-6) -D2 dissection = removal of N1 and N2 nodes (nodes along left gastric, common hepatic, celiac and splenic arteries, stations 7-11) -R0 = negative microscopic margin -R1 = negative gross margin, positive microscopic margin -R2 = positive gross margin -Adjuvant therapy: Adjuvant 5-fluorouracil for T3, T4, or node positive disease following R0 resection Palliation - Obstruction – proximal lesions can be stented, distal lesions bypassed with gastreojejunostomy - Bleeding or pain: XRT

Answer 18

– MC benign gastric tumor Mesenchymal tumor!! = SARCOMA  Does not spread to lymph nodesNO lymphadenopathy Comes from interstitial Cells of Cajal MC found in stomach. Non-gastric GIST = poor prognostic factor MC mets to liver. Sx: MC present with GI bleed!! On Imaging: Hypervascular, exophytic, heterogeneous mass, often with central necrosis. C-KIT+, CD117, DOG-1 and CD34 Work up:  CT scan is the image of choice to diagnose!!! - Don’t need biopsy, imaging is enough. Even if biopsy is negative, and imaging concerning for GIST, they need surgical resection Submucosal mass on EGD – most EGD biopsy is negative US – hypoechoic, smooth edges Path – spindle cells and connective tissue Malignant > 5 cm or > 5 mitosis/50HPF or IF GIST LOCATION IS OUTSIDE THE STOMACH

Answer 19

- If in stomach and < 2 cm and asymptomatic and confirmed with US  f/u EUS every 6-12 months - > 2 cm or symptomatic, need wedge (Not formal) resection with negative margin only. No Nodes taken - Imatinib for recurrence If metastatic disease or borderline resectable, present  start with imatinib, then reassess for surgery R0 vs R1 no difference in mortality. Do not need to go back to surgery for R1 margin  give imatinib Imatinib after resection for 3 years S/E = CHF Imatinib (Gleevec) also recommended for unresectable, metastatic, or recurrence

Answer 20

MALTOMA – low grade B cell NHL Patients present with nausea, epigastric pain/burn, weight loss Do not present with B symptoms: fevers, chills, night sweats MC location Is stomach Depth of invasion through stomach wall correlates with decreasing responsiveness to H. Pylori treatment - Stage I: IE = lesions restricted to stomach = Will respond to H. Pylori treatment - Stage II: IIE = lesions spread to lymph nodes = IIE or above; likely won’t respond to H. Pylori treatment - IIIE = Lesion in GI, + lymph nodes on both sides of diaphragm - IVE = Extension to extra GI tissue Related to H. Pylori Dx: Need EUS with Bx Tx: Treat H. pylori for all 1st regardless of stage. If it does not regress on repeat EGD; Tx: XRT is curative - If H. Pylori negativE: go straight to XRT - Success of H. Pylori treatment should be done with urea breath test 6 weeks after - Need serial endoscopy to assess response for treatment too. If minimal histologic disease: continue to do serial EGD No real role for surgery here unless bleeding or perf Advanced disease nodes outside of perigastric: stage III or IV: H. pylori Tx and chem-XRT (CHOP-R)

Answer 21

Gastric lymphoma – have ulcer symptoms. MC location for extra-nodal lymphoma. MC NHL diffuse large B cell 60% Dx: EGD and biopsy. Tx: chemo-XRT. Surgery very rare, only for stage I (Confined to mucosa) disease and palliative treatment

Answer 22

Elevated gastrin levels found in: - Gastrinoma - Retained gastric antrum - GOO - Vagotomy - Pernicious anemia - PPI use - Chronic gastritis

Answer 23

- MC #1 iron deficiency! (iron needs acidity to be absorbed in duodenum) - B12/Folate - Calcium (osteoporosis)

Answer 24

Psoas sign (pain on extension of the thigh) - retrocecal appendicitis

Answer 25

Obturator sign (pain on passive internal rotation of a flexed hip) - pelvic appendicitis

Answer 26

Preserve short gastric for subtotal Start with diagnostic laparascopy 1. Divide falciform 2. Divide gastrocolic ligament, left gastroepiploic, and short gastric, omentectomy (station 4) 3. Infrapyloric mobilization, divide right gastroepiploic and GDA 4. Suprapyloric mobilization, divide gastrohepatic lig, Divide hepatoduodenal lig to find and divide right gastric 5. Transect duodenum 1 cm distal to pylorus 6. D2 lymphadenectomy 7. Gastric transection 8. Roux En Y EJ/GJ

Answer 27

-Lynch syndrome (DNA mismatch genes) -Juvenile polyposis syndrome (SMAD4) -Peutz-Jehgers Syndrome -Familial adenomatous polyposis (APC gene on 5q21)

Answer 28

Retained antral tissue within duodenal stump after gastric resection -G cells bathed in alkaline fluid= continuous gastrin release= acid production in proximal stomach remnant and ulceration -Check gastrin to r/o gastrin-secreting tumor -With Billroth II or Roux-en-Y -Tx: PPI; vagotomy, resection of retained antrum

Answer 29

-Tachycardia, diaphoresis, dizzy, flushing -Tx= small meals, no sugary drinks; refractory= octreotide -Early dumping syndrome (20-30 min after meal): abrupt hyperosmolar load to small intestine -Late dumping syndrome (1-4 hours after meal): rapid carbohydrate load to small intestine resulting in large insulin surge and rebound hypoglycemia -After gastrectomy or vagotomy and pyloroplasty

Answer 30

-post-prandial epigastric pain, N/V; not relieved with vomiting -After Bilroth I and Bilroth II reconstructions -Dx: impedance studies -Tx: pro kinetic agents, bile acid binding resins; conversion to RNY -At least 50 cm for Roux limb will avoid recurrent bile reflux -Braun enterostomy: anastomosis between afferent and efferent limb

Answer 31

-acute or chronic obstruction of afferent jejunal limb following Bilroth II reconstruction -Increased luminal pressure of afferent limb -Obstructive jaundice, cholangitis, pancreatitis from back pressure up biliopancreatic system -Duodenal stump blow out -Bacterial overgrowth in afferent limb -> bacteria deconjugate bile acids= steatorrhea, malnutrition, avitamin B-12 deficiency leading to megaloblastic anemia. -Tx: conversion to Roux-en-Y or Bilroth I; bacterial overgrowth can be managed first with antibiotics (high relapse rate though) -If B2 patient presents with bowel obstruction, no NGT and decompression; emergent surgery. Similar to bypass patients with internal hernia. -Patient with history of antrectomy and Bilroth II reconstruction in distant past presents with intermittent abdominal pain and distention which is relieved after bilious emesis, megaloblastic anemia on laboratory work up. What is this? -Afferent limb syndrome

Answer 32

-Open gastrostomy tube placement -Chosen when anatomy is hostile, multiple operations, adhesions present -> PEG not safe -3 cm below costal margin, 3 cm to left of midline in anterior wall of stomach; purse string

Answer 33

-EBV associated with nasopharyngeal cancer, Hodgkin disease, Burkitt lymphoma, subset of gastric cancer, lymphoproliferative disease in AIDS EBV associated gastric cancers: male predominance, located more commonlyh in gastric cardia or post-surgical gastric stump, finding of lymphocytic infiltration, decreased occurence of lymph node metastasis, better prognosis