stomach 2 Flashcards
What is the most common cause of upper GI bleeding?
Peptic ulcer disease (PUD).
Which artery is most commonly involved in duodenal ulcer bleeding?
Gastroduodenal artery.
What are signs of slow GI bleeding?
Iron deficiency anemia, coffee ground vomit, and melena.
What are signs of rapid and severe GI bleeding?
Hematemesis or melena.
What is the diagnostic and therapeutic test of choice for GI bleeding due to PUD?
Upper GI endoscopy.
What are the initial management steps for acute slow GI bleeding?
ABCs, large bore IV access, fluids, blood transfusion if needed, NPO, NGT, IV PPIs, and antibiotics.
When should endoscopy be done in a patient with controlled GI bleeding and stable condition?
Within 24 hours.
What should be done if GI bleeding is uncontrolled or the patient is unstable?
Urgent endoscopy.
What is the management for ulcers with high re-bleeding risk?
Surgical hemostasis with sutures or pyloroplasty.
What are clinical features of gastric outlet obstruction?
Nausea, vomiting of undigested food, GERD symptoms, early satiety, epigastric fullness, weight loss.
What physical exam finding suggests gastric outlet obstruction?
Succussion splash (+/– visible peristalsis). is a sloshing sound heard during abdominal examination when the patient is rocked side to side.
What electrolyte imbalance is associated with gastric outlet obstruction?
Hypochloremic, hypokalemic metabolic alkalosis with hyponatremia.
What is the diagnostic test involving saline in gastric outlet obstruction?
Saline load test – if aspirate >400 ml after 30 minutes, test is positive.
How it’s done:
1. A nasogastric (NG) tube is inserted and the stomach is emptied completely.
2. 750–1000 mL of normal saline is slowly instilled into the stomach through the NG tube.
3. After 30 minutes, the stomach contents are aspirated back.
What is the initial management of gastric outlet obstruction?
Nasogastric suction, correct electrolytes and fluid deficits, nutritional support.
What surgery is often needed in gastric outlet obstruction?
Pyloroplasty (in ~75% of cases)
is a surgical procedure to widen the opening of the pylorus, which is the lower part of the stomach that connects to the small intestine (duodenum).help food pass more easily from the stomach to the duodenum.
What acid-base disorder can develop in gastric outlet obstruction?
Paradoxical aciduria due to metabolic alkalosis.
is a condition where the urine is acidic despite the body being in a state of metabolic alkalosis — which seems contradictory, hence the term paradoxical.
Where do perforations commonly occur in peptic ulcer disease?
Anterior duodenal ulcers and gastric ulcers
What are the classic clinical features of ulcer perforation?
Acute severe epigastric pain (may become diffuse), worsened by movement/respiration, signs of peritonitis, and hemodynamic instability.
What is Valentino’s sign?
RLQ pain from perforated ulcer tracking down paracolic gutter, often misdiagnosed as appendicitis.
What are the key physical exam findings in a patient with perforated ulcer?
Ill appearance, still posture, shallow breathing, absent bowel sounds, epigastric tenderness, involuntary guarding, broad-like rigidity, and very painful percussion.
What is the best initial diagnostic test for suspected perforated ulcer?
Upright chest X-ray (CXR) showing free air under diaphragm.
If upright CXR is not possible, what alternative view can be used to detect perforation?
A: Left lateral decubitus CXR
What imaging is most sensitive for detecting free intra-abdominal air?
ct
What are the emergency management steps for a perforated ulcer?
ABCs, IV fluids, blood collection, IV PPIs, antibiotics, and emergency laparotomy.
Why is the omentum used in perforation surgery?
Because ulcer edges are friable; omentum is placed over the perforation to support closure.
What type of incision is used for emergency laparotomy in ulcer perforation?
Upper midline incision.
What is the goal of surgery in peptic ulcer disease?
Reduce gastric acid secretion and excise the ulcer.
What are surgical indications for peptic ulcer disease?
Failure of 12-week treatment, cancer suspicion, or complications (bleeding, obstruction, perforation).
What is the typical surgery for duodenal ulcers?
Highly selective vagotomy ± ulcer excision.
What types of gastric ulcers need truncal vagotomy?
Type II and III (due to acid hypersecretion).
What is the surgical procedure for:
• Type I gastric ulcer?
Ulcer excision + Billroth I (distal gastrectomy + gastroduodenostomy).
What is the surgical procedure for:
• Type II and III gastric ulcers?
Ulcer excision + truncal vagotomy + pyloroplasty.
What is the surgical procedure for:
• Type IV gastric ulcer?
Ulcer excision + Billroth II (distal gastrectomy + gastrojejunostomy).
What are the main nutritional disturbances after ulcer surgery?
Vitamin B12 and iron deficiency.
What is a marginal ulcer and where does it occur?
Ulcers that occur on stumps or anastomosis sites, usually related to incomplete vagotomy.
What are the clinical features of a marginal ulcer?
The patient presents with peptic ulcer disease (PUD) symptoms again.
What investigation confirms the diagnosis of a marginal ulcer?
Endoscopy
What is the management of a marginal ulcer?
Trial of PPIs and consider re-operation if needed.
What is post-vagotomy diarrhea and how common is it?
Diarrhea occurring in many patients after vagotomy; it typically improves over time.
What causes dumping syndrome?
Unregulated rapid movement of gastric contents into the small intestine, often hyperosmolar, leading to symptoms.
What are the two types of dumping syndrome based on timing?
• Early: Occurs 5–15 minutes post-prandially
• Late: Occurs 2–4 hours post-prandially
What are the GI symptoms of dumping syndrome?
Nausea, vomiting, diarrhea, flatus, and bloating.
What are the vasomotor symptoms of dumping syndrome?
Tachycardia, palpitations, flushing, diaphoresis, dizziness.
What is a late complication of dumping syndrome?
A: Hypoglycemia.
How is dumping syndrome managed?
Dietary modification
• Small, frequent meals
• Low in carbohydrates, high in proteins
• Avoid fluids with meals
What is afferent (or efferent) loop syndrome?
Obstruction or dilation of the afferent limb in a Billroth II procedure due to kinking, angulation, volvulus, or adhesions.
What are the clinical features of afferent loop syndrome?
• Post-prandial RUQ pain
• Abdominal fullness
• Bilious vomiting that relieves symptoms
• Steatorrhea
What investigations are used for afferent loop syndrome?
• Ultrasound: Shows dilated afferent loop
• Barium meal: Contrast enters afferent loop
What is the management for afferent loop syndrome?
Surgical revision (e.g., conversion to Billroth I or Roux-en-Y).
What is biliary gastritis (reflux gastritis)?
A: Bile reflux into the stomach causing mucosal irritation and gastritis.
What are the clinical features of biliary gastritis?
Bilious vomiting with gastritis symptoms.
How is biliary gastritis diagnosed?
Endoscopy
What is the management of biliary gastritis?
A: Revision surgery is indicated.
Which blood type is associated with gastric cancer
Blood type A (Think: there is an “A” in gastric but no “O” or “B” = gAstric = type “A”)
What are the symptoms of gastric cancer ?
The acronym “WEAPON”:
Weight loss
Emesis
Anorexia
Pain/epigastric discomfort
Obstruction
Nausea
What is a Blumer’s shelf?
Solid peritoneal deposit anterior to the rectum, forming a “shelf,” palpated on rectal examination
What is a Virchow’s node?
Metastatic gastric cancer to the nodes in the left supraclavicular fossa
What is a surveillance laboratory finding?
CEA elevated in 30% of cases (if +, useful for postoperative surveillance)
What is the histology? of gastric cancer
adenocarcinoma
Which morphologic type is named after a “leather bottle”?
Linitis plastica—the entire stomach is involved and looks thickened (10% of cancers)
Which patients with gastric cancer are NONoperative?
- Distant metastasis (e.g., liver metastasis) 2. Peritoneal implants
What is the genetic alteration seen in >50% of patients with gastric cancer?
P53
What is the treatment? of gastric cancer
Surgical resection with wide (>5 cm checked by frozen section) margins and lymph node dissection
What operation is performed for tumor in the:
Antrum?
Distal subtotal gastrectomy
What operation is performed for tumor in the:
midbody and proximal
Total gastrectomy
What is a total gastrectomy?
Stomach is removed and a Roux-en-Y limb is sewn to the esophagus
When should splenectomy be performed?
When the tumor directly invades the spleen/splenic hilum or with splenic hilar adenopathy
What is the differential diagnosis for gastric tumors?
Adenocarcinoma, leiomyoma, leiomyosarcoma, lymphoma, carcinoid, ectopic pancreatic tissue, gastrinoma, benign gastric ulcer, polyp
