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Stomach 2 Flashcards

1
Q

Hereditary diffuse gastric cancer is an inherited form of gastric CA, caused by what mutation?

A

E-cadherin mutation

***80% of these pts will develop gastric CA

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2
Q

Li Fraumeni syndrome is an AD syndrome caused by mutation what gene?

A

p53

**have risk of many malignancies, including gastric Ca

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3
Q

Hereditary non-polyposis colorectal cancer is AKA?

A

lynch syndrome

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4
Q

Lynch syndrome is a mutation in what?

A

assc w/ microsatellite instability

**also assc w/ increased risk of ovarian + gastric Ca

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5
Q

What is a micro-satellite?

A

lengths of DNA where 1 to 5 nucleotides motifs are repeated several times

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6
Q

What are some genes over-expressed in gastric Ca?

A

c-met

k-sam

c-erbB2

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7
Q

Pts with pernicious anemia are at increased risk of gastric Ca, what’s the defining feature of this dx?

A

achlorhydria

chief and parietal cells are destroyed by an autoimmune response

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8
Q

MOA of PPIs?

A

block H-K pump within the parietal cell

block all acid secretion in the stomach

***as a result pts develop hyper-gastrinemia

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9
Q

Few classification systems used to characterize gastric Ca?

A

Bormann classification–> uses macroscopic appearance, V types

Lauren classification–> separates gastric Ca into intestinal vs. diffuse type

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10
Q

What are some features of intestinal type gastric Ca?

A

arises in setting of a pre-cancerous condition; like gastric atrophy and intestinal metaplasia

M>W

incidence increases with age

mets via hematogenous spread

environmental causes involved

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11
Q

What are some features of diffuse type gastric Ca?

A

poorly differentiated, lacks glands

has tiny clusters of signet ring cells

W>M

younger age group affected

assc. w/blood type A

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12
Q

Diffuse type gastric Ca associated with what blood type?

A

type A

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13
Q

Better prognosis with intestinal or diffuse type gastric Ca?

A

intestinal type gastric Ca

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14
Q

Supraclavicular mets of gastric Ca called what?

A

Virchow’s nodes

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15
Q

What are Virchow’s nodes?

A

gastric Ca that has mets to supraclavicular nodes

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16
Q

What is a Sister Mary Joseph node?

A

gastric Ca that has mets to peri-umbilical area

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17
Q

Gastric Ca drop mets to ovaries called what?

A

Krukenberg tumors

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18
Q

Peritoneal gastric Ca mets felt on rectal exam called what?

A

Bloomer’s shelf

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19
Q

Most widely used staging system for gastric Ca?

A

TNM

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20
Q

In the TNM staging system for gastric Ca, how many nodes needs to be evaluated?

A

15

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21
Q

What’s the number of nodes that need to be evaluated in gastric Ca?

A

15

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22
Q

For gastric cancers of distal stomach, including the body and antrum, what operation do we perform?

A

distal gastrectomy

*distal margin should be proximal duodenum

frozen section should be performed prior to reconstruction

can do Bilroth I vs II

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23
Q

When performing gastrectomies for gastric Ca, how wide of a margin do we want?

A

at least 6 cm

studies have shown tumor spread as far as 5 cm

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24
Q

What surgery do we perform for proximal gastric Ca?

A

total gastrectomy w/Roux-en-y w/esophagojejunostomy

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25
Q

When do we perform endoscopic resection of early gastric Ca?

A

tumor is limited to the mucosa

there is NO lymphovascular invasion

tumor is smaller than 2 cm

there are no ulcers

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26
Q

Most recurrences of gastric cancer occur within what time frame?

A

3 yrs

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27
Q

Where does gastric Ca tend to spread to?

A

liver, lung, bone

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28
Q

MOst common site of lymphomas in the GI system>

A

stomach

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29
Q

Where do we see lymphomas most commonly in the GI system?

A

stomach

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30
Q

Share some facts about gastric lymphomas:

A

occur in older pts (6-7th decade)
M>F

usually occur in antrum

50% of pts will present with anemia

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31
Q

M0st common gastric lymphoma?

A

diffuse large B cell lymphoma (55%)

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32
Q

Most common gastric lymphomas?

A

diffuse large B cell (55%)

gastric MALT lymphoma (40%)

Burkitt’s lymphoma (3%)

mantle cell and follicular lymphoma (1%)

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33
Q

Risk factors for development of diffuse large B cell lymphoma??

A

h. pylori

immunodeficiencies

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34
Q

Burkitt’s lymphoma of stomach associated with what?

A

Epstein-barr virus

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35
Q

This type of gastric lymphoma is very aggressive, tends to affect younger pts, usually found in cardia of stomach;

A

Burkitt’s lymphoma

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36
Q

Tx for gastric lymphoma?

A

surgery controversial

most treated w/chemotherapy alone

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37
Q

Most common chemotherapy regimen for gastric lymphoma is?

A

CHOP

cyclophosphamide
doxorubicin
vincristine
prednisone

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38
Q

When is surgery for gastric lymphoma performed?

A

pts w/limited gastric disease

pts w/recurrence of treatment failure

pts w/complications like bleeding, obstruction, perforation

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39
Q

Gastric MALT lymphoma is usually preceded by what?

A

h-pylori associated gastritis

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40
Q

With this type of gastric lymphoma we see H. pylori involvement and increased NK-B activity;

A

gastric MALT lymphoma

41
Q

Tx for gastric MALT lymphomas?

A

usually tx for h.pylori showed remission in 75% of pts

42
Q

These gastric tumors derived from interstitial cells of Cajal:

A

GISTs

43
Q

Where do we GISTs come from?

A

originate from interstitial cells of Cajal, pacemaker intestinal cells

44
Q

Where do we commonly find GISts?

A

stomach

small intestine

colon

45
Q

GISTs stain for what CD?

A

CD117

CD 34

46
Q

C-kit (CD 117) proto-oncogene associated with what cancer?

A

GIST

47
Q

What CD do GISTs express?

A

90% c-kit proto-oncogene for CD 117

80% for CD 34

48
Q

Mainstay of tx for GISTs?

A

complete surgical excision

49
Q

Demographics of GISTs?

A

usually pts >50

equal m/f ratio

**Mostly develop de novo

50
Q

How do pts with GISTs present?

A

bleeding, abdominal pain, discomfort

51
Q

Why is long term follow up requires for GISTs?

A

recurrence can occur as late as 20 yrs

52
Q

What are the most important risk factors for determining if a GIST is malignant?

A

tumor size >10 cm

>5 mitoses HPF

53
Q

What is GLEEVEC?

A

imatinib

used as adjuvant therapy for GISTs

54
Q

MOA of imatinib?

A

tyrosine kinase inhibitor

55
Q

What drug do we use for GISTs?

A

imatinib–> tyrosine kinase inhibitor

56
Q

Most common locations for carcinoid tumors?

A

small intestine
appendix
rectum
rarely stomach

57
Q

What is Menetriere’s disease?

A

rare acquired pre-malignant disease characerized by massive gastric folds in the body and fundus of stomach

mucosa has a cobblestone or cerebriform appearance

58
Q

Menetriere’s dx is associated with what metabolic dernagements?

A

protein loss from stomach

excessive mucus production

achlorhydria

59
Q

What causes Menetriere’s dx?

A

cause unknown

assc. w/cytmegalovirus in kids and h.pylori in adults

60
Q

Tx for Menetriere’s dx?

A

acid suppression
ocreotide
h. pylori eradication

total gastrectomy for pts who have continued protein loss despite medical therapy

61
Q

This is related to forceful vomiting and retching, that results in disruption of gastric mucosa on the lesser curve at GE junction;

A

mallory weiss tear

62
Q

Overall mortality rate for Mallory Weiss tears?

A

3-4%

highest in alcoholic pts with portal htn

63
Q

How to manage a Mallory Weiss tear surgically?

A

most pts w/bleeding can be managed endoscopically

surgery is rare; usually done via anterior gastrotomy, bleeding site is oversewn with 2-0 silk sutures

64
Q

What is a DIeulafoy gastric lesion?

A

abnormally large, tortuous artery coursing thru the submucosa

65
Q

What causes the bleeding seen in Dieulafoy gastric lesions?

A

you have large tortuous arteries coursing thru the submucosa

pulsations of artery erode the mucosa

artery is then exposed to gastric contents and bleeds

**these lesions usually seen 6-10 cm from GE junction

66
Q

Classic presentation of a bleeding Dieulafoy lesion?

A

sudden onset massive painless recurrent hematemesis w/hypotension

67
Q

What causes gastric varices to develop?

A

can develop from splenic vein thrombosis causing htn

can develop from portal htn

68
Q

Gastric volvulus is uncommon and it can occur in two axes:

A

longitudinal axis; organoaxial (line drawn across lesser curve and greater curve)

vertical axis; mesoaxial (line drawn from GE jxn to pylorus)

69
Q

Difference between organoaxial and mesoaxial gastric volvulus?

A

organoaxial occur acutely, assc/ w diaphragmatic defect

mesoaxial volvulus is partial < 180 degrees, its recurrent, not assc. w/diaphragmatic defect

70
Q

Borchardt’s triad with gastric volvulus?

A

sudden onset sever abd pain

recurrent retching, minimal vomitus

unable to pass an NG tube

71
Q

Tx for acute gastric volvulus?

A

surgical emergency

stomach is reduced and uncoiled thru a trans-abdominal approach

72
Q

What are bezoars?

A

collections of non-digestable material

usually vegetable material; phytobezoars

trichobezoars; hair

73
Q

What is gastrostomy performed for?

A

alimentation vs decompression

74
Q

How is gastrostomy performed?

A

percutaneously (most common)

open

laparoscopic

75
Q

Open techniques for gastrostomy tube placement?

A

Stamm method*** most common can be done open vs laparoscopic

Witzel

Janeway method

76
Q

Complications of gastrostomy?

A

leakage w/peritonitis
infection
dislodgment
aspiration pneumonia

77
Q

What causes dumping syndrome?

A

caused by destruction or bypass of the pyloric sphincter

78
Q

Early dumping syndrome?

A

abrupt delivery of a hyperosmolar load into the small bowel due to ablation of pylorus or decreased gastric compliance

15-30 mins after a meal

pt becomes sweaty, weak, light headed, tachycardic

79
Q

Late dumping syndrome?

A

2-3 hrs after a meal

usually due to post-prandial hypoglycemia

usually relieved by administration of sugar

80
Q

Medical management of dumping syndrome?

A 
dietary management 
somatostatin analogues (ocreotide) (100 micrograms subcutaneously twice daily)
81
Q

How does ocreotide help in dumping syndrome?

A

helps ameliorate abnormal hormone pattern

helps restore a fasting motility pattern

82
Q

Greatest risk factors for stress gastritis?

A

prolonged ventilation >48 hrs

coagulopathy

83
Q

What causes late dumping syndrome seen 2-3 hrs after a meal?

A

rapid dumping of carbs into the intestines

pts become hypoglycemic due to hyperinsulinemia as a result of carb load

84
Q

What causes symptoms of late dumping syndrome?

A

carb load enters small intestine–> rapidly absorbed

hyperinsulinemia causes hypoglycemia

hypoglycemia triggers adrenal to make catecholamines–> tachycardia, tremulousness, sweating

85
Q

Where do we find type 2 gastric ulcers on the Johnson classification?

A

gastric body + duodenum

**assc w/acid

86
Q

What is a Cameron’s lesion?

A

chronic enteric blood loss from linear erosions at the level of the diaphragm within a hiatal hernia

87
Q

A gastric emptying study is considered abnormal if what

A

if >60% of radiotracer is present in stomach at 2 hrs

if >10% of radiotracer is present in stomach at 4 hrs

88
Q

To maintain adequate stomach perfusion which arteries do we need to preserve?

A

1/4 arteries needs to be intact

celiac artery supplies most of stomach

(4 main arteries are left + right gastric, left + right gastroepiploic)

89
Q

Left gastro-epipoloic comes off of what artery?

A

splenic

90
Q

How do we treat a 3 cm perforated anterior duodenal ulcer?

A

ulcer too big to close primarily, too much tension

jejunal serosal patch (Thal) should be used , less chance of a leak

to optimize post-op healing, can do temp pyloroplasty with gastrojejunosotomy

91
Q

GISTs stain for?

A

c-kit

92
Q

How do GISTs spread?

A

hematogenously

**Most commonly spread to liver and peritoneal surfaces

93
Q

Where do GISTs spread to?

A

liver

94
Q

Pts presenting with a Mallory-Weiss tear that resolve, when do you get repeat endoscopy?

A

not necessary

95
Q

Gastrinomas AKA?

A

zollinger-ellison syndrome

96
Q

How do diagnose a gastrinoma, Zollinger-Ellison syndrome?

A

secretin stimulation test

measure baseline gastrin levels

2 units/kg of secretin are injected and gastrin levels measured at 5 min intervals for 30 mins

gastrin level > 200 above basal level supports diagnosis

97
Q

5 year survival of gastric Ca with no neoadjuvant therapy;

A

I: 88-94%

II: 68-82%

IIIA: 54%, IIIB: 36%, IIIC: 18%

V: 4-5%

98
Q

When do we see Curling ulcers?

A

seen after burns >30% TBSA

99
Q

Benefits of diagnostic laparoscopy vs PET in looking for mets in advanced gastric CA?

A

PET misses 50% of mets

diagnostic lap is better

appendix (39 decks)

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