Stomach Flashcards
Give a differential for thickened, lobular folds in the body and antrum
Gastritis - H. pylori
Zollinger-Ellison
Lymphoma
Which ulcer is h. pylori more associated with?
Duodenal (90%) vs Gastric (70%)
Give a differential for small, round, filling defects with a small central collection of barium
Erosive (varioloform) gastritis Barium precipitate (dont have mound of edema) Crohns (will have other lesions)
What are the features of a benign gastric ulcer
Round or oval crater
Folds that CROSS the mound of surrounding edema
Symmetric and smooth filling defect surrounding the crater
Extension of the ulcer beyond the normal gastric lumen contour
Smooth and symmetric radiating gastric folds
Where do most benign ulcers occur
Along the lesser curvature or posterior wall of the antrum/body
Benign ulcers along the greater curvature are associated with what
aspirin coated medication
What is a hamptons line
Line of nonulcerated acid-resistant mucosa around the ulcer crater - BENIGN feature
How does a healing ulcer presents? When do they start to heal?
Linear configuration
Can split into 2 smaller crates as reepitheliazation occurs
8 weeks
What are the signs of a healed ulcer?
Radiating folds with retraction indicates fibrosis
Area gastricae in the scarred region
What is a benign sump ulcer? Differentiate between an intramural diverticulum.
An ulcer crater in the dependent stomach along the distal greater curvature (like a sump collection)
Usually due to medication
Smooth surfaced and tapers gradually. Surrounding edema has abrupt margins
Diverticulum will change shape with peristalsis and not have surrounding edema
What size is a giant ulcer? Is there any prognostic indication based on size? multiplicity?
> 3cm
Size doesnt matter
Multiple favor benign cause, but should be evaluated individually
What are the major complications of gastric ulcers?
Bleeding - most common
Perforation
Obstruction
Perforation with fistula formation
What is the most common cause of gastrocolic fistulas?
Primary carcinoma of stomach or colon
Differentail for enlarged rugal folds, hypersecretion, peptic ulcers, and thickened folds in the proximal small bowel
Zollinger - ellison
Lymphoma
Gastric Ca - focal mass or narrowing
Menetrier - proximal stomach only
What is zollinger - ellison syndrome?
Pathology
How many are malignant?
What associated sydrome? How many?
Symptoms
Diagnostic test?
Gastric secreting islet cell neoplasm
Marked hypersecretion of HCl with peptic ulcer disease
50% are malignant
1/4 have MEN1 (parathyroid, pitiutary, pheochromocytoma)
Intracatble peptic ulcer disease with malabsorption
Paradoxical increase in gastrin with secretin injection
What is an aphthous ulcer? What is it seen in ?
Central ulceration with surrounding mound of edema
Crohns (will have other GI involvement)
Erosive gastritis
Markedly enlarged gastric folds in the proximal stomach?
Menetrier disease (hypertrophic gastropathy)
Hyperplasia of surface epithelial cells with abundant mucus cells. Results in achlorhydria due to replacement of parietal cells.
Folds will be organized and follow distribution of normal rugae (unlike lymphomatous proliferation)
What is a differentiating feature between hyperplastic and adenomatous gastric polyps?
What do multiple small polyps designate?
Hyperplastic - multiple, 1cm, usually carry malignant potential if >2cm
Innumerable - FAP
What types of gastric polyp is seen in FAP? Duodenal polyp?
Gastric - hyperplastic
Duodenal - adenomatous
What are the two main variations of FAP?
Gardner - FAP, desmoid tumors, osteoma, epidermoid cysts, papillary thyroid
Turcot - FAP, CNS tumor (gliomas, medulloblastomas)
What type of polyp is seen in FAP associated symdromes?
The other polyposis syndromes? (canada chronkite, peutz jeugher)
Hyperplastic
Hamartomas
What are the following syndromes?
Mucocutaneous pigmentation, GI malignancy, gynecologic malignancy
Mucocutaneous lesions, thyroid abnormalities, breast abnormalities
Stomach, small bowel, colon, ectodermal changes (skin, hiar, nails)
Peutz-Jeugher
Cowden
Cronkhite-Canada
Differential for well demarcated, smooth surfaced mass
Submucosal tumor
GIST (most common submucosal gastric tumpor) Lipoma Fibroma Carcinoid Neurogenic tumors, leiomyoma
What characteristics help differentiate a malignant GIST?
Size - >10cm
Irregular shape
Central necrosis
Differentiate a lipoma/GIST from an ectopic pancreatic rest
EPR will have a central ulceration and be near the antrum
What are characteristics of malignant gastric ulcer?
Fold clubbing, tapering, interruption, and fusion
Nodular adjacent tissue
Abrupt transition between the surrounding tissue and normal gastric tissue
Crater doesnt project beyond expected location of the gastric wall
Radiating folds stop at the crater edge and do not reach the crater edge
Carter is wider than deep
What is the carmen meniscus sign?
Seen when a malignant ulcer straddles the lesser curvature and compression aposes both surfaces of the surrounding tumor.
Appears as a crescent (half moon) on the lesser curvature with nodular tumor surrounding the periphery
What are the risk factors for gastric carcinoma
High starch diets
Polycyclic hydrocarbons (smoked meats)
Nitrosamines (processed meats)
Nodular appearance of the gastric serosa indicates what
Extension to the omentum
What are the common nodal groups for gastric mets
lymphomaspecifically?
Parapancreatic, paraaortic, middle colic
Gastrohepatic (lesser and greater curvature)
Where are 4 common spots for peritoneal metastases
Pouch of douglas
Sigmoid mesocolon
Right paracoloic gutter
Small bowel mesentery
At what level does lymphadenopathy indicate lymphoma vs gastric carcinoma?
At or below the level of the renal pedicles
What is the most common nonnodal site for nonhodgkins lymphoma
Stomach
What are features that suggest gastric lymphoma over adenocarcinoma?
Multiplicity, submucosal, extesnion beyond the pylorus
What is the differential for a solitary ulcerated lesion in the stomach
GIST Primary gastric adenocarcinoma lymphoma ectopic pancreatic rest Metastatic melanoma
What is a bezoar
Concretions of ingested material
Mottled soft tissue mass which is not attached to a gastric wall and through which is interspersed barium
Differentiated by its free movement
What is the incidence of ectopic pancreatic rests?
How do the appear radiographically
14%
Umbilicated submucosal nodule with the distal stomach usually
What are two causes of gastric varices
Portal venous hypertension
Splenic vein occlusion
How can one differentiate splenic vein occlusion as the source of varices from portal hypertension?
Splenic vein occlusion will not have esophageal varices, because of the secondary drainage via short gastric veins. Blood will flow to thw gastric fundus plexus and return to the portal system via the left gastric
Smooth, symmetric tapering at the antrum suggests what 4 dx? “Rams horn” appearance
Scarring from PUD
Granulomatous disease - distal (antrum) stomach most commonly affected
Scirrhous carcinoma
Metastatic breast cancer (Scirrhous appearance)
Nodularity and narrowing of the distal stomach and nodular fold thickening in the small bowel suggests what?
Where is the best site for biopsy? Tx?
Eosinophlic gastroenteritis (Nodular appearance separates from other granulomatous diseases)
Antrum
Self limited
What is the differential for a featureless stomach?
Overdistension
Atrophic gastritis
What are the two types of atrophic gastritis?
Type A - autoimmune antibodies to parietal cells and intrinsic factor. usually affects the BODY and FUNDUS
Type B - H. pylori associated. usually affects the ANTRUM
Differentiate caustic stricture of the antrum from granulomatous disease.
Caustic will have a classic history of ingestion, lesions in the esophagus and duodenum, and be ABRUPT in margination
Granulomatous will be a smooth tapered narrowing.
What is a linitis plastica appearance? What is the pathology?
“Leather bottle” appearance, carcinomatous spread along the submucosa causes a desmoplastic reaction that looks like a narrowed water bottle.
What are the types of gastric adenocarcinoma? What is the difference?
Polypoid and ulcerative do not enhance
Scirrhous will enhance and is submucosal
What 4 entities can have a “linitis plastica” appearance?
Scirrhous gastric cancer
Metastatic BREAST cancer
Omental mets (lymphoma) alont the gastrocolic ligament
Granulomatous disease
What is a marginal/stomal ulcer? Where do they usually occur?
Perianastomotic ulcer developing after a gastorenterostomy.
Usually occur on the EFFERENT limb of the JEJUNUM, within 2 cm of the stoma.
Marginal ulcers should raise suspicion of what conditions
Incomplete vagotomy, retained gastric antrum (parietal cells), zollinger-ellison, hypercalcemia, smoking
What is afferent loop syndrome?
Dilated, fluid filled duodenum s/p billroth II
What is blind loop syndrome?
A sequelae of afferent loop syndrome, whereby obstruction leads to bacterial overgrowth, vitamin B12 deficiency, and megaloblastic anemia
What is a blown duodenal stump?
Breakdown or leakage of the afferent limb (duodenum) after a billroth II
Which limb more commonly intussucepts after billroth II?
Jejunal (efferent)
What are the two appearances of postgastrectomy carcinoma?
Constricting and diffuse, which will cause narrowing
Polypoid
What is the timeline for gastric remnant carcinoma vs primary tumor appearance
Remnant - several months
Primary - 20-30years
What are the 3 steps in a traditional gastric bypass
- creation of a small gastric pouch
- jejunogastrostomy using a jejunal roux limb with a small gastric stomal opening
- Side-to-side anastamosis of the excluded limb with the antegrade jejunal roux limb
What is the timeline and percentage of anastomotic leak postop gastric bypass
1-2 days, 1-5%
What is the incidence of internal hernia after gastric bypass? What are the imaging findings? Where is the most common defect?
2%
Clustered bowel loops, visible entrance and exit limbs, displaced jejunojejunal suture line, change in bowel configuration, stasis within herniated loops
Transverse mesocolon
Where do most gastric diverticula arise?
Posterior surface of fundus near GE junction
Will contain mucosal folds and change with peristalsis
Differentiate gastric ulcer and partial diverticulum
Diverticulum will change with peristalsis, usually located along greater curvature
Asymptomatic intramural pneumatosis is seen with what
Corticosteroid use
What are the two gastric volvuli? How do they differ? Which on is worse?
Organoaxial - along longitudinal axis of stomach, more common. Associated with hiatal hernia. Greater curvature is located superior and GE junction is in normal location
Mesenteroaxial - folds stomach in half, GE junction is displaced superiorly. More prone to ischemia.
