Stomach Flashcards

1
Q

Blood supply to stomach

A

Greater curve = R/L gastroepiploic arteries

Lesser curve = R/L Gastrics

Pylorus = Gastroduodenal artery

Fundus = Short gastrics

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2
Q

Innervation of stomach

A

“LARP”

Anterior = L Vagus nerve (gives branch to liver)

Posterior = R Vagus nerve (gives Celiac branch and the “criminal nerve of Grassi”)

Gastroduodenal pain = sensation via sympathetic afferents from level T5 (below nips) to T10 (umbilicus)

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3
Q

What are the causes of B12 deficiency?

A

1) Gastrectomy - loss of intrinsic factor-secreting tissue
2) Disease or resection of terminal ileum - malabsorption of B12
3) Pernicious anemia - AI destruction of parietal cells
4) Insufficient dietary intake - B12 is in most foods of animal origin

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4
Q

Parietal cells

A

Fundus and body

“oxyntic cells”

Secrete HCl and intrinsic factor

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5
Q

Chief cells

A

“peptic cells”

Fundus and body

Secrete pepsinogen. Pepsinogen is activated by HCl to form pepsin which digests proteins

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6
Q

G cells

A

Antrum

Secrete Gastrin - stimulates gastric acid secretion, pepsin secretion, and mucosal growth of GI tract (trophic action)

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7
Q

What stimulates acid secretion by parietal cells?

A

Vagus nerve (ACh via M3 receptors)

Histamine (H2 receptors)

Gastrin (via gastrin receptors)

Proton pump (H/K ATPase) is final common pathway

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8
Q

What stimulates release of gastrin from G cells?

A

Gastrin-releasing peptide (GRP)

Presence of digested protein products (AAs) in stomach

Inhibited by somatostatin and low antral pH (

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9
Q

What affects gastric mucosal barrier?

A

NSAIDs - damage it

Prostaglandin E - enhances it

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10
Q

What inhibits gastric HCO3 secretion into the mucosal barrier?

A

NSAIDs

Acetazolamide

Alpha blockers

Alcohol

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11
Q

PUD epi

A

H pylori, NSAIDs, smoking

FHx of ulcers, Z-E (gastrinoma), corticosteroids (high dose or longterm)

Ulcer incidence increases with age for both GUs and DUs

DU emerges two decades earlier than GU, particularly in men

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12
Q

Complications of PUD

A

1) Bleeding - 20% incidence
- hemorrhage: dizziness, syncope, hematemesis, melena

2) Perforation - 7% incidence - sudden severe midepigastric pain radiating to R shoulder with peritoneal signs and free peritoneal air

Posterior perf of a DU will cause pain that radiates to back and can cause pancreatitis or cause GI bleeding (erosion of gastroduodenal artery). Chest or abdominal film may not show free air bc the posterior duodenum is retroperitoneal

Anterior perf will show free air under diaphragm 70% of the time

3) Obstruction (gastric outlet) - due to scarring and edema; early satiety, anorexia, vomiting, weight loss

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13
Q

What are some alarm symptoms that indicate an EGD is needed

A

Weight loss

Recurrent vomiting

Dysphagia

Bleeding

Anemia

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14
Q

Duodenal Ulcer pathophys

A

Increased acid production (different from gastric ulcers)

H Pylori may weaken mucosal defenses

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15
Q

Causes of Duodenal Ulcers

A

1) H Pylori - makes urease which breaks down protective mucous lining of stomach. 10-20% of people with H Pylori develop PUD (H pylori may colonize 90% of us though so infection does not necessarily mean PUD)
2) NSAIDs/steroids - inhibit production of prostaglandin E, which stimulates mucosal barrier production
3) ZE syndrome - Gastrinoma (gastrin secreting tumor near pancreas - 2/3 are malignant). 20% of ZE patients have associated MEN1 (parathyroid hyperplasia, pancreatic islet tumors, pituitary tumors); diarrhea is common

ZE accounts of 0.1-1% of patients with ulcer, but over 90% of ZE patients have PUD (you can even see jejunal ulcers)

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16
Q

Clinical signs of Duodenal ulcers

A

Burning, gnawing epigastric pain that occurs with an empty stomach and is relieved by food or antacids

Nighttime awakening (when stomach empties)

N/v

Associated with blood type O

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17
Q

Dx of DUs

A

DU: EGD, but most symptomatic cases of DU are easily diagnosed clinically

H Pylori
1) EGD with bx - allows culture and sensitivity (very hard organism to culture - multiple specimens needed during bx)

2) Serology - Anti-Hpylori IgG indicates current or prior infection

Urease breath test: C-13/C-14 labeled urea ingested. If gastric urease is present, the carbon isotope can be detected as CO2 isotopes in breath

ZE - fasting serum gastrin > 1000.
- Secretin stimulation test: Secretin (gastrin inhibitor) is delivered parenterally usually with calcium and its effect on gastrin secretion is measured. In ZE, there is a paradoxical astronomic rise in serum gastrin

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18
Q

Tx for DUs

A

Medical:

1) Risk mods
- D/C NSAIDs, steroids, smoking
- Prostaglandin analogues (misoprostol)

2) Acid reduction
- PPI: 90% cure rate after 4 weeks
- H2 blockers (cimetidine, ranitidine, famotidine, nizatidine): 85-95% cure rate after 8w
- Antacids

3) Eradication of H Pylori
- Triple therapy (2w regimen with BID dosing) - PPI + Amoxicilin + Clarithromycin - 70-85% eradication rate
- If allergic to penicillin, can use metronidazole for amoxacillin
- If patient fails 1 course of therapy, can try alternate regimen using dif combo or quad therapy (2w PPI + bismuth + tetracycline + metronidazole) - 75-90% eradication rate

Surgical - indicated when ulcer is refractory to 12w of medical tx or if hemorrhage, obstruction or perf is present
1) Truncal vagotomy and selective vagotomy - high morbidity (Dumping syndrome) but successful just not used much anymore

2) *** procedure of choice is highly selective vagotomy - parietal cell vagotomy/prox gastric vagotomy
- individual branches of anterior and posterior nerves of Latarjet in gastrohepatic ligament going to lesser curve of stomach are divided. Terminal branches to pylorus and antrum are spared - NO NEED FOR GASTRIC DRAINAGE
- lowest rate of dumping, but higher recurrence rate
- Recurrence depends on site of ulcer preop. Prepyloric = 30% recurrence. Lowest recurrence is with vagotomy + antrectomy

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19
Q

Most common location for DU

A

Posterior duodenal wall within 2cm of pylorus

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20
Q

What are some complications that are specific to surgery for PUD?

A

GAME PAD

Gallstones
Afferent loop syndrome
Marginal ulcer
Efferent loop obstruction

Postvagotomy diarrhea (#1)
Alkaline reflux gastritis
Dumping syndrome

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21
Q

Gastric ulcer pathophys

A

Decreased protection against acid; acid protection may not even be elevated (can even occur with achlorhydria)

Can be caused by reflux of duodenal contents (pyloric sphincter dysfunction) and decreased mucus and HCO3 production

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22
Q

Causes of GUs

A

NSAIDs and steroids inhibit PGE (PGE stimulates production of protective mucus barrier)

H Pylori - makes urease which breaks down gastric mucosal barrier

Obviously smoking is a risk factor

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23
Q

Classification of GUs

A

Location determines classification and is important for treatment

“One is Less, Two has Two, Three is Pre, Four is by the Door”

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24
Q

Type I GU

A

Most common

Near angularis incisura on lesser curvature

From normal/decreased acid secretion; decreased mucosal defense

Surg tx = distal gastrectomy with ulcer excision

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25
Type II GU
Associated with DU (active or quiescent) From normal or increased acid secretion Surg tx = Antrectomy with truncal vagotomy and ulcer excision
26
Type III GU
Prepyloric From normal or increased acid secretion Surg tx = Antrectomy with truncal vagotomy and ulcer excision
27
Type IV GU
Near GEJ Normal or subnormal acid secretion; decreased mucosal defense Surg tx = distal gastrectomy with ulcer excision and esophagogastrojejunostomy
28
Signs/symptoms of GUs
Burning, gnawing epigastric pain that occurs with anything in the stomach; pain is worst after eating Anorexia/weight loss Vomiting Associated with blood type A
29
Dx of GUs
EGD All GUs are biopsied - 3% are associated with gastric cancer
30
Tx of GUs
Medical - same as DUs Surg - by type and indication
31
Signs of duodenal perforation
Bleeding from the Back (posterior duodenal erosion/perf involving gastroduodenal artery) Free Air from Anterior duodenal perf Anterior is more common than posterior
32
Curling's ulcer
Gastric stress ulcers in patients with severe burns
33
Cushing's ulcer
Gastric stress ulcer related to severe CNS damage
34
Gastritis
Acute or chronic inflammation of stomach lining Etiologies similar to PUD; EGD needed to tell the difference Dx via EGD Tx is same as medical treatment of gastric ulcers
35
Complications of chronic gastritis
Gastric atrophy Gastric metaplasia Pernicious anemia (lower production of IF from parietal cells due to idiopathic atrophy of gastric mucosa and later malabsorption of B12)
36
Etiologies of gastritis
GNASHING ``` Gastric reflux (bile or pancreatic secretions) Nicotine Alcohol Stress H Pylori and other infx Ischemia NSAIDs Glucocorticoids (longterm) ```
37
What are the 2 types of chronic gastritis?
A (fundal) - pernicious anemia, parietal cell antibodies, achlorhydria, autoimmune disease B (antral) - Bug (H pylori in almost all)
38
Which H2 blocker is known to be a P450 inhibitor?
Cimetidine Prolongs action of drugs cleared by this system
39
Postvagotomy diarrhea
A common postgastrectomy complication #1 complication of vagotomy Self-limited Symptomatic tx with motility-reducing agents (kaolin-pectin, loperamide, diphenoxylate) Refractory cases may respond to cholestyramine (bile-salt binding agent)
40
Dumping syndromes
Complciation postgastrectomy Complication of gastric surgery thought to come from unregulated movement of gastric contents from stomach to SI Symptoms usually 5-15mins postprandially (early dumping) due to high osmolar load reaching SI or 2-4hrs postprandial (late dumping) due to hypoglycemia N/v, belching, diarrhea, tachycardia, palpitations, flushing, diaphoresis, dizziness, syncope Treated by dietary mods - small, multiple low-carb/fat meals; avoid excess liquid intake Severe cases (1%) that do not respond to dietary mods can be treated with octreotide (synthetic somatostatin - helps delay gastric emptying time and transit through SI)
41
Alkaline reflux gastritis
Another postgastrectomy complication Diagnosis of exclusion after recurrent ulcer has been ruled out; nonspecific EGD and bx findings (edematous, inflamed gastric mucosa) p/w postprandial pain and bilious vomiting Surg management (medical is difficult) = RY gastojejunostomy with a long (50cm) Roux limb. Bilious vomiting may improve, but symptoms (early satiety, bloating) may persist
42
Afferent loop syndrome
Another postgastrectomy complication Obstruction of afferent limb following gastrojejunostomy (Billroth II). 2/3 present in postop week 1 Symptoms = postprandial RUQ pain, bilious vomiting, steatorrhea (with concomitant malabsorption of fats, B12), anemia Dx = afferent loop will be devoid of contrast in UGI series Tx = endoscopic balloon dilation or surgical revision of loop if that fails
43
Nutritional deficiencies following gastrectomy
B12 Fe Osteoporosis (reduced calcium absorption)
44
Common causes of Gastric outlet obstruction
Malignant tumors of stomach and head of pancreas Obstructing gastric or duodenal ulcers Usually with duodenal ulcer Chronic ulcer causes secondary edema or scarring, which occludes lumen
45
Symptoms of GOO
Early - early satiety - gastric reflux - abdominal distention Late - vomiting - dehydration - hypochloremic, hypokalemic metabolic alkalosis with paradoxical aciduria - weight loss
46
Dx of GOO
EGD or Barium swallow
47
Tx of GOO
Truncal vagotomy and pyloroplasty or gastrojejunostomy after 7d of NG decompression and antisecretory treatment NG decompression is necessary to normalize the size of the dilated stomach
48
Causes of upper GI hemorrhage
``` Ulcer (peptic) Varices Gastritis AV malformation Mallory-Weiss tear ```
49
Signs/symptoms of upper GI hemorrhage
Hematemesis (bright red or coffee grounds) Hypotension Tachy Bleeding that produces 60cc of blood or more will produce black, tarry stool (melena) Very brisk upper GI bleeds can be associated with bright red blood per rectum (hematochezia) and hypotension
50
Diagnosis of upper GI hemorrhage
Gastric lavage with NS or free water to assess severity of bleeding (old v new) Rectal exam CBC EGD Bleeding scan - detects active bleeding by infusing Tc-labeled RBCs and watching their collection in GI tract. It can be done in about an hour and can detect bleeds as slow as 0.1 ml/min, but location specificity is only 60-70%. CTA is faster and detects bleeds up to 0.5 ml/min Arteriography
51
Tx of upper GI bleed
Depends on etiology and severity Bleeding varices are ligated, or sclerosed via EGD Most M-W tears resolve on own For severe bleeds: - IVF and blood needed - Somatostatin (inhibits gastric, intestinal, and biliary motility, decreases visceral blood flow) - Consider balloon tamponade for varices Surgery - About 5% of the time, upper GI bleeding cannot be controlled via endoscopic or other methods and emergent laparotomy will be needed - For DUs, a longitudinal incision is made across pylorus and prox duodenum. Bleeding is controlled by undersewing the vessel on either side of the bleed
52
Risk of ulcers rebleeding
In hospital = 33% GUs are 3x more likely to rebleed than DUs
53
Prereq to bariatric surgery
Participation in supervised dietary program without success
54
Adenocarcinoma Epi
Gastric cancer is in general a disease of the elderly (age over 60), men>women, blacks>whites Adeno is 95% of malignant gastric cancer Leading cause of cancer death in Japan
55
Risk factors for adenocarcinoma of stomach
FAP Chronic atrophic gastritis H Pylori (6x risk) Post-partial gastrectomy (15+ years) Pernicious anemia Diet (foods high in nitrites - preserved, smoked, cured) Cigarette smoking
56
Pathology of gastric adeno
Polyploid: 25-50%, no real necrosis or ulceration Ulcerative: 25-50%, sharp margins Superficial spreading: 3-10%, involves mucosa and submucosa only - BEST PROGNOSIS Linitis plastica: 7-10%, "leather bottle" type, involves all layers, extremely poor prognosis
57
Signs/symptoms gastric adeno
Early: Mostly asymptomatic Late: Anorexia/weight loss, nausea, vomiting, dysphagia, melena, hematemesis; pain is constant, nonradiating, and worse with food. Anemia - from blood loss, pernicious
58
Krukenberg tumor
Metastasis to ovaries
59
Blumer's shelf
Metastasis to pelvic cul-de-sac, felt on digital rectal exam
60
Virchow's node
Metastasis to lymph node palpable in L supraclavicular fossa
61
Sister Mary Joseph nodule
Periumbilical metastatic nodules
62
Dx of gastric adeno
Upper GI EGD - best method. allows for bx. definitive > 95% sensitivity and specificity Upper GI series - with double contrast. 80-96% sens, 90% spec (operator dependent). excellent method in skilled hands Abdominal CT - good for detecting distant mets, also used for preop staging, but suboptimal Endoscopic US - good for detecting depth of invasion
63
Staging of gastric adenocarcinoma
T1s = carcinoma in situ - intraepithelial tumor without invasion of lamina propria T1 = invades lamina propria or submucosa T2a = invades muscularis propria T2b = invades subserosa T3 = penetrates serosa (visceral peritoneum) without invasion of adjacent structures T4 = Invades adjacent structures (spleen, colon, liver, diaphragm, pancreas, abdominal wall, adrenals, kidney, SI, retroperitoneum) ``` N1 = mets to 1-6 regional LNs N2 = 7-15 N3 = >15 ``` Stage 1A = T1N0M0 (70-80% 5yr) Stage 1B = T1N1M0 or T2a/2bN0M0 (55-70%) Stage 2 = T1N2M0 or T2N1M0 or T3N0M0 (40-50%) Stage 3a = T2N2M0 or T3N1M0 or T4N0M0 (10-20%) Stage 3b = T3N2M0 (10-20%) Stage 4 = T1-3N3M0 or T4N1-3M0 or AnyTAnyNM1 (
64
Tx of gastric adenocarcinoma
Radical subtotal gastrectomy can be curative in early disease confined to superficial layers of stomach (less than 1/3 of all patients due to late presentations) Chemo - sometimes used palliatively for nonsurg candidates; no role for adjuvant chemo
65
Prognosis of gastric adenocarcinoma
Tx is major prognostic factor - patients who are not resected have worse prognosis Location - prox gastric cancer is worse than distal lesions Tumor markers - high preOp levels of CEA and CA19-9 have worse outcomes Other factors = histo, regional LN spread
66
Gastric lymphoma epi
``` #2 most common malignant gastric cancer Stomach is most common site of primary GI lymphoma (majority are B cell non hodgkin) but lymphoma comprises only 4% of all gastric tumors ``` Increased risk with H pylori
67
Signs of gastric lymphoma
Nonspecific; include abdominal discomfort, nausea, vomiting, anorexia, weight loss, and hemorrhage, occult bleeding and anemia (half of patients)
68
Dx of gastric lymphoma
Made by endoscopic bx, nor readily distinguishable from adenocarcinoma by simple inspection Bone marrow aspiration and gallium bone scans can diagnose mets
69
Tx of gastric lymphoma
MALT (low grade) - treat H pylori MALT (high grade) or non-MALT - radiation/chemo +/- surg resection Resection reserved for patients with bleeding or perforation
70
Prognosis of gastric lymphoma
Poor factors are: Involving lesser curvature of stomach Large tumor size Advanced stage
71
GI stomal tumor
Mesenchymal tumors arising from gastric stroma; submucosal and slow growing Stomach is #1 site Dif histologies - from spindle cell tumors to epithelioid to pleomorphic 95% of GIST have c-kit (CD117) expression All are malignant Treated by surgical resection and Gleevec (imatinib) Prognosis depends on completeness of resection, presence of mets, and the mitotic index
72
Benign tumors/adenomatous polyps
10-20% of all gastric polyps The only ones with any real malignant potential - others are mostly asymptomatic and uncommon Biopsy if > 5mm to check for neoplasia
73
Menetrier's Disease definition
Hypertrophic gastropathy (enlarged, tortuous gastric rugae) Protein-losing enteropathy Mucosal thickening secondary to hyperplasia of glandular cells replacing chief and parietal cells Low grade inflammatory infiltrate - not a form of gastritis
74
Signs of Menetrier's
Most commonly middle aged man who presents with epigastric pain, weight loss, diarrhea, hypoproteinemia Less common is n/v, anorexia, occult GI bleed Gastric acid secretion can be high, normal or low
75
Dx of Menetrier's
EGD with deep mucosal bx is definitive Barium swallow will reveal large gastric folds and thickened rugae May look like gastric cancer on barium swallow
76
Complications of Menetrier's
``` Gastric ulcer Gastric cancer (increased incidence so monitor closely) ```
77
Tx of Menetrier's
Anticholinergics H2 blockers to reduce protein loss High protein diet Treatment of ulcers/cancers if present and eradication of H pylori Severe disease may require gastrectomy
78
Bezoars definition
Concretions of nondigestible matter that accumulate in stomach. May consist of hair (trichobezoar), vegetable matter (phytobezoar - esp in people who may have eaten persimmon), or charcoal (used in management of toxic ingestions) May develop after gastric surgery
79
Symptoms of Bezoars
Similar to GOO Occasionally causes ulceration and bleeding
80
Dx of Bezoars
EGD
81
Tx of Bezoars
Proteolytic enzymes - papain Mechanical fragmentation with endoscope Surg removal
82
Dieulafoy's Lesion
Mucosal end artery that causes pressure necrosis and erodes into stomach and ruptures Massive, recurrent painless hematemesis Dx = EGD Tx = endoscopic sclerosing therapy or electrocoagulation Wedge resection
83
Gastric volvulus definition
Torsion/twisting of stomach typically along long axis. Often linked with paraesophageal hernia. May be acute, must usually chronic
84
Gastric volvulus symptoms
Brochardt's triad 1) Intermittent severe epigastric pain and distention 2) Inability to vomit 3) Difficult passage of NG tube
85
Gastric volvulus dx and tx
Upper GI contrast study Surgical repair of accompanying hernia Gastropexy - fixes stomach to anterior abdominal wall Gastric resection if there is necrosis