Stomach Flashcards
MALT is a precursor to?
Gastric lymphoma
Regresses with H.pylori tx
Clo test detects?
Urease from H pylori
Gastric ulcers: type I, II, III, IV, V
I: lesser curve II: 2 ulcers (lesser curve and duodenal) III: prepyloric IV: high lesser curve V: anywhere a/w NSAID use
Risk factors for gastric adenocarcinoma?
Adenoma > 2 cm
Nitrosamines
Chronic atrophic gastritis/pernicious anemia
Gastric lymphoma tx
Chemo and radiation
Surgery for complications
Types of hiatal hernia
- Type 1: sliding hiatal hernia o If asymptomatic, can observe - Type 2: paraesophageal hernia o Always needs repair - Type 3: sliding hiatal hernia + paraesophageal hernia o Always needs repair - Type 4: entire stomach + organ in chest o Always needs repair
Repair of hiatal hernia
o Reduce hernia sac and brought back into esophagus
o Mesh, operator dependent
o Permanent suture to close crura
o Fundoplication
o Colles gastropexy í if unable to get length of esophagus freed
Types of gastric ulcers:
- Type 1: lesser curve
- Type 2: gastric ulcer a/w duodenal ulcer
o A/w high acid output - Type 3: pre-pyloric (distal)
o A/w high acid output - Type 4: ulcer near GEJ
- Type 5: anywhere, NSAID related
High risk recurrent GI bleed
o Active bleeding pulsatile vessel
o Visible vessel
o Adherent clot
o Clean ulcer base
Surgery for bleeding gastric ulcer
Midline laparotomy, anterior gastrotomy, oversew the bleeding area, make sure to bx, close gastrotomy
Surgery for bleeding duodenal ulcer
longitudinal anterior duodenotomy, control bleeding with sutures placed in superior and inferior positions of the ulcer to avoid CBD, ligate GDA above duodenum if bleeding continues after that, approximate ulcer crater and close the duodenotomy transversely
Ulcer Perforation tx
Antibiotics: broad-spectrum, +fungal
Surgical management: omental patch repair
Contained leak: non-op is reasonable if HDS
Refractory ulcer disease tx
Truncal vagotomy and pyloroplasty
Selective vagotomy
Vagotomy and antrectomy with Billroth reconstruction
Siewart-Stein classifications for GEJ cancers
- Type 1: distal esophagus, 1-5 cm above GEJ
- Type 2: cardia, within 1 cm above or below GEJ
- Type 3: 2-5 cm below GEJ in the stomach
Gastric volvulus associated with
paraesophageal hernia
Gastric volvulus rotations
- Organo-axial: rotates along the axis of the stomach from GEJ to the pylorus (vertical, coronal plane)
- Meso-axial rotation: along the short axis of stomach, bi-secting the lesser and greater curvature
Gastric volvulus tx
- Tx: emergent surgery
o Reduce the hernia
o Crural repair
o Gastropexy
o If needed, partial gastrectomy for de-vitalized tissue
o If not fit for surgery: endoscopic decompression, double-PEG tube
Alarm sx of GERD
dysphagia, odynophagia, weight loss, GI bleeding
W/u with EGD
DeMeester score:
% of time that pH in esophagus is <4, % of upright time with pH <4, % of supine time with pH <4, number of reflux episodes >5 min, and the longest reflux episode
> 14.72 = reflux
Bile reflux test
Impedence testing
Tx: roux-en-y
Surgical goals of anti-reflux surgery
” Restore normal anatomic position of the stomach and GEJ within the abdomen
“ Recreate anti-reflux valve, with negative intrathoracic pressure
“ Reduce hiatal hernia
“ Free esophagus in mediastinum
“ Close crura
“ 2 cm long fundoplication
Partial wraps useful in?
Motility disorders
Dor
Anterior partial fundoplication
Toupe
Posterior partial fundoplication
Tension capnothorax management
Enlarge pleural tear to prevent tension, red rubber catheter from pleura into abdomen to equalize pressures, needle decompression
Severe dysphagia, not handling secretions well post-fundoplication surgery
redo in OR
Retained antrum syndrome
retained antral tissue in the duodenal stump after a gastric resection
o G-cells cause continuous acid release -> ulceration in remnant stomach
o Tx: PPI, refer for vagotomy and resection of retained antrum
Late vs early dumping syndrome
o Early dumping syndrome
“ 20-30 min after a meal
“ Due to abrupt hyperosmolar load to small intestine
o Late dumping syndrome
“ 1-4 hrs after a meal
“ Rapid carb load in small intestine
“ Large insulin surge with rebound hypoglycemia
Bile reflux tx
o Dx: impedence studies
o Tx: medical management (pro-kinetics, bile-acid binding resins)
“ Surgical management: roux-en-y
“ 50 cm of roux limb to prevent bile reflux
Afferent loop syndrome
o Acute or chronic obstruction of afferent loop from Billroth II
o Sx: obstructive jaundice, cholangitis, pancreatitis
o Most concerning for duodenal stump blowout
o Bacterial overgrowth in limb in chronic afferent loop syndrome í can lead to steatorrhea, B12 deficiency, malnutrition due to deconjugation of bile acids from bacteria
“ Tx: antibiotics
“ Often need to convert to roux-en-y
“ Often present with bowel obstruction syndromes, if concerned about dilation/obstruction of afferent loop í Billroth II patients need emergent surgery
CDH1 gene
autosomal dominant familial gastric cancer
“ Need to do prophylactic gastrectomy
Role of Staging laparoscopy with peritoneal washings in gastric cancer?
Clinical stage > T1b tumors if chemoradiation or surgery being considered
T stages in gastric cancer
o T1a: before submucosa o T1b: invades submucosa o T2: muscularis propria o T3: invades subserosa o T4: invades through serosa into adjacent structures
Unresectable gastric cancers
o Peritoneal involvement
o Distal mets
o Root of mesentery or paraortic nodal disease
o Encasement of any major vascular structures (splenic not included)
Who get neoadjuvant in gastric cancer?
o Patient with any nodal involvement
o T2 or higher
Number of LN needed in resection for gastric cancer?
15
Margins for resection in gastric cancer?
4-5 cm
D1/D2 nodes
D1: peri-gastric nodes along greater or lesser curve
“ Nodal station 1-6
D2: peri-gastric nodes + LN around vessels
“ Nodal station 1-11
“ Increased morbidity with this in the US, improved survival in Asia
Surgical options in gastric cancer
o Total gastrectomy: proximal tumors
“ Esophagojejunostomy
o Subtotal gastrectomy: preferred for distal lesions
o Splenectomy: not performed unless spleen or hilum has tumor involvement
Who gets adjuvant tx?
o T3 or T4 or node positive disease, R0 resection -> adjuvant 5-FU chemo
Zollinger-Ellison syndrome
gastrin >1000, multiple duodenal ulcers
MALToma histology and tx
expansion of marginal zone and development of neoplastic lymphoid cells, tx with antibiotics for H pylori, often regress
Parietal cell function
Produce acid when 1 or more of 3 receptors are stimulated:
- Acetylcholine receptor (vagus nerve)
- gastrin receptor (D cells)
- histamine receptor (enterochromaffin like cells)
Where is acid produced in the stomach?
Proximal stomach - parietal cells
Antrum produces gastrin
Slipped gastric band treatment
HDS - removal of fluid from the band to give symptomatic relief and schedule for elective revision of gastric band
Unstable patient - need to rule out gastric incarceration, urgent laparoscopy
Ideal angle of band: 45 degrees
Dieulafoy lesion
Vascular malformations along lesser curve of the stomach, within 6 cm of GEJ
Caused by mucosal erosion into submucosal vessel, usually difficult to identify unless actively bleeding
Watermelon stomch
gastric antral vascular ectasia
Series of dilated vessels appearing as a longitudinal linear red streak on the antrum mucosa
Tx- endoscopic treatment, antrectomy if refractory bleeding
