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QUESTION NOTES > STOMACH > Flashcards

STOMACH Flashcards

1
Q

What does GIST look like?

A

submucosal gastric mass w/ central necrosis

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2
Q

GIST arises from…?

A

interstitial cells of Cajal

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3
Q

Stains for GIST

A

c-kit (CD-117) and CD-34

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4
Q

GIST mets to where?

A

heme spread -> commonly spread to liver + peritoneal surfaces

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5
Q

Gastric carcinoids arise from what cells?

A

enterochromaffin cells

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6
Q

3 types of gastric carcinoids + mgmt?

A
  1. 2/2 atrophic gastritis/pernicious anemia (MC), low malignant potential -> local excision if <2cm + antrectomy
  2. 2/2 ZES -> less aggressive, typically complete regression after antrectomy
  3. sporadic, greatest malignant potential
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7
Q

Anatomical changes of stomach w/ hypergastrinemia 2/2 ZES vs. atrophic gastritis

A

ZES -> hypertrophic mucosa

atrophic gastritis -> lack of rugal folds

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8
Q

Most common Cx of gastric ulcer

A

perforation

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9
Q

Factors that predict MALT lymphoma Tx failure after H.pylori eradication

A
  • transmural tumor excision
  • nodal involvement
  • transformation into large-cell phenotype
  • T(11;18)
  • nuclear BCL-10 expression
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10
Q

Gastric ulcers mostly found where on stomach?

A

lesser curvature

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11
Q

Dyspepsia + failure PPI mgmt… next step?

A
  • upper endoscopy + mucosal biopsy (to r/o H.pylori)
  • if ulcer, need all 4 quadrant biopsy of ulcer margin
  • if H.pylori, treat, then re-eval after 2-3 months
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12
Q

Rate of bleeding detected by: angiography

A

> 0.5-1 cc/min

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13
Q

Rate of bleeding detected by: 99mtechnetium (Tc)-labeled RBC scan

A

0.04-0.1 cc/min, but have higher rate of inaccuracy dx location of bleed compared to angio

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14
Q

Surface epithelial cells of stomach secrete…?

A

mucus + bicarb (to maintain neutral pH 7.0 in gastric surface cell microenviro)

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15
Q

absolute C/I to PEG placement (6)

A
  • massive ascites (impairs tract formation and healing -> fluid leak and increase risk infection)
  • uncorrectable coagulopathy
  • peritonitis
  • severe malnutrition
  • gastric outlet obstruction (bc unable to pass endoscope into stomach)
  • life expectancy <30d
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16
Q

Is hiatal hernia C/I for PEG placement?

A

no - makes placement difficult, but insufflation will allow stomach to be closely approx with abdominal wall

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17
Q

Characteristic of GIST w/ high malignant potential? Mgmt?

A
  • > 5cm and <10cm with >5 mitoses/hpf (49-85% mortality)

- may benefit from adjuvant imatinib

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18
Q

Characteristic of GIST w/ low-mod malignant potential?

A
  • 2-5cm w/ >5 mitoses/hpf, or

- >10cm with <5 mitoses/hpf

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19
Q

Cameron’s lesion

A

source of chronic blood loss 2/2 mechanically induced linear erosions at level of diaphragm within hiatal hernia; needs operative mgmt

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20
Q

Borchardt triad

A
  • severe epigastric pain
  • inability to vomit
  • inability to pass NGT

-> think acute gastric volvulus (emergent surgery)

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21
Q

Gastrinoma triangle borders? Associated with?

A
  • ZES (gastrinoma) associated with MEN1

- jxn CD/CBD + jxn head/neck of pancreas + jxn 2nd/3rd duodenum

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22
Q

Reconstructive techniques following total gastrectomy

A
  1. RNY esophagojejunostomy
  2. RNY w/ pouch
  3. RNY w/ pouch w/ interposition
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23
Q

Non-ulcerogenic causes of hypergastrinemia

A

nl to low gastric acid secretion

  • atrophic gastritis
  • pernicious anemia
  • hx vagotomy
  • renal failure
  • short-gut syndrome
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24
Q

Ulcerogenic causes of hypergastrinemia

A

excess gastric acid secretion

  • antral G-cell hyperplasia or hyperfunction
  • gastric outlet obstruction
  • retained excluded gastric antrum
  • ZES
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25
Q

Mgmt gastric volvulus in poor surgical candidate

A

endoscopic decompression + single or double PEG (2-pt fixation to prevent re-volvulizing)

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26
Q

MC complication of vagotomy; tx?

A

diarrhea; Tx: PO cholestyramine

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27
Q

Highest risk re-bleeding if see this on EGD gastric ulcer

A

actively bleeding or visible vessel (even if not bleeding)

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28
Q

Types of gastric ulcer 2/2 high acid secretion

A

Type 2 + 3

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29
Q

Types of gastric ulcer 2/2 poor mucosal protection

A

Type 1 + 4

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30
Q

Type of gastric ulcer 2/2 NSAID use

A

5

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31
Q

Virchow’s node

A

supraclavicular node associated with gastric CA mets

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32
Q

Sister Mary Joseph node

A

periumbilical node

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33
Q

Most sensitive test H.pylori

A

Ab test

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34
Q

Best test to document resolution of H.pylori

A

urease breath test

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35
Q

When use imatinib for GIST?

A
  • tumors >5cm
  • > 5 mitoses per hpf
  • metastatic
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36
Q

Gastric volvulus associated with what type of hernia?

A

paraesophageal

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37
Q

Criminal nerve of DeGrassi

A

if did not divide all of celiac plexus (right vagus) -> will cause persistent hyperacid state

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38
Q

DeMeester Score based on…?

A

ambulatory pH testing:

  • total % time GERD with pH <4
  • total % time GERD upright
  • total % time GERD supine
  • # reflux episodes >5min
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39
Q

w/u GERD

A
  1. barium swallow
  2. EGD (biopsy if needed)
  3. pH testing
  4. esophageal manometry: esp important if considering doing Nissan; need normal motility
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40
Q

Peri-op difficulty ventilating pt during Nissen procedure… think? Tx?

A

capnothorax (CO2 leaking into chest); tx: need more enlarge tear into chest

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41
Q

When do Collis gastroplasty?

A

if during paraesophageal hernia repair and cannot get enough mobilization of esophagus… then need to do this esophageal lengthening procedure

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42
Q

Sxs dumping syndrome

A

after eating -> tachycardia, diaphoresis, flushing, dizziness

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43
Q

Mechanism of early vs. late dumping syndrome

A 
early = due to abrupt osmolar load to small bowel
late = due to rapid carb load leading to insulin surge + hypoglycemia
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44
Q

If had Bilroth or RNY, and present with sxs concerning for SBO… mgmt?

A

emergent surgery - high risk rupture

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45
Q

T-stage gastric CA

A 
T1A = lamina propria or muscularis mucosa
T1B = submucosa
T2 = muscularis propria
T3 = subserosa
T4 = through serosa, into adjacent structures
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46
Q

N-stage gastric CA

A 
N1 = 1-2
N2 = 3-6
N3 = >6
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47
Q

When need staging laparoscopy for gastric CA?

A

> T1B if CRT or surgery being considered bc occult mets

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48
Q

If splenic vessels involved in gastric CA… unresectable?

A

no, can resect + splenectomy

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49
Q

Unresectable gastric CA (4)

A
  • lap staging finds peritoneal involvement
  • distant mets
  • root of mesentery or periaortic nodal disease seen on biopsy
  • encasement of any vascular structure (not including splenic)
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50
Q

When do neoadjuvant for gastric CA?

A

> /= T3 or LN positive based of EUS

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51
Q

w/u staging gastric CA

A

CT A/C/P
EUS w/ FNA
laparoscopy

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52
Q

Margins and # nodes for gastric CA resection?

A

> 4-6cm margins (bc known to have wide lateral spread); 15 nodes

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53
Q

Nodal stations of gastric CA

A 
D1 = 1-6 stations (perigastric nodes along greater/lesser curve)
D2 = 1-6, and 7-11 station (included common hepatic, celiac, and splenic... essentially down to aorta)
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54
Q

Hx Bilroth 2 + intermittent abdominal pain that relieves w/ emesis + megaloblastic anemia… dx?

A

afferent limb syndrome

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55
Q

Role of PPI in H.pylori treatment

A

relief - does NOT reduce healing time

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56
Q

Gastric vs. duodenal ulcers… risk of malignancy?

A

gastric&raquo_space; duodenal (hence why to biopsy ALL gastric ulcers)

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57
Q

ZES triad

A

gastric acid hypersecretion + peptic ulcer disease + gastrinoma

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58
Q

Young pt w/ perf gastric ulcer… suspect?

A

ZES

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59
Q

Repair mgmt of large perf anterior duodenal ulcer

A

Thal patch (jejunal serosal repair) - less recurrent leak than w/ omental patch; cannot close primarily bc tension

+/- temp pyloroplasty + gastroJ reconstruction (to optimize healing)

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60
Q

Uncontrolled bleeding from duodenal ulcer… suspect?

A

posterior ulcer -> erosion to GDA

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61
Q

Best study of choice for suspected recurrent hiatal hernia

A

upper GI (detail to size, type of recurrence, location of GE jxn, etc)

62
Q

What is gastric tonometry used for?

A

measure luminal PCO2, with thought that luminal = mucosal PCO2, which can be used to calculate mucosal pH - monitor tissue perfusion in critical pts

63
Q

Why not use PPI w/ antacids or H2-blockers?

A

bc PPIs require acidic environment to be activated

64
Q

What is afferent loop syndrome (aka. blind loop syndrome)?

A

mechanical issue where afferent loop becomes partially or completely obstructed

65
Q

Afferent loop syndrome MC associated with what surgery?

A

antecolic Billroth II loop reconstructions with long (>30cm) afferent limb

66
Q

Mgmt afferent loop syndrome

A

surgery (billroth II -> RNY)

67
Q

Bile reflux gastritis 2/2 to…? Results in what histology?

A

exposure of gastric mucosa to bile, panc secretions, and duodenal contents -> intestinalization of gastric glands w/ inflammation

68
Q

Bile reflux gastritis MC seen after what surgery?

A

Billroth II bc defective pyloric channel

69
Q

EGD instrumentation: flexible endoscope

A

for investigating stomach to navigate its curvature and to retroflex

70
Q

EGD instrumentation: double-channel

A

for foreign object retrieval bc dx + therapeutic instruments can be passed thru scope

71
Q

EGD instrumentation: esophageal overtube

A

to protect esophageal mucosa and upper airway when pulling foreign body out of GI tract

72
Q

EGD instrumentation: forceps

A

to retrieve flat objects

73
Q

Recurrent ulcer disease s/p selective vagotomy… think?

A

incomplete posterior vagotomy - criminal nerve of Grassi

74
Q

Presentation of MALToma in small bowel

A

can present w/ obstructive sxs -> need resection + H.pylori treatement

75
Q

RF for gastric polyps

A

atrophic gastritis, H.pylori

76
Q

MC type gastric polyp

A

hyperplastic polyp

77
Q

Malignant potential in fundic polyp?

A

NO.

78
Q

Pt s/p lap gastric banding, presenting with erythema and port tenderness… high concern for…?

A

band erosion into stomach

79
Q

Dx gastric band c/b band erosion

A

upper endoscopy

80
Q

Gastric ulcer associated with large hiatal hernias?

A

Cameron ulcer

81
Q

Type of gastric ulcer associated with active or occult duodenal ulcer?

A

Type 2

82
Q

NSAID effect on gastrum?

A

decreases mucus secretion -> Type V ulcer

83
Q

Parietal cells stimulated to secrete acid by…?

A
  1. ACh (via vagus nerve)
  2. gastrin (G-cells)
  3. histamine (enterochromaffin-like cells)
84
Q

How does properly placed gastric band appear on plain film?

A

~45 degree upward angle from horizontal

85
Q

Gastric varices typically found where on stomach?

A

Cardia

86
Q

What is: Dieulafoy lesion?

A

vascular malformation along lesser curve (within 6cm of GE jxn); 2/2 erosion of gastric mucosa overlying submucosal vessels -> life-threatening arterial hemorrhage

*if not bleeding, often mistaken as normal mucosa on EGD

87
Q

What is: watermelon stomach?

A

gastric antral vascular ectasia - series of dilated vessels appearing as longitudinal linear red streaks on antrum mucosa

88
Q

Typical presentation of gastric antral vascular ectasia?

A

persistent Fe-deficiency anemia from occult blood loss (hemorrhage rare)

89
Q

Sleeve gastrectomy has higher incidence of what Cx compared to RNY gastric bypass?

A
  • leak
  • esophageal reflux (as high as 30%)
  • durability of sleeve beyond 5-yrs is unknown
90
Q

Sleeve gastrectomy has lower incidence of…? compared to RNY gastric bypass?

A
  • lower overall Cx rate

- lower incidence post-op malnutrition

91
Q

Sleeve gastrectomy vs. RNYGB in curing T2DM?

A

same - ~40% cured within 1 year for both

92
Q

MCC upper GI bleeding

A

peptic ulcer disease

93
Q

Mgmt unresectable GIST (c-kit mutation pos)

A

imatinib (400mg/day, unless KIT exon9 mutation, then 800mg/day) -> repeat staging in 6-mo -> 60% pts will be able to receive R0 resection -> stay on imatinib for 24-36mo

94
Q

MC side effect imatinib

A

edema, fluid retention

95
Q

Fxn of interstitial cells of Cajal

A

neural pacemaker cells responsible for smooth muscle activity in GI tract

96
Q

Fundic gastric polyps associated with…?

A
  • PPI use

- FAP

97
Q

In young pt with multiple fundic gastric polyps on endoscopy, suspect…?

A

FAP - need work-up

98
Q

Hyperplastic polyps associated with…?

A
  • H-pylori infection

- chronic gastritis

99
Q

Surveillance after gastric adenomatous polyp removal

A

endoscopy 6-12mo

100
Q

Endoscopic surveillance for Vanek tumors (inflammatory fibroid polyp)

A

none - no malignant potential

101
Q

Pt presenting with pain, dysphagia, N/V 12-mo s/p gastric bypass think…

A

marginal ulcer

102
Q

Risk factors for development of marginal ulcers s/p gastric bypass

A
  • smoking**
  • larger gastric pouch (>6cm long, >5cm wide)
  • NSAIDs
  • alcohol
103
Q

MALT is what kind of lymphoma?

A

B-cell lymphoma

104
Q

Bloody NG aspirate (not coffee ground) predicts what findings on endoscopy?

A

high-risk findings (active bleeding site, visible vessel, adherent clot)

105
Q

What is the Blatchford score?

A

helps identify need for endoscopic intervention

106
Q

What Blatchford score indicates 50% risk of needing endoscopic intervention

A

6+

107
Q

Indication for vagotomy in treatment of PUD

A

only for complicated PUD in pts with active tobacco smoking, NSAID use, or intolerance to NSAID

108
Q

Epidemiology for proximal vs. distal gastric cancers

A

Proximal: M>F 2:1; H.pylori is protective/risk-lowering
Distal: black > white; association with H.pylori

109
Q

Size of gastric ulcer to consider surgical mgmt

A

> 2cm

110
Q

Dx for gastroparesis

A

gastric emptying scintigraphy

111
Q

Mgmt asymptomatic Type 3 paraesophageal hernia in elderly pt

A

observation

112
Q

Best imaging to assess effectiveness of Heller myotomy

A

timed barium esophagram

113
Q

Persistent dysphagia (and delayed barium esophagram) s/p myotomy… need to do…?

A

esophageal manometry w/ amyl nitrite challenge - to differentiate incomplete myotomy vs. obstruction due to wrap too tight - amyl nitrite will relax incomplete myotomy

114
Q

If determine via manometry s/p myotomy that wrap is too tight… need to do what imaging to determine next mgmt?

A

EGD - if fixed obstruction requires surgical reintervention (slipped fundoplication) vs. pneumatic dilation

115
Q

Siewert classification of EGJ adenoCA

A

I: distal esophagus; located within 1-5cm above EGJ
II: true cardia CA; 1cm above to 2cm below EGJ
III: gastric; between 2-5cm distal to EGJ (although may enrouch to distal esophagus)

116
Q

Mgmt EGJ cancers

A

complete macro and microscopic tumor resection

117
Q

Mgmt GIST (dependent on size)

A

local surgical excision with neg margins (LN mets rare so NO LN resection) - +/- imatinib therapy
=/<5cm - laparoscopic wedge resection
>5cm - require laparotomy
<1cm may be observed with repeat EGD in 1-yr

118
Q

Mgmt perforated duodenal ulcer 2/2 complicated PUD - HDS

A

truncal vagotomy + antrectomy (lower recurrence rate than highly selective vagotomy + gastroJ)

119
Q

When do Belsey-Mark IV procedure?

A

when not enough fundus for fundiplication - rarely done anymore. (can also do collis gastroplasty)

120
Q

Incomplete vagotomy more common Cx in truncal vs. highly selective vagotomy?

A

highly selective vagotomy

121
Q

Mgmt unstable pt presenting with prepyloric gastric ulcer

A

biopsy, omental patch repair, washout

122
Q

Mgmt sporadic type III gastric carcinoid tumor

A 
(elevated urine 5-HIAA, normal gastrin level)
gastric resection (may be partial) + regional lymphadenectomy
123
Q

Mgmt alkaline (bile) reflux gastritis

A

medical mgmt for symptom relief, but if intractable, then conversion previous gastric surgery -> RNY

124
Q

What should be done surgically to avoid bile reflux gastritis?

A

Make Roux limb at least 45cm long

125
Q

Origin of right gastroepiploic artery?

A

GDA artery (off common hepatic artery)

126
Q

Origina of right gastric artery?

A

common hepatic artery (after GDA branches off)

127
Q

Origin of left gastroepiploic artery?

A

Splenic artery

128
Q

If have AD mutation in CDH1, then need…?

A

prophylactic gastrectomy between age 18-40 … also high risk breast CA

129
Q

How many biopsies needed for accurate >95% ulcer for CA?

A

7

130
Q

Physical Exam findings for metastatic gastric CA (6)

A
  • Virchows node
  • Sister Mary node
  • Krunkenberg node
  • Blumer shelf (nodes in pouch of Douglas)
  • Irish node (axillary node)
  • Trousseau syndrome
131
Q

Surgical resection for gastric cancer

A

R0 resection + omentectomy + regional LN dissection

132
Q

Resection for proximal vs. distal gastric cancer

A

Proximal - total gastrectomy (bc less reflux and other complications compared to subtotal)
Distal - subtotal

133
Q

Mgmt gastroparesis refractory to dietary modifications and medical mgmt

A

Gastric pacemaker or pyloroplasty (feeding tube or TPN only if nutrition state is critical or if all other options have failed)

134
Q

SE metoclopramide

A
  • prolonged QT

- tardive dyskinesia

135
Q

Which type of vagotomy requires pyloroplasty (drainage procedure)?

A

Truncal vagotomy

136
Q

Where is laparoscopic adjustable gastric band placed anatomically?

A

@ proximal stomach

137
Q

Pt with recurrent UGI bleed s/p first attempt EGD control… next step?

A

repeat EGD - 25% pts will fail, but no increase in mortality for pts that go for second attempt at endo

138
Q

If recurrent UGI bleeding after second attempt EGD control… next step?

A

angiogram with embolization

139
Q

What is the Roux limb?

A

intestinal segment following surgery that is the primary recipient of food

140
Q

Anatomical RF for developing afferent loop syndrome?

A

afferent limb >30-40cm + anastomosis to gastric remnant in antecolic fashion

141
Q

Duodenal stump rupture after gastrectomy due to… what reasons?

A
  • inadequate duodenal stump closure
  • obstruction of afferent loop
  • local pancreatitis
  • poor surgical technique
142
Q

MC pattern of inflammation associated with H.pylori infection

A

mild-to-mod inflammation in ALL regions of stomach (most with this pattern do not develop PUD)

143
Q

Three major patterns of inflam response associated with H.pylori

A
  1. mild-to-mod inflam in all regions of stomach
  2. high acid output + devel of duo and prepyloric ulcers
  3. predom body of stomach - gastric atrophy, hypergastrin, precursor for gastric cancer
144
Q

Pts with duodenal ulcer tend to have what level of bicarb secretion?

A

lower basal and stimulatory duodenal bicarb section -> hence, impairment of mucosal defense -> prone to ulcers

145
Q

MOA erythromycin as promotility agent

A

Acts on motilin receptors located on SM in GI tract

146
Q

Dx gastric band erosion

A

Upper endoscopy

147
Q

Mgmt kinking of tubing that connects gastric band to subQ port (unable to add/remove fluid)

A

Exploration of port and tubing under local anesthesia

148
Q

Tx H.pylori

A

PPI + 2 Abx (amoxicillin, metronidazole, tetracycline, clarithromycin)

149
Q

RF development of gastric adenoCA

A
  • smoking, alcohol
  • pernicious anemia
  • EBV infection
  • iron and tin manufacturing
  • high nitrogen foods (smoked)
  • Type A blood type
  • previous H.pylori infection, chronic gastritis -> development of pilots
150
Q

MCC gastroparesis (#1, #2, #3)

A 
MC: idiopathic
#2: DM
#3: cavalry injuries (ie. s/p Nissen)
151
Q

MC site extranodal lymphoma

A

Stomach

QUESTION NOTES (28 decks)

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