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Surgery > Stomach > Flashcards

Stomach Flashcards

1
Q

Stomach develops at gestation during

A

5th week

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2
Q

Distal to GEJ

Most proximal portion of stomach

A

Cardia

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3
Q

Most superior portion of stomach

Separated from esophagus by cardiac notch or angle of His

A

Fundus

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4
Q

Fundus to pylorus

Largest portion of stomach

A

Corpus

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5
Q

Begins at angularis incisura wider leading to narrower pylorus

A

Antrum

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6
Q

Pyloric sphincter

controls release of gastric content into duodenun

A

pylorus

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7
Q

Layers of stomach

A

Mucosa: epithelium, lamina propria, muscularis mucosa (simple columnar cell)
Submucosa: strongest (CT and Meissner’s)
Muscularis propria or externa: inner oblique, middle circular, outer longitudinal, Auerbach’s
Serosa: visceral peritoneum

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8
Q

Forms characteristic rugae

A

Muscularis mucosa

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9
Q

40% of gastric epithelium

secretes pepsinogen

A

Chief cells

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10
Q

13% of gastric epithelium

HCl and IF secretion

A

Parieta oxyntic cells

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11
Q

Mucuous neck cells secrete

A

Mucuous

HCO3

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12
Q

D cells secrete

A

somatostatin

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13
Q

enterochromaffin cells

A

serotonin

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14
Q

enterochromaffin like cells

A

histamine

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15
Q

Surface epithelial cell
Mucuous cell
Non branching connected to pits glands
Mucuous and HC03

A

Cardia

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16
Q 
Mucuous cell, parietal and chief cells
Oxyntic glands
Tubular branching
Multiple gland empty into single pits
Mucuous, HC03 some HCl and IF
A

Fundus

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17
Q

Mucuous cell, parietal, chief, ECL, D cell
Oxyntic gland (fundus)
HCl, IF, pepsinogen and mucous

A

Corpus

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18
Q

Mucous cell, G cell and D cell
Pyloric gland
Straight and empty into deep pits
Mucous HCO3 gastrin and somatostatin

A

Antrum

Pylorus

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19
Q

40% of gastric epithelium

Secrete mucuous and HC03

A

Mucous neck cell

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20
Q 
3% of gastric epithelium
G cells
D cells
ECL 
ECL like cells
A

Endocrine cells

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21
Q

Secrete serotonin

A

Kulchitsky cell

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22
Q

Left gastric vein is also called

A

coronary vein

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23
Q

Communicates with portal system and systemic venous system via esophageal plexus
Involved in varices formation

A

Left gastric vein

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24
Q

Blood supply of stomach

A 
Left gastric artery
Right gastric artery
Left gastroepiploic artery
Right gastroepiploic artery
Short gastric artery
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25
Q

location of left vagus

A

anterior to stomach

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26
Q

branch of vagus nerve that comes off anteriorly on lesser curvature
cut in selective vagotomy but preserved in highly selective vagotomy

A

Laterjet nerve

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27
Q

Right vagus Runs posterior to stomach and gives off

A

Criminal nerve of Grassi

if undivider during vagotomy->recurrent ulcer

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28
Q

Parasympathetic inn of stomach

A

Vagus

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29
Q

Sympathetic innvervation of stomach

A

Celiac plexus

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30
Q

D1 perigastric nodes

A

Greater and lesser curvature

2,4,6 Greater curve
1,3,5 Lesser curve

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31
Q

D2 nodes

A

Left gastric artery, Common hepatic artery, celiac axis, splenic hilum, splenic artery

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32
Q

D3 nodes

A

Hepatoduodenal ligament

Mesenteric root node

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33
Q

D4 nodes

A

Paraaortic

Paracolic

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34
Q

Ach Vagus nerve mechanism of release

A

IP3 activation
Inc intracellular Ca
Protein kinase C activation

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35
Q

Gastrin G cell mechanism of release

A

IP3 activation
Inc intracellular Ca
Protein kinase C activation

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36
Q

Histamine ECL cell mechanism of release

A

Activated adenylate cyclase
Inc cAMP
Protein kinase A activation

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37
Q

Etiologies of stress gastritis

A

Sepsis
Shock
Severe burns

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38
Q

Tx for PUD

A

2 week course of lansoprazole, metronidazole, amoxicillin

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39
Q

Men 40-60
60-90% assoc with H pylori
NSAID use
Rule out gastric adenocarcinoma always

A

Gastric ulcer

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40
Q

Gastric ulcer type associated with blood type A

A

Type I

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41
Q 
Younger population 25-40
Excess HCl secretion (ZES)
90% H pylori infection related
Stress
Chemical ingestion
Tobacco and alcohol
A

Duodenal

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42
Q

Gastritis from toxic substances
NSAID, alcohol, drugs
Abdominal pain, UGIB, Perforation

Tx: remove cause, PPI or H2
Vagotomy with pyloroplasty for severe

A

Erosive gastritis

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43
Q

Alkaline bile refluxes into stomach leading to irritation and mucosal inflammation
Common after pyloroplasty or Bilroth II
Severe POSTPRANDIAL abdominal pain
Endoscopy with biopsy
Reconstruct with Roux-en-Y gastrojejunostomy

A

Alkaline reflux

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44
Q

From sepsis, shock, burns >30% TBSA leading to mucosal ischemia
UGIB
Endoscopy with biopsy
IV resuscitation, anti acid

A

Curling’s ulcer gastritis

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45
Q

CNS tumor/trauma causing inc in gastrin and HCl secretion
UGIB
Endoscopy with biopsy
IV resuscitation, anti acid

A

Cushing’s ulcer gastritis

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46
Q 
B12 def
Weight loss, megaloblastic anemia
Endoscopy with biopsy
Intrinsic factor administration
If severe: total gastrectomy with IV B12
A

Pernicious anemia gastritis

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47
Q

Most common type of gastric ulcer

Associated with blood type A

A

Type I

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48
Q

Types II-IV gastric ulcers are associated with

A

Blood type O

49
Q

Burning epigastric pain exacerbated by food

A

Gastric ulcer

50
Q

Epigastric pain relieved by food

A

Duodenal ulcer

51
Q

Most cost effective diagnostic test in PUD

A

UGI Contrast study

UGI endoscopy allows biopsy

All should have H pylori assessment: serology, endoscopy with biopsy (rapid urease, histology and culture)

52
Q

Distal portion of lesser curvature

Normal or DEC HCl

A

Type I Gastric ulcer

53
Q

Dista portion of lesser curvature
Associated with duodenal ulcer
Inc HCl

A

Type II Gastric ulcer

54
Q

Prepyloric or pyloric

Inc HCl

A

Type III Gastric ulcer

55
Q

Proximal portion of lesser curvature

Normal or dec HCl

A

Type IV Gastric ulcer

56
Q

Anywhere

Normal or inc HCl

A

Type V gastric ulcer medication NSAID induced

57
Q

Perforations of PUD occur

eroding

A

Posteriorly

Gastroduodenal artery

58
Q

General rule for PUD surgery

A

The smaller the less anatomically altering procedure (ex HSV) dec morbidity and mortality but inc ulcer recurrence

59
Q

Triple therapy

A 
PPI
2 antibiotics (clarithromycin, arithromycin, amoxicillin, metronidazole)
60
Q

All gastric ulcers must be biopsied to rule out

A

adenocarcinoma

61
Q 
25, M
Intermittent burning epigastric pain
Long standing diarrhea, unintentional weight loss
Nephrolithiasis
HYPERCALCEMIA
Anemia
Serum gastrin = 1350 
Dx:
Mx:
A

MEN I
Four gland parathyroidectomy with autotransplantation
Tx gastrinoma with PPI

62
Q

Rare gastrin secreting tumor (gastrinoma)
65% malignant half multiple 25% in MEN I
Severe intracrable multiple ulcer
Diarrhea, weight loss, steatorrhea
Serum gastrin >1000 And inc serum gastrin level >200 AFTER SECRETIN challenge
Endoscopy: mucosal hypertrophy with ulcer at proximal duodenum

A

Zollinger-Ellison Syndrome

63
Q

ZES dx

A

Abdominal CT MRI
Endoscopic UTZ
Ocreotide scan

64
Q

Gastrinoma triangle

A

Pancreatic neck
Porta hepatis
Third portion of duodenum

65
Q 
Gastric or duodenal ulcer
Inc liquid emptying rate
Quick technically easy 
Good for unstable patients
Diarrhea, dumping 
10% recurrence
A

Truncal vagotomy

Pyloroplasty

66
Q 
For gastric or duodenal ulcer
Inc liquid empyting
Lowest rate of recurrence 0-2%
Diarrhea dumping
Requires reconstruction 
1% mortality
A

Truncal vagotomy

Antrectomy

67
Q 
For gastric or duodenal ulcer except Type III
Normal or Inc liquid empyting
Post solid emptying is normal 
Dec receptive relaxation 
Increased satiety
Preservation of pyloroantral function
Not effective for type III 
Recurrence of 15-20%
A

Highly selective vagotomy HSV

68
Q 
Intractable pain, bleeding, perforation and obstruction
Inc liquid emptying rate
Early satiety
GERD
Curative preventing malignancy
Requires reconstruction
A

Subtotal gastrectomy

69
Q

Triad of ZES

A

Hypersecretion of HCl
Severe PUD
Gastrinoma

70
Q

Non ZES causes of hypergastrinemia

A 
GOO
Anemia pernicious
PPI
Atrophic gastritis
Antrum retained/excluded
Renal failure
71
Q

Large tortuous submucosal artery in proximal stomach
Pulsation cause ulceration of mucosa leading to intraluminal bleeding

Dx and tx:

A

Dieulafoy’s lesion

Endoscopy (electrocoagulation, photocoagulation, sclerotherapy, band ligation, clipping)

72
Q

Most common pathology of esophagus of all aged

Loss of gastroesophageal barrier with retrograde flow of gastric content into esophagus

A

GERD

73
Q

GERD RF

A

Inc gastric pressure (pregnancy, obesity)
Motility disorder disruptiong tone (scleroderma)
Hiatal hernia
Inc gastric acid production (ZES)
Tobacco
Alcohol
Caffeine

74
Q

Dx of pathologic GERD

A

ph Monitoring must assess:
Longest reflux episode
Number of episodes and number of episodes more than or equal to 5 minutes
Total time during which ph is <4
Total upright and supine time during which ph <4

75
Q

GERD Tx

A

H2 or PPI first line
Lifestyle modification

Sx: suspected or proven malignancy, gastric necrosis, gastric obstruction, severe hemorrhage or perforation and failure of medical

76
Q

Most commonly performed operation for GERD

A

Nissen fundoplication 360 degree

Others:

Toupet 180
Belsey Mark IV 270 through chest
Esophageal lengthening Collis

77
Q

Complications of antireflux procedure

A 
Pneumothorax most common
Wrap herniation
Gas bloat syndrome
Perforation
Hemorrhage (splenic laceration)
78
Q

Most common form of gastric cancer

Second most common cancer world wide

A

Gastric adenocarcinoma

79
Q

Gastric adenocarcinoma rf

A 
Male
Blood type A
Age (peak 7th)
Chronic inflammaion 
Tobacco
Low socioeconomic status and family history
Gastric cancer
80
Q

Glandular histology in older patient
Distal stomach
Associated with H pylori and atrophic gastristis

A

Intestinal type of gastric adenocarcinoma

81
Q

Younger patient
Proximal stomach
Extensive submucosa, transmural involvement
Metastatic
Signet ring cell with aggressive histology
Linitis plastica

A

Diffuse type of gastric adenocarcinoma

82
Q

Diffuse neoplasm involving entire stomach to give leather bottle appearance

A

Linitis plastica

83
Q

Dx of gastric adenocarcinoma

A

Upper endoscopy with multiple biopsies

CT identifies metastasis

Endoscopic uts for staging

84
Q

Gastric adenocarcinoma sx

A

Surgical resection with 6cm resection margin

85
Q

For proximal gastric adenocarcinoma, sx

A

Total gastrectomy preferred

Associated with inc morbidity and mortality

86
Q

Distal lesion gastric adenocarcinoma sx

A

Subtotal gastrectomy with margins preferred

87
Q

Right supraclavicular LN on gastric ca

A

Virchow’s

88
Q

Periumbilical lymph node

A

Sister Mary Joseph’s

89
Q

Peritoneal lymph node

palpable on rectal exam

A

Blumer’s shelf

90
Q

Ovarian metastasis from gastric carcinoma

A

Krukenberg tumor

91
Q

Prognosis of gastric carcinoma

A

5% survival in 10-20%

92
Q

Recurrence of gastric carcinoma because of

A

Locoregional failure

Peritoneal dissemination

93
Q

Surveillance post surgery for gastric carcinoma

A

Exam, labs, CXR every 4 months in 1st year
Every 6 months in 2nd year
Annual thereafter
CT of abdomen and pelvis with upper endoscopy regular interval

94
Q

Submucosal mesenchymal tumors from interstitial cells of cajal
Most common in stomach

A

GIST

95
Q

GIST mutation

A

TK mutation KIT protooncogene

96
Q 
Explosive diarrhea
Abdominal pain, nausea and vomiting
Inc HR, syncope, diaphoresis 
within 20-30 minutes of eating
Rapid passage of high osmolarity food from stomach to SI -> H20 shift into SI lumen

Tx: snall meals with high protein low simple carb
Supine after eating
Ocreotide

Convert bilroth to roux-en-y or reverse intestinal segment

A

Dumping syndrome, early

97
Q 
Explosive diarrhea
Abdominal pain, nausea and vomiting
Inc HR, syncope, diaphoresis 
2-3 HOURS after eating
Hyperactive insulin release leading to hypoglycemia after glucose load

Tx: snall meals with high protein low simple carb
Supine after eating
Ocreotide

Convert bilroth to roux-en-y or reverse intestinal segment

A

Dumping syndrome, late

98
Q

Partial obstruction of afferent limb leading to post prandial pain and fullness, billious projectile vomiting
Inc afferent loop pressure

A

Afferent loop syndrome

99
Q

Obstruction of efferent limb

Leading to abdominal pain, bilious vomiting and distention

A

Efferent loop syndrome

100
Q

Severe epigastric pan without billious vomiting and weight loss caused by reflux of alkaline material into stomach and esophagus

A

Alkaline reflux gastritis

101
Q

Epigastric pain, vomiting, weight loss due to abnormal gastric emptying

Abnormality in motility not mechanicsl obstruction

A

Roux syndrome

102
Q

Postoperative gastritis and ulcer due to inc HCl secretion

Retained antral mucosa in duodenal stump continuously bathed in alkaline secretion stimulating gastrin releease

A

Retained antrum

103
Q

Common after Bilroth II reconstruction

A

Afferent loop syndrome

Alkaline reflux gastritis

104
Q

Epigastric paib
Indigestiob
GI BLEEDING (hematemesis, melena)

IHC +

A

GIST

KIT

105
Q

Nonmetastatic GIST tx

A

En bloc resection with margins without lymph node dissection

106
Q

Metastatic, unresectable recurrent tumor:

Medication

A

Imatinib mesylate (tk inhibitor) then resect completely

55% - 5yr survival

107
Q

Most common site for primary GI lymphoma

A

Gastric MALTOma and lymphoma

108
Q

Gastric lymphoma and maltoma tx

Anemia
Satiety
Pain
Weakness
Fatigue
A

Chemoradiation since resection does not improve survival

Tx early maltoma with eradication of H pylori

109
Q

48, f
Post Roux-en-Y gastric bypass with abdominal pain and bloating
Tachycardic, distended abdomen with rebound tenderness and guarding

CT: Distention of distal gastric segment and biliopancreatic limb

Next step:

A

IV fluid resuscitation
Immediate reoperation to correct internal hernia
Reexplore to prevent strangulation and rupture of gastric staple line

110
Q

> 100 lbs overweight ag serious risk for obesity related disorder

A

Mortally obese

111
Q

Indications for bariatric surgery

A

BMI >40 kg/m2
>35 kg/m2 with comorb (HTN, DM, hyperlipidemia and oa)
Psych stability
Documented failed attempt at dietary weight loss
Complete understanding of operation and risk

112
Q

GI hormone involved in regulation of insulin release

A

GIP

CCK

113
Q

PUD with inc HCl

A

Type I or IV

114
Q

Ulcer not responsive to HSV

A

Type III

115
Q

Lap band placement which the gastrohepatic ligament is divided a plane between right diaphragmatic crus and overlying fat pad resected

A

Para flaccida

116
Q

Strongest layer of GI wall

A

Submucosa

117
Q

60 y, f
+ peritoneal cytology for gastric carcinoma
Is her disease stage IV?

A

No

Without gross metastases, not IV

118
Q

Ventral and dorsal structures from foramen of Winslow

A

Portal vein and inferior vena cava

Surgery (17 decks)

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