Stomach Flashcards
1
Q
Stomach develops at gestation during
A
5th week
2
Q
Distal to GEJ
Most proximal portion of stomach
A
Cardia
3
Q
Most superior portion of stomach
Separated from esophagus by cardiac notch or angle of His
A
Fundus
4
Q
Fundus to pylorus
Largest portion of stomach
A
Corpus
5
Q
Begins at angularis incisura wider leading to narrower pylorus
A
Antrum
6
Q
Pyloric sphincter
controls release of gastric content into duodenun
A
pylorus
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
8
Q
Forms characteristic rugae
A
Muscularis mucosa
9
Q
40% of gastric epithelium
secretes pepsinogen
A
Chief cells
10
Q
13% of gastric epithelium
HCl and IF secretion
A
Parieta oxyntic cells
11
Q
Mucuous neck cells secrete
A
Mucuous
HCO3
12
Q
D cells secrete
A
somatostatin
13
Q
enterochromaffin cells
A
serotonin
14
Q
enterochromaffin like cells
A
histamine
15
Q
Surface epithelial cell
Mucuous cell
Non branching connected to pits glands
Mucuous and HC03
A
Cardia
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
17
Q
Mucuous cell, parietal, chief, ECL, D cell
Oxyntic gland (fundus)
HCl, IF, pepsinogen and mucous
A
Corpus
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
19
Q
40% of gastric epithelium
Secrete mucuous and HC03
A
Mucous neck cell
20
Q
3% of gastric epithelium G cells D cells ECL ECL like cells
A
Endocrine cells
21
Q
Secrete serotonin
A
Kulchitsky cell
22
Q
Left gastric vein is also called
A
coronary vein
23
Q
Communicates with portal system and systemic venous system via esophageal plexus
Involved in varices formation
A
Left gastric vein
24
Q
Blood supply of stomach
A
Left gastric artery Right gastric artery Left gastroepiploic artery Right gastroepiploic artery Short gastric artery
25
location of left vagus
anterior to stomach
26
branch of vagus nerve that comes off anteriorly on lesser curvature
cut in selective vagotomy but preserved in highly selective vagotomy
Laterjet nerve
27
Right vagus Runs posterior to stomach and gives off
Criminal nerve of Grassi
| if undivider during vagotomy->recurrent ulcer
28
Parasympathetic inn of stomach
Vagus
29
Sympathetic innvervation of stomach
Celiac plexus
30
D1 perigastric nodes
Greater and lesser curvature
2,4,6 Greater curve
1,3,5 Lesser curve
31
D2 nodes
Left gastric artery, Common hepatic artery, celiac axis, splenic hilum, splenic artery
32
D3 nodes
Hepatoduodenal ligament
| Mesenteric root node
33
D4 nodes
Paraaortic
| Paracolic
34
Ach Vagus nerve mechanism of release
IP3 activation
Inc intracellular Ca
Protein kinase C activation
35
Gastrin G cell mechanism of release
IP3 activation
Inc intracellular Ca
Protein kinase C activation
36
Histamine ECL cell mechanism of release
Activated adenylate cyclase
Inc cAMP
Protein kinase A activation
37
Etiologies of stress gastritis
Sepsis
Shock
Severe burns
38
Tx for PUD
2 week course of lansoprazole, metronidazole, amoxicillin
39
Men 40-60
60-90% assoc with H pylori
NSAID use
Rule out gastric adenocarcinoma always
Gastric ulcer
40
Gastric ulcer type associated with blood type A
Type I
41
```
Younger population 25-40
Excess HCl secretion (ZES)
90% H pylori infection related
Stress
Chemical ingestion
Tobacco and alcohol
```
Duodenal
42
Gastritis from toxic substances
NSAID, alcohol, drugs
Abdominal pain, UGIB, Perforation
Tx: remove cause, PPI or H2
Vagotomy with pyloroplasty for severe
Erosive gastritis
43
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
Alkaline reflux
44
From sepsis, shock, burns >30% TBSA leading to mucosal ischemia
UGIB
Endoscopy with biopsy
IV resuscitation, anti acid
Curling’s ulcer gastritis
45
CNS tumor/trauma causing inc in gastrin and HCl secretion
UGIB
Endoscopy with biopsy
IV resuscitation, anti acid
Cushing’s ulcer gastritis
46
```
B12 def
Weight loss, megaloblastic anemia
Endoscopy with biopsy
Intrinsic factor administration
If severe: total gastrectomy with IV B12
```
Pernicious anemia gastritis
47
Most common type of gastric ulcer
| Associated with blood type A
Type I
48
Types II-IV gastric ulcers are associated with
Blood type O
49
Burning epigastric pain exacerbated by food
Gastric ulcer
50
Epigastric pain relieved by food
Duodenal ulcer
51
Most cost effective diagnostic test in PUD
UGI Contrast study
UGI endoscopy allows biopsy
All should have H pylori assessment: serology, endoscopy with biopsy (rapid urease, histology and culture)
52
Distal portion of lesser curvature
| Normal or DEC HCl
Type I Gastric ulcer
53
Dista portion of lesser curvature
Associated with duodenal ulcer
Inc HCl
Type II Gastric ulcer
54
Prepyloric or pyloric
| Inc HCl
Type III Gastric ulcer
55
Proximal portion of lesser curvature
| Normal or dec HCl
Type IV Gastric ulcer
56
Anywhere
| Normal or inc HCl
Type V gastric ulcer medication NSAID induced
57
Perforations of PUD occur
| eroding
Posteriorly
| Gastroduodenal artery
58
General rule for PUD surgery
The smaller the less anatomically altering procedure (ex HSV) dec morbidity and mortality but inc ulcer recurrence
59
Triple therapy
```
PPI
2 antibiotics (clarithromycin, arithromycin, amoxicillin, metronidazole)
```
60
All gastric ulcers must be biopsied to rule out
adenocarcinoma
61
```
25, M
Intermittent burning epigastric pain
Long standing diarrhea, unintentional weight loss
Nephrolithiasis
HYPERCALCEMIA
Anemia
Serum gastrin = 1350
Dx:
Mx:
```
MEN I
Four gland parathyroidectomy with autotransplantation
Tx gastrinoma with PPI
62
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
Zollinger-Ellison Syndrome
63
ZES dx
Abdominal CT MRI
Endoscopic UTZ
Ocreotide scan
64
Gastrinoma triangle
Pancreatic neck
Porta hepatis
Third portion of duodenum
65
```
Gastric or duodenal ulcer
Inc liquid emptying rate
Quick technically easy
Good for unstable patients
Diarrhea, dumping
10% recurrence
```
Truncal vagotomy
| Pyloroplasty
66
```
For gastric or duodenal ulcer
Inc liquid empyting
Lowest rate of recurrence 0-2%
Diarrhea dumping
Requires reconstruction
1% mortality
```
Truncal vagotomy
| Antrectomy
67
```
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%
```
Highly selective vagotomy HSV
68
```
Intractable pain, bleeding, perforation and obstruction
Inc liquid emptying rate
Early satiety
GERD
Curative preventing malignancy
Requires reconstruction
```
Subtotal gastrectomy
69
Triad of ZES
Hypersecretion of HCl
Severe PUD
Gastrinoma
70
Non ZES causes of hypergastrinemia
```
GOO
Anemia pernicious
PPI
Atrophic gastritis
Antrum retained/excluded
Renal failure
```
71
Large tortuous submucosal artery in proximal stomach
Pulsation cause ulceration of mucosa leading to intraluminal bleeding
Dx and tx:
Dieulafoy’s lesion
Endoscopy (electrocoagulation, photocoagulation, sclerotherapy, band ligation, clipping)
72
Most common pathology of esophagus of all aged
| Loss of gastroesophageal barrier with retrograde flow of gastric content into esophagus
GERD
73
GERD RF
Inc gastric pressure (pregnancy, obesity)
Motility disorder disruptiong tone (scleroderma)
Hiatal hernia
Inc gastric acid production (ZES)
Tobacco
Alcohol
Caffeine
74
Dx of pathologic GERD
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
GERD Tx
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
Most commonly performed operation for GERD
Nissen fundoplication 360 degree
Others:
Toupet 180
Belsey Mark IV 270 through chest
Esophageal lengthening Collis
77
Complications of antireflux procedure
```
Pneumothorax most common
Wrap herniation
Gas bloat syndrome
Perforation
Hemorrhage (splenic laceration)
```
78
Most common form of gastric cancer
| Second most common cancer world wide
Gastric adenocarcinoma
79
Gastric adenocarcinoma rf
```
Male
Blood type A
Age (peak 7th)
Chronic inflammaion
Tobacco
Low socioeconomic status and family history
Gastric cancer
```
80
Glandular histology in older patient
Distal stomach
Associated with H pylori and atrophic gastristis
Intestinal type of gastric adenocarcinoma
81
Younger patient
Proximal stomach
Extensive submucosa, transmural involvement
Metastatic
Signet ring cell with aggressive histology
Linitis plastica
Diffuse type of gastric adenocarcinoma
82
Diffuse neoplasm involving entire stomach to give leather bottle appearance
Linitis plastica
83
Dx of gastric adenocarcinoma
Upper endoscopy with multiple biopsies
CT identifies metastasis
Endoscopic uts for staging
84
Gastric adenocarcinoma sx
Surgical resection with 6cm resection margin
85
For proximal gastric adenocarcinoma, sx
Total gastrectomy preferred
| Associated with inc morbidity and mortality
86
Distal lesion gastric adenocarcinoma sx
Subtotal gastrectomy with margins preferred
87
Right supraclavicular LN on gastric ca
Virchow’s
88
Periumbilical lymph node
Sister Mary Joseph’s
89
Peritoneal lymph node
| palpable on rectal exam
Blumer’s shelf
90
Ovarian metastasis from gastric carcinoma
Krukenberg tumor
91
Prognosis of gastric carcinoma
5% survival in 10-20%
92
Recurrence of gastric carcinoma because of
Locoregional failure
| Peritoneal dissemination
93
Surveillance post surgery for gastric carcinoma
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
Submucosal mesenchymal tumors from interstitial cells of cajal
Most common in stomach
GIST
95
GIST mutation
TK mutation KIT protooncogene
96
```
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
Dumping syndrome, early
97
```
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
Dumping syndrome, late
98
Partial obstruction of afferent limb leading to post prandial pain and fullness, billious projectile vomiting
Inc afferent loop pressure
Afferent loop syndrome
99
Obstruction of efferent limb
| Leading to abdominal pain, bilious vomiting and distention
Efferent loop syndrome
100
Severe epigastric pan without billious vomiting and weight loss caused by reflux of alkaline material into stomach and esophagus
Alkaline reflux gastritis
101
Epigastric pain, vomiting, weight loss due to abnormal gastric emptying
Abnormality in motility not mechanicsl obstruction
Roux syndrome
102
Postoperative gastritis and ulcer due to inc HCl secretion
| Retained antral mucosa in duodenal stump continuously bathed in alkaline secretion stimulating gastrin releease
Retained antrum
103
Common after Bilroth II reconstruction
Afferent loop syndrome
| Alkaline reflux gastritis
104
Epigastric paib
Indigestiob
GI BLEEDING (hematemesis, melena)
IHC +
GIST
KIT
105
Nonmetastatic GIST tx
En bloc resection with margins without lymph node dissection
106
Metastatic, unresectable recurrent tumor:
Medication
Imatinib mesylate (tk inhibitor) then resect completely
55% - 5yr survival
107
Most common site for primary GI lymphoma
Gastric MALTOma and lymphoma
108
Gastric lymphoma and maltoma tx
```
Anemia
Satiety
Pain
Weakness
Fatigue
```
Chemoradiation since resection does not improve survival
Tx early maltoma with eradication of H pylori
109
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:
IV fluid resuscitation
Immediate reoperation to correct internal hernia
Reexplore to prevent strangulation and rupture of gastric staple line
110
>100 lbs overweight ag serious risk for obesity related disorder
Mortally obese
111
Indications for bariatric surgery
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
GI hormone involved in regulation of insulin release
GIP
| CCK
113
PUD with inc HCl
Type I or IV
114
Ulcer not responsive to HSV
Type III
115
Lap band placement which the gastrohepatic ligament is divided a plane between right diaphragmatic crus and overlying fat pad resected
Para flaccida
116
Strongest layer of GI wall
Submucosa
117
60 y, f
+ peritoneal cytology for gastric carcinoma
Is her disease stage IV?
No
| Without gross metastases, not IV
118
Ventral and dorsal structures from foramen of Winslow
Portal vein and inferior vena cava
