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General Surgery > Stomach > Flashcards

Stomach Flashcards

1
Q

Gastric cancer presentation

A
  • weight loss
  • epigastric abdominal pain
  • dysphagia (if at EGJ)
  • nausea and early satiety
  • occult GI bleeding
  • Virchows node (supraclavicular)
  • Sister Mary Joseph’s node (periumbilical)
  • left axillary node
  • Krukenberg tumor (enlarged ovary or ovarian mass)
  • Blumers shelf (mass in rectal cul de sac)
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2
Q

Gastric cancer work up and staging

A
  • barium swallow
  • CT
  • EGD with biopsy
  • Staging
    • CT chest/abd/pelvis for mets
    • EUS for T and N stage
    • if T2N0 or higher, PET/CT
    • staging laparoscopy (on patients with more than T1 lesion on EUS and no evidence of stage IV disease)
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3
Q

TNM stages Gastric cancer

A

T1a invades lamina propria

T1b invades submucosa

T2 muscularis propria

T3 subserosa

T4 through serosa

N1 1-2 LN

N2 3-6 LN

N3 > or = 7

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4
Q

what makes a gastric cancer unresectable

A
  • peritoneal involvement
  • distant mets
  • paraaortic LN +
  • invasion of major vascular structure (such as aorta)
  • encasement or occlusion of hepatic a. or celiac axis
  • distal splenic vessels are NOT unresectable
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5
Q

when do you give neoadjuvant chemo to gastric cancer patients

who gets post op chemo/xrt

A

neoadjuvant

  • > or = T2
  • any + LNs

adjuvant chemo/radiation (5FU)

  • resected T2-4 cancer
  • node positive gastric ca if less than a D2 LN resection was done
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6
Q
  1. what are risk factors of gastric cancer
  2. what is Lauren classification
  3. what is significant about being CDH1 autosomal dominant
A
  1. H. pylori, nitrates, salt
  2. intestinal type and diffuse type
  3. prophylactic gastrectomy and increase risk of breast cancer
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7
Q

Surgical resection of gastric cancer

A
  • distal tumors (distal 2/3 of stomach)
    • partial gastrectomy with LN resection
  • proximal tumors
    • total gastrectomy
  • LN resections: D2
    • includes D1 (perigastric)
    • includes D2 (left gastric a, common hepatic a., celiac a., splenic hilum and splenic a.)
    • goal is examining of 15 LN or more
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8
Q

list post-gastrectomy anastomosis complications

A

Anastomosis complications

  • duodenal stump leak
  • stricture
  • afferent loop syndrome
  • efferent loop syndrome
  • jejunal intussesception
  • internal hernia
  • marginal ulcer
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9
Q

list post gastrectomy transit complications

A
  • dumping
  • post vagotomy diarrhea
  • gastric stasis
  • alkaline gastritis
  • roux stasis syndrome
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10
Q

describe dumping syndrome

A

Early dumping

  • 10-30 min after food
  • hyperosmolar chyme dumped into small bowel
  • N/V, crampy pain, belching
  • diaphoresis, palpitations, flushing

Late Dumping

  • hypoglycemia following post prandial insulin peak
  • hours post food
  • same symptoms
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11
Q

treatment of dumping syndrome

A

small frequent meals high in fiber and protein

octeotride MAY help

if fails medical therapy⇒Roux en Y gastroJ

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12
Q

how do you treat duodenal stump leak?

A
  • if early
    • emergency surgery
      • duodenostomy, drainage, NPO, TPN
  • if late (more than a week of sx)
    • drain with CT guidance, NPO, TPN
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13
Q

describe sx and diagnosis of afferent loop syndrome

A
  • mechanical obstruction of afferent limb
  • RUQ pain, non bilious vomiting, pain relieved with bilious emesis
  • diagnosis: CT scan shows dilated afferent limb
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14
Q

how do you treat afferent loop syndrome

A
  • convert to roux en y or Braun enteroenterostomy
  • can also decrease length of afferent limb
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15
Q

describe pathophys, sx and dx of efferent loop syndrome

A
  • causes gastric outlet obstruction
  • sx: epigastric pain, distension and bilious vomiting
  • dx: CT scan or UGI series
  • tx
    • balloon dilation
    • or find obstruction and relieve it
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16
Q

describe sx of internal hernia

A

acute abdominal pain with or without abdominal distention or vomiting

17
Q

how can you prevent internal hernias

A

close all mesenteric defects and suture mesocolon to stomach at gastroJ

18
Q

describe marginal ulcer and its pathophysiology

A
  • recurrent peptic ulcer post peptic ulcer surgery
  • may mean:
    • incomplete vagotomy
    • retained gastric antrum
    • ZES
    • NSAID abuse
    • H.pylori
    • cancer
19
Q

describe postvagotomy diarrhea and tx

A
  • 30% of patients post truncal vagotomy
  • unconjugate biler salts passing to colon
  • mostly self-limiting
  • tx:
    • can use cholestyramine
    • can place 10cm reversed jejual loop in continuity of 100cm to LOT (but not really used anymore)
20
Q

describe sx/dx gastric stasis

A
  • epigastric fullness with meals, then emesis of undigested food, abd. pain and weight loss
  • dx: UGI series (r/o obstruction and define anatomy)
  • upper endoscopy (r/o anastomotic strictures or marginal ulcers that can contribute to delayed empyting
21
Q

treatment of gastric stasis

A
  • small frequent meals, reglan, EES
  • if doesnt work
    • re-operation with near total or total gastrectomy with esophagoJ. B II with Braun is preferred reconstruction
22
Q
A
23
Q

describe pathophys, sx and dx and tx of alkaline gastritis

A
  • reflux of bile into stomach causing gastritis
  • persistent burning epigastric pain and chronic nausea aggravated by meals
  • diagnosis of exclusion, but can do endoscopy
  • tx:
    • roux en y
    • henley⇒interposition
    • Braun with B2
24
Q

describe pathophys, sx, dx and tx of Roux stasis syndrome

A
  • some patients develop sx of vomiting, epigastric pain and weight loss after roux en y
  • net propulsive activity TOWARD stomach in roux limb
  • dx: need UGI, nuclear med gastric emptying study
  • tx:
    1. prokinetic agents
    2. if fails, operate and take more stomach (near total) and do new roux en y
    3. a B2 with Braun may prevent this
25
Q

what are risk factors for gastric ulcer

A
  • male
  • tobacco
  • EtOH
  • NSAIDS
  • H. Pylori
  • uremia
  • stress
  • steroids
  • chemo
26
Q

what is the most important thing to test for with gastric ulcer

A

H.pylori (bx is best but can also do CLO test)

27
Q

describe the types of gastric ulcers

A
  • type 1: lesser curve
  • type 2: 2 ulcers (one at lesser curve and one at duodenum)
  • type 3: pre-pyloric ulcer
  • type 4: lesser curve high along cardia
  • type 5: ulcer associated with NSAIDS
28
Q

treatment of gastric ulcer

A

PPI and H. Pylori treatment

29
Q

surgical indications for gastric ulcer

A
  • perforation
  • bleeding
  • obstruction
  • cant exclude cancer
  • intractibility (>3months)
30
Q

what is the surgery for gastric ulcers

A

truncal vagotomy and antrectomy with ulcer excision

(may need separate excision)

31
Q

what type of ulcer do you get with head trauma?

what type in burn patients?

A

Cushings ulcer

Curlings ulcer

32
Q

describe sx, dx, and tx of GIST

A
  • most common benign neoplasm
  • sx: usually asymptomatic, but can have obstruction or bleeding
  • dx: bx will be c-kit positive
    • it is malignant if >5cm or >5mitoses/50HPF
  • tx:
    • resect with 1cm margins
    • no nodal dissection
    • if malignant, treat with imatinib (Gleevec)
33
Q

what is MALT lymphoma associated with and how it is treated

A
  • related to H. pylori
  • regresses after treatment for H.pylori
  • if it doesnt, then XRT
34
Q

what are criteria for bariatric surgery (4 of them)

A
  1. BMI >40 or >35 with co-existing conditions
  2. Failure of nonsurgical methods of weight reduction
  3. psychological stability
  4. absence of drug and EtOH abuse
35
Q

Complications of Roux en y gastric bypass

A
  1. leak
  2. marginal ulcers
    1. develop in 10%, on jejunum tx: PPI
  3. stenosis
    1. tx with dilation
  4. dilation of excluded stomach
    1. dx on AXR, tx is Gtube
  5. SBO
    1. surgical emergency 2° possible SB herniation, strangulation, infarction and necrosis

General Surgery (9 decks)

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