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)
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)
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
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
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
6
Q
- what are risk factors of gastric cancer
- what is Lauren classification
- what is significant about being CDH1 autosomal dominant
A
- H. pylori, nitrates, salt
- intestinal type and diffuse type
- prophylactic gastrectomy and increase risk of breast cancer
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
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
9
Q
list post gastrectomy transit complications
A
- dumping
- post vagotomy diarrhea
- gastric stasis
- alkaline gastritis
- roux stasis syndrome
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
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
12
Q
how do you treat duodenal stump leak?
A
- if early
- emergency surgery
- duodenostomy, drainage, NPO, TPN
- emergency surgery
- if late (more than a week of sx)
- drain with CT guidance, NPO, TPN
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
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
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
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:
- prokinetic agents
- if fails, operate and take more stomach (near total) and do new roux en y
- a B2 with Braun may prevent this
25
what are risk factors for gastric ulcer
* male
* tobacco
* EtOH
* NSAIDS
* H. Pylori
* uremia
* stress
* steroids
* chemo
26
what is the most important thing to test for with gastric ulcer
H.pylori (bx is best but can also do CLO test)
27
describe the types of gastric ulcers
* 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
treatment of gastric ulcer
PPI and H. Pylori treatment
29
surgical indications for gastric ulcer
* perforation
* bleeding
* obstruction
* cant exclude cancer
* intractibility (\>3months)
30
what is the surgery for gastric ulcers
truncal vagotomy and antrectomy with ulcer excision
(may need separate excision)
31
what type of ulcer do you get with head trauma?
what type in burn patients?
Cushings ulcer
Curlings ulcer
32
describe sx, dx, and tx of GIST
* 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
what is MALT lymphoma associated with and how it is treated
* related to H. pylori
* regresses after treatment for H.pylori
* if it doesnt, then XRT
34
what are criteria for bariatric surgery (4 of them)
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
Complications of Roux en y gastric bypass
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
