STOMACH Flashcards
Layers of the Stomach
MUCOSA - first and innermost layer
SUBMUCOSA - 2nd layer
- rich in branching blood vessels, lymphatics, collagen, various inflammatory cells, and nerve fibers
- Meissner’s autonomic submucosal plexus
- gives strength to GI anastomoses
MUSCULARIS EXTERNA (muscularis propria) - 3rd layer
-consists of an incomplete inner oblique layer
-a complete middle circular layer (continuous with the esophageal circular muscle and the circular muscle of the pylorus)
-a complete outer longitudinal layer (continuous with the longitudinal layer of the esophagus and
duodenum)
-Auerbach’s myenteric plexus
-interstitial cells of Cajal (ICC)
-specialized pacemaker cells
SEROSA (visceral peritoneum)
- last and outermost layer
- provides significant tensile strength to gastric anastomoses
- when tumors originating in the mucosa penetrate and breach the serosa, microscopic or gross peritoneal metastases are common, presumably from shedding of tumor cells that would not have occurred if the serosa had not been penetrated
Innervation of the Stomach
Parasympathetic: vagus nerve (CN X)
Sympathetic: celiac plexus (T5-T12)
Opening into the lesser sac
Foramen of Winslow
Parietal cells
HCl
IF
Chief cells
pepsinogen
Mucous neck cells
bicarbonate
mucus
G cells
gastrin
Location of G cells
antrum
Pepsin
Proteolytic enzyme that hydrolyzes peptide bonds
Protein secreted by the parietal cells that combines with vitamin B12 and allows
for absorption in the terminal ileum
Intrinsic Factor (IF)
GERD
Excessive reflux of gastric contents into the esophagus, “heartburn or pyrosis”
Branch that the POSTERIOR VAGUS sends to the posterior FUNDUS
Criminal nerve of Grassi
Heartburn
substernal burning type discomfort
beginning in the epigastrium and radiating upward
often aggravated by meals, spicy or fatty foods, chocolate, alcohol, and coffee
can be worse in the supine position
Effortless return of acid or bitter gastric contents into the chest, pharynx, or mouth
Regurgitation
GERD management
Small meals
PPIs (proton-pump inhibitors) or H2 blockers
Elevation of head at night and no meals prior to sleeping
GERD indications for surgery
Intractability (failure of medical treatment)
Respiratory problems as a result of reflux and aspiration of gastric contents (e.g., pneumonia)
Severe esophageal injury (e.g., ulcers, hemorrhage, stricture, w/w/o Barrett’s
esophagus)
COLUMNAR METAPLASIA from the normal squamous epithelium as a result of chronic irritation from reflux
Barrett’s esophagus
Cancer develops in Barrett’s esophagus
Adenocarcinoma
360 fundoplication—2 cm long (laparoscopically)
Lap Nissen
240 to 270 fundoplication performed through a thoracic approach
Belsey Mark IV
Arcuate ligament repair (close large esophageal hiatus) and gastropexy to diaphragm (suture stomach to diaphragm)
Hill
Incomplete (around 200) posterior wrap (laparoscopic) often used with severe decreased esophageal motility
Toupet
Nissen wrap
Work by improving the lower esophageal sphincter: 1. Increasing LES tone 2. Elongating LES ~3 cm 3. Returning LES into abdominal cavity
Nissen wrap
Work by improving the lower esophageal sphincter: 1. Increasing LES tone 2. Elongating LES ~3 cm 3. Returning LES into abdominal cavity
Postoperative complications of Lap Nissen
- Gas-bloat syndrome
- Stricture
- Dysphagia
- Spleen injury requiring splenectomy
- Esophageal perforation
- Pneumothorax
Gas-bloat syndrome
Inability to burp or vomit
Gastric Cancer associated risk factors
Diet—smoked meats, high nitrates, low fruits and vegetables, alcohol, tobacco
Environment—raised in high-risk area, poor socioeconomic status, atrophic gastritis, MALE gender, blood type A,
previous partial gastrectomy, pernicious anemia, polyps, Helicobacter pylori
Gastric cancer symptoms
Weight loss Emesis Anorexia Pain/epigastric discomfort Obstruction Nausea
Most common early symptoms of gastric cancer
Mild epigastric discomfort and indigestion
Symptom of PROXIMAL gastric cancer
Dysphagia (gastroesophageal
junction/cardia)
Blumer’s shelf
Solid peritoneal deposit anterior to the rectum, forming a “shelf,” palpated on RECTAL examination
Virchow’s nodes
Metastatic gastric cancer to the nodes in the LEFT SUPRACLAVICULAR FOSSA
Sister Mary Joseph’s
sign
PERIUMBILICAL lymph node gastric cancer metastases
presents as periumbilical mass
Krukenberg’s tumor
Gastric cancer (or other adenocarcinoma) that has metastasized to the OVARY
Irish node
LEFT AXILLARY adenopathy from gastric cancer
metastasis
Differential Diagnosis for gastric tumors
Adenocarcinoma leiomyoma leiomyosarcoma lymphoma carcinoid ectopic pancreatic tissue gastrinoma benign gastric ulcer polyp
