Stomach

Question 1

Gastric anatomy

1. Draw the 5 areas.
2. Where is the duodenal bulb?

Answer 1

1. See below.
2. Duodenal bulb is the bulbous part, immediately distal to the pyloric sphincter.

Question 2

Location-based trivia; name the common locations of the following entities:

1. H. pylori gastritis
2. Zollinger-Ellison
3. Crohns
4. Menetrier’s
5. Lymphoma

Answer 2

1. antrum
2. duodenal bulb: recall the Z-E triangle
3. uncommon in stomach, but when it is, it likes the antrum
4. fundus; classically spares the antrum
5. crosses the pylorus; although adenoca does it more

Question 3

Thickened gastric folds:

1. What is the typical look of gastritis on CT and how do you differentiate from adenoca or lymphoma?

Answer 3

1. Nodular, low-density submucosal edema.
   * Erosions may be present.

Question 4

Thickened gastric folds: Menetrier disease

1. What causes this?
2. Epi-2 and causes.
3. What happens to pts clinically?
4. Ix app-3.

Answer 4

1. It’s idiopathic.
2. Bimodal: kids and adults.
   
   1. Kids: CMV-related.
3. They lose albumin from loss into the gastric lumen/gastritis.
4. Affects the fundus, spares the antrum.
   
   1. Thickened gastric folds.

Question 5

Benign gastric masses: GIST

1. Commonality.
2. Most common site in GI tract?
3. Age group?
4. 2 associated syndromes.
5. Are associated LNs common?
6. Appearance of malignant GISTs.

Answer 5

1. Most common mesenchymal tumour of the GI tract.
2. 70% in stomach.
3. Old people: rare before 40 yrs.
4. Carneys & NF-1.
5. NO ASSOCIATED LYMPH NODES!
6. Large (>10cm) w/ ulceration, central necrosis & possible perforation.

Question 6

Which syndrome features GISTs, in a triad?

Answer 6

Carney’s triad (Carneys _E_at _G_arbage)

1. chondromas: pulmonary (aka hamartoma)
2. extra-adrenal pheo
3. GIST

Question 7

• Name the 3 famous gastric cancer nodes & locations.

Answer 7

• Irish node: axillary.
• Virchow node/Troisier’s sign: L supraclavicular.
  
  • Troisier’s sign = hard/enlarged L supraclavicular node, considered a sign of abdo mets.
• Sister Mary Joseph nodule: umbilical.
  
  • Sister Mary Joseph (Julia) Dempsey (1856-1939) was the surgical assistant to William Mayo in the early days of the Mayo Clinic. She noted this finding in the umbilicus of pts w/advanced malignancy & published a paper on it. It is the only sign in clinical medicine named after a nurse.

Question 8

Malignant gastric masses: gastric cancer

1. 2 types & prevalence of each.
2. Age group
3. Biggest RF
4. Name of entity when it spreads to the ovary
5. Risk of gastric carcinoma in a gastroenterostomy remnant.
6. What is linitis plastica?

Answer 8

1. Adeno (95%); lymphoma (5%).
2. 70 yrs median age.
3. H. pylori.
4. Krukenberg tumour
5. 2-6x increased risk
6. Leather bottle stomach (see below), which is a result of scirrhous adenoca from either breast or lung mets.

Question 9

Malignant gastric masses: GIST (malignant)

1. Most common organ of origin?
2. Appearance?
3. Do they cause gastric outlet obstruction?

Answer 9

1. Stomach.
2. Large (>10cm), soft tissue density mass, w/exophytic extension, central necrosis & mucosal ulceration.
3. Rarely.

Question 10

Malignant gastric masses: lymphoma

1. 2 pathologic types.
2. Which lymphoma is the stomach most common extranodal site?
3. What does lymphoma tend to do (2)?
4. Which gastric ca more commonly crosses the pylorus & why?
5. What is an important Tx point?

Answer 10

1. Primary (MALT); secondary (systemic lymphoma).
2. NHL.
3. Even when extensive, will not cause obstruction; also, it likes to cross the pylorus.
4. Gastric adeno, technically, does this more often as it’s way more commone (95% of all gastric ca).
5. Gastric lymphoma may rupture w/chemo.

Question 11

Malignant gastric masses: mets

1. Commonality?
2. Most common culprit?

Answer 11

1. Very rare.
2. Melanoma, just like the GB and spleen.

Question 12

Gastric ulcers: benign vs. malignant

1. Draw the table comparing them.
2. Which Aunt Minnie signs are associated w/each?

Answer 12

1. See below.
2. Aunt Minnie’s:
   
   • Carmen meniscus = malignant
   • Hampton’s line = benign

Question 13

Gastric ulcers: chronic aspirin use

1. Prevalence in chronic aspirin users.
2. What is the buzzword here?
3. Where does aspirin not cause ulcers?
   
   1. …and if you see multiple ulcers in that location, what entity should you consider?

Answer 13

1. ~80%.
2. Multiple gastric ulcers.
3. The duodenum.
   
   1. Zollinger-Ellison.

Question 14

Misc. gastric: ram’s horn deformity

1. Aka?
2. What is the path here?
3. DDx-6

Answer 14

1. Pseudo-Billroth 1, as it looks like the pylorus is removed.
2. Scarring occurs which causes tapering of the antrum, so the stomach looks like a ram’s horn.
3. DDx:
   
   1. peptic ulcers
   2. Crohns
   3. sarcoid
   4. TB
   5. syphilis
   6. scirrhous carcinoma

Question 15

Misc. gastric: gastric volvulus

1. Defn.
2. 2 types, describe each.
   
   1. RFs-2 for the first.
3. Which is more common in adults vs. kids?
4. Classic triad presentation?

Answer 15

1. The stomach twists on its mesentery at least 180° to cause obstruction.
2. 2 types:
   
   1. Organoaxial: greater curvature flips over the lesser curvature, i.e., stomach flips along its cardiopyloric line.
      
      1. WAY more common overall (60%).
      2. Seen in little old ladies/adults.
      3. RFs: trauma, para esophageal hernia.
   2. Mesenteroaxial:
      
      1. More common in kids.
3. Triad of Borchardt:
   
   1. Severe, sudden epigastric pain.
   2. Intractable retching w/o vomiting.
   3. Inability to pass an NG.

Question 16

Misc. gastric: gastric diverticulum

1. Most common location?
2. From what part of the stomach do these usually arise?
3. Are these common?
4. This can be a great mimic in x-sectional studies and another mimic in fluoro–what are those?

Answer 16

1. Gastric fundus, posterior surface.
2. Gastric cardia.
3. NO! They’re the least common of all GI diverticula.
4. X-sectional: L adrenal.
   
   1. Fluoro: gastric ulcer.

Question 17

Misc. gastric: gastric varices

1. Classic question: what causes isolated gastric varices?
2. What 2 entities can precipitate this cause?

Answer 17

1. Thrombosed splenic vein.
2. Pancreatitis or pancreatic cancer.

Question 18

Misc. gastric: areae gastricae

1. What are these?
2. When do these enlarge-3?
3. When are they obliterated-2?

Answer 18

1. Normal, fine reticular network seen on double contrast fluoro studies. The normal appearance is polygonal islands of mucosa measuring 2-4mm.
2. Enlarge:
   
   1. Elderly pts.
   2. H. pylori.
   3. Next to an ulcer
3. Disappear:
   
   1. Gastric cancer.
   2. Atrophic gastritis.

Question 19

Billroth 1

1. Procedure
2. Indications - 3
3. Advantages - 2

Answer 19

1. Gastroduodenectomy: partial gastrectomy (pylorus removed) & end-to-end anastomosis of antrum to the duodenal stump.
2. Indications:
   
   1. pyloric dysfunction
   2. gastric ca
   3. ulcers
3. Less post-op gastritis compared to Billroth 2
   
   1. Can also be converted to a R-en-Y if required.

Question 20

Billroth 2

1. Procedure
2. Indications - 2
3. Risks - 3

Answer 20

1. Partial gastrectomy + side-to-side gastrojejunostomy through the transverse mesocolon.
   
   1. The duodenum is resected at the ampulla of Vater = afferent or biliopancreatic limb.
2. Gastric ca or severe ulcer in the distal stomach.
3. Risks:
   
   1. Dumping syndrome:
   2. Afferent loop syndrome:
   3. Increased risk of gastric adenoca 10-20 years post-op:

Question 21

Roux-en-Y:

1. Procedure
   
   1. Which is the Roux limb?
2. Indications - 2
3. Advantages - 2.
4. Risks - 3

Answer 21

1. Most of the stomach is divided out, making a pouch.
   
   • The proximal jejunum is resected and anastomosed proximally to the gastric pouch. This is the gastro-jejunal, efferent, or Roux limb.
   • The excluded stomach attaches to the duodenum as usual.
   • The proximal jejunum of the afferent limb is then end-to-side anastomosed with the Roux limb to form the distal J-J anastomosis, which is the crotch of the Y.
2. Indications: weight loss usually.
   
   1. Can also be done as an alternative to Billroth if the tumour has invaded the duodenum or pancreatic head.
3. Advantages: less risk of reflux; less risk of recurrent gastric ca.
4. Risks:
   
   1. Gallstones
   2. Internal hernia

Question 22

Gastric bypass complications: afferent loop syndrome

1. Common?
2. With which 3 can this happen?
3. Most common cause.
   
   1. 3 causes of that.
4. Much less common cause.
5. Sequela?
6. Ix-2?

Answer 22

1. Relatively common: 13% of Whipples.
2. Billroth 2, R-en-Y, Whipple.
3. Obstruction.
   
   1. Adhesions
   2. Hernia
   3. Recurrent tumour
4. Preferential gastric drainage into the afferent loop.
5. GB dilation & pancreatitis.
6. Dilated bowel in RUQ; U-shaped bowel loop adjacent to pancreas, usually containing water attenuation fluid.

Question 23

Gastric bypass complications: others

1. Name 5 others & points to go with each.

Answer 23

1. Jejunogastric intussusception:
   
   • Rare (recall the ZSFGH case).
   • Usually the efferent limb herniates.
   • High mortality if acute.
2. Bile reflux gastritis: gastric fold thickening 2dry to bile acid reflux.
3. Gastro-gastric fistula: seen in R-en-Y only.
   
   • They gain weight years later & the anastomosis breaks down, and is not painful.
4. Dumping syndrome: rapid transit of undigested food from the stomach.
   
   • Can be diagnosed w/Tc gastric emptying study.
   • Tx: convert Billroth to R-en-Y.
5. Cancer: 3-6x risk of gastric adenoca in the gastric remnant.

Question 24

• 4 syndromes that feature hamartomatous gastric polyps.

Answer 24

• Peutz-Jeghers
• Cowden
• Juvenile polyposis syndrome
• Cronkhite-Canada

Question 25

**Ulcer trivia:** 1. Chance of a gastric ulcer being cancer. 2. Are duodenal ulcers ever cancer? 3. Pathology of gastric ulcers? 4. Pathology of duodenal ulcers? 5. Are duodenal ulcers usually solitary? 1. What's going on if not?

Answer 25

1. 5% 2. NO! (For the purposes of MCQs.) 3. Altered mucosal resistance. 4. Increased peptic acid. 5. Yes they are. 1. If not, think Z-E.

Question 26

**Gastric adenoca vs. gastic lymphoma:** List 5 things that gastric adeno is more likely to do relative to lymphoma.

Answer 26

* GA is more likely to be in the distal stomach. * GA is more likely to cause gastric outlet obstruction. * GA is more likely to limit stomach distensibility + peristalsis. * GA is more likely to be a focal mass (95% of all gastric tumours are adenos). * GA is more likely to extend beyond the serosa & obliteratre adjacent fat planes.

Question 27

* Essential trivia: what is the most common GI tract location for sarcoid? * Where specifically?

Answer 27

* The stomach. * Gastric antrum.

Question 28

* What is the most common cause for wall thickening & luminal narrowing of the gastric antrum?

Answer 28

* Gastritis. * This is very common. * Primary gastric adeno, lymphoma & mets are all much less common.