Stomach Flashcards
Gastric anatomy
- Draw the 5 areas.
- Where is the duodenal bulb?
- See below.
- Duodenal bulb is the bulbous part, immediately distal to the pyloric sphincter.

Location-based trivia; name the common locations of the following entities:
- H. pylori gastritis
- Zollinger-Ellison
- Crohns
- Menetrier’s
- Lymphoma
- antrum
- duodenal bulb: recall the Z-E triangle
- uncommon in stomach, but when it is, it likes the antrum
- fundus; classically spares the antrum
- crosses the pylorus; although adenoca does it more

Thickened gastric folds:
- What is the typical look of gastritis on CT and how do you differentiate from adenoca or lymphoma?
- Nodular, low-density submucosal edema.
* Erosions may be present.

Thickened gastric folds: Menetrier disease
- What causes this?
- Epi-2 and causes.
- What happens to pts clinically?
- Ix app-3.
- It’s idiopathic.
- Bimodal: kids and adults.
- Kids: CMV-related.
- They lose albumin from loss into the gastric lumen/gastritis.
- Affects the fundus, spares the antrum.
- Thickened gastric folds.

Benign gastric masses: GIST
- Commonality.
- Most common site in GI tract?
- Age group?
- 2 associated syndromes.
- Are associated LNs common?
- Appearance of malignant GISTs.
- Most common mesenchymal tumour of the GI tract.
- 70% in stomach.
- Old people: rare before 40 yrs.
- Carneys & NF-1.
- NO ASSOCIATED LYMPH NODES!
- Large (>10cm) w/ ulceration, central necrosis & possible perforation.

Which syndrome features GISTs, in a triad?
Carney’s triad (Carneys _E_at _G_arbage)
- chondromas: pulmonary (aka hamartoma)
- extra-adrenal pheo
- GIST

- Name the 3 famous gastric cancer nodes & locations.
- 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.

Malignant gastric masses: gastric cancer
- 2 types & prevalence of each.
- Age group
- Biggest RF
- Name of entity when it spreads to the ovary
- Risk of gastric carcinoma in a gastroenterostomy remnant.
- What is linitis plastica?
- Adeno (95%); lymphoma (5%).
- 70 yrs median age.
- H. pylori.
- Krukenberg tumour
- 2-6x increased risk
- Leather bottle stomach (see below), which is a result of scirrhous adenoca from either breast or lung mets.

Malignant gastric masses: GIST (malignant)
- Most common organ of origin?
- Appearance?
- Do they cause gastric outlet obstruction?
- Stomach.
- Large (>10cm), soft tissue density mass, w/exophytic extension, central necrosis & mucosal ulceration.
- Rarely.

Malignant gastric masses: lymphoma
- 2 pathologic types.
- Which lymphoma is the stomach most common extranodal site?
- What does lymphoma tend to do (2)?
- Which gastric ca more commonly crosses the pylorus & why?
- What is an important Tx point?
- Primary (MALT); secondary (systemic lymphoma).
- NHL.
- Even when extensive, will not cause obstruction; also, it likes to cross the pylorus.
- Gastric adeno, technically, does this more often as it’s way more commone (95% of all gastric ca).
- Gastric lymphoma may rupture w/chemo.

Malignant gastric masses: mets
- Commonality?
- Most common culprit?
- Very rare.
- Melanoma, just like the GB and spleen.

Gastric ulcers: benign vs. malignant
- Draw the table comparing them.
- Which Aunt Minnie signs are associated w/each?
- See below.
- Aunt Minnie’s:
- Carmen meniscus = malignant
- Hampton’s line = benign

Gastric ulcers: chronic aspirin use
- Prevalence in chronic aspirin users.
- What is the buzzword here?
- Where does aspirin not cause ulcers?
- …and if you see multiple ulcers in that location, what entity should you consider?
- ~80%.
- Multiple gastric ulcers.
- The duodenum.
- Zollinger-Ellison.

Misc. gastric: ram’s horn deformity
- Aka?
- What is the path here?
- DDx-6
- Pseudo-Billroth 1, as it looks like the pylorus is removed.
- Scarring occurs which causes tapering of the antrum, so the stomach looks like a ram’s horn.
- DDx:
- peptic ulcers
- Crohns
- sarcoid
- TB
- syphilis
- scirrhous carcinoma

Misc. gastric: gastric volvulus
- Defn.
- 2 types, describe each.
- RFs-2 for the first.
- Which is more common in adults vs. kids?
- Classic triad presentation?
- The stomach twists on its mesentery at least 180° to cause obstruction.
- 2 types:
-
Organoaxial: greater curvature flips over the lesser curvature, i.e., stomach flips along its cardiopyloric line.
- WAY more common overall (60%).
- Seen in little old ladies/adults.
- RFs: trauma, para esophageal hernia.
-
Mesenteroaxial:
- More common in kids.
-
Organoaxial: greater curvature flips over the lesser curvature, i.e., stomach flips along its cardiopyloric line.
-
Triad of Borchardt:
- Severe, sudden epigastric pain.
- Intractable retching w/o vomiting.
- Inability to pass an NG.

Misc. gastric: gastric diverticulum
- Most common location?
- From what part of the stomach do these usually arise?
- Are these common?
- This can be a great mimic in x-sectional studies and another mimic in fluoro–what are those?
- Gastric fundus, posterior surface.
- Gastric cardia.
- NO! They’re the least common of all GI diverticula.
- X-sectional: L adrenal.
- Fluoro: gastric ulcer.

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

- Thrombosed splenic vein.
- Pancreatitis or pancreatic cancer.

Misc. gastric: areae gastricae
- What are these?
- When do these enlarge-3?
- When are they obliterated-2?
- Normal, fine reticular network seen on double contrast fluoro studies. The normal appearance is polygonal islands of mucosa measuring 2-4mm.
- Enlarge:
- Elderly pts.
- H. pylori.
- Next to an ulcer
- Disappear:
- Gastric cancer.
- Atrophic gastritis.

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

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

Roux-en-Y:
- Procedure
- Which is the Roux limb?
- Indications - 2
- Advantages - 2.
- Risks - 3
- 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.
-
Indications: weight loss usually.
- Can also be done as an alternative to Billroth if the tumour has invaded the duodenum or pancreatic head.
- Advantages: less risk of reflux; less risk of recurrent gastric ca.
-
Risks:
- Gallstones
- Internal hernia

Gastric bypass complications: afferent loop syndrome
- Common?
- With which 3 can this happen?
- Most common cause.
- 3 causes of that.
- Much less common cause.
- Sequela?
- Ix-2?
- Relatively common: 13% of Whipples.
- Billroth 2, R-en-Y, Whipple.
- Obstruction.
- Adhesions
- Hernia
- Recurrent tumour
- Preferential gastric drainage into the afferent loop.
- GB dilation & pancreatitis.
- Dilated bowel in RUQ; U-shaped bowel loop adjacent to pancreas, usually containing water attenuation fluid.

Gastric bypass complications: others
- Name 5 others & points to go with each.
-
Jejunogastric intussusception:
- Rare (recall the ZSFGH case).
- Usually the efferent limb herniates.
- High mortality if acute.
- Bile reflux gastritis: gastric fold thickening 2dry to bile acid reflux.
-
Gastro-gastric fistula: seen in R-en-Y only.
- They gain weight years later & the anastomosis breaks down, and is not painful.
-
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.
- Cancer: 3-6x risk of gastric adenoca in the gastric remnant.

- 4 syndromes that feature hamartomatous gastric polyps.

- Peutz-Jeghers
- Cowden
- Juvenile polyposis syndrome
- Cronkhite-Canada
Ulcer trivia:
- Chance of a gastric ulcer being cancer.
- Are duodenal ulcers ever cancer?
- Pathology of gastric ulcers?
- Pathology of duodenal ulcers?
- Are duodenal ulcers usually solitary?
- What’s going on if not?
- 5%
- NO! (For the purposes of MCQs.)
- Altered mucosal resistance.
- Increased peptic acid.
- Yes they are.
- If not, think Z-E.

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

- Essential trivia: what is the most common GI tract location for sarcoid?
- Where specifically?
- The stomach.
- Gastric antrum.

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

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