stomach and duodenum Flashcards
esophageal motility disorder characterized by failure of the circular esophageal muscle in the distal 2cm of the esophagus to relax
achalasia
definite mucosal change from gastric epithelium to intestinal epithelium (striated columnar cells w interspersed goblet cells) and 1-3cm long smooth muscle valve known as pylorus
gastroduodenal junction
what does the pylorus do
prevents reflux of duodenal contents into stomach; controls gastric emptying
antrectomy
distal gastric resection that removes the gastrin producing cells of the stomach
basal acid secretion
circadian rhythm w highest levels at night and lower levels in the morning
what is responsible for creating the concentrated acid environment within the lumen of the stomach
H for K, ATPase
diffuse erythema and disruption of the mucosa of the stomach; assoc w ingestion of irritating agents
gastritis
Schilling test
used to determine cause of bit B12 def: pernicious anemia or small intestinal bacterial overgrowth
what two things promote ulcer formation by altering the balance between the protective and potentially harmful components of the gastric environment
H. pylori and NSAIDs
causes a chronic active gastritis w dysregulation of gastrin and acid secretions
h. pylori
inhibit cox1 which is essential for prostaglandin synthesis, thereby altering local blood flow, mucus production,and bicarb secretion in the stomach
nsaids
mc cause of benign gastric ulcer ds
h pylori and nsaids
type 1 gastric ulcers
most frequent, occur along lesser curvature of the stomach in the zone above the antrum; normal or low acid output
type 2 gastric ulcers
arise in combo w duodenal ulcers; acid hyper secretion
type 3 gastric ulcers
dev in prepyloric region; acid hypersecretion
type 4 gastric ulcers
least frequent, occur high on lesser curvature near GE junction; normal or low acid output
how is h pylori spread
gastrooral or fecal oral
s/sx of uncomplicated gastric ulcers
gnawing epigastric pain that can radiate to back; anorexia and wl because assoc w ingestion of food
s/sx complicated gastric ulcers
may or may not have any prior to perforation or bleeding
what confirms the presence of an ulcer
EGD; any gastric ulcer found needs to be bx for malignancy; always bx for h pylori
endoscopic features suggestive of malignancy
bunched up ulcer border or large (>3cm) ulcer size; presence of achlorhydria
besides EGD another dx study gastric ulcer
barium upper GI contrast; con is can’t bx
first line therapy for uncomplicated gastric ulcer disease
cessation of all potential ulcerogenic agents (tobacco, nsaids, aspirin, steroids, alcohol); tx h pylori w abx; acid suppression therapy; cytoprotective agents (sucralfate, misoprostol)
abx to tx H pylori
clarithromycin, amoxicillin, metronidazole, tetracycline, bismuth, omeprazole
what is mandatory after initiating medical tx for gastric ulcer
repeat endoscopy; after 6 weeks ulcer should show healing
surgical tx for nonhealing, obstructing or refractory gastric ulcers types 1-3
excision; antrectomy (50% gastrectomy, mc performed), GI continuity restored to either proximal duodenum (Billroth 1), loop of proximal jejunum (billroth 2) or transposed limb of jejunum isolated from biliopancreatic secretions (Roux en y)
Which gi reconstruction may be assoc w impaired gastric emptying and intestinal transit
roux en y
pts w type 2 and 3 often receive what n addition to antrectomy for further dec gastric acid secretion
truncal vagotomies
surgical tx type 4
may require near total gastrectomy w roux en y reconstruction
tx emergent operation for perforated pyloric channel ulcer prev unrecog
oversew and omental patch without resection
inflammation of the stomach mucosa that may be assoc w erosions and hemorrhage
acute gastritis
s/sx acute gastritis
n, v, hematemesis, melena, or hematochezia
causes of acute gastritis
h pylori, nsaid, aspirin, bile reflux, alcohol irradiation, local trauma
tx acute gastritis
acid suppression, removal of noxious agent, occasional gastric decompression, nutritional support
pts can develop mucosal erosions beginning in the proximal stomach and progressing rapidly throughout the rest of the organ
stress gastritis
ulcer formation in major burn victims (curling’s ulcer) and patients w cns injury (cushing’s ulcer)
stress gastritis
prophylaxis in critical ill pt since stress gastritis can dev within 48hr
PPI, h2 rec blockers, sucralfate, misoprostol
intraluminal ph should not dec below
4.0
mc complication of stress gastritis
hemorrhage; watch for blood per rectum, blood in ng aspirate, or drop in blood ocunt
what confirms the dx of stress gastritis
endoscopy
hypertrophic gastritis (menetrier’s ds)
rare disorder of the lining of the stomach characterized by massive hypertrophy of the gastric rugae
s/sx hypertrophic gastritis (menetriers)
epigastric pain, n, v occult hemorrhage, anorexia, wl, diarrhea; hypoproteinemia and peripheral edema
tx hypertrophic gastritis (menetriers)
acid suppression w ppi, h2 or antacids; high protein diet
upper GI hemorrhage secondary to linear tearing of the mucosa at the GE junction
mallory weiss syndrome
when do mallory weiss tears usually occur
after episodes of strong valsalva maneuver causes mechanical stress on mucosa in region; retching, heavy lifting, childbirth, vomiting, blunt abd trauma, seizures
eval of mallory weiss tear
ng tube and gastric lavage; if blood then endoscopy, nuclear scintigraphy or selective angiography
tx mallory weiss tear
fluid resuscitation, stabilization; acid suppression; if bleeding persists then electrocautery, heater probe or injection therapy
gastric polyp
hyperplastic or adenomatous in nature. Hyperplastic polyps are more common and are typically benign, although rare cancerous transformation has been reported. Adenomatous polyps have a higher risk of malignant degeneration, especially those >1.5 cm. When a gastric polyp is diagnosed, the physician should consider the possibility of other polyps within the GI tract and polyposis syndromes.
presence of multiple benign polyps in small intestine and sometimes portions of gi tract, melanin spots on lips and buccal mucosa
peutz jeghers syndrome- auto dom
accumulation of lg mass of indigestible fiber within the stomach
bezoar (vegetable=phytobezoar) (hair=trichobezoar)
mc stomach cancer
adenocarcinoma
risk factors for gastric adenocarcinoma
h pylori infx, pernicious anemia, achlorhydria, chronic gastritis; caustic injury from lye ingestion; adenomatous polyps
mc category of gastric adenocarcinoma
ulcerative carcinomas
two histologic types of gastric adenocarcinoma
intestinal (older pt and spreads hematogenously) and diffuse (signet ring cells, younger, type A blood, spreads lymphatics and local extension)
term used to describe complete infiltration of the stomach w carcinoma
linitis plastica; stomach looks like a leather bottle
s/sx of later stages of gastric carcinoma
epigastric pain, wl, dysphagia, hematemesis, melena, n, v; iron def anemia or guaiac positive stools
dx imaging gastric carcinoma
upper endoscopy, bx, endoscopic us, cxr, ct abd/pelvis;PET
dx lab gastric carcinoma
cbc, electrolytes, creatinine level, lfts
what do pts undergo who don’t have any evidence of metazoic ds on initial workup
laparoscopic staging
surgical tx of gastric carcinoma
Complete surgical resection in an attempt to cure gastric adenocarcinoma should only be undertaken in the presence of localized disease. Considerable debate exists regarding the extent of such a resection. For most distal lesions, many surgeons favor a radical subtotal gastrectomy. In this procedure, approximately 85% of the stomach is removed, including the omentum. The proximal portion of the resected specimen is then immediately examined by the pathologist (i.e., frozen section) to verify that it is free of tumor involvement. Only after such verification is GI continuity restored by means of a Roux-en-Y gastrojejunostomy. Total gastrectomy is reserved for either large distal lesions or more proximal tumors. Splenectomy or pancreatectomy may also need to be included in the operative procedure. They should, however, be avoided unless absolutely necessary.
NCCN guidelines of chemo w gastric carcinoma
perioperative chemo using epirubicin, cisplatin, and 5 fluorouracil for lesions invade beyond lamina propria or have positive nodes
is chemoradiotherapy necessary for less invasive lesions (only invade submucosa)
no can be excised without but 5 fluorouracil w or without leucovorin is recommended after
indications for palliative surgical intervention of gastric carcinoma
proximal or distal tumor obstruction and bleeding
gastric carcinoma stage 1
mucosa, muscularis mucosa, submucosa
gastric carcinoma stage 2
mucosa, muscularis mucosa, submucosa, muscularis propria
gastric carcinoma stage 3
mucosa, muscularis mucosa, submucosa, muscularis propria, lymph nodes
gastric carcinoma stage 4
mucosa, muscularis mucosa, submucosa, muscularis propria, lymph nodes, distant metastases or contiguous spread
primary source of almost 2/3 of all gi lymphomas
stomach; older and nonhodgkins predominates
s/sx gastric lymphoma
upper abd pain, lw, fatigue, bleeding
dx gastric lymphoma
tissue bx during upper endoscopy; sometimes during surgical exploration
if dx is made prop what workup should be done for gastric lymphoma
cxr, abd ct, bone marrow bx
tx gastric lymphoma
chemo but has risk of gastric perforation or hemorrhage; or resection followed w chemo or radiation
submucosal growths of the GI tract arising from variety of cell types
formerly known as leiomyomas and leiomyosarcomas but now gastrointestinal stromal tumors (GISTs)
what suggests malignancy with GISTs
large tumor size >6cm and tumor necrosis
s/sx GISTs
asyp; nonspecific abd pain, but bleeding and obstruction can manifest; may present w abdominal mass
eval of GISTs
upper endoscopy, endoscopic us, abdominal ct
most common site of GIST and mc site for disseminated disease
stomach; liver
tx GIST
local excision w margin of 2-3cm included; if aggressive chemo using imatinib mesylate
two ucergenic agents for duodenum
h pylori and nsaids; maybe tobacco
s/sx uncomplicated duodenal ulcers
burning epigastric abd pain that is gnawing in character; can radiate to back; occur 1-3hrs after food and accentuated by fasting; awaken from sleep; relief w acid suppressants; food intake can also improve pain
older dx imaging uncomplicated duodenal ulcer
upper gi series (not used as much), gastric acid analysis (ng tube placed in stomach for samples of gastric aspirates for 1 hr, >4 basal acid output)
noninvasive dx testing for uncomplicated duodenal ulcer
quantitative and qualitative serologic antibody,urease tests, and fecal antigen test for h pylori; upper endoscopy*
tx uncomplicated duodenal ulcer
stop ulcerogenic agents, acid suppression therapy, abx h pylori
4 main manifestations of complicated PUD
perforation, hemorrhage, gastric outlet obstruction, intractability
s/sx pt w perforated ulcer
acute onset of severe epigastric pain, tachycardia, rigid abdomen; may have rlq rebound tenderness
eval of perforated ulcer
upright chest radiograph- evidence of free intraperitoneal air (pneumoperitoneum) outlining diaphragm or liver, cbc and bmp
s/sx bleeding ulcer
hematemesis, melena, blood per rectum, hypotension,tachycardia, pallor, mental status changes, active bleeding
eval bleeding ulcer
ng tube w gastric lavage, endoscopy, serial hematocrits and coag parameters, blood type and cross match
s/sx gastric outlet obstruction resulting from chronic ulcer scarring
inability to tolerate oral intake, projectile vomiting shortly after eating, lw, dehydration, upper abd fullness, dec skin turgor, dry mucus membranes, epigastric peristaltic waves
eval gastric outlet obstruction
electrolyte and creatinine levels- often have hypokalemic, hypochloremic metabolic alkalosis
s/sx intractable ulcers
persistent ds after adequate nonop therapy, pe same as pt w uncomplicated PUD
tx complicated pud
initial stabilization phase (resuscitation and nonop therapy) if doesn’t work then surgery
tx perforated ulcer
surgical emergency; fluid resuscitation and nasogastric decompression; oversewing the ulcer w buttressing w a tag of momentum is performed followed by intensive tx w PPIs and abx
tx hemorrhage ulcer
volume resuscitation then Advanced Trauma Life Support (ATLS) guidelines: 2L crystalloid followed by whole blood; stomach decompressed using NG tube; high dose PPI therapy, then coag abnorm corrected; upper endoscopy w electrocautery; surgery for refractory bleeding (>6u in first 12hr)
tx gastric outlet obstruction
stomach is decompressed w an NG tube for 5-6d or until returns to normal size, NPO, nutrition/fluids through IV w normal saline crystalloid and total parenteral nutrition; surgery
tx intractable ulcers
surgical intervention to dec acid secretion through interruption of the vagal neural pathway w or without removal of gastrin producing cells in antrum usually by truncal vagotomy and pyloroplasty
proximal gastric vagotomy
antiulcer operations; selectively denervates vagal stimulation to the parietal cells; maintains function of the pyloric sphincter
dumping syndrome
complex myriad symptoms; may include cramps abd pain and diarrhea; secondary to ablation of the pyloric sphincter mechanism
familial adenomatous polyposis
auto dom dev w polyps in the colon and gastroduodenal region; possible malig so close monitoring
Zollinger-Ellison syndrome
severe variant of duodenal ulcer ds; results from the independent production of gastrin by a tumor (gastrinoma) that arises in the pancreas or paraduodenal area
ZE syndrome has strong assoc w what endocrine neoplasm
multiple endocrine neoplasia type 1 syndrome (MEN 1)
characteristics of MEN 1
pituitary adenomas, hyperparathyroidism, pancreatic islet cell tumors
s/sx ZE syndrome
ulcer like symptoms w concomitant chronic or severe diarrhea
dx ZE syndroma
establishing presence of hypergastrinemia w hyper secretion of acid so a fasting serum gastrin level is necessary; make sure PPI discontinued stopped 1 week prior; >1000 is dx; secretin stimulation test inc >200; gastric ph
tx ZE syndrome
total gastrectomy w esophageal anastomosis; high dose PPI or H2 rec antag; hormonal manipulation w somatostatin octreotide
tx ZE syndrome w MEN1
parathyroidectomy +/- surgical exploration
mc site for adenocarcinoma in the small bowel
duodenum; 2/3 in the second part in the periampullary region
s/sx adenocarcinoma of duodenum
nonspecific abd pain w wl to intestinal/gastric outlet obstruction; melena or hematochezia due to ulceration of the lesion; pe unremarkable
dx adenocarcinoma of duodenum
upper endoscopy w tissue bx; ct
tx adenocarcinoma of duodenum
surgical excision; pancreaticoduodenectomy is in 1/2 part of duodenum; duodenojejunostomy if in 3/4 part; unresectable have diverting gastroenterostomy; postop radiation
what happens when the stomach is denervated
control of gastric emptying is abolished
if someone is having a complicated postop course what is used for eval
upper GI series- doc extent of gastric resection and type of reconstruction, determine cause of vomiting, asses gastric emptying and motility
symptoms that occur after ingestion of food of high osmolarity
early dumping syndrome
15m after eating pt presents w anxiety, weakness, tachycardia, diaphoresis, and palpitations; extreme weakness and wants to lie down; cramps abd pain, borborygmi heard
early dumping syndrome
what is happening during early dumping syndrome
uncontrolled emptying of hypertonic fluid into small intestine which moves rapidly from intravascular space into intraluminal space leading to intravasc vol depletion
tx early dumping syndrome
avoid hypertonic liquid meals, alter vol of each meal, ingest fat w each meal to slow gastric emptying; ingest liquids 30min before or after meal; frequent small meals; if doesn’t work roux en y gastrojejunostomy may be necessary
late dumping syndrome
same symptoms of early but begin within 3 hours after meal and not assoc w borborygmi or diarrhea
cause of late dumping syndrome
rapid changes in serum glucose and insulin levels leading to hypoglycemia
tx late dumping syndrome
small snack 2 hr after meals (crackers/pb); acarbose; if all else fails surgery
what do almost half the pts who undergo a truncal vagotomy experience
change in bowel habits (inc freq, more liquid)
causes of postvagotomy diarrhea
enhanced intestinal motility (vagal denervation), rapid gastric emptying, bile malabsorption, and bacterial overgrowth
tx postvagotomy diarrhea
fluid intake restricted; food w low fluid content; antidiarrheal/antimotility agents (codeine, diphenoxylate hydrochloride, loperamide); cholestyramine or somatostatin; if refractory to med man then reversed 10cm set of jejunum inserted 100cm distal to ligament of treitz
afferent loop obstruction occurs after which reconstruction
gastrectomy w billroth 2
cause of afferent loop obstruction
kink in afferent limb adjacent to anastomosis; pancreatic and biliary secretions are trapped in limb and cause distention
s/sx afferent loop obstruction
severe abd cramping mimed after ingestion of meal; pain as crushing; within 45 min feel abd rush assoc w inc pain then n and v of dark brown bitter tasting material; symp resolve w vomiting; wl
tx afferent loop obstruction
exploration of the abdomen and conversion of billroth 2 anastomosis to either a roux en u gastrojejunostomy or billroth 1 gastroduodenostomy
blind loop syndrome is more common after what procedure
billroth 2; bypass of small intestine secondary to radiation injury or morbid obesity
assoc w bacterial overgrowth in the limb of intestine that is excluded from the flow of chyme; interferes w folate and bit b12 metab
blind loop syndrome
a def of vit b 12 leads to
megaloblastic anemia
s/sx blind loop syndrome
steatorrhea, diarrhea, wl, weakness
dx blind loop syndorme
schilling test using cobalamin found to IF is abnormal
tx blind loop syndrome
oral broad spectrum abx cover aerobic and anaerobic bacteria (tetracycline); conversion to billroth 1 gastroduodenostomy
alkaline reflux gastritis is seen in pts in which what contents reflux into the denervated stomach
duodenal, pancreatic, and biliary contents
s/sx alkaline reflux gastritis
weakness, wl, persistent n, epigastric abd pain radiates to back, anemia
what will an upper endoscopy reveal w alkaline reflux gastritis
edematous, bile stained gastric epithelium that is atrophic and erythematous;inflammatory changes w corkscrew appearance of submucosal blood vessels; need to take bx
inflammatory changes w corkscrew appearance of submucosal blood vessels
alkaline reflux gastritis
tx alkaline reflux gastritis
surgical correction consists of diverting duodenal contents away from stomach w long limb roux en y gastrojejunostomy; minimum distance between gastrojejunostomy and entry point of biliopancreatic limb draining the digestive juices into intestine is 40cm (18in)
where do marginal ulcers develop
jejunal side of gastrojejunostomy anastomosis
why do marginal ulcer develop
secondary to ischemia but also smoking
s/sx marginal ulcers
abd pain during eating along w n/v
what does upper endoscopy show for marginal ulcer
ulcer on jejunal side no more than 2cm distal to anastomosis
conservative management of marginal ulcer
stop tobacco use and start PPI; severe NPO and TPN; surgery
recurrent ulcer ds following surgical intervention in benign PUD is most commonly due to
incomplete vagotomy; posterior vagal trunk or branch of right posterior nerve (criminal nerve of Grassi) is left intact
dx recurrent ulcer ds
upper endoscopy is used to help confirm persistent vagal innervation to the stomach. Congo red is used to demonstrate areas of pH drop in the gastric mucosa after the administration of an acid secretagogue (pentagastrin). Such regions have intact vagal innervation
what should be eval for pts w recurrent ulceration and verified complete vagotomy
search for endocrine etiology; fan hx MEN1; calcium and parathyroid hormone levels for hyperparathyroidism; gastrin levels
mc metabolic abnorm after gastric resection
anemias
medication for late dumping syndrome
acarbose- alpha glucosidase hyrolase inhibitor
medication for postvagotmy diarrhea and alkaline reflux gastritis
cholestyraime- bile salt binding agent
medication for postvagotomy diarrhea and dumping syndrome
somatostatin- secretory inhibitor
medication for gastric atony
metoclopramide- promotility agent
medication for marginal ulcer and alkaline reflux gastritis
sucralfate- gi protectant
medication for postvagotomy diarrhea
diphenoxylate hydrochloride or loperamide
10kcal/day of extra energy can result in how much weight gain over the course of a year
1lb
what 3 things play an important role in appetite regulation within the body
hypothalamus, stomach, adipocyte:Food intake is triggered by the release of the hormone ghrelin from gastric oxyntic cells. This compound stimulates the release of neuropeptides in the “hunger center” of the hypothalamus, increasing caloric consumption. To signal adequate caloric load, the adipocyte releases the hormone leptin, which activates the “satiety center” of the hypothalamus. In this manner, food intake is decreased.
bmi=weight (kg)/ height (m)(squared) ranges
40 (severely obese)
3 categories for tx for overweight and obese ppl
behavior modification (all BMIs), pharmacotherapy (all BMI except underweight), surgical intervention (obese or severely obese)
calorie range for low calorie diet
500-1000kcal/day so for women this is reached at 1000-1200kcal/day and men 1200-1500kcal/day; will lose 0.45-.9kg/week
goal of low calorie diet
10% weight loss over 6 months
long term weight reduction agent that is FDA approved
sibutramine and orlistat
3 different bariatric procedures that limit food intake by forcing the pt to eat smaller portions
adjustable gastric banding (AGB), sleeve gastrectomy (SG) and vertical banded gastroplasty (VBG)
malabsoprtive operation that alters food processing by limiting its absorption in the intestines
biliopancreatic diversion (BPD) w or without duodenal switch (BPD/DS)
combined restrictive and malabsorptive operation for bariatric procedures
roux en y gastric bypass
roux en y
creation of small proximal gastric pouch by transecting the stomach; roux limb measures 75-150cm in length
adjustable gastric banding (AGB)
creation of proximal gastric pouch using inflatable band and placement of access port;A pars flaccida technique is used to create a posterior gastric tunnel from the lesser curve to the angle of His. The band is then positioned and secured by imbricating its anterior aspect. The distal fundus is sutured to the proximal gastric pouch. The port is placed on the abdominal muscle fascia. Adjustments of the band are made by instilling sterile solution percutaneously via the access port.
sleeve gastrectomy (SG)
surgeon removes approximately 85% of the stomach laparoscopically so that the stomach takes the shape of a tube or “sleeve” This procedure is not reversible. Unlike many other forms of bariatric surgery, the pylorus and stomach innervation remain intact.
BPD and BPD/DS
BPD is basically a subtotal gastrectomy with a very distal Roux-en-Y reconstruction. BPD/DS involves SG, duodenal transection with duodenojejunostomy creation, and very distal jejunoileostomy
vertical banded gastroplasty
reation of a proximal gastric pouch by stomach partitioning and the reinforcement of the stoma with banding. Partitioning is usually via gastric stapling, and polypropylene is a popular banding material
early complication of bariatric procedures (periop or before pt discharged)
anastomotic leak (roux), dvt and pe (roux, ABG, SG), bleeding (roux, abg, sg), infection (roux,abg, sg), splenic or visceral injury (roux, abg, sg)
late complications of bariatric procedures (after discharge)
nutritional disturbances (roux, abg, sg), marginal ulcers and anastomotic strictures (roux), internal hernia (roux), afferent limb syndrome (roux), cholelithiasis (roux, sg), band slippage (sg), esophageal dilation (ABG, sg), band erosion (abg)
mc site of anastomotic leak
gastrojejunostomy
s/sx of anastomotic leak
abd pain, unexplained tachycardia, tachypnea, hypoxia
dx anastomotic leak
upper gi series or abd ct w oral contrast
tx anastomotic leak
percut drainage and parenteral nutrition; if not surgery
tx dvt or pe after bariatric surgery
enoxaparin or unfractionated heparin for initial tx then oral anticoag w warfarin for 6m
bariatric surgical patients are instructed to consume extra what after surgery so don’t dev nutrition disturbance
protein (60-80g/d)
mc def of gastric bypass pts
iron def (65mg/d plus vit c) then b12 (IM or subling)
pt complain of progressive intolerance of solids/liquids w postprandial abd pain and vomiting
stricture after bariatric surgery
pt w abd pain, n, nonbilious vomiting after bariatric surgery
biliopancreatic limb obstruction
since cholelithiasis can occur due to rapid wl following gastric bypass surgery what is taken for 6m postop
ursodeoxycholic acid 300mg BID
tx for pt for has roux en y done and regained weight due to pouch or pouch outlet enlargemnt
stomaphyx
guidelines for adolescents to receive bariatric surgery
tried for 6m to lose weight w no success, vmi >40, reached adult height, serious obesity related health problems, psych eval pt and parents
A 60-year-old man comes to the emergency room because of hematemesis and bright red blood per rectum. He reports a history of gnawing epigastric pain radiating to the back and improved with eating. His past medical history is significant only for frequent headaches and back pain, for which he takes nonsteroidal anti-inflammatory drugs (NSAIDs) and over-the-counter medications. On physical exam, he is pale, hypotensive, and tachycardic. After resuscitation, initial upper endoscopy reveals evidence of an upper gastrointestinal hemorrhage and an ulcer in the posterior duodenal bulb. Which blood vessel is the most likely source of bleeding?
The patient presents to the emergency room with evidence of a massive upper gastrointestinal hemorrhage (hematemesis with bright red blood with hypotension and tachycardia). His symptoms of gnawing epigastric pain radiating to the back and Improved with eating suggest a posterior bulb duodenal ulcer. Ulcers in this location can erode into the gastroduodenal artery as It passes behind the first portion of the duodenum, causing massive gastrointestinal hemorrhage. The left gastric artery arises from the celiac axis. The common hepatic artery divides Into the gastroduodenal and proper hepatic arteries. The right gastric artery arises from the proper hepatic artery. The superior mesenteric artery is a branch off the aorta.
A 63-year-old man came to the office because of epigastric pain of 2 months’ duration not relieved with antacids. He has a history of an adenomatous gastric polyp removed 3 years ago. At upper endoscopy, he was found to a have another gastric polyp in his antrum that, on endoscopic ultrasound, appeared to be superficial and not associated with any enlarged lymph nodes. Pathological analysis of the polyp reveals evidence of adenocarcinoma invading into the submucosa. On clinical staging, there Is no evidence of distant metastasis. The next step in therapy for this patient is
subtotal gastrectomy
This patient has an early stage gastric cancer (i.e., no evidence of metastasis or perigastric lymph nodes) on clinical staging and is a candidate for potentially curative resection. Patients with minimal evidence of gastric wall invasion (i.e., mucosal or submucosal invasion) do not require any preoperative therapy and should proceed straight to surgical resection. In this patient with an antral lesion, a subtotal gastrectomy is Indicated with frozen section analysis of surgical margins to ensure adequate resection. Wedge resection is not recommended. In patients with evidence of greater gastric wall invasion (I.e., invasion to and beyond the lamina propria), perioperative chemotherapy with epirublcin, clsplatln, and 5-fluorouracil has been demonstrated to provide a survival benefit.
A 34-year-old woman is being evaluated for epigastric pain and Is found to have an ulcer In the anterior duodenal bulb on upper endoscopy. Rapid urease testing of a mucosal biopsy of the antrum of the stomach is positive. In addition to omeprazole, appropriate therapy at this time would include a 2-week course of omeprazole, metronidazole, and
All patients presenting with duodenal ulceration should undergo testing for the presence of Helicobacter pylori Infection. The rapid urease test can be performed on antral stomach biopsies and Is Indicative of infection if positive. If H. pylori infection is present, it should be eradicated. First-line therapy includes acid suppression with clarithromycin and amoxicillin or clarithromycin and metronidazole for a minimum of 7 days. Traditional quadruple therapy Is a second-line treatment and consists of acid suppression with bismuth, metronidazole, and tetracycline for a minimum of 7 days.
A 53-year-old woman comes to clinic for evaluation for weight loss. She has recently diagnosed diabetes, asthma, sleep apnea, and hypertension. Her BMI is 38 kg/m2. Which of the following weight loss options Is most appropriate for this patient?
This patient has type II obesity with the life-threatening comorbidity of sleep apnea. As such, she qualifies for surgical intervention according to 1998 NIH guidelines. Weight loss surgery is the only treatment option to demonstrate sustained, substantial weight loss. Gastric bypass, therefore, is Indicated. Very low calorie diets are not recommended for weight loss by the NIH guidelines. Although low-calorie diets, sibutramine, and orlistat are all options in treating obese patients, those individuals who qualify for surgery should undergo it if they are deemed appropriate candidates.
A 42-year-old woman comes to the emergency room with epigastric pain radiating to right upper quadrant. She underwent a laparoscopic adjustable gastric band 6 months ago. She has lost approximately 80 lbs over the 6 months. She is afebrile with stable vital signs. A right upper quadrant ultrasound is shown below. Which of the following medications would have been most effective In preventing this complication?
This patient has developed symptomatic cholelithiasis following rapid weight loss after a bariatric procedure. The ultrasound shows several echogenlc stones within the gallbladder. Without pharmacotherapy, the risk of gallstone formation during this period approaches 30%. The prophylactic use of ursodeoxycholic acid decreases the risk of gallstone formation to approximately 2%. Sucralfate is used to promote healing of anastomotic ulcers. Cholestyramine Is used in the treatment of alkaline reflux gastritis to bind bile salts. Calcium citrate Is given to bariatric patients to prevent calcium deficiency and subsequent osteoporosis. Omeprazole is a proton pump Inhibitor used in the treatment of anastomotic ulcers.
