Stomach and duodenum Flashcards
What are classic symptoms of afferent loop syndrome?
severe epigastric pain and cramps
bilious vomiting with relief of symptoms
why does afferent loops syndrome happen?
obstruction of the afferent loop resulting in accumulation of pancreatic and hepatobiliary secretions causing sever epigastric pain
resulting high intraluminal pressure forces the fluid into the stomach resulting in bilious vomiting and relief of symptoms
what is the treatment of afferent loop syndrome?
surgical correction
-conversion of billroth II to billroth I anastomosis
-enteroenterostomy below the stoma
-creation of a roux en y procedure
what is the length of the roux limb?
variable but often 100-150 cm
-100 cm in smaller patients (BMI 40-50)
-125-130 cm (BMI 50-55)
-150 in larger patients (BMI greater than 55)
In a patient with a recurrent duodenal ulcer bleed that is unstable, what is the next step of management?
duodenotomy and oversewing of the vessel
In a patient with a recurrent duodenal ulcer bleed that is stable, what is the next step of management?
repeat endoscopy
what is Petersen’s defect/space?
area between the mesentery of the roux (alimentary) limb and the transverse mesocolon
what two mesenteric defects can attribute to internal hernia in a roux en y bypass?
petersen’s defect
jejunojejunostomy
what test should you do to determine if h.pylori infection has been eradicated
urea breath test 4 weeks after completion of therapy
biliary reflux gastritis most commonly happens after what surgery?
billroth II gastrojejunostomy
what ulcer is associated with large hiatal hernias?
Cameron ulcer
what is the management of a duodenal perforation in an unstable patient?
controlled duodenal fistula, temporary pyloric exclusion, and gastrojejunostomy
what is the management of a duodenal perforation in a stable patient?
either the first portion of the duodenum is resected and reconstruct or jejunoserosal patch
what is the management of a duodenal perforation that is small less than 1-2 cm
primary repair
what is the management of a duodenal perforation that is 1-3 cm?
graham patch
patient’s with chronic pancreatitis may not be able to absorb what?
long chain fatty acids
what is the treatment for small bowel lymphoma
wide excision and lymph node dissection followed by adjuvant chemorads
a villous adenoma in the small bowel has what chance of cancer?
about 40%
what is the optimal way to close a loop ileostomy opening
circumferential subcuticular wound approximation
what is the most common malignant mass of the jejunum?
metastatic melanoma
what is the most common presentation of mesenteric venous thrombosis?
nonspecific abdominal pain, vomiting, diarrhea
What are the 4 types of hiatal hernias?
Type 1 (sliding type, mc), Type 2 (paraesophageal, need repair), type 3 (sliding and paraesophageal, need repair), type 4 (entire stomach is in the chest with a part of another organ in the chest)
which types of hiatal hernias need to be fixed?
Types 2, 3, 4
Type 1 only if symptomatic
Ulcer on body of stomach, incisor, and duodenal ulcer (active or healed)
Type II gastric ulcer
Medication induced gastric ulcer (can be anywhere)
Type V gastric ulcer
Prepyloric gastric ulcer
Type III gastric ulcer
Ulcer on the lesser curve, incisura
Type I gastric ulcer
Ulcer high on lesser curve, near GE junction
Type IV gastric ulcer
which gastric ulcer types are due to acid hyper secretion?
Types II and III (more distal ulcers)
which types of gastric ulcers would respond to vagotomy?
Types II and III
Which gastric ulcers are due to less protection of the gastric lining?
Types I and IV
Type I Stewart Stein EGJ tumor
distal part of esophagus between 1-5 cm above anatomic GEJ
Type II Siewart Stein EGJ tumor
Cardia (within 1 cm above and 2 cm below the EGJ)
Type III Sieward Stein EGJ tumor
Subcardial stomach (2-5 cm below EGJ)
which Stewart Stein tumors are treated more like adenocarcinoma of the esophagus?
Types I and II
How is Type III Stewart Stein tumors treated?
according to guidelines for gastric adenocarcinoma
What is the most common type of gastric volvulus?
organoaxial
what are the two types of gastric volvulus?
organoaxial and mesoaxial
organoaxial gastric volvulus
mesoaxial gastric volvulus
Gastric volvulus that rotates along the short axis of stomach bisecting the lesser and greater curvature
Mesoaxial volvulus
Gastric volvulus that rotates along the axis of the stomach from the GE junction to the pylorus
Organoaxial volvulus
How are gastric volvulus’ usually treated?
emergent surgery (hernia repair, gastropexy, partial gastrectomy if devitalized)
Can endoscopic decompression be used for gastric volvulus?
Yes, in frail patients with double PEG tubes (high perforation risk)
organoaxial gastric volvulus
what are the alarm symptoms for GERD
dysphagia, odynophagia, weight loss, anemia, GI bleeding
If a patient has atypical GERD symptoms with hx of GI surgery
bile reflux
get impedance probe ,usually needs RNY reconstruction
what work up do you need before doing any surgery for GERD?
barium swallow
EGD
ambulatory ph testing
esophageal manometry to r/o motility disorder (can’t do full Nissen if dysmotility)
What Demeester score means GERD
> 14.72
What is a Dor fundoplication
anterior 180-200 degree wrap
What is a Toupet fundoplication?
posterior 270 degree wrap
What is a Thal fundoplication
270 degree anterior wrap
What is a Belsey
270 degree anterior thoracic wrap
What is a Lind repair?
300 degree posterior wrap
During fundoplication surgery, patient is hard to ventilate, what is the problem?
capnothorax - enlarge tear to avoid tension capnothorax, place red rubber into the pleura and other end in the abdomen to equalize the pressure, at end of surgery bring one end outside the abdomen and place to water seal while valsalva administered (can also needle decompress intra op but need to prep lower chest)
what do you order if patient is having dysphagia after fundoplication surgery
esophagram - look for recurrent hernia, slipped warp, if not present may need dilation
when to use mesh with hiatal hernias?
large hiatal hernias (>5/8 cm) - decreases short term recurrence
what is the risk of rebreeding with an actively bleeding pulsatile vessel on EGD?
up to 80%
what is the risk of rebreeding on EGD with a visible vessel
up to 50%
what is the risk of rebreeding with adherent clot on EGD?
15-25%
what is the risk of rebreeding if an ulcer with clean base is seen on EGD?
<5%
what is the most common cause of gastric bleeding?
H. pylori and NSAIDS
how often is there underlying malignancy with gastric ulcers?
about 5%
With gastric adenocarcinoma, which T stage do you have to do a staging laparoscopy?
Greater than T1b (invades submucosa, past lamina proprietor which is T1a)
Can hold off if already has mets, getting definitive chemorads, or palliation only
what surgeries can you do for patients with perforated gastroduodenal ulcer that is refractory to medical management
truncal vagotomy and pyloroplasty
highly selective vagotomy
vagotomy and antrectomy (higher morbidity, needs Billroth)
who gets neoadjuvant therapy for gastric adenoma carcinoma?
T2 or greater, and N stage
what is unresectable for gastric cancer?
peritoneal involvement, distal mets, root of mesentery involvement or paraaortic nodal disease confirmed by bx, encasement of major vascular structure (excluding splenic vessels)
What margins do you need for gastric adenocarcinoma and how many lymph nodes?
at least 4 cm and at least 15 nodes
what is the resection for proximal (Siewart II) gastric adenocarcinoma?
total w/esophagojejunostomy - distal part of esophagus may need to be resected for adequate margins
What surgery do you do for distal (Stewart III) gastric adenocarcinoma?
subtotal gastrectomy
how are cancers crossing the GE junction managed?
like esophageal cancer
Do you need to do a prophylactic splenectomy for gastric cancer?
No, only if spleen or hilum are grossly involved
Which T stage needs en bloc resection of all involved structures?
T4
What is a D1 node resection?
removal of N1 nodes (peri gastric nodes along greater and lesser curve)
What stations are in a D1 node resection?
Stations 1-6
What is a D2 resection?
removal of N1 and N2 nodes (lesser/greater curve, left gastric, common hepatic, celiac, and splenic arteries)
What stations is a D2 resection?
Stations 1-6 and 7-11
what does R0 mean
negative microscopic margin
what does R1 mean
negative gross margin, positive microscopic margin
what does R2 mean
positive gross margin
what are the two types of gastric cancers?
intestinal or diffuse type
What is the gene associated with hereditary diffuse gastric cancer?
AD, 2/2 germane mutation in CDH1
what is the treatment for hereditary diffuse gastric cancer
prophylactic gastrectomy recommended between 18-40 years for CDH1 carriers
women with CDH1 are at increased risk of what other cancers?
breast cancer similar to BRCA patients
what are other hereditary syndromes with increased risk for gastric cancer?
Lynch syndrome (DNA mismatch), Juvenile polyposis syndrome (SMAD4), Peutz-Jehgers syndrome, Familial adenomatous polyposis (APC gene on 5q21)
How do you stage gastric cancer?
routine labs, CT C/A/P, EUS with FNA, PET/CT
what is the stomach transit time?
3-4 hours
gastroduodenal pain is sensed through which afferent fibers?
sympathetic fibers of T5-10
what are the branches of the celiac artery
left gastric, common hepatic, splenic artery
the gastroepiploic and short gastric arteries are branches of which artery
splenic artery
the right gastroepiploic artery is a branch of which artery
GDA
The greater curvature is supplied by which arteries
right and left gastroepiploics, short gastrics
the pylorus is supplied by which artery
GDA
which glands are mucus producing
cardia glands
chief cells
pepsinogen (1st enzyme of proteolysis)
parietal cells
release H+ and intrinsic factor
what increases acid production?
acetylcholine (vagus), gastrin (G cells antrum), histamine (mast cells)
acetylcholine and gastrin activates what?
phospholipase which activates Ca calmodulin which activates phosphorylase kinase leading to acid production
Histamine activates
adenylate cyclase which increase cAMP and activates protein kinase A which increases acid
Phosphorylase kinase and protein kinase A phosphorylate
H+/K+ ATPase to increase acid and K absorption
PPI block
H+/K+ ATPase in parietal cell membrane (final pathway for H+ release)
what are inhibitors of parietal cells
somatostatin, prostaglandins (PGE1), secretin, CCK
what does intrinsic factor do?
bind B12 and reabsorbed in the terminal ileum
Types of cells in the fundus and body glands
chief, parietal
types of cells in the antrum and pylorus glands
G cells, D cells, mucus and HCO3
G cells release
Gastrin - reason why antrectomy is helpful for ulcer disease
G cells are inhibited by
H+ in duodenum
G cells are stimulated by
amino acids, acetylcholine
D cells secrete
somatostatin which inhibit gastrin and acid release
what glands secrete alkaline mucus in the duodenum
Brunner’s glands
what is the MCC of rapid gastric emptying
previous surgery (#1), ulcers
where is the tear usually for a Mallory Weiss tear?
lesser curve
what is Menetrier’s disease?
mucus cell hyperplasia, increase in rural folds
IF a mallory weiss tear does not resolve with EGD what is the next step?
gastrostomy and oversewing of the vessel
where is a truncal vagotomy done?
divides vagal trunk at level of esophagus, increases emptying of solids
addition of pyloroplasty results in increase of solid emptying
where is a highly selective vagotomy done?
divides individual fibers and preserves the crow’s foot - normal emptying of solids
other alterations that happen with truncal vagotomy
decrease acid output by 90%, increase gastrin, gastrin cell hyperplasia, decrease exocrine pancreas fn, decrease postprandial bile flow, increase gallbladder volumes, decrease vaguely mediated hormones
what is the mc problem following vagotomy?
diarrhea caused by sustained migrating motor complex (MMC) forcing bile acids into the colon
how do you treat diarrhea after a vagotomy?
cholestyramine and loperamide
anterior duodenal ulcers usually
perforate
posterior duodenal ulcers usually
bleed from the GDA
where does stress gastritis happen
in the fundus usually 3-10 days after the event (multiple trauma, burn, complicated post op)
Type A chronic gastritis happens where?
fundus - associated with pernicious anemia, automimmune dz
Type B chronic gastritis happens where?
Antrum - associated with H. pylori
what is the classic symptoms of gastric adenocarcinoma
pain unrelieved by eating and weight loss
what is a Krukenberg tumor
gastric cancer mets to the ovaries
what are Virchow’s nodes
mets to supraclavicular node
what is the MC benign neoplasm in the stomach
GIST, can be malignant
biopsy of a GIST shows
C-KIT positive
GISTS are malignant if
> 5 cm or >5 mitoses/50 HPF
what is the treatment for GIST cancer?
resection with 1 cm margin, no nodal dissection
what is the chemo for GIST
imatinib (Gleevac)
Imatinib works how?
tyrosine kinase inhibitor
How do you treat a MALT lymphoma?
treat H. pylori
what is the most common location of a MALT lymphoma
stomach, lesser curve
extra nodal lymphoma most commonly happens in the
stomach
treatment for gastric lymphoma
primarily chemorads, surgery possible for only stage I disease (tumor confined to stomach mucosa, only partial resection is needed)
