Stomach, C41 P270-281 Flashcards by Tiggee R

ANATOMY
Identify the parts of the stomach:
P270 (Picture)

Cardia
Fundus
Body
Antrum
Incisura angularis
Lesser curvature
Greater curvature
Pylorus

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ANATOMY
Identify the blood supply to
the stomach:
P271 (Picture)

Left gastric artery
Right gastric artery
Right gastroepiploic artery
Left gastroepiploic artery
Short gastrics (from spleen)

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ANATOMY
What space lies behind the stomach?
P271

Lesser sac; the pancreas lies behind the

stomach

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ANATOMY
What is the opening into the
lesser sac?
P271

Foramen of Winslow

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ANATOMY
What are the folds of gastric
mucosa called?
P271

Rugae

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GASTRIC PHYSIOLOGY
Define the products of the
following stomach cells:
Gastric parietal cells
P271

HCl

Intrinsic factor

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GASTRIC PHYSIOLOGY
Define the products of the
following stomach cells:
Chief cells
P271

PEPsinogen (Think: “a PEPpy chief”)

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GASTRIC PHYSIOLOGY
Define the products of the
following stomach cells:
Mucous neck cells
P271

Bicarbonate

Mucus

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GASTRIC PHYSIOLOGY
Define the products of the
following stomach cells:
G cells
P271

Gastrin (Think: G cells = Gastrin)

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GASTRIC PHYSIOLOGY
Where are G cells located?
P271

Antrum

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GASTRIC PHYSIOLOGY
What is pepsin?
P271

Proteolytic enzyme that hydrolyzes peptide

bonds

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GASTRIC PHYSIOLOGY
What is intrinsic factor?
P271

Protein secreted by the parietal cells that
combines with vitamin B12 and allows
for absorption in the terminal ileum

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What is it?
P272

Excessive reflux of gastric contents into

the esophagus, “heartburn”

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What is pyrosis?
P272

Medical term for heartburn

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What are the causes?
P272

Decreased lower esophageal sphincter
    (LES) tone ( >50% of cases)
Decreased esophageal motility to clear
    refluxed fluid
Gastric outlet obstruction
Hiatal hernia in ≈50% of patients

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What are the signs/symptoms?
P272

Heartburn, regurgitation, respiratory
problems/pneumonia from aspiration of
refluxed gastric contents; substernal pain

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What disease must be ruled
out when the symptoms of
GERD are present?
P272

Coronary artery disease

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What tests are included in
the workup?
P272

EGD
UGI contrast study with esophagogram
24-hour acid analysis (pH probe in
    esophagus)
Manometry, EKG, CXR

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What is the medical treatment?
P272

Small meals
PPIs (proton-pump inhibitors) or
    H(2) blockers
Elevation of head at night and no meals
    prior to sleeping

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What are the indications for surgery?
P272

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, ± Barrett’s
esophagus)

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What is Barrett’s esophagus?
P272

Columnar metaplasia from the normal
squamous epithelium as a result of
chronic irritation from reflux

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What is the major concern
with Barrett’s esophagus?
P273

Developing cancer

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What type of cancer develops
in Barrett’s esophagus?
P273

Adenocarcinoma

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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What percentage of patients
with GERD develops
Barrett’s esophagus?
P273

10%

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``` GASTROESOPHAGEAL REFLUX DISEASE (GERD) What percentage of patients with Barrett’s esophagus will develop adenocarcinoma? P273 ```

7% lifetime (5%–10%)

``` GASTROESOPHAGEAL REFLUX DISEASE (GERD) What is the treatment of Barrett’s esophagus with dysplasia? P273 ```

``` Nonsurgical: endoscopic mucosal resection and photodynamic therapy; other options include radiofrequency ablation, cryoablation (these methods are also often used for mucosal adenocarcinoma) ```

``` GASTROESOPHAGEAL REFLUX DISEASE (GERD) Define the following surgical options for severe GERD: Lap Nissen P273 (picture) ```

360 fundoplication—2 cm long | laparoscopically

``` GASTROESOPHAGEAL REFLUX DISEASE (GERD) Define the following surgical options for severe GERD: Belsey mark IV P274 (picture) ```

240 to 270 fundoplication performed | through a thoracic approach

``` GASTROESOPHAGEAL REFLUX DISEASE (GERD) Define the following surgical options for severe GERD: Hill P274 (picture) ```

Arcuate ligament repair (close large esophageal hiatus) and gastropexy to diaphragm (suture stomach to diaphragm)

``` GASTROESOPHAGEAL REFLUX DISEASE (GERD) Define the following surgical options for severe GERD: Toupet P275 (picture) ```

Incomplete (around 200) posterior wrap (laparoscopic) often used with severe decreased esophageal motility

GASTROESOPHAGEAL REFLUX DISEASE (GERD) How does the Nissen wrap work? P275

``` Thought to work by improving the lower esophageal sphincter: 1. Increasing LES tone 2. Elongating LES ≈3 cm 3. Returning LES into abdominal cavity ```

GASTROESOPHAGEAL REFLUX DISEASE (GERD) In what percentage of patients does Lap Nissen work? P275

85% (70%–95%)

GASTROESOPHAGEAL REFLUX DISEASE (GERD) What are the postoperative complications of Lap Nissen? P275

1. Gas-bloat syndrome 2. Stricture 3. Dysphagia 4. Spleen injury requiring splenectomy 5. Esophageal perforation 6. Pneumothorax

GASTROESOPHAGEAL REFLUX DISEASE (GERD) What is gas-bloat syndrome? P275

Inability to burp or vomit

GASTRIC CANCER What is the incidence? P275

``` Low in United States (10/100,000); high in Japan (78/100,000) ```

GASTRIC CANCER What are the associated risk factors? P275

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 What is the average age at the time of discovery? P276

>60 years

GASTRIC CANCER What is the ratio of male to female patients? P276

3:2

``` GASTRIC CANCER Which blood type is associated with gastric cancer? P276 ```

Blood type A (there is an “A” in gastric | but no “O” or “B” = gAstric = type “A”)

GASTRIC CANCER What are the symptoms? P276

``` “WEAPON”: Weight loss Emesis Anorexia Pain/epigastric discomfort Obstruction Nausea ```

GASTRIC CANCER What are the most common early symptoms? P276

Mild epigastric discomfort and | indigestion

GASTRIC CANCER What is the most common symptom? P276

Weight loss

GASTRIC CANCER What are the signs? P276

Anemia, melena, heme occult, epigastric mass (in advanced disease), hepatomegaly, coffee-ground emesis, Blumer’s shelf, Virchow’s node, enlarged ovaries, axillary adenopathy

``` GASTRIC CANCER What does the patient with gastric cancer have if he or she has proximal colon distension? P276 ```

Colonic obstruction by direct invasion | rare

GASTRIC CANCER What is the symptom of proximal gastric cancer? P276

Dysphagia (gastroesophageal | junction/cardia)

GASTRIC CANCER What is a Blumer’s shelf? P276

Solid peritoneal deposit anterior to the rectum, forming a “shelf,” palpated on rectal examination

GASTRIC CANCER What is a Virchow’s node? P276

Metastatic gastric cancer to the nodes in | the left supraclavicular fossa

GASTRIC CANCER What is Sister Mary Joseph’s sign? P277

Periumbilical lymph node gastric cancer | metastases; presents as periumbilical mass

GASTRIC CANCER What is a Krukenberg’s tumor? P277

``` Gastric cancer (or other adenocarcinoma) that has metastasized to the ovary ```

GASTRIC CANCER What is “Irish’s” node? P277

Left axillary adenopathy from gastric cancer | metastasis

GASTRIC CANCER What is a surveillance laboratory finding? P277

CEA elevated in 30% of cases (if , useful | for postoperative surveillance)

GASTRIC CANCER What is the initial workup? P277

EGD with biopsy, endoscopic U/S to evaluate the level of invasion, CT of abdomen/pelvis for metastasis, CXR, labs

GASTRIC CANCER What is the histology? P277

Adenocarcinoma

GASTRIC CANCER What is the differential diagnosis for gastric tumors? P277

Adenocarcinoma, leiomyoma, leiomyosarcoma, lymphoma, carcinoid, ectopic pancreatic tissue, gastrinoma, benign gastric ulcer, polyp

GASTRIC CANCER What are the two histologic types? P277

1. Intestinal (glands) | 2. Diffuse (no glands)

GASTRIC CANCER What is the morphology? P277

Ulcerative (75%) Polypoid (10%) Scirrhous (10%) Superficial (5%)

``` GASTRIC CANCER Are gastric cancers more common on the lesser or greater curvatures? P277 ```

Lesser (“less is more”)

``` GASTRIC CANCER What is more common, proximal or distal gastric cancer? P277 ```

Proximal

``` GASTRIC CANCER Which morphologic type is named after a “leather bottle”? P277 ```

Linitis plastica—the entire stomach is involved and looks thickened (10% of cancers)

GASTRIC CANCER How do gastric adenocarcinomas metastasize? P277

Hematogenously and lymphatically

GASTRIC CANCER Which patients with gastric cancer are NONoperative? P278

1. Distant metastasis (e.g., liver metastasis) | 2. Peritoneal implants

GASTRIC CANCER What is the role of laparoscopy? P278

To rule out peritoneal implants and to | evaluate for liver metastasis

``` GASTRIC CANCER What is the genetic alteration seen in >50% of patients with gastric cancer? P278 ```

P53

GASTRIC CANCER How can you remember P53 for gastric cancer? P278

Gastric Cancer = GC = P53; or, think: | “GCP . . . 53”—it sings!

GASTRIC CANCER What is the treatment? P278

Surgical resection with wide (5 cm checked by frozen section) margins and lymph node dissection

GASTRIC CANCER What operation is performed for tumor in the: Antrum? P278

Distal subtotal gastrectomy

GASTRIC CANCER What operation is performed for tumor in the: Midbody? P278

Total gastrectomy

GASTRIC CANCER What operation is performed for tumor in the: Proximal? P278

Total gastrectomy

GASTRIC CANCER What is a subtotal gastrectomy? P278 (picture)

Subtotal gastrectomy = 75% of stomach | removed

GASTRIC CANCER What is a total gastrectomy? P279 (picture)

Stomach is removed and a Roux-en-Y | limb is sewn to the esophagus

GASTRIC CANCER What type of anastomosis? P279 (picture)

Billroth II or Roux-en-Y (never use a | Billroth I)

GASTRIC CANCER When should splenectomy be performed? P279

When the tumor directly invades the spleen/splenic hilum or with splenic hilar adenopathy

GASTRIC CANCER Define “extended lymph node dissection.” P279

``` Usually D1 and D2: D1 are perigastric LNs D2 include: splenic artery LNs, hepatic artery LNs, anterior mesocolon LNs, anterior pancreas LNs, crural LNs ```

GASTRIC CANCER What percentage of patients are inoperable at presentation? P279

≈10% to 15%

GASTRIC CANCER What is the adjuvant treatment? P279

Stages II and III: postoperative | chemotherapy and radiation

GASTRIC CANCER What is the 5-year survival rate for gastric cancer? P279

25% of patients are alive 5 years after diagnosis in the United States (in Japan, 50% are alive at 5 years)

``` GASTRIC CANCER Why is it thought that the postoperative survival is so much higher in Japan? P280 ```

Aggressive screening and capturing early | cancers

GIST What is it? P280

GastroIntestinal Stromal Tumor

GIST What was it previously known as? P280

Leiomyosarcoma

GIST What is the cell of origin? P280

CAJAL, interstitial cells of Cajal

GIST Where is it found? P280

GI tract—“esophagus to rectum”—most commonly found in stomach (60%), small bowel (30%), duodenum (5%), rectum (3%), colon (2%), esophagus (1%)

GIST What are the symptoms? P280

GI bleed, occult GI bleed, abdominal pain, abdominal mass, nausea, distention

GIST How is it diagnosed? P280

CT scan, EGD, colonoscopy

GIST How are distant metastases diagnosed? P280

PET scan

GIST What is the tumor marker? P280

C-KIT (CD117 antigen)

GIST What is the prognosis? P280

Local spread, distant metastases Poor long-term prognosis: size >5cm, mitotic rate >5 per 50 HPF (high power field)

GIST What is the treatment? P280

Resect with negative margins, +/- | chemotherapy

GIST Is there a need for lymph node dissection? P280

``` GIST What is the chemotherapy for metastatic or advanced disease? P280 ```

Imatinib—tyrosine kinase inhibitor

MALTOMA What is it? P281

Mucosal-Associated Lymphoproliferative | Tissue

MALTOMA What is the most common site? P281

Stomach (70%)

MALTOMA What is the causative agent? P281

H. pylori

MALTOMA What is the medical treatment? P281

Nonsurgical—treat for H. pylori with triple therapy and chemotherapy/XRT in refractory cases

GASTRIC VOLVULUS What is it? P281

Twisting of the stomach

GASTRIC VOLVULUS What are the symptoms? P281

``` Borchardt’s triad: 1. Distention of epigastrium 2. Cannot pass an NGT 3. Emesis followed by inability to vomit ```

GASTRIC VOLVULUS What is the treatment? P281

Exploratory laparotomy to untwist, and | gastropexy