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Section II General Surgery P203Surgical Recall Sixth > Stomach, C41 P270-281 > Flashcards

Stomach, C41 P270-281 Flashcards

1
Q

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

A
  1. Cardia
  2. Fundus
  3. Body
  4. Antrum
  5. Incisura angularis
  6. Lesser curvature
  7. Greater curvature
  8. Pylorus
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2
Q

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

A
  1. Left gastric artery
  2. Right gastric artery
  3. Right gastroepiploic artery
  4. Left gastroepiploic artery
  5. Short gastrics (from spleen)
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3
Q

ANATOMY
What space lies behind the stomach?
P271

A

Lesser sac; the pancreas lies behind the

stomach

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4
Q

ANATOMY
What is the opening into the
lesser sac?
P271

A

Foramen of Winslow

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5
Q

ANATOMY
What are the folds of gastric
mucosa called?
P271

A

Rugae

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6
Q 
GASTRIC PHYSIOLOGY
Define the products of the
following stomach cells:
Gastric parietal cells
P271
A

HCl

Intrinsic factor

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7
Q 
GASTRIC PHYSIOLOGY
Define the products of the
following stomach cells:
Chief cells
P271
A

PEPsinogen (Think: “a PEPpy chief”)

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8
Q 
GASTRIC PHYSIOLOGY
Define the products of the
following stomach cells:
Mucous neck cells
P271
A

Bicarbonate

Mucus

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9
Q 
GASTRIC PHYSIOLOGY
Define the products of the
following stomach cells:
G cells
P271
A

Gastrin (Think: G cells = Gastrin)

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10
Q

GASTRIC PHYSIOLOGY
Where are G cells located?
P271

A

Antrum

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11
Q

GASTRIC PHYSIOLOGY
What is pepsin?
P271

A

Proteolytic enzyme that hydrolyzes peptide

bonds

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12
Q

GASTRIC PHYSIOLOGY
What is intrinsic factor?
P271

A

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

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13
Q

GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What is it?
P272

A

Excessive reflux of gastric contents into

the esophagus, “heartburn”

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14
Q

GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What is pyrosis?
P272

A

Medical term for heartburn

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15
Q

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

A 
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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16
Q

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

A

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

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17
Q 
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What disease must be ruled
out when the symptoms of
GERD are present?
P272
A

Coronary artery disease

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18
Q

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

A 
EGD
UGI contrast study with esophagogram
24-hour acid analysis (pH probe in
    esophagus)
Manometry, EKG, CXR
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19
Q

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

A 
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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20
Q

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

A

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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21
Q

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

A

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

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22
Q

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

A

Developing cancer

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23
Q

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

A

Adenocarcinoma

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24
Q 
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What percentage of patients
with GERD develops
Barrett’s esophagus?
P273
A

10%

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25
Q 
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What percentage of patients
with Barrett’s esophagus will
develop adenocarcinoma?
P273
A

7% lifetime (5%–10%)

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26
Q 
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
What is the treatment of
Barrett’s esophagus with
dysplasia?
P273
A 
Nonsurgical: endoscopic mucosal
resection and photodynamic therapy;
other options include radiofrequency
ablation, cryoablation (these methods
are also often used for mucosal
adenocarcinoma)
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27
Q 
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Define the following surgical options for severe
GERD:
Lap Nissen
P273 (picture)
A

360 fundoplication—2 cm long

laparoscopically

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28
Q 
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Define the following surgical options for severe
GERD:
Belsey mark IV
P274 (picture)
A

240 to 270 fundoplication performed

through a thoracic approach

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29
Q 
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Define the following surgical options for severe
GERD:
Hill
P274 (picture)
A

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

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30
Q 
GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Define the following surgical options for severe
GERD:
Toupet
P275 (picture)
A

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

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31
Q

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

A 
Thought to work by improving the lower
esophageal sphincter:
1. Increasing LES tone
2. Elongating LES ≈3 cm
3. Returning LES into abdominal cavity
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32
Q

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

A

85% (70%–95%)

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33
Q

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

A
  1. Gas-bloat syndrome
  2. Stricture
  3. Dysphagia
  4. Spleen injury requiring splenectomy
  5. Esophageal perforation
  6. Pneumothorax
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34
Q

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

A

Inability to burp or vomit

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35
Q

GASTRIC CANCER
What is the incidence?
P275

A 
Low in United States (10/100,000); high
in Japan (78/100,000)
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36
Q

GASTRIC CANCER
What are the associated risk factors?
P275

A

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

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37
Q

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

A

> 60 years

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38
Q

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

A

3:2

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39
Q 
GASTRIC CANCER
Which blood type is
associated with gastric
cancer?
P276
A

Blood type A (there is an “A” in gastric

but no “O” or “B” = gAstric = type “A”)

40
Q

GASTRIC CANCER
What are the symptoms?
P276

A 
“WEAPON”:
    Weight loss
    Emesis
    Anorexia
    Pain/epigastric discomfort
    Obstruction
    Nausea
41
Q

GASTRIC CANCER
What are the most common
early symptoms?
P276

A

Mild epigastric discomfort and

indigestion

42
Q

GASTRIC CANCER
What is the most common symptom?
P276

A

Weight loss

43
Q

GASTRIC CANCER
What are the signs?
P276

A

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

44
Q 
GASTRIC CANCER
What does the patient with
gastric cancer have if he
or she has proximal colon
distension?
P276
A

Colonic obstruction by direct invasion

rare

45
Q

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

A

Dysphagia (gastroesophageal

junction/cardia)

46
Q

GASTRIC CANCER
What is a Blumer’s shelf?
P276

A

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

47
Q

GASTRIC CANCER
What is a Virchow’s node?
P276

A

Metastatic gastric cancer to the nodes in

the left supraclavicular fossa

48
Q

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

A

Periumbilical lymph node gastric cancer

metastases; presents as periumbilical mass

49
Q

GASTRIC CANCER
What is a Krukenberg’s
tumor?
P277

A 
Gastric cancer (or other adenocarcinoma)
that has metastasized to the ovary
50
Q

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

A

Left axillary adenopathy from gastric cancer

metastasis

51
Q

GASTRIC CANCER
What is a surveillance
laboratory finding?
P277

A

CEA elevated in 30% of cases (if , useful

for postoperative surveillance)

52
Q

GASTRIC CANCER
What is the initial workup?
P277

A

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

53
Q

GASTRIC CANCER
What is the histology?
P277

A

Adenocarcinoma

54
Q

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

A

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

55
Q

GASTRIC CANCER
What are the two histologic types?
P277

A
  1. Intestinal (glands)

2. Diffuse (no glands)

56
Q

GASTRIC CANCER
What is the morphology?
P277

A

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

57
Q 
GASTRIC CANCER
Are gastric cancers more
common on the lesser or
greater curvatures?
P277
A

Lesser (“less is more”)

58
Q 
GASTRIC CANCER
What is more common,
proximal or distal gastric
cancer?
P277
A

Proximal

59
Q 
GASTRIC CANCER
Which morphologic type
is named after a “leather
bottle”?
P277
A

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

60
Q

GASTRIC CANCER
How do gastric adenocarcinomas
metastasize?
P277

A

Hematogenously and lymphatically

61
Q

GASTRIC CANCER
Which patients with gastric
cancer are NONoperative?
P278

A
  1. Distant metastasis (e.g., liver metastasis)

2. Peritoneal implants

62
Q

GASTRIC CANCER
What is the role of
laparoscopy?
P278

A

To rule out peritoneal implants and to

evaluate for liver metastasis

63
Q 
GASTRIC CANCER
What is the genetic
alteration seen in >50% of
patients with gastric cancer?
P278
A

P53

64
Q

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

A

Gastric Cancer = GC = P53; or, think:

“GCP . . . 53”—it sings!

65
Q

GASTRIC CANCER
What is the treatment?
P278

A

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

66
Q

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

A

Distal subtotal gastrectomy

67
Q

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

A

Total gastrectomy

68
Q

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

A

Total gastrectomy

69
Q

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

A

Subtotal gastrectomy = 75% of stomach

removed

70
Q

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

A

Stomach is removed and a Roux-en-Y

limb is sewn to the esophagus

71
Q

GASTRIC CANCER
What type of anastomosis?
P279 (picture)

A

Billroth II or Roux-en-Y (never use a

Billroth I)

72
Q

GASTRIC CANCER
When should splenectomy
be performed?
P279

A

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

73
Q

GASTRIC CANCER
Define “extended lymph
node dissection.”
P279

A 
Usually D1 and D2:
    D1 are perigastric LNs
    D2 include: splenic artery LNs,
      hepatic artery LNs, anterior
      mesocolon LNs, anterior pancreas
      LNs, crural LNs
74
Q

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

A

≈10% to 15%

75
Q

GASTRIC CANCER
What is the adjuvant
treatment?
P279

A

Stages II and III: postoperative

chemotherapy and radiation

76
Q

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

A

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

77
Q 
GASTRIC CANCER
Why is it thought that the
postoperative survival is so
much higher in Japan?
P280
A

Aggressive screening and capturing early

cancers

78
Q

GIST
What is it?
P280

A

GastroIntestinal Stromal Tumor

79
Q

GIST
What was it previously
known as?
P280

A

Leiomyosarcoma

80
Q

GIST
What is the cell of origin?
P280

A

CAJAL, interstitial cells of Cajal

81
Q

GIST
Where is it found?
P280

A

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

82
Q

GIST
What are the symptoms?
P280

A

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

83
Q

GIST
How is it diagnosed?
P280

A

CT scan, EGD, colonoscopy

84
Q

GIST
How are distant metastases
diagnosed?
P280

A

PET scan

85
Q

GIST
What is the tumor marker?
P280

A

C-KIT (CD117 antigen)

86
Q

GIST
What is the prognosis?
P280

A

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

87
Q

GIST
What is the treatment?
P280

A

Resect with negative margins, +/-

chemotherapy

88
Q

GIST
Is there a need for lymph
node dissection?
P280

A

NO

89
Q 
GIST
What is the chemotherapy
for metastatic or advanced
disease?
P280
A

Imatinib—tyrosine kinase inhibitor

90
Q

MALTOMA
What is it?
P281

A

Mucosal-Associated Lymphoproliferative

Tissue

91
Q

MALTOMA
What is the most common site?
P281

A

Stomach (70%)

92
Q

MALTOMA
What is the causative agent?
P281

A

H. pylori

93
Q

MALTOMA
What is the medical treatment?
P281

A

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

94
Q

GASTRIC VOLVULUS
What is it?
P281

A

Twisting of the stomach

95
Q

GASTRIC VOLVULUS
What are the symptoms?
P281

A 
Borchardt’s triad:
1. Distention of epigastrium
2. Cannot pass an NGT
3. Emesis followed by inability to
    vomit
96
Q

GASTRIC VOLVULUS
What is the treatment?
P281

A

Exploratory laparotomy to untwist, and

gastropexy

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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