stomach final absite Flashcards
1
Q
Inferiorly, the stomach is attached to ___ via___
A
Transverse colon via gastrocolic omentum
2
Q
The lesser curvature is thethered to the liver by
A
Hepatogastric ligament (lesser omentum)
3
Q
What’s posterior to the stomach
A
Lesser omental bursa and pancreas
4
Q
Right gastroepiploic artery rises from
A
Gastroduodenal artery (GDA) behind the first portion of the duodenum
5
Q
Left gastroepiploic artery arises from
A
Splenic artery, meets the right one on the greater curvature
6
Q
The right gastric artery arises from
A
The hepatic artery (proper hepatic) near the pylorus and hepatoduodenal ligament
7
Q
The right and left gastric veins drain into
A
Portal vein
8
Q
Right gastroepiploic vein drains into
A
SMV near the inferior border of pancreatic neck
9
Q
Components of the celiac trunk
A
Left gastricCommon hepatic arterySplenic artery
10
Q
Branches of the splenic artery that supply the stomach
A
Left gastroepiploic and short gastric
11
Q
Blood supply to the greater curvature
A
Right and left gastroepiploics, short gastrics
12
Q
What is the right gastroepiploic a branch of?
A
Gastroduodenal artery
13
Q
Blood supply of lesser curvature
A
Right and left gastrics
14
Q
What is the right gastric a branch off?
A
The common hepatic artery
15
Q
Blood supply of the pylorus
A
Gastroduodenal artery
16
Q
Left gastroepiploic vein drains into the
A
Splenic vein
17
Q
What supplies the gastric remnant following a radical subtotal gastrectomy
A
Short gastric as long as spelling artery is ok
18
Q
Common hepatic branches into
A
Proper hepatic and GDA
19
Q
Type of cells making up the stomach
A
Simple columnar cells, and mucus secreting cells mostly in cardiac
20
Q
Fundus and body cells and stimulation
A
Parietal cells (release acid and intrinsic factor), chief cells secrete pepsinogen (chief role so chief cells).
21
Q
Stimulation of parietal cells
A
Stimulated by Vagus via Ach, gastrin from g cell, and histamine
22
Q
Stomach antrum secretes
A
G cells and D cells (somatostatin)
23
Q
Produces pepsinogen (1st enzyme in proteolysis)
A
Chief cells
24
Q
Release hydrogen and intrinsic factor
A
Parietal cells
25
If retained antrum syndrome, basal stomach acid, gastrin level in response to secretin
Basal high bc still masking gastrin, gastrin high, gastric acid secretion in response to secretion stimulations test would drop in comparison to gastronoma.
Secretin normally would decrease gastric acid, high in gastronoma.
Antrum syndrome, hyperstimualtion of gastrin from lack of acid hitting g cells and downregulating them
26
Role of somatostatin
Inhibits secretin of gastric acid, pepsinogen , pancreatic secretions, decreased GB contraction, decreased insulin and glucagon release
27
organioaxial vulvus - stomach
Triggered by reduceding volvues, need Nissan. GE junction to pylorus.
28
Forceful vomiting and hematemesis following
Mallory weiss tear, mucosal tear, EGD and clip along lesser curve MC
29
Truncal vagotomy
Go 5 cm up one esphagus and get left and right, trying to get criminal nerve of grassi, increase emptying of liquid. Lose innervation fo pylorus so solids also affected. Unless you perform a pyloroplasty. Decrease gastric acid production by 90%, increase gastrin overall from gastrin cell hyperplasia, decrease exocrine pancreatic function, decrease bile flow, increase GB volume, decreased in vagaly mediated hormones
30
Selected vagotomy
Trying to Maintain vagus innervation below the liver, so below hepatic branches to get stomach fibers. Normal solid emptying
31
Hepatic branches
LARP- left become anterior continues over to the liver, posterior becomes the celiac
32
Emptying of stomach following vagotomy
Increased because lose the receptor reflex, increased emptying liquid of stomach.
33
What are patients complain off after a vagotomy, treatment?
Diarrhea, give cholestyramine for treatment
34
What causes bile secretion?
Cholinergic stimulation causes contraction of the gallbladder and relaxation of the sphincter of Oddi, which means that bile is secretedinto the intestine.
35
Upper GI bleed?
Above ligament of treitz
36
Upper GI bleed first line?
ABC, 2 large bores, resuscitation, early endoscopy
37
Bleeding ulcers, types?
Active bleeding - 60% of re-bleed
Base of ulcer - 40%
Diffuse oozing - 30%
38
Upper endoscopy and can’t control bleeding?
OR, empiric treatment for h pylori
39
Already on h pylori tx, but are going to OR for uncontrolled bleeding?
Think about vagotomy
40
Duodenal ulcers location
Duodenal bulb, first portion
41
Anterior ulceration of duodenum, presentation?
Free perf in peritoneum, pneumoperitoneum
42
Posterior ulceration of duodenum, presentation?
Into GDA (bleed), more common.
43
Posterior ulceration of duodenum with significant bleed that can’t be controlled by endoscopy. Needle and suture? Careful with what
Duodenotomy, GDA ligation, 3 suture ligation. Proximal , distal and transverse pancreatic branch . Use O vycryl suture, UR6 needle. Careful with CBD.
44
Anterior perforation tx?
Graham patch using omentum
45
Graham patch?
2 suture into anterior portion of duodenum and bring omentum , if on PPI and + h.pylori treatment = vagal
46
Quadruple therapy?
Amox, clarithromycin, PPI +bismuth
47
Best test for h pylori?
EGD with biopsy and histology
48
Most sensitive test for h pylori?
Antibody test
49
Best test for documenting resolution?
Breath test - urease
50
Young patient, multiple ulcers, some in distal portions?
Zollinger
| Gastronome - secretin test if not super diagnostic, gastrin level (>200, def > 1000),
51
Gastric ulcers - type I?
Low along body lesser curve, 50-60%
| Poor mucosa protection
52
Gastric ulcers - type IV?
high lesser curve < 10%, poor mucosa protection
53
Type 2 gastric ulcer
2 ulcers (lesser curve and duodenal); similar to duodenal ulcer with high acid secretion
54
Type 3 gastric ulcer
pre-pyloric ulcer; similar to duodenal ulcer with high acid secretion
55
Types related to high acid secretion?
Type II, lesser curve and duodenum from high acid
| Type III, prepylorus also high acid
56
Which gastric ulcer is secondary to meds?
Type 5, 5% NSAID use
57
Main-stem treatment?
Trugnal vagotomy, antrectomy, consider separate ulcer excision and exclude cancer
58
Antrectomy, reconstructions
Vagotomy first
- Bilroth I - hooking stomach directly to duodenum, complications
- Bilroth II - hooking stomach into jejunum, symptoms of dumping and alkaline, common complications: afferent loop obstruction
- RNY - preferred in younger patients.
Anatomy of modern Roux-en-Y gastric bypass. Modern gastric bypass consists of a divided pouch gastroplasty with Rouxen-Y jejunojejunal reconstruction. The Roux limb is most commonly placed in the antecolic position. Intestinal limbs are termed with either standard Roux (Roux, afferent, efferent) or bariatric (alimentary, biliopancreatic, common channel) nomenclature as shown.
59
Afferent loop syndrome, tx?
Overgrowth of bacteria can present with megaloblastic anemia, b12 deficiency, bile reflux gastritis (tx to convert to RNY, need at least 6 cm from pancreatic/biliary limb to avoid this)
Conversion of Billroth II gastrojejunostomy to Roux-en-Y gastrojejunostomy. The afferent limb is divided (A) and intestinal continuity is reestablished by anastomosis 50 to 60 cm downstream from the original gastrojejunostomy (B).
60
Most common benign gastric neoplasm, although can be malignant
Symptoms: usually asymptomatic, but obstruction and bleeding can occur
GIST
61
What will be positive in biopsy of GIST?
C-KIT
62
GIST receptor
Receptor CK
63
What are poor options for surgical repair of gastric ulcers?
Omental patch and ligation of bleeding vessels are poor options for gastric ulcers due to high recurrence of symptoms and risk of gastric CA in the ulcer.
64
What’s CK
Tyrosine kinase receptor
65
Dx and tx of GIST
Dx: biopsy - are C-KIT positiveTx: resection with 1 cm margins; Chemotherapy with imatinib (Gleevac, tyrosine kinase inhibitor) if malignant
66
When are GIST considered malignant?
> 5 cm or > 5 mitoses / 50 HPF (high-powered field)
67
TK inhibitor that can be treatment for malignant GIST?
Imatinib (Gleevax; tyrosine kinase inhibitor) look at pathology report and seize, if > 5 cm: tx with adjuvant Gleevax, look at mitosis per hpf, If >5, use this.
68
Resection margins for GIST
1 cm margins
69
How do GISTs look on ultrasound?
Hypoechoic on ultrasound; smooth edges
70
Macroscopic margins
Don’t need macroscopic margins
71
Lymphomas - maltoma tx
Triple therapy ABX given relationship with h pylori or radiation if non-responsive
72
Extraenodal lymphoma, MC site
stomach, non-hodgkin B cell type, tx with chemo and radiation, expect if stage 1 and confined to
73
cushings ulcer
Head injury patient
74
Curlings culer
Burn patient
75
Camerons ulcer
Pressure point next to hiatal hernia
76
Gastric cancer with mets to ovaries
Kruckenberg tumor
77
Enlarged supraclavicular node associated with metastatic gastric cancer
Virchows node
78
Supra umbilical
Sister Mary Joseph node
79
Hiatal hernia - type 1
Sliding
80
Hiatal hernia - type 2
Para-esophageal hernia
81
Hiatal hernia - type 3
Combining sliding and paraesophageal
82
Hiatal hernia - type 4
Entire stomach into chest + another organ***
83
Hiatal hernia treatments
2,3,4 all need surgical intervention - 2,3 risk stratified if too frail may need to avoid surgery
Ultimately: nissen fundoplication
84
Bouchards triad
Chest pain retching without vomiting and inability to pass NGT
85
Tenets to nissen
Reduce hernia and sac, excise sac out of chest, mediastinal mobilization of esophagus (2-3 cm intraadbominally) reaproxiamte crura, perform wrap over a large 50-54 French bougie to recreate natural valve to prevent reflux
86
Complication after Nissen
MC: dysphagia, some is expected so put them on CLD, if worried barium swallow. Ar they tolerating their own secretions? If not, then OR too tight wrap and swelling.
87
What if you cant get esophagus down the stomach?
Coulis gastroplasty - elongate esophagus by coming down to tubliainzg stomach in greater curve
88
What stimulates parietal cells?
Acetylcholine (vagus nerve), gastrin (from G cells in antrum), and histamine (from mast cells) cause H+ release
89
What is the pathway of acetylcholine (vagus nerve) and gastrin?
Activates phospholipase (PIP -> DAG + IP3 + Increase Ca); Ca-calmodulin activates phosphorylase kinase -> H+ release
90
What is the pathway of histamine?
Activates adenylate cyclase -> cAMP -> activates protein kinase A -> increased H+ release
91
How do phosphorylase and protein kinase A work?
Phosphorylate H+/K+ ATPase to increase H+ secretion and K+ absorption
92
Blocks H+/K+ ATPase in parietal cell membrane (final pathway for H+ release)
Omeprazole
93
Inhibitors of parietal cells
Somatostatin, prostaglandins (PGE1), secretin, CCK
94
Binds B12 and the complex is reabsorbed in the terminal ileum
Intrinsic factor
95
Antrum and pylorus glands
Mucus and HCO3- secreting glands.G cells (gastrin).D cells (somatostatin)
96
Secreting glands - protect stomach
Mucus and HCO3- (Antrum and pylorus glands)
97
Release gastrin - reason why antrectomy is helpful for ulcer disease
G cells
98
What inhibits G cells?
H+ in duodenum
99
What stimulates G cells?
Amino acids, acetylcholine
100
Secrete somatostatin, inhibit gastrin and acid release
D cells
101
In duodenum; secrete alkaline mucus
Brunner's glands
102
Released with antral and duodenal acidification
Somatostain, CCK, and secretin
103
Stomach transit time
3-4 hours
104
Where does stomach peristalsis occur?
Distal stomach (antrum)
105
How is gastroduodenal pain sensed
Through afferent sympathetic fibers T5-T10
106
What do cardia glands secrete?
Mucus
107
What are the causes of rapid gastric emptying?
Previous surgery (#1), ulcers
108
What are the causes of delayed gastric emptying?
Diabetes, opiates, anticholingerics, hypothyroidism
109
(Hair) - hard to pull outTx?
Trichobezoars- Tx: EGD generally inadequate; likely need gastrostomy and removal
110
(fiber) - often in diabetics with poor gastric emptyingTx?
Phytobezoars (fiber)Tx: enzymes, EGD, diet changes
111
Vascular malformation; can bleed
Dieulafoy's ulcer
112
Mucous cell hyperplasia, increased rugal folds
Menetrier's disease
113
- Associated with type II (paraesophageal) hernia- Nausea without vomiting; severe pain; usually organoaxial volvulusTreatment?
Gastric volvulusTx: reduction and Nissen
114
- Secondary to forceful vomiting- Presents as hematemesis following severe retching- Bleeding often stops spontaneously
Mallory-Weiss tear
115
What type of volvulus is a gastric volvulus?
Organoaxial volvulus
116
Dx/Tx: Mallory Weiss Tear
EGD with hemo-clips; tear is usually on the lesser curvature (near GE junction)
117
Where is the Mallory Weiss Tear located?
Usually on the lesser curvature (near GE junction)
118
What if you have continued bleeding after EGD with hemo-clips for Mallory Weiss tear?
If continued bleeding, may need gastrostomy and oversewing of the vessel.
119
What is the physiologic effect of vagotomy?
Both truncal and proximal forms increase liquid emptying -> vaguely mediated receptive relaxation if removed (results in increased gastric pressure that accelerates liquid emptying)
120
Vagotomy:Divides vagal trunks at the level of the esophagus; decreases emptying of solids
Truncal vagotomy
121
Vagotomy:- highly selective- divides individual fibers, preserves "crow's foot", normal emptying of solids
Proximal vagotomy
122
Emptying of solids: truncal vs proximal vagotomy
Truncal: decreased emptying of solidsProximal: normal emptying of solids
123
How can you increase solid emptying with truncal vagotomy?
Addition of pyloroplasty to truncal vagotomy results in increased solid emptying.
124
Physiologic effects of truncal vagotomy- Gastric effects- Nongastric effects- Diarrhea
- Gastric: decreased acid output by 90%, increased gastrin cell hyperplasia- Nongastric: decreased exocrine pancreas function, decreased postprandial bile flow, increased gallbladder volumes, decreased release of vaguely mediated hormones - Diarrhea: MC problem following vagotomy
125
MC common problem following vagotomy
Diarrhea (40%)
126
What causes diarrhea following vagotomy?
Caused by sustained MMCs (migrating motor complex) forcing bile acids into the colon
127
Name that vagotomy: both nerve trunks are divided at the level of the diaphragmatic hiatus
Truncal vagotomy
128
Name that vagotomy: division of the vagal fibers that supply the gastric funds. Branches to the antropyloric region of the stomach are not transected, and the hepatic and celiac divisions of the vagus nerves remain intact.
Proximal gastric vagotomy
129
Risk factors: upper gastroinestinal bleeding
Previous UGIB, PUD, NSAIDs, smoking, liver disease, esophageal varices, splenic vein thrombosis, sepsis, burn injuries, trauma, severe vomiting.
130
Dx/Tx: UGIB
EGD (confirm bleeding is from ulcer); can potentially treat with hemo-clips, Epi injection, cautery
131
Mgmt: UGIB with slow bleeding and having trouble localizing source
Tagged RBC scan
132
UGIB: biggest risk factor for rebleeding at the time of EGD
#1 spurting blood vessel (60%) chance of rebleed#2 visible blood vessel (40% chance of rebleed)#3 diffuse oozing (30% chance of rebleed)
133
Highest risk factor for mortality with non-variceal UGIB
Continued or re-bleeding
134
Treatment: patient with liver failure is likely bleeding from esophageal varices, not an ulcer
EGD with variceal bands or sclerotherapy; TIPS if that fails
135
- From increased acid production and decreased defense- Most common peptic ulcer; more common in men
Duodenal ulcers
136
Location of duodenal ulcers
Usually in 1st part of the duodenum; usually anterior.
137
Complications of duodenal ulcers:- Anterior- Posterior
- Anterior ulcers perforate- Posterior ulcers bleed from gastroduodenal artery
138
Symptoms: epigastric pain radiating to the back; abates with eating but recurs 30 minutes after- Dx/Tx?
Duodenal ulcer- Dx: endoscopy- Tx: PPI, triple therapy for H. pylori -> bismuth salts, amoxicillin, and metronidazole/tetracycline (BAM or BAT)
139
What has decreased incidence of surgery for ulcer?
Surgery for ulcer rarely indicated since PPIs
140
What do you need to rule out in patients with complicated ulcer disease?
Need to rule out gastrinoma
141
Gastric acid hyper secretion.Peptic ulcers.Gastrinoma.
Zollinger-Ellison Syndrome
142
Surgical indications for duodenal ulcer
Perforation. Protracted bleeding despite EGD therapy. Obstruction. Intractability despite medical therapy. Inability to rule out cancer. PPI with duodenal ulcer complication.
143
Duodenal ulcer: if patient has been on a PPI and has complications
If a patient has been on a PPI, an acid-reducing surgical procedure is required in addition to surgery for any complications
144
Surgical options (acid-reducing surgery) for duodenal ulcers
- Proximal vagotomy- Truncal vagotomy and pyloroplasty- Truncal vagotomy and antrectomy- Reconstruction after antrectomy - Roux-en-Y gastro-jejunostomy (best)
145
Surgery duodenal ulcer: lowest rate of complications, no need for astral or pylorus procedure; 10-15% ulcer recurrence, 0.1% mortality
Proximal vagotomy
146
Ulcer recurrence / mortality after proximal vagotomy
- 10-15% ulcer recurrence- 0.1% mortality
147
Ulcer recurrence / mortality after truncal vagotomy and pyloroplasty
- 5-10% ulcer recurrence- 1% mortality
148
Ulcer recurrence / mortality after truncal vagotomy and antrectomy
- 1-2% ulcer recurrence (lowest rate of recurrence)- 2% mortality
149
Why is roux-en-y gastro-jejunostomy the best procedure for reconstruction after antrectomy?
Less dumping syndrome and reflux gastritis compared to Bilroth I (gastro-duodenal anastomosis) and Billroth II (gastro-jejunal anastomosis)
150
Most frequent complication of duodenal ulcers
Bleeding (usually minor but can be life threatening)
151
Definition of major bleeding in duodenal ulcer
> 6 units of blood in 24 hours or patient remains hypotensive despite transfusion
152
Tx: bleeding from duodenal ulcer
EGD 1st - hemoclips , cauterize, Epi injection
153
Surgery: bleeding duodenal ulcers
Duodenotomy and gastroduodenal artery (GDA) ligation.- Avoid hitting common bile duct (posterior) with GDA ligation- If patient has been on a PPI, need acid-reducing surgery as well
154
Initial treatment of choice for obstruction from duodenal ulcer
PPI and serial dilation
155
Surgical options: duodenal ulcer obstruction
Antrectomy and truncal vagotomy (best); include ulcer in resection if it's located proximal to ampulla of Vater
156
What do you need to rule out in duodenal ulcer obstruction?
Need to biopsy area of resection to rule out CA
157
Duodenal ulcer perforation: % will have free air
80% will have free air
158
- patient usually have sudden epigastric pain; can have generalized peritonitis- pain can radiate to the prevocalic gutters with dependent drainage of gastric content
Duodenal ulcer perforation
159
Tx: duodenal ulcer perforation
Graham patch (place momentum over the perforation)- Also need acid-reducing surgery if the patient has been on a PPI
160
Definition of intractable duodenal ulcers
> 3 months without relief while on escalating doses of PPI
161
What is diagnosis of intractable duodenal ulcers based on?
Based in EGD mucosal findings, not symptoms
162
Tx: intractability of duodenal ulcers
Acid-reducing surgery
163
- Older men, slow healing- 80% on lesser curvature of the stomach- Symptoms: epigastric pain radiating to the back; relieved with eating but recurs 30 minutes later; melena or guaiac-positive stools
Gastric ulcers
164
Risk factors for gastric ulcer
Male, tobacco, ETOH, NSAIDs, H. pylori, uremia, stress (burns, sepsis, and trauma), steroids, chemotherapy
165
Where are most gastric ulcers located?
80% on lesser curvature of the stomach
166
What is difference in mortality between gastric and duodenal ulcer hemorrhage?
Hemorrhage is associated with higher mortality than duodenal ulcers.
167
Gastric ulcers: best test for H. pylori
Histiologic examination of biopsies from antrum
168
Test for H.pylori, detects urease released from H. pylori
CLO test (rapid urease test)
169
Surgical indications for gastric ulcers
Perforation, bleeding not controlled with EGD, obstruction, cannot exclude malignancy, intractability (> 3 months without relief - based on mucosal findings)
170
Tx: gastric ulcer
Truncal vagotomy and antrectomy best for complications; try to include the ulcer with resection (extended antrectomy) - need separate ulcer excision if that is not possible (gastric ulcers are resected at time of surgery due to high risk of gastric CA)
171
- Occurs 3-10 days after event; lesions appear in fundus first- Tx: PPI- EGD with cautery of specific bleeding point may be effective
Stress gastritis
172
Where do lesions in stress gastritis appear?
Lesions appear in fundus first
173
Chronic gastritis type: associated with pernicious anemia, autoimmune disease
Type A (fundus)
174
Chronic gastritis type: associated with H. pylori
Type B (antral)
175
Treatment Chronic Gastritis
PPI
176
Pain unrelieved by eating, weight loss
Gastric cancer
177
Where are 40% of gastric cancers located?
Antrum
178
Gastric cancer-related deaths in Japan
Accounts for 50% of cancer-related deaths in Japan
179
Dx: gastric cancer
EGD
180
Risk factors: gastric cancer
Adenomatous polyps, tobacco, previous gastric operations, intestinal metaplasia, atrophic gastritis, pernicious anemia, type A blood, nitrosamines
181
15% risk of gastric cancer.- Tx: endoscopic resection
Adenomatous polpys
182
Gastric metastasis to supraclavicular node
Virchow's node
183
Increased in high-risk populations. Older men. Japan. Rare in United StatesSurgical treatment: try to perform subtotal gastrectomy (need 10-cm margins)
Intestinal-type gastric CA
184
Low risk populations. Women. Most common type in the United States.Diffuse lymphatic invasion, no glands.Surgery: total gastrectomy bc of diffuse nature of linitis plastica
Diffuse gastric cancer
185
Prognosis: intestinal-type gastric CA vs diffuse gastric cancer
Less favorable prognosis than intestinal-type gastric CA (overall 5-YS - 25%)
186
Margins for intestinal-type gastric CA
need 10 cm margins
187
Chemotherapy for gastric cancer
Poor prognosis:- 5 FU, doxorubicin, mitomycin C
188
Gastric cancer: management of metastatic disease outside area of resection
Contraindication to resection unless performing surgery for palliation.
189
When to consider palliation of gastric cancer?
- Obstruction - proximal lesions can be scented; distal lesions can be bypassed with gastrojejunostomy- Low to moderate bleeding or pain - Tx: XRT
190
What if surgical management fails for palliation of gastric cancer (stents, gastrojejunostomy, XRT)?
If these fail, consider palliative gastrectomy for obstruction or bleeding.
191
- Related to H. pylori infection- Usually regresses after treatment for H. pylori
Mucosa-associated lymphoid tissue lymphoma (MALT lymphoma)
192
MC location of MALT lymphoma
Stomach
193
Treatment: MALT lymphoma
Triple-therapy antibiotics for H. pylori and surveillance.If MALT does not regress, need XRT.
194
What if MALT lymphoma does not resolve with triple therapy antibiotics for H.pylori?
If MALT does not regress, need XRT
195
- Have ulcer symptoms- Usually non-Hodgkin's lymphoma (B cell)- Overall 5-year survival rate > 50%
Gastric lymphomas
196
MC location for extra-nodal gastric lympoma
Stomach
197
Dx: Gastric lymphoma
EGD with biopsy
198
Primary treatment modalities of gastric lymphoma
Chemotherapy and XRT are primary treatment modalities; surgery for complications
199
When is surgery indicated for gastric lymphoma?
Surgery possibly indicated only for stage 1 disease (tumor confined to stomach mucosa) and then only partial resection is indicated
200
Overall 5-year survival rate for gastric lymphoma
> 50%
201
Criteria for patient selection for bariatric surgery (need all 4)
- BMI > 40 kg/m^2 or BMI > 35 kg/m^2 with coexisting comorbidities- Failure of nonsurgical methods of weight reduction- Psychological stability- Absence of drug or alcohol abuse
202
What type of obesity is worse prognosis in general population?
Central obesity
203
What gets better are surgery for morbid obesity?
DM, cholesterol, sleep apnea, HTN, urinary incontinence, GERD, venous stasis ulcers, pseudotumor cerebri, joint pain, migraines, depressions, PCOS, NASH
204
- Better weight loss than just banding.- Risk of marginal ulcers, leak, necrosis, B12 deficiency, IDA, gallstones- Perform cholecystectomy during operation if stones present- UGI on POD 2
Roux-en-Y gastric bypass
205
Failure rate of roux-en-y gastric bypass
10% failure rate due to high-carbohydrate snacking
206
What are the signs of a leak after roux-en-y gastric bypass?
- Ischemia: MCC leak- Signs of leak: increased RR, increased HR, abdominal pain, fever, elevated WBCs
207
Dx / Tx: leak after roux-en-y gastric bypass
Dx: UGITx: early leak (not contained) -> re-op; late leak (Weeks out from surgery, likely contained) -> percutaneous drain, antibiotics
208
Incidence of marginal ulcers after roux-en-y gastric bypass
Develop in 10%Tx: PPI
209
Management of stenosis after roux-en-y gastric bypass
Usually responds to serial dilation
210
Complications of roux-en-y gastric bypass
- Leak- Marginal ulcers- Stenosis
211
MCC leak after roux-en-y gastric bypass
Ischemia
212
After roux-en-y gastric bypass:- Hiccoughs, large stomach bubble- Dx: AXR- Tx: G-tube (gastrostomy tube)
Dilation of excluded stomach postop
213
s/p roux-en-y gastric bypass:- nausea and vomiting, intermittent abodminal pain- AXR shows dilated SB
Small bowel obstruction- Surgical emergency
214
Why is SBO s/p roux-en-y gastric bypass a surgical emergency?
Due to the high risk of small bowel herniation, strangulation, infarction and subsequent necrosis.- Tx: surgical exploration
215
- these operations are no longer done- a/w liver cirrhosis, kidney stones, and osteoporosis (decreased calcium)- need to correct these patients and perform roux-en-y gastric bypass if encountered
jejunoileal bypass
216
- can occur after gastrectomy or after vagotomy and pyloroplasty- occurs form rapid entering of carbohydrates into the small bowel.- can almost always be treated medically (and dietary changes)
Dumping syndrome
217
2 phases of dumping syndrome
- Hyperosmotic load causes fluid shift into bowel (hypotension, diarrhea, dizziness)- hypoglycemia from reactive increase in insulin and decrease in glucose (2nd phase rarely occurs)
218
Tx: dumping syndrome
Small, low-fat, low-carb, high-protein meals; no liquids with meals, no lying down after meals; octreotide
219
Surgical options for dumping syndrome (Rarely needed)
- Conversion of Billroth 1 or Billroth 2 to Roux-en-y gastrojejunostomy- Operations to increase gastric reservoir (jejunal pouch) or increased emptying time (Reversed jejunal loop)
220
postprandial epigastric pain associated with n/v; pain not relieved with vomiting
Alkaline reflux gastritis
221
Dx / Tx: alkaline reflux gastritis
Dx: evidence of bile reflux into the stomach; histologic evidence of gastritisTx: PPI, cholestyramine, metoclopramide
222
Surgical options for alkaline reflux gastritis
Conversion of Billroth 1 or Billroth 2 to Roux-en-Y gastrojejunostomy with afferent limb 60 cm distal to gastro jejunostomy
223
- Delayed gastric emptying- Symptoms: n/v, pain, early satiety
Chronic gastric atony
224
Chronic gastric atony:Dx / Tx / Surgical options
Dx: gastric emptying studyTx: metoclopramide, prokineticsSurgical option: near total gastrectomy with roux-en y
225
- Early satiety- Actually want this for gastric bypass patients
Small gastric remnant
226
Small gastric remnant:Dx / Tx / Surgical option
- Dx: EGD- Tx: small meals- Surgical option: jejunal pouch reconstruction
227
- With billroth 2 or roux-en-y; caused by poor motility- Symptoms: pain, steatorrhea (bacterial beconjugation of bile), B12 deficiency (bacteria use it up), malabsorption
Blind-loop syndrome
228
What causes blind-loop syndrome with billroth 2 or roux-en-y?
Caused by bacterial overgrowth (E coli, GNRs) from stasis in afferent limb
229
Dx: blind-loop syndrome
EGD of afferent limb with aspirate and culture for organisms
230
Tx: blind loop syndrome
Tetracycline and flagyl, metoclopramide to improve motility
231
Surgical option: blind-loop syndrome
Re-anastomosis with shorter (40-cm) afferent limb to relieve obstruction
232
- Symptoms of obstruction - n/v, abdominal pain- Dx: UGI, EGD- Tx: balloon dilation- Surgical option: find site of obstruction and relieve it
Efferent-loop obstruction
233
- Secondary to non-conjugated bile salts in the colon (osmotic diarrhea)- Causes by sustained postprandial organized MMCs
Post-vagotomy diarrhea
234
Tx / Surgical option: post-vagotomy diarrhea
Tx: cholestyramine, octreotideSurgical option: reversed interposition jejunal graft
235
What causes post-vagotomy diarrhea?
Reversed interposition jejunal graft
236
Management: duodenal stump blow-out
Place lateral duodenostomy tube and drains
237
Potential PEG complications
Insertion into the liver or colon
