stomach & general abdomen Flashcards
GIST
most common nonepithelial tumors of the GI tract
mutations in c-KIT (CD117) or platelet-derived growth factor receptor alpha (PDGFRA) genes are commonly seen
sarcoma of the interstitial cells of cajal
GIST mgmt
5+ cm in size with more than 5 mitoses per high-power field requires preop IMATINIB tyrosine kinase inhibitor - if resistant, try sunitinib
just want R0 or 1 cm margin
adjuvant imatinib x 3 years
not nodal spread (no need for nodal dissection)
gist mets
liver and peritoneal surfaces
where does RIGHT gastric aa branch
from proper hepatic artery AFTER GDA takeoff
stomach cells
chief, partietal cell
chief: pepsinogen
parietal : release H and intrinsic factor
parietal cell reactio
ACh and gastrin cause PHOSPHOLIPASE acivation
PIP, DAG IP3 CALCIUM.***.=
Ca-calmodulin activates kinase to release H.
histamin activates adenylate cyclase.
increase CAMP, PKA to release H.
gastrin released from?
G cells (antrum).
gastrin regulation
inhibited by H in duodenum
stinulated by amino acids/ACh
Brunners glands where/what
duodenum; secrete ALKALINE MUCUS
inbhitors of parietal cell HKATPase
somatostatin, prostagland PGE1, secretin , CCK
hereditary diffuse gastric cancer.
AD… CDH1, which encodes the cell-cell adhesion protein E-cadherin
ppx gastrectomy 20-40 YO
women have increased breast ca risk
other syndromes ass’d gastric ca
Lynch, jevnile polyposis SMAD4, peutz jeghers, FAP 5q21
esophageal FBO removal timing
<24 hrs
stomach FBO removal timing
<24 hrs if sharp objects, >5cm, and magnets, and 1+day (blunt >2cm and batteries)
coin FBO
dx XR. retrieve if symptomatic or if stays (anywhere for 3-4 wks)
can leave in esophagus if asx
EGD tools for battery ingestion
A double-channel endoscope is preferred for foreign object retrieval so diagnostic and therapeutic instruments can be passed through the scope.
An esophageal overtube should be used for this patient to protect the esophageal mucosa and upper airway when pulling the object out of the alimentary tract.
Forceps are preferred when retrieving flat objects such as disk batteries or coins.
how to evaluate the celiac lymph node basin
US probe on L lobe of the liver (during dx lap for staging gastric adeno ie)
rectus sheath hematoma grades
type I hematoma is small and confined within the rectus muscle, and it does not cross the midline or dissect fascial planes
type II hematoma is confined within the rectus muscle; however, it can dissect along the transversalis fascial plane or cross the midline»_space; need to trend Hemoglobins and see if unstable, then can go to embolization
type III hematoma is usually below the arcuate line, large in size, and presents with blood in the prevesical space of Retzius and/or hemoperitoneum.»_space; needs angiography & embolization.
exit site PD catheter infection
obtain culture and start empiric abx
bacterial peritonitis 2/2 PD catheter
start Abx, hold off on taking catheter out until failure of ab 4-5 days, or if fungal peritonitis, or if intraabdominal pathology suspected
abx of choice for SBP 2/2 PD catheter
Intraperitoneal gentamicin and ceftriaxone
mesenteric simple cyst
Benign
F>M
Small>large bowel
full of: serous or chyle fluid
mgmt: enucleate or marsupialize (if too big)
harmonic scalpel works
minimal thermal injury; dividing tissue < 6 mm using coag; monopolar can just use the blade alone; no tissue sticking; SLOW CYCLING of active blade during coag can spread hemostasis. RAPID CYCLING of cutting allows for precision.
disrupts protein H bonds and causes coagulation
insulation failure on bovie
stray marks near operative field
argon beam mechanism
energy transferred across argon gas
2m necrosis (superficial coag)
and is NONCONTACT so hemostasis is good for liver // smokeless
gore tex vs dacron
gore text = PTFE = no fibroblast ingrowth
dacron = polypropylene =- allows fibroblast ingrowth (think mesh)
veress/trocar injury rate
0.1%
Nd;YAG laser
good for deep penetration (bronchial lesions)
1-2 mm cut
3-10mm vaporize
1-2 cm coagulates
capacitative and direct coupling
charge dispersed through other instruments which would result on burns on contacted organ
monopolar thermal injury
2-3 days after index case
pneumoperitoneum effects (during lap)
increased intrathoracic pressure
decreased functional residual capacity and Vt (resp acidosis)
atelectasis
hypercarbia (diffusion)
hypercarbia -> systemic arterial vasodilation and myocardial depression
hyeprcarbia ->increased pulmonary vascular resistance (worsens pulmHTN and RV failure)
compression of IVC causing decreased preload and increased afterload overall hypotension from liimited cardiac output and myocardial depression (bradycardia)
stretching of vagal receptrs (cardiac slowing)
ideal pneumoperitoneum pressures
12-15 mm Hg
fine dissection requiring very precise heat?
use BIPOLAR
co2 embolism = gas lock effect
embolism in RA or RV blocking outflow from RV
increased end tidal CO2, hypotension, pulmonary hypertension, CV collapse
mgmt co2 embolism
cessation insufflation, Trendelenberg and LLD to keep them in the RA. HF O2, fluids, aspiration via CVC in RIJ
granulation tissue painful around PEG site
silver nitrate; don’t put protective padding (can cause tension)
what nerve must be included in vagotomy for ulcer disease
criminal nerve of Grassi (branch of posterior vagus)
gastric carcinoid tumors 3 types
- atrophic gastritis or pernicious anemia
- Zollinger-Ellison syndrome
- tumors occur sporadically.
mgmt gastric carcinoid tumor
complete regression of all tumors after antrectomy alone has been documented in patients with atrophic gastritis and multiple small carcinoids
local excision of the dominant tumor with antrectomy
GIST spread
hematogenously; to liver and peritoneal surfaces > spleen
GIST prognosis
Tumors 5-10 cm and 5+ mitoses per HPF were found to have the highest malignant potential. Need imatinib.
<2 cm and <5 mitoses per HPF = benign, NTD
2-5cm and <5 mitoses per HPF
and 10+cm with <5mitoses per HPF
worst px: esophag/colorectal primary, >10cm, >10M/10 HPF, local invasion, distant mets
bleeding duodenal peptic ulcer mgmt after 2x egd
The patient is likely bleeding from the GDA due to erosion from a posterior ulcer.
anterior duodenotomy and oversewn with a three-point U stitch, ligating the main vessel (GDA) superiorly and inferiorly and preventing back-bleeding with a medial stitch (transverse pancreatic aa). If this patient is stable in the operating room, a **vagotomy and pyloroplasty would be indicated because he has known peptic ulcer disease
no need to Bx if duodenal; transverse duodenal CLOSURE
MC cause of gastric ulcer
NSAIDs and H.pylori (but higher incidence of cancer compared to duodenal ulcer)
surgical tx of gastric ulcer that is BLEEDING
make sure to Bx…..
anterior gastrotomy, oversew, BIOPSY, close
need to Bx the ulcer and antrum ( to r/o H. pylori)
staging gastric ca
Start with EGD (identify it)
PETCT CAP
then EUS (T staging) with FNA
then Staging laparoscopy is essentialIF GREATER THAN T1B in the staging of gastric cancer (N and M) - NCCN
Peritoneal lavage with cytology testing is an important component of staging laparoscopy. mean overall survival of 14 to 20 months.
T1a: invade lamina propria
T1b: submuocsa
T2: invade muscular propria
T3: invade subseerosa
T4: into adjacent strucutr
N1: 1-2
N2: 3-6
N3 7+
M1 survival is 3-6 mos
Bile reflux gastritis
after Billroth II reconstruction as a consequence of a defective pyloric channel. It results from exposure of the gastric mucosa to bile, pancreatic secretions, and duodenal contents.
(intestinalization of gastric glands with inflammation).
mgmt: Conversion to Roux-en-Y gastrojejunostomy with a Roux limb of at least 40 cm is associated with symptomatic relief in up to 85% of patients. Distal Braun enteroenterostomy has been shown to improve symptoms of bile reflux gastritis in 53% of patients.
surveillance after gastrectomy for gastric adeno
stage II disease: CT of the chest, abdomen, and pelvis is necessary every 6 to 12 months for 2 years and then annually for up to 5 years
stage I disease, CT of the chest, abdomen, and pelvis should be performed as needed
internal hernia diagnosis (hx of RNY)
PO & IV contrast-enhanced CT scan of the abdomen and pelvis
= mesenteric swirl with volvulus of the Roux limb.
Afferent loop syndrome
Aff loop in B2 becomes partially or completely obstructed… diarrhea then obstructive jaundice and pancreatitis
pain relieved with bilious emesis
CT shows dilated afferent limb
mgmt afferent loop syndrome
surgical correction; eliminate the likely LONG afferent limb via conversion to RNY or enteroenterostomy below the stoma
abx too but limited; balloon but limited
efferent limb syndrome like an internal hernia
sx: n/v, pain
dx: CT
mgmt: surgical emergency!
perforated G or D ulcer from ulcer disease? first occurence or patient is not stable enough at subsequent episdoes
omental patch repair
perforated G or D ulcer from ulcer disease? SECOND occurrence (failed >12 mo medical therapy) and patient is stable enough
- Highly selective vagotomy - divide the anterior and posterior nerves of Latarjet and preserving the “crow’s feet” division at the antrum. 10% recurrence.
- Truncal vagotomy with pyloroplasty has a 10% to 12% ulcer recurrence rate
**3. Truncal vagotomy with antrectomy [for GASTRIC ULCERS ANTRUM] followed by Billroth I or Billroth II (TL 2 is answer if duodenal disease) reconstruction has a lower ulcer recurrence rate at 1% to 2% since both cephalic and gastric phases of acid secretion are eliminated. Fiser says RNY is BEST after truncal + antrectomy
need to Bx and get the ulcer out at time of stomach surgery
mgmt gastric ca, margins and nodes
5-6 cm proximal
2 cm distal margins
at least 16 nodes (D1)
Neoadj T2 or N.
UnresectBle: paraaortic, encasement of vessels (aside from splenics), metastatic, peritoneal involvement
mgmt gastric ca linitis plastica
total gastrectomy because very diffuse
dumping syndrome early
20-30 minutes after eating
more common
pathophys: rapid shift of intracellular fluid into the intestinal lumen is incorrect because it is an extracellular fluid shift; likewise, this is more commonly related to early dumping syndrome effects
dumping syndrome late
2-3 hrs after eating.
sx: CARDIOVASCULAR, PALPITATIONS, TACHY, DIAPHROESIS, FAINTING, FLUSHING, BLURRED VISION
esp after B2
pathophys: rapid gastric emptying, specifically carbohydrates being delivered to the small intestine. These carbohydrates are quickly absorbed, causing hyperglycemia and insulin release. Subsequent overcompensation leads to profound hypoglycemia and increased catecholamine release from the adrenal glands.
mgmt: 6 small meals, separate liquid/solid, avoid sugar, increase fiber, candy between meals
siewert stein classification for GEJ tumors
Type I: ca in distal esophagus 1-5cm above anatomic GEJ
Type II; ca 1cm above nd 2 cm below GEJ
Type III: 2-5cm below GEJ
siewert I - III tx
I and II: esophageal ca
III: gastric ca
gastric antral vascular ectasia GAVE disease
watermelon stomach; hyperemic mucosal tissue
mgmt of bleed: ablation with argon plasma coagulation
NSAID related ulcer pathogen
reduced production of mucosal prostagladnings from inhibition of COX
thus, decreased mucosal blood flow and bicarb/mucin secretion
duo perf <1 cm
primary repair
1-3 cm duo perf
graham patch as long as also included acid reducing procedure
or pylorplasty (includes duo injury obviously) with acid reducing procedure
> 3cm duo perf
jejunal serosal patch wth acid reducing procedure
hyperplastic polyp mgmt
resect completely if > 0.5 cm
cushing ulcer
single and DEEP… GASTRIC ULCER
head trauma.
curling ulcer
BURN > 30%
mostly duodenal
stress ulcers
shallow, multiple, proximal stomach (like fundus) in 3-10 days from insult
stress ulcer ppx
GCS 10 or below
traumatic spinal cord injury
INR > 1.5, PTT > 2x normal
plt < 50K
severe burn 20+ TBSA
types of chronic gastritis
A: PERNICIOUS anemia, AI disease (fundus)
B: H pylori (antral)
UGIB bleed post-EGD surveillance
after ex, 4-6 wk repeat (but not if mallory weiss)
mallory weiss tear in stomach
mostly on lesser curve hear teh GEJ…
tx with EGD and HEMOCLIP!»_space;> gastrostomy & oversewing of vessel
D2 vs D1 dissection gastric ca
D2 showed superior recurrence free survival with trend toward increased survival
survival of R0 gastric adeno intestinal… (the good one)
35%
hormone changes after RYGB bariatric
ghrelin lower - decreased hunger
leptin higher - increased satiety
neuropeptide Y lower - decreased appetite
MC site of stricture/leak after LSG?
incisura angularis
dx with CT with PO & IV contrast
small bowel adenocarcinoma resection margin & nodes
10 cm proximal, 5 cm distal margin
+wedge of mesenteric nodes
OK to primary anastomse
2 ducts into D2?
duct of Wirsung (going through ampulla of Vater) and duct of Santorini (accessory)
arterial supply to duo
superior pancreaticuduodeanl artery ( Off GDA)
inferior pancreaticoduodenal artery (off SMA)
have anterior and posterior branches
how long jejunum
100cm long
vasa recta length jej vs ileum
long in jej, short in ileum
location of fe absorption
DUO
location B12 absorption
TI with intrinisic factor
location bile acids absorption
ileum
location folate aborption
TI
where is the most absorption in gut? (esp NaCl and water)
JEJUNUM
ileum length
150cm
enzymes of brush border
maltase, sucrase, dextriniase, lactase
goblet cell secretion
mucin
paneth cell secretion
secretory granules, enzymes
enterochromaffin cells = KULCHITSKY CELLS secrete
APUD, 5-HT, carcinoid precursor
Bruner’s glands
alkaline solution secretion
APC of intestinal wall?
M cells
IgA in gut
released in gut; transverses breast milk
MMC migrating motor complex
phase I: rest
II: acceleration, GB contraction
III: peristalsis (*MOTILIN)
IV: deceleration
bile aci reabsorption
95% are reabsorbed
50% passively via unconjugated salts into ileum
50% actively via conjugated salts into NaKATPase in TI
short gut syndrome suspicioin
75cmbowel to survive off TPN
50 cm with competent ileocecal valve
tests in short gut syndrome
sudan red stain: fecal fat
schilling test: radiolabeled B12 in urine
mgmt short gut
restrict fat, PPI, lomotil
MC cause of LBO
cancer
MC cause of SBO
hernia (If no OR before), adhesions (if OR before)
gallstone ileus location
stone in TI
fistula infundibulum to D2
mgmt gallstoneileus
remove stone (enterotomy)
leave fistula alone if sick
or chole and close duo if not sick
meckel’s
2 ft from ICV, 2% population, 2YO, TRUE DIVERTIC, 2inches
pathophys meckel’s
failure of closure of OMPAHLOMESENTERIC DUCT
presentation meckel’s
painless GIB < 2YO
or SBO in adult
ectopic tissue in meckel’s
panreatic > gastric
panc = pain
gastric = bleeding
mgmt incidental finding of meckel’s
resect if thickened (suspect gastric mucosa) or very small neck
dx of meckel’s
Mekcel’s scan (technetium 99) if can’t localize
mgmt of sx meckel’s
diverticulectomy with segmental resection if complicated diverticulitis or if neck > 1/3 bowel lumen, or if base inflamed
duodenal diverticulum mgmt
segmental resection if sx-ic unless in D2
if in D2, justa-ampullary - HJ (biliary sx) or ERCP with stent (pancreatic sx)
mgmt of large skin tags in Crohn’s
don’t touch it
serotonin
made in Kulkchitsky cells (enterochromaffin /argentaffin cell)
part of AMINE PRECURSOR DECARBOXYLASE SYSTEM APUD.
breakdown into 5-HIAA (can measure this in urine)
carcinoid syndrome
from bulky liver mets
sx carcinoid syndrome
flushing (kallikrein), diarrhea (serotonin), ashtma (bradyinin), RHvalve lesions
dx carcinoid syndrome
- chromogranin A level (HIGHEST SENSITIVITY for detecting tumor)
- localize with OCTREOTIDE SCAN (BEST for localization)
- add on 24hr urine 5-HIAA
MC site of carcinoid in small bowel
appendix > ileumm > rectum
mgmt carcinoid
< 2 cm: wide local
2+ cm: oncologic resection (SCORE: >1cm)
chemotherpay (streptozocin and 5-FU) if unresectable, octretodie for sx***, albuterol, a-blockers (for flushing)
small bowel adenoma prsentation
usually DUO
bleeding/obstruction
mgmt small bowel adenoma
resect (via endoscopy)
small bowel adenocarcinoma presentation
usually DUO
obstruction/*jaundice
mgmt small bowel adenocarcinoma
resection and adenectomy x 8 nodes at least
5mm margins, send frozen
Whipple if D2
Tis-T1 to submucosa only D1, D3, D4 can be endoscopically attempted
assocaitions with duodenal adenocarcinoma
FAP, Gardner’s, von Recklinghausen’s NF1
(test for mismatch repair MMR or microsatellite instability MSI testing)
leiomyosarcoma dx in small boewel
bx = >5 mitoses/50HPF and atypia or necrosis
negative for C-kit (r/o GIST)
mgmt leiomyosarcoma
resetion without adenectomy
small bowel lymphoma
mostly ileum, Non hodkins
dx lymphoma small bowel
CT scan and node sampling
mgmt lymphoma small bowel
wide en bloc resection with nodes
if in D2, chemoXRT only – no Whipple
mgmt parastomal hernias
don’t fix unless symptomatic
MC stomal infection
Candida
pathophys diversion colitis
lack of SCFA to the diverted segment
mgmt of diversion colitis
enemas of SCFA
uric acid kidney stones after ileostomy
loss of bicarb – these are radioLUCENT
mgmt of salmonella typhoid enteritis (RLQ pain, rash, large mesenteric LN)
bactrim
veress injury incidence
0.1%
laproscopic approach to SBO indications
laparoscopic approach is appropriate in patients with fewer than three previous operations, early presentation, proximal site of obstruction with mild distention, or an anticipated single adhesive band
before DLI reversal what imaging should you get
rectal contrast study
increase risk of small bowel adenocarcinoma with CROHNS
especially in TI
panc polypeptide
causes decreased panc & gb secretion
most release of somatostatin (D)
from antrum in response to acid in duodenum
motilin acts on
antrum
bombesin
gastrin releasing peptide; increased motor activity & panc & gastric stuff
GLP2
good for short gut - increases intestinal mucosal growht & improves fluid absorption
MALToma gastric tx
QUAD H pylori tx; if still there, XRT.
if 11;18 +, then XRT from the beginning too
if can’t do XRT< then do rituximab
if H. pylori negative, just do XRT (or rituximab)
peptide YY
from TI;
inhibit acid secretion and stomach contraction
small bowel MALToma tx
observation is ok
blind loop syndrome
postgastrectomy complication esp B2 or RNY, poor motility
sx: pain, STEATORRHEA (bac deconjugate bile), B12 def(bac eat it), malabsorption
bacterial overgrowth in afferent.. inc Bacteroids, anaerobics, enterococci
dx: d-xylose test carb, EGD and aspirate bugs
tx: Abx (tetracycline flagyl, Reglan, Augmentin), and TPN-B12
or make shorter afferent limb ~ 40 cm
amifostine
protects intestin from radiation damage
dieulafoy ulcer
vascular malformation; can bleed
menetriers disease
mucous cell hyperplasia; increase rugal folds
highly selective vagotomy
PROXIMAL vagotomy at the level of the lesser sac; divides individual fibers (preserve crows foot) normal SOLID EMPTYING. divides criminal nerve of grassi
truncal vagotomy
divide vagal trunks at level of esophagus
need to add empyting procedure (pyloroplasty or antrectomy with RNY GJ > B1/B2 2/2 dumping and alkaline reflux gastritis)
gastrin cell hyperplasia
after truncal vagotomy
diarrhea after vagotomy
MC complication
from sustained **MMCs forcing bile acids into colon
mgmt: cholestyramine and loperamide
pyloroplasty
Heineke Mikulicz pyloroplasty
quad therapy H pylori
PPI
clarithromycin
metronidazole vs amoxicillin
BI
obstruction 2/2 DU
don’t forget bx
resect with antrectomy and truncal vagotomy (include ulcer in resection if proximal to ampulla)
best test for H pylori eradication
ureas breath test
gastric adenocarcinoma chemo
5FU, doxorubicin, mitomycin C
Indicated for all: clinical T2, nodal
Entire upfront prior (just like esophageal)
stomach lymphoma
MC extranodal Lymphoma (mostly NHL)
sotmach lymphoma mgmt
chemo and XRT
just resection for stage I
5 yr survival for gastric lymphoma
50%
bariatric surgery indications
BMI > 40 or 35 w/ comorbidities
no drug/EtOH
mental health
failure of lifestyle
contraindications to elective ventral hernia repair?
BMI > 50
HgbA1c 8+
active smoking
what comorbidity does not get better with bariatric surgery?
peripheral artery disease
RNY GB
with chole if stones
UGI POD 2
marginal ulcer RNY GB
10%
PPI
in jejunum
dilated excluded stomach postop
G tube
alkaline reflux gastritis
postprandial PAIN, VOMITING DOESN’T HELP
esp after B1 or B2
dx: impedance testing
mgmt alkaline reflux gastritis
RNY conversion 50 cm afferent.
medicien: PPI, cholestyramine, Reglan
high output fistula volume
> 500 cc/day
fluid resuscitation, 4-6 mo (12 wks) surgery (don’t prolong TPN), imodium vs octreotide
low output ECF
<200cc/day
tx: regular diet, wound management
increase ileostomy length if under tension, technique
release adhesion to mobilize mesentery
divide proximal vessels if needed (lots collaterals)
mgmt stricture in crohns
conservative trial
if fail,
@ anastomosis: DILATE
@ colon: RESECT (could be ca)
@ 2+ locations: SUBTOTAL
@ small bowel LONG segment: STRICTUROPLASTY (super long: side to side isoperistaltic; not super long: Heinecke) c
@ small bowel short/isolateed: RESECT
timing of ostomy reversal
at least 6 weeks; ideally 12 weeks
papaverine utility
increasing mesenteric perfusion in global low flow (on pressors ie)
chronic mesenteric ischemia vs acute
chronic: can consider angiography/stent
acute: needs an embolectomy
H ppylori pathophys
colonization on mucosa in patches of GASTRIC METAPLASIA; make ulcer very vulnerable to acid/pepsin/urease
Bariatric surgery postop vitamin deficiencies
D»_space;> B12 and Fe
can’t tolerate pneumoperit in indicated chole?
don’t abort; go to open.
worried about adhesive disease and want to go lap?
hasson.
best prognosis colon sessie polyp
MSI
biliopancreatic diversion with duodenal switch
gastric pouch + pylorus to distal ileum (250cm from pylorus) + BP limb to terminal ileus (50-100cm from ICV)
not done because: osteoporosis, cirrhosis, kidney stones
Witzel jejunostomy
30 cm from LoT J tube
idiopathic retroperitoneal fibrosis RPF = Osmond’s disease
chronic inflammation
fibroblast proliferation
extracellular matrix deposition
maybe 2/2 hypersensitivity to methysergide
(lower back/abd/flank pain, hydronephrosis, big ole mass looking thing that attenuates like muscle and compresses the cava, medial deviation of ureters)
elevated IgG4 sometimes
dx: MOST SENSITIVE test is IV pyelogram to see trapped ureters
histo: Type I collagen around vessels, hyaline rings around vessels
tx: HD-glucocorticoids x 4-8 wks +/- rituximab/methotrexate/MM if nonresponder to steroids
+ free up ureters if renal failure and wrap ureters in omentum
don’t rly have to do a biopsy
normal basal acid secretion
<5 mEq
GLP2
sitmulate mucosal growth & improve absoprtion in short gut
bowel function
small bowel hours
stoamch 24-48 hours
colon 48-72 hours
short bowel
<100 cm
or <50cm with ICV.+ colon
petersen space
defect between mesentery of ROUX and T-mesocolon (MC internal hernia)
other spots for internal hernia in RNY
jejunojejunostomy defect
petersen (roux meentery & transverse mesocolon)
mesocolic (roux limb posterior to t-colon in retrocolic bypass
bx findings in stress gastritis
coagulation necrosis and lymphocyte infiltration into lamina propria
bx findings in NGT trauma
focal mechanical trauma
bx findings in H pylori
gastric atrophy (early) - intestinal metaplasia (late)
borchardt triad
gastric volvulus
retching, cannot pass NGT, epigastric pain
worse px with volvulus? high M&M?
PEH
tx gastric volvulus (ass’d with PEH 2, 3 and 4
emergent reduction
repair hernia
and do a ?partial Nissen to anchor the stomach
may need resection of anything devitalized
antireflux surgery goal intraabdominal esophagus?
3 cm
NGT placement in perforated ulcer
place it. this is what BTK says
thal patch
> 3cm perforations may need JEJUNAL SEROSAL PATCH instead of omental patch
retained antrum syndrome
after gastrectomy… constant G cells (ie in duodenum) within alkaline fluid leads to constant gastrin release..
tx: PPI, vagotomy, resection of retained antrum (and check for pNET gastrinoma)
MC cause sb bleeding
angiodysplasia
MC rp tumor
LYMPHOMA > LIPOSARCOMA
MC mesenteric tumor
LIPOSARCOMA … the more central, the more malignant
omental cyst
1/3 malignant (MC is a met) so just resect
no bx needed
secretin D cells
increase pancreatic BICARB release, inhibit gastrin release, inhibit HCl release
pancreatic polypeptide – END DIGESTION
islet in pancreas secretes….
stim by food and digestion
to decrease pancreatic and gallbladder secretions.
motilin released in what phase of peristalsis
phase III (also erythromycin acts on same receptor)
phases of peristalsis
resting > accelerating > peristalsis III (MOTILIN) > decelerating
peristalsis pain from what nerves
sympathetic fibers T5-T10 AFFERENTS
what size gastric ulcer may need surgical intervention
2 cm
duo ulcer MC location
ANTERIOR wall D1
truncal vagotomy and antrectomy (what kind of recon)
should do. RNY.
because less dumping syndrome + less alkaline reflux gastritis compared to BI and BII
modified graham
close defect first and then place omentum
graham: just put omentum
what is intractible ulcer disease
MUCOSAL findings (ulcer) (not sx) while on escalating PPI doses for 3 months**
MC gastric ulcer location
lesser curve (obvi from H pylori first) > NSAID s
gastric adenomatous polyp
15% risk of cancer
endoscopic resection is tx
krukenberg tumor
gastric adeno ca met to ovaries
virchows nodes
gastric adeno to supraclavicular node
MC cause of leak after RNY
ishcemia
tx of distended remannt stomach after RNY
G tube
where is iron absorbed
duo
