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ABSITE > 30 Stomach > Flashcards

30 Stomach Flashcards

1
Q

Risk factors for UGI Bleed?

A 
Previous UGI bleed
Peptic ulcer disease
NSAID use
Smoking
Liver disease
Esophageal varices
Splenic vein thrombosis
Sepsis
Burn injuries
Trauma
Severe vomiting
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2
Q

How to you diagnose/treat an UGI bleed?

A

EGD

Treat with hemo-clips, Epi injections, cautery

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3
Q

On EGD, you find no stigmata of hemorrhage and a clean ulcer base: how do you proceed?

A

Biopsy of antral mucosa for H. Pylori

OP tx with Omprazole and Abx

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4
Q

On EGD, you find stigmata of bleeding: how do you proceed?

A

Endoscopic hemostasis methods (hemo-clips, Epi injections, cautery)
Biopsy of antral mucosa
Examine for further bleeding

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5
Q

What are the stigmata of bleeding for an UGI bleed?

A

Active bleeding
Oozing
Adherent clog
Visible vessel

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6
Q

After initial treatment of bleeding on EGD, you now have cessation of bleeding: how do you proceed?

A

IP observation

Omeprazole and Abx

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7
Q

After initial treatment of bleeding on EGD, you now have recurrent bleeding: how do you proceed?

(Or you cannot perform endoscopic therapy and/or patient is hemodynamically unstable?)

A

Operative treatment
IP recovery
Omeprazole and Abx for H. pylori

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8
Q

UGI bleed with slow bleeding causing difficulty localizing the source - how do you proceed?

A

Tagged RBC scan

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9
Q

What are the biggest risk factors for rebleeding at the time of EGD for UGI bleed?

A

Spurting blood vessel (60%)
Visible blood vessel (40%)
Diffusion oozing (30%)

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10
Q

Greatest risk factor for mortality with non-variceal UGI bleed?

A

Continued or recurrent bleeding

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11
Q

Liver failure patient presents with UGI bleed - what is likely cause? How do you proceed?

A 
Esophageal varices (NOT ulcer)
EGD with variceal bands or sclerotherapy
If that fails - TIPS
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12
Q

Cause of duodenal ulcers?

A

Increased acid production and decreased mucosal defences

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13
Q

What is the most common site for peptic uclers? More common m/f?

A

Duodenal ulcers

Males

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14
Q

Most likely site for duodenal ulcers?

A

1st part of the duodenum (remember they are related to acid)

Usually anterior

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15
Q

Complications related to anterior duodenal ulcers?

A

Perforation

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16
Q

Complications related to posterior duodenal ulcers?

A

Bleeding (from gastroduodenal artery)

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17
Q

Symptoms of a duodenal ulcer?

A

Epigastric pain radiation to the back

Abates with eating, but reoccurs after 30min

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18
Q

Diagnosis for duodenal ulcer?

A

EGD

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19
Q

Treatment for duodenal ulcer?

A

PPI (omeprazole)

Triple therapy for H. Pylori (bismuth salts, amoxicillin, metronidazole/tetracycline)

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20
Q

Define Zolinger-Ellison syndrome

A

Gastrinoma, gastric acid hypersecretion, multiple peptic ulcers

Suspect in patient with multiple ulcers that does not respond to PPI treatment

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21
Q

Surgical indications in duodenal ulcers?

A

Perforation
Protracted bleeding (despite EGD therapy)
Obstruction
Intractability despite medical therapy
Inability to rule out cancer (ulcer remains despite treatment)

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22
Q

In addition to surgical repair for complications, what must you do for patients with complicated duodenal ulcers that develop complications while on PPIs?

A

Acid-reducing surgical proceedure

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23
Q

What are the surgical options for duodenal ulcers?

A

Acid-reducing surgery:

  • Proximal vagotomy
  • Truncal vagotomy and pyloroplast
  • Truncal vagotomy and antrectomy
  • Reconstruction after antrectomy -> Roux-en-Y gastro-jejunostomy
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24
Q

Duodenal ulcer surgery - recurrence and mortality?

Proximal vagotomy

A

10-15% ulcer recurrence
0.1% mortality
Bonus - lowest complication rate, no need for antral or pylorus procedure (maintains pyloric function)

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25
Q

Duodenal ulcer surgery - recurrence and mortality?

Truncal vagotomy and pyloroplasty

A

5-10% ulcer recurrence

1% mortality

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26
Q

Duodenal ulcer surgery - recurrence and mortality?

Truncal vagotomy and antrectomy

A

1-2% ulcer recurrence (best)
2% mortality
Requires reconstruction of GIT

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27
Q

Methods of reconstruction after Truncal vagotomy and antrectomy?

A 
Roux-en-Y gastro-jejunostomy (best)
Billroth I (gastro-duodenal anastomosis)
Billroth II (gastro-jejunal anastomosis)
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28
Q

Why is a Roux-en-Y gastro-jejunostomy better than the Billroth procedures?

A

Less dumping syndrome and reflex gastritis

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29
Q

What is the most frequent complication of duodenal ulcers?

A

Bleeding

Generally minor, but can be life threatening

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30
Q

What qualifies as a major bleed?

A

> 6 units of blood in 24 hours or patient remains hypotensive despite transfusion

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31
Q

Initial treatment of duodenal ulcer bleed?

A

EGD - hemoclips, cauterize and EPI injection

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32
Q

Surgical intervention of duodenal ulcer bleed?

A

Duodenotomy and gastroduodenal artery (GDA) ligation

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33
Q

What do you need to avoid when GDA ligation?

A

Common bile duct (posterior)

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34
Q

What is the initial treatment for obstruction related to duodenal ulcer?

A

PPIs and serial dilation

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35
Q

Surgical intervention for duodenal ulcer obstruction?

A

Antrectomy and truncal vagotomy

Do bx to rule out cancer

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36
Q

When you do have to include the duodenal ulcer in surgical treatment for obstruction?

A

When it is proximal to the ampulla of Vater

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37
Q

What percentage of duodenal ulcer perforations will have free air?

A

80%

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38
Q

Symptoms of a duodenal ulcer perforation?

A

Sudden, sharp epigastric pain
Generalized peritonitis
Pain can radiate to pericolic gutters with dependent drainage of gastric content

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39
Q

Surgical treatment of duodenal ulcer perforation?

A

Graham patch (omentum placed over perforation) and acid-reducing surgery (if patient had been on a PPI)

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40
Q

How do you define intractability related to duodenal ulcers?

A

> 3 months without relieft while on escalating does of PPI; based on EGD findings

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41
Q

Treatment of intractable duodenal ulcers?

A

Acid-reducing surgery

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42
Q

Risk factors for gastric ulcers?

A 
Male
Tobacco
ETOH
NSAIDs
H. pylori
Uremia
Stress (burns, sepsis, trauma)
Steroids
Chemotherapy
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43
Q

Most common location of gastric ulcer?

A

Lesser curvature of the stomach (80%)

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44
Q

Which UGI bleed has greater mortality - gastric ulcer or duodenal ulcer?

A

Gastric ulcer

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45
Q

Symptoms of gastric ulcers?

A

Epigastric pain radiating to the back
Relieved by eating but reoccurs 30 minutes later (maybe - some say worsened by eating, others say no effect)
Melena or guaiac-positive stools

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46
Q

Best test for H. Pylori?

A

Histiologic examination of biopsies from antrum

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47
Q

What is the CLO test?

A

Rapid urease test

Non-invasive test for H. pylori - detects the urease it releases

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48
Q

Type I gastric ulcer?

A

Lesser curve, low along body of stomach

Due to decreased mucosal protection

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49
Q

Type II gastric ulcer?

A

Two ulcers - lesser curve and duodenal

Associated with high acid secretion

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50
Q

Type III gastric ulcer?

A

Pre-pyloric ulcer

Associated with high acid secretion

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51
Q

Type IV gastric ulcer?

A

Lesser curve, high along cardia of stomach

Decreased mucosal protection

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52
Q

Type V gastric ulcer?

A

Associated with NSAID use

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53
Q

Which gastric ulcers are associated with decreased mucosal protection? What is the difference?

A

Types I and IV
I - low on lesser curve (body)
IV - high on lesser curve (cardia)

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54
Q

Which gastric ulcers are associated with high acid secretion? What is the difference?

A

Types II and III
II - Two ulcers - lesser curve and duodenal
III - Pre-pyloric

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55
Q

What are the indications for surgical intervention for gastric ulcers?

A 
Perforation
Bleeding not controlled with EGD
Obstruction
Cannot exclude malignancy
Intractability (>3 months without relief - based on EGD)
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56
Q

What is the surgical treatment for gastric ulcer complications?

A

Truncal vagotomy and antrectomy

Include the ulcer - extended antrectomy OR separate ulcer excision

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57
Q

Why do you have to resect a gastric ulcer at time of surgical intervention?

A

Associated high risk of gastric cancer

58
Q

Stomach transit time

A

3-4 hours

59
Q

Location of peristalsis in stomach?

A

Distal stomach (antrum) only

60
Q

Carries sensation of gastroduodenal pain?

A

Afferent sympathetic fibers T5-10

61
Q

Branches of the celiac trunk

A

Left gastric
Common hepatic artery
Splenic artery
Left gastroepiploic and short gastrics (from splenic artery)

62
Q

Blood supply to greater curvature of stomach

A

Right and left gastroepiploics
Short gastrics
Right gastroepiploic is a branch of the gastroduodenal artery

63
Q

Blood supply to the lesser curvature of stomach

A

Right and left gastrics

Right gastric is a branch off the common hepatic artery

64
Q

Blood supply to the pylorus

A

Gastroduodenal artery

65
Q

Mucosa of the stomach

A

Lined with simple columnar epithelium

66
Q

Cardia glands

A

Mucus secreting

67
Q

Fundus and body glands

A

Chief cells

Parietal cells

68
Q

What do parietal cells release?

A

H+ and intrinsic factor

69
Q

Stimulation for H+ release from parietal cells?

A

Acetylcholine (vagus nerve)
Gastrin (From G cells in antrum)
Histamine (from mast cells)

70
Q

Secondary messengers for acetylecholine in parietal cells?

A

Phospholipase (PIP –> DAG + IP3 to increase Ca)
Ca-calmodulin activates phosphorylase kinase –>
phosphorylates H+/K+ ATPase to increase H+ secretion and K+ absorption

71
Q

Secondary messengers for Gastrin in parietal cells?

A

Phospholipase (PIP –> DAG + IP3 to increase Ca)
Ca-calmodulin activates phosphorylase kinase –>
phosphorylates H+/K+ ATPase to increase H+ secretion and K+ absorption

72
Q

Secondary messengers for histamine in parietal cells?

A

Activates adenylate cyclase –> cAMP –> activates protein kinase A –> phosphorylates H+/K+ ATPase to increase H+ secretion and K+ absorption

73
Q

MOA of Omeprazole

A

Blocks H+/K+ATPase in parietal cell membrane

Final pathway for H+ release

74
Q

Inhibitors of parietal cells

A

Somatostatin
Prostaglandin (PGE1)
Secretin
CCK

75
Q

Effect of intrinsic factor

A

Binds B12 and the complex is reabsorbed in the terminal ileum

76
Q

Antrum and pylorus glands

A

Mucus glands
HCO3 glands
G cells
D cells

77
Q

Activity of G cells

A

Located in antrum
Release gastrin
Inhibited by H+ in duodenum
Stimulated by AA, acetylcholine

78
Q

Activity of D cells

A

Secrete somatostatin

Inhibit gastrin and acid release

79
Q

Brunner’s glands

A

Located in duodenum

Secrete alkaline mucus

80
Q

Stimulation for release of somatostatin, CCK, secretin

A

Released with antral and duodenal acidification

81
Q

Causes for rapid gastric emptying

A

Previous surgery*

Ulcers

82
Q

Causes for delayed gastric emptying

A

Diabetes
Opiates
Anticholinergics
Hypothyroidism

83
Q

Trichobezoars

A

Hair - hard to pull out

Tx: EGD generally inadequate; likely will need gastrostomy and removal

84
Q

Dieulafoy’s ulcer

A

Vascular malformation

Can bleed

85
Q

Menetrier’s disease

A

Mucous cell hyperplasia

Increased rugal folds

86
Q

Gastric volvulus

A

Associated with type II (paraesophegeal) hernia
Nausea without vomiting, severe pain
Usually organoaxial volvulus
Tx: reduction and nissen

87
Q

Mallory-Weiss tear

A

Secondary to forceful vomiting
Presents as hematemesis following severe retching
Mucosal tear
Bleeding often stops spontaneously
Dx/Tx: EGD with hemo-clips
Tear is usually on lesser curvature, near GE junction
If continued bleeding - gastrostomy and oversewing of the vessel

88
Q

Physiologic changes due to vagotomy

A

Increased liquid emptying –> vagally mediated receptive relaxation is removed
Results in increased gastric pressure that accelerates liquid emptying

89
Q

Truncal vagotomy

A

Divides vagal trunks at level of esophagus

Decreased emptying of solids

90
Q

Proximal vagotomy

A

AKA highly selective vagotomy
Divides individual fibers - preserves crow’s foot
Normal emptying of solids

91
Q

Physiologic changes when a pylorplasty is added to truncal vagotomy

A

Increased solid emptying

92
Q

Gastric effects of truncal vagotomy

A

Decreased acid output by 90%
Increased gastrin secretion
Gastrin cell hyperplasia

93
Q

Nongastric effects of truncal vagotomy

A

Decreased exocrine panreas function
Decreased postprandial bile flow
Increased gallbladder volumes
Decreased release of vagally mediated hormones

94
Q

Most common problem following vagotomy?

A

Diarrhea

Caused by sustained MMCs (migrating motor complex) forcing bile acids into the colon

95
Q

What is the cause if ulcer recurs?

A

Missed criminal nerve of Grassi

Branch of Rt vagus nerve - provides stimulation to the gastric cardia

96
Q

Heineke-Mikulicz pylorplasty

A

Longitudinal incision of the pyloric sphincter followed by a transverse closure

97
Q

Stress gastritis

A

Occurs 3-10 days after event
Lesions appear in the fundus first
Tx: PPI
EGD with cautery of specific bleeding points may be effective

98
Q

Chronic gastritis - type A

A

Fundus

Associated with pernicious anemia, autoimmune disease

99
Q

Chronic gastritis - type B

A

Antral

Associated with H. pylori

100
Q

Treatment for chronic gastritis

A

PPI

101
Q

Symptoms of gastric cancer

A

Pain unrelieved by eating

Weight loss

102
Q

Diagnosis of gastric cancer

A

EGD

103
Q

Risk factors for gastric cancer

A 
Adenomatous polyps
Tobacco
Previous gastric operations
Intestinal metaplasia
Atrophic gastritis
Pernicious anemia
Type A blood
Nitrosamines
104
Q

Adenomatous polyps - gastric

A

15% risk of cancer

Tx: endoscopic resection

105
Q

Krukenberg tumor

A

Metastases to ovaries

106
Q

Virchow’s nodes

A

Metastases to supraclavicular node

107
Q

Intestinal-type gastric cancer

A

Increased in high-risk populations
Older men
Japan (rare in US)
Tx: subtotal gastrectomy (need 10cm margins)

108
Q

Diffuse gastric cancer

A 
AKA linitis plastica
Low-risk populations, Women, Most common in US
Diffuse lymphatic invasion - no glands
Less favorable prognosis (5-YS 25%)
Tx: total gastrectomy
109
Q

Chemotherapy for gastric cancer

A

Poor response

5-FU, doxorubicin, mitomycin C

110
Q

Palliation of gastric cancer

A 
Obstruction:
- Proximal lesion - stenting
- Distal lesion - bypass with gastrojejunostomy
Low to moderate bleeding/pain - tx: XRT
Fail --> palliative gastrectomy
111
Q

Gastrointestinal stromal tumors (GIST) of stomach

A 
Most common benign gastric tumor - can be malignant
Sx: asymptomatic, obstruction, bleeding
Dx: US - hypoechoic, smooth edges
- Biopsy - C-KIT positive 
Tx: Resection with 1cm margin
Chemotherapy - Imatinib (for malignant)
112
Q

Indicators of malignancy in GIST tumors

A

> 5cm

>5 mitoses/50 HPF

113
Q

Imatinib

A

Gleevec
Tyrosine kinase inhibitor
Used to treat malignant GIST tumors

114
Q

Muscosa-associated lymphoid tissue lymphoma (MALT lymphoma) of stomach

A

Related to H. pylori infection
Regress after tx for H. pylori (triple-therapy abx)
If MALT does not regress - XRT

115
Q

Gastric lymphoma

A

Ulcer symptoms
Stomach is the most-common location for extra-nodal lymphoma
Usually non-Hodgkin’s lymphoma (B-cell)
Dx: EGD with biopsy
Tx: Chemotherapy, XRT
Sx: Partial resection for stage I disease (confined to stomach mucosa)

116
Q

Criteria for patient selection for bariatric surgery (need all 4)

A

BMI >40 (or BMI >35 with coexisting comorbidities)
Failure of nonsurgical methods of weight reduction
Psychological stability
Absence of drug and alcohol abuse

117
Q

What gets better after bariatric surgery?

A 
Diabetes
Cholesterol
Sleep apnea
HTN
Urinary incontinence
GERD
Venous stasis ulcer
Pseudotumor cerebri
Joint pain
Migraines
Depression
Polycystic ovarian syndrome
nonalcoholic fatty liver disease
118
Q

Complications of Roux-en-Y gastric bypass

A

Marginal ulcers
Leak
Necrosis
B12 deficiency (intrinsic factor needs acidic environment to bind B12)
Iron-deficiency anemia (bypasses duodenum where iron is absorbed)
Gallstones (from rapid weight loss)

119
Q

What do 10% of Roux-en-Y bypass patients fail?

A

High-carbohydrate snacking

120
Q

What is the most common cause of leak in Roux-en-Y bypass?

A

Ischemia

121
Q

Signs of leak after roux-en-Y bypass?

A 
Increased respiratory rate
Increased heart rate
Abdominal pain
Fever
Elevated WBCs
122
Q

S/P Roux-en-Y bypass - Treatment of marginal ulcers

A

Occur in 10%

PPI

123
Q

S/P Roux-en-Y bypass - Treatment of stenosis

A

Response to serial dilation

124
Q

S/P Roux-en-Y bypass - Dilation of excluded stomach post-op

A

Hiccups, large stomach bubble
Dx: AXR
Tx: Gastrostomy tube

125
Q

S/P Roux-en-Y bypass - Small bowel obstruction

A

Nausea, vomiting, intermittent abdominal pain
Dx: AXR (small bowel dilation
Surgical emergency due to risk of small bowel herniation (internal hernia), strangulation, infarction and necrosis
Tx: surgical exploration

126
Q

Jejunoileal bypass

A

Operation is no longer done
Associated with liver cirrhosis, kidney stones, osteoporosis (decreased calcium)
Need to correct these patients and perform Roux-en-Y gastric bypass if ileojejunal bypass is encountered

127
Q

Post-gastrectomy complication: Dumping syndrome

A

Rapid entry of carbohydrates into the small bowel
2 phases - hyperosmotic load (fluid shift into bowel); hypoglycemia
Tx: small, low-fat, low-carb, high-protein meals; no liquid with meals; no lying down after meals; octretide
Sx: Conversion of BRI/BRII to R-Y gastrojejunostomy; increase gastric reservoir (jejunal pouch) or increase empthing time (reversed jejunal loop)

128
Q

Phases of dumping syndrome

A

Phase 1 - hyperosmotic load causes fluid shift into bowel - hypotension, diarrhea, dizziness
Phase 2 - hypoglycemia from reactive increase in insulin and decrease in glucose

129
Q

Post-gastrectomy complication: Alkaline reflux gastritis

A

Postprandial epigastric pain associated with N/V; pain does not improve with vomiting.
Dx: bile reflux in stomach; gastritis
Tx: PPI, cholestyramine, metoclopramide
Sx: Conversion of BRI/BRII to RY gastrojejunostomy with afferent limb 60cm distal to gastrojejunostomy

130
Q

Post-gastrectomy complication: treated with PPI, cholestyramine, metoclopramide

A

Alkaline reflux gastritis

131
Q

Post-gastrectomy complication: Chronic gastric atony

A 
Delayed gastric emptying
sx: nausea, vomiting, pain, early satiety
Dx: gastric emptying study
Tx: metoclopramide, prokinetics
Sx: near-total gastrectomy with RY
132
Q

Post-gastrectomy complication: Treated with metoclopramide, prokinetics

A

Chronic gastric atony

133
Q

Post-gastrectomy complication: Small gastric remnant

A

Early satiety
Dx: EGD
Tx: Small meals
Sx: Jejunal pouch construction

134
Q

Post-gastrectomy complication: Blind-loop syndrome

A

BRII or RY - poor motility
Sx: pain, steatorrhea, B12 deficiency, malabsorption
Caused by bacterial overgrowth (E.coli, GNR) from stasis in afferent limb
Dx: EGD of afferent limb with aspirate/cultures
Tx: tetracycline & flagyl, metoclopramide
Sx: Re-anastomosis with shorter (40cm) afferent limb

135
Q

Post-gastrectomy complication: Treated with Tetracycline & Flagyl, Metoclopramide

A

Blind-loop syndrome

136
Q

Post-gastrectomy complication: Afferent-loop obstruction

A

BRII or RY - mechanical obstruction of afferent limb
Sx: RUQ pain, seatorrhea, nonbilious vomiting, pain relived with bilious emesis
Due to long afferent limb
Dx: CT scan
Tx: Balloon dilation
Sx: Re-anastomosis with shorter (40cm) afferent limb

137
Q

Post-gastrectomy complication: Efferent-loop obstruction

A

Symptoms of obstruction - nausea, vomiting, abdominal pain
Dx: UGI, EGD
Tx: balloon dilation
Sx: Find site of obstruction and relieve it

138
Q

Post-gastrectomy complication: Post-vagotomy diarrhea

A

Secondary to non-conjugated bile salts in the colon (osmotic diarrhea)
Caused by sustained postprandial organized MMCs
Tx: cholestyramine, octreotide
Sx: reversed interposition jejunal graft

139
Q

Post-gastrectomy complication: Duodenal stump blow-out

A

Place lateral duodenostomy tube and drinas

140
Q

PEG complications

A

Insertion into liver or colon

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