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169 Cards in this Set
- Front
- Back
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The pylorus is inervated by what
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Vagal innervation
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how many parts are there to the duodenum? what are they?
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4
1. bulb of the duodenum 2. descending duodenum 3. transverse duodenum 4. ascending part of duodenum |
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in what portion of the duodenum are most ulcers located?
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the first portion, 90%
duodenal bulb |
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4th portion- (ascending) enters the jejunum at?
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ligament of treitz
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The fundus of the stomach, and also the upper portion of the greater curvature, is supplied by the?
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short gastric artery which arises from splenic artery.
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The lesser curvature of the stomach is supplied by the _______ inferiorly and the _________ superiorly which also supplies the cardiac region.
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right gastric artery
left gastric artery |
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The greater curvature is supplied by the ________ inferiorly and the __________ superiorly.
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right gastroepiploic artery
left gastroepiploic artery |
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What is the Mayo vein?
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The pre-pyloric vein
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The stomach produces and secretes how much gastric acid per day?
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2-3 liters
basal secretion levels highest in the evenings |
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The ______ are folds in the stomach wall to help grind food
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ruggae
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What are the 4 laters of the stomach wall?
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Inside to outside:
1. mucosa 2. submucos (meissner's pelxus) 3. muscularis externa (Auerbach's plexus) 3. Serosa |
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Meissner’s plexus has _____________ which provides secretomotor innervation to the mucosa nearest the lumen of the gut.
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parasympathetic fibers
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This layer is responsible for creating the motion that churns and physically breaks down the food.
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inner oblique layer
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pyloric sphincter contained in this layer. This layer is concentric to the longitudinal axis of the stomach.
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middle circular layer
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what is the most abundant cell in the stomach?
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Mucous cells
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where are mucous cells found?
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cardia, fundus, and pylorus
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These cells Secrete a bicarbonate-rich mucous that coats the gastric surface important in protection
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Mucous cells
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these cells Protects the epithelium from acid and other chemical insults
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mucous cells
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where are parietal cells found?
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fundus, cardia and pylorus
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These cells Secretes hydrochloric acid and intrinsic factor
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Parietal cells
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what receptors on parietal cells stimulate release of HCl acid?
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histamne, acetylcholine and gastrin
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_________ environment necessary for the activation of pepsinogen and inactivation of ingested microorganisms and bacteria
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Acidic
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where are chief cells mainly found?
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fundus
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what do chief cells secrete?
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pepsinogen, inactive from of pepsin
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pepsinogen is activated by what into pepsin?
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stomach acid
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what is the fnx of pepsin?
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breaks dow proteins into peptides
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what triggers the release of pepsinogen?
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gastrin and the vagus nerve when food is ingested
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what is the major site of G cells?
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Antrum
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what is the princpile hormone secreted by G cells?
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gastrin
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G cells active what reflex?
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the gastroileal reflex which moves chyme, from the lileum to colon
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what can inhibit gastrin?
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pH normally less than 4 and somatostatin
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gastrin causes an increase in?
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secretion of HCL from parietal cells, secretion of pepsinogen from chief cells and increased stomach motility
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This peptide decreases both gastric acid release and gastric motility
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Gastric Inhibitory Peptide (GIP)
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what does enteroglucagon do?
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decreases gastric acid and motility
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what substances does the stomach absorb?
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some lipid-soluable compounds
Aspirin, NSAIDS Caffeine Ethanol Water Simple sugars Amino Acids |
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what are the 3 phases of acid secretion?
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Cephalic, gastric, Intestinal
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What percent of the total gastric acid secretions to be produced is stimulated by anticipation of eating and the smell or taste of food.
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cephalic phase 30%
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what percent of the acid secreted is stimulated by the distention of the stomach with food. Digestion then produces proteins, which causes increased gastrin production
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60%, gastric phase
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produced in the small intestine
Mostly pancreatic effect, but can decrease stomach acid secretion |
Secretin
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causes gall bladder contractions
decreases gastric emptying increases release of pancreatic juice (neutralizes chyme) |
CCK
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gastrin and _____ stimulate the parietal cells to produce gastric acid
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parasympathetic nervous systems (vagus nerve). Meissner's plexus (intramural) influence secretions as well.
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nerve endings in the stomach secrete two stimulatory neurotransmitters:
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acetylcholine and gastrin-releasign peptide
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The release of this substance, stimulated by gastrin and acetylcholine, is the most important positive regulation mechanism of the secretion of gastric acid in the stomach.
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histamine
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Histamine release is inhibited by?
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somatostatin
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95% of duodenal ulcers occur where?
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in the first portion of the duodenum within 2cm of the pylorus
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what are PUD risk factors?
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H. pylori
cigarette smoking (ischema, stimulates histamine) ETOH NSAIDs uremia ZE delayed gastric emptying steroids coffee |
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Inhibit cyclooxygenase activity and prostaglandin production
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NSAIDs
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what 3 factors make up the trinity of ulcer disease?
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bleeding, obstruction, perforation
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With NSAIDs, is it Cox 1 or 2 that leads to destruction of stomach mucosa integrity?
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Cox 1
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Ammonia, cytotoxins, proteases and other enzymes produced by ________ have also been implicated in epithelial damage and degradation of the mucous layer
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H. Pylori
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What is the MC sx of PUD? what are other sx?
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1. Epigastric pain (MC)
2. gnawing or burning sensation - occurs 2-3 hrs after meals. Relieved by food or antacids. 3. pt. awaken with pain at night 4. pain may radiate to back (consider penetration) 5. dyspepsia, including belching, bloating, dissension, fatty food intolerance 6. Waterbrash 7. hearburn 8. chest discomfort 9. Nausea 10. Vomiting 11. Anorexia/weight loss 12. Hematemesis / melena from gastrointestinal bleeding. |
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Ulcers due to this may be painless and initially preset as an upper GI bleed
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NSAIDS
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Nocturnal pain that awakens a patient is highly suggestive of a?
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duodenal ulcer
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Appears midmorning
Worse several hours after meals and relieved with food or antacids |
duodenal ulcer
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Symptoms less consistent
Eating will relieve or exacerbate pain |
gastric ulcer sx
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_______ ulcers are more often associated with symptoms of obstruction such as bloating, nausea and vomiting secondary to edema and scarring from ulcer disease
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Pyloric channel ulcers
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what are 4 clinical findings in PUD?
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1. epigastric tenderness
2. guaiac positive stool resulting from occult blood loss 3. Melena resultign from acute or subacute GI bleeding 4. Succussion splash from partial or complete gastric outlet obstruction. |
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what do we use to make the dx for PUD?
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suggested by hx but confirmed by EGD
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what is the preferred and most highly sensitive dx test in eval of patiens with suspected gastric or duodenal ulcers?
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EGD its dx and therapeutic!
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***Indications for ulcer surgery include***
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1. hemorrahage
2. Intractability 3. Perforation 4. Obstruction |
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How can we dx H. Pylori?
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biopsy, blood or breath test
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what medical therapy can we use for PUD?
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PPI, bismuth, abx for H.pylor
Lifestyle modification surgical therapy for a small number of patients |
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what do we want to rule out in recurrent duodenal ulcers?
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H. pylori
measure fasting plasma gastrin to r/o zollinger-ellison syndrom R/o maligancny R/o CMV in immunosuppresed pop'n |
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What type of gastric ulcer?
Along lesser curvature |
Type 1
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What type of gastric ulcer?
Body of stomach along with a DU |
Type II
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What type of gastric ulcer?
Prepyloric ulcer |
Type III
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What type of gastric ulcer?
next to GE junction |
Type IV
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NSAIDs are Potent cyclo-oxygenase inhibitors and prevent the _______________ which are necessary for the production of gastric protective mucus and bicarbonate.
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gastric synthesis of prostaglandins
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What should we do for people with gastric ulcers? Even if resolution of sxs occur?
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BIOPSY! resolution of sx and healing of ucler with tx to not ensure that its not a carcinoma.
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If the ulcer does not heal within 6 weeks, what is recommended?
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repeat biopsy
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what type of ulcer will have greater night time pain and heartburn?
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duodenal ulcer
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when are duodenal and gastric ulcers most likely to occur? at what age?
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gastric >30
duodenal 30-60 |
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what are (4) complications of PUD?
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Free perforation
Gastric outlet obstruction Hemorrhage Penetration |
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what is the MC complication of PUD?
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hemorrahge
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Hematemesis
Hematochezia Melena (dark tarry stools) Weakness (anemia?) Orthostasis syncope are sx of what complication from peptic ulcer dz? |
hemorrhage
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this ulcer complication will present as an acute abdomen
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free perforation
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Boardlike abdomen with absent or diminished bowel sounds
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free perforation
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Succussion splash
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Gastric Outlet Obstruction
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Caused by scarring, spasm, or inflammation associated with an ulcer
Vomiting, occurring more frequently at the end of the day and often as late as 6 h after the last meal Persistent bloating or fullness after eating and loss of appetite Succussion splash |
GOO
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The MC reason for recurrent peptic ulcer is?
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unsuccessful eradication of H. Pylori
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what will be the sign of posterior duodenal perforation?
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bleeding (b/c of location of gastric artery)
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what will be the sign of anterior duodenal perforation?
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free air in the peritoneum
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Describe an omental patch (Graham patch)
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Three sutures through both side of defect, isolate portion of omentum, place into defect, tie sutures over the omentum, sealing the defect.
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a surgical procedure that involved the resection of the vagus nerve to reduce acid secretion is known as?
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a vagotomy
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what are the 3 types of vagotomy?
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truncal
selective highly selective |
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Treatment option for chronic duodenal ulcers and gastric outlet obstruction
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truncal
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Once considered the gold standard but is now usually reserved for patients who have failed "triple therapy" against h. pylori
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truncal vagotomy
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if you do a truncal vagotomy what other procedure must you do?
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pyloroplasty needed to avoid gastric obstruction
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in a selctive vagotomy Stomach is essentially denervated, but innervation to ___________ is preserved
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celiac ganglion and biliary system is preserved
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Branches of the anterior and posterior nerves of Latarjet are divided at lesser curvature in this procedure?
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highly selective vagotomy
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______is indicated in the treatment of gastric ulcers refractory to medical therapy, complicated by perforation, bleeding, or obstruction, or recurrent after adequate treatment of H pylori.
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antrectomy
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What is the mortality rate for Vagotomy and Antrectomy
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1-3%
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Operation for ulcer disease in which the pylorus is removed in addition to the antrum and the proximal stomach is anastamosed directly to the duodenum
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Billroth 1
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who was the first polish surgeon to describe Billroth 1?
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Ludwik RyDygier
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The greater curvature of the stomach is connected to the first part of the jejunum in a side-to-side anastamosis –gastrojejunostomy.
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billroth II
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Reconstruction after antrectomy
Indicated in refractory peptic ulcer disease or severe duodenal scarring |
billroth 2
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gastrojejunostomy with closure of duodenal stump
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Billroth II
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what is the stomach cancer that prof. chelcun has?
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hereditary diffuse gastric cancer
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Usually done for gastric neoplasms, massive diffuse bleeding or ZE palliation
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total gastrectomy
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what is the mortality rate and recurrence rate with total gastrectomy?
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mortality 5%
recurrence <1% |
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Gastric neoplasia, recurrent ulcerations after truncal vagotomy and antrectomy are indications for what procedure?
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sub-total gastrectomy
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Roux-en-Y is what kind of procedure?
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total gastrectomy. The isoperistaltic jejunal limb shoul dbe 45-60cm long
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what are complications of total gastrectomy?
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Loss of a storage place for food while it is being digested.
Patient will have to eat small amounts of food regularly in order to prevent gastric dumping syndrome Loss of the intrinsic-factor-secreting parietal cells |
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what are marginal ulcers?
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recurrent ulcers at surgical site. Most common in the jejunum mucosa near site of gastrojejunostomy. Probably due to incomplete vagotomy
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what is the MC post-gastrectomy complication?
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early dumping syndrome (20% occurrence with 2% with major problems)
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uncontrolled emptying of pylorus pour hyperosmolar gastric contents into proximal small bowel. what is this syndrome called?
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early dumping syndrome
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what are Sx of early dumpin syndrome?
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nausea, sweating, tachy, weakness, syncope
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How do we treat early dumping syndrome?
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Rx with anticholinergics, Roux-en-Y surgery if severe
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Nausea and bilious emesis after eating
Related to edema at the gastrojejunostomy |
Afferent loop syndrome
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a submucosal vascular malformation usually located in the gastric fundus.
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Dieulafoy's ulcer
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what is a mallory-weiss tear?
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longitudinal tear in the proximal gastric mucosa near the esophageal-gastric junction
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Occurs 1-3 hours after a meal
Empties foods high in carbs into the proximal small bowel |
late dumping syndrome
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Creation of an anastomosis between the stomach and jejunum leaves a segment of small bowel, most commonly consisting of duodenum and proximal jejunum, lying upstream from the gastrojejunostomy. This is called?
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afferent loop
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This limb of intestine conducts bile, pancreatic juices, and other proximal intestinal secretions toward the gastrojejunostomy
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afferent loop
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Post-prandial pain and vomiting with gastritis
Rx with Roux-en-Y |
Bile reflux gastritis
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what are risk factors for gastric cancer?
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Age >60
Males >Females Risk factors: Diet- nitrosamines, ETOH, smoking, low in fruits and veggies, heavy metal exposure Genetic - blood type A, Lynch syndrome, AfricanAmerican ethnicity, Family hx of gastric cancer |
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what are signs and sx of gastric cancer?
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1. post prandial epigastric pain unrelieved by feeding
2. anorexia 3. weight loss 4. N/V 5. Dysphagia 6. melena 7. Hematemesis 8. Early satiety 9. anemia 10. positive hemoccult 11. epigastric mass 12. Blumer's shelf 13. Virchow node 14. enlarged ovaries (krukenberg tumor) 15. Irish's node (left anterior axiallary node) |
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Left anterior axillary lymph node, a site often involved by metastatic gastric CA
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Irish's node
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what is a krukenberg tumor?
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gastric cancer that metastasizes to the ovaries
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aorto-enteric fistula presents how?
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herald bleed? vomit red blood and then completely insanguinate
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what is Curling's ulcer?
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stress ulcer in patients with burns.
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what is a Von-Rokitansky-Cushing syndrome?
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seen with head injuries --> develop ulcers
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what are causes of UGIB in the duodenum?
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CUshings, CUrlings, Aorto-enteric fistula , duodenal ulcer, erosion of pancreatic mass
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what are esophageal causes of UGIB?
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varicies, esophagitis, malignancy
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what are gastric causes of UGIB?
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mallory weiss, ulcers, Gastritis, AVM, gastric varicies, tumors, dieulafoy's lesion
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what are the top 5 causes of UGI bleeding?
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1. PUD 45%
2. gastritis 20% 3. Esophageal varicies 20% 4. Mallory Weiss 10% 5. other <5% a. aorto-duodenal fistula b. gastric neoplasm |
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what is the number once cause of upper GI hemorrhage?
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PUD (25% DU, 20% gastric)
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what are medical causes of UGI Bleeding?
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1. leukemia
2. hemophilia 3. thrombocytopenia 4. coagulopathy 5. anti-coagulation-- all disorders of coagulation 7. hereditary hemorrhagic telangiectasia |
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what is a risk factor of UGIB that is not seen in PUD?
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liver disease
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What are the dx steps for UGIB?
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1. type and cross
2. CBC - can get h/H, platelets (make sure they can clot) 3. PT/PTT (any reason they aren't clotting) 4. Electrolytes and BUN/ cr 5. LFTs 6. Upright chest x ray (did they perf?) 7. consider serial Hcts |
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what are the three things we must do to treat UGIB?
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1. resuscitate
2. Investigate 3. Treat |
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what kind of nasograstric tube do we use in UGIB? what do we use it for?
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18 Fr
use it for saline lavage -- irrigate with ROOM TEMP water or saline until clear |
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the diagnostic method of choice for upper gastrointestinal bleeding!!!!
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Endoscopy (EGD) 95% accuracy
both dx and therapeutic |
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with an EGD bleeding can be managed by?
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1. thermal therapy (coagulation)
2. injection with vasoconstrictors 3. hemoclips 4. argon plasma coagulator |
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What do we do in post EGD management after an ulcer is dx and bleeding is controlled endoscopically?
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1. The patient should be given acid suppression (H2 blockers, PPIs)
2. NPO - do not feed them! 3. wait for 24 hrs for no evidence of rebleeding, then you can start them on oral diet and oral PPI's and then 4. start them H. Pylori therapy |
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what is the tube called that we use to treat varices? (esophageal)
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Sengstaken-Blakemore tube
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ulcer is a submucosal vascular malformation usually located in the gastric fundus.
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Deiulafoy's ulcer
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Longitudinal tear in the proximal gastric mucosa near the esophageal-gastric junction
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mallory-weiss tear
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the pancrease is located where in respect to the stomach?
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posterior
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in adults the volume of a relaxed stomach is? can hold up to ?
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45ml hold up to 3 Liters!
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the pylorus is innervated by what nerve?
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vagal innervation
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90% of duodenal ulcers are located where?
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duodenal bulp
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the ampulla of vater is located in what portion of the duodenum
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2nd portion - descending duodenum
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the 3rd portion of the duodenum is wedged between which two strcutures?
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aorta and SMA
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What is the suspensory ligament of the duodenum?
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ligament of trietz
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what is the name of the vein that overlies the pylorus?
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Vein of Mayo
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has parasympathetic fibers which provides secretomotor innervation to the mucosa nearest the lumen of the gut.
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meissner's plexus (secretion)
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which layer of the stomach has three layers instead of the usual two found in the digestive tract?
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muscularis externa
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found in this layer which provides motor innervation, having both parasympathetic and sympathetic input (Hirschprungs, achalasia)
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Auerbach's plexus
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is the most important positive regulation mechanism of the secretion of gastric acid in the stomach, stimulated by what?
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histamine release
stimulated gastrin and acetylcholine |
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erosions are most superficial and do not involve the?
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muscularis mucosa
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an AVM formed located in the fundus of the stomach. Can be the cause of recurrent, massive GI bleeding that can cause high fatality rate if condition remains unrecognized
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Dieulafoy's ulcer
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patient has gastic ulcer. upon treatment with H. pylori 3x abx the patient feels better. What is the next step?
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Get a biopsy of the ulcer! All gastric ulcers should be biopsied even if resolution of sx and healing with tx -- does not ensure that it is not a carcinoma
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If a gastric ulcer does not heal within ______ we should do a repeat bx
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6 weeks
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indication for DU or GU?
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HIPO
1. hemorrhage 2. Intractibility 3. Perforation 4. obstrution |
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do you get more heart burn with gastric or duodenal ulcer?
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duodenal
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the most common reason for recurrent peptic ulcer is?
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unsuccessful eradication of H.Pylori
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What is more likely to have recurrence? Ulcer from high acid or h.pylori?
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Depends, if you stop medication, H2, PPIs then >60% chance of recurrence after 1 year.
Once you reradiate h.pylori very unlikely to get recurrenc, <10% |
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what could be reasons for refractory ulcer disease?
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1. did you not eradicate the H.pylori? recheck
2. Are you missing something? other dz, ZE? 3. Are they using more NSAIDS, smoking, etc? 4. IF it was a gastric ulcer you need to go back and biopsy it again. |
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when would you consider doing an omental patch (Graham patch)
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in a perforated ulcer for a person who is either uncomplicated with no hx of dz and its an easy scenario OR
a person who is in dire situtation and you just want to get in an get out. |
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if you have a patient with ulcer caused by excessive use of motrin and they have a perforation what treatment would you use?
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If uncomplicated patient do a graham patch as definitive treatment as well as life style modification to get them to stop using so much NSAIDS and prevent recurrence
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this type of vagotomy used to be the gold standard but is now reserved for patients who failed triple therapy against H. pylori
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truncal vagotomy
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in this procedure Anterior and posterior vagus is divided distal to the celiac and hepatic branches. Stomach is essentially denervated, but innervation to celiac ganglion and biliary system preserved
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selective vagotomy
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when doing an antrectomy the release of osmotic chyme into the small intestine can lead to? The increased insulin release can lead to?
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Diarrhea -- dumping syndrome
hypoglycemia |
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when you do an antrectomy do you also do a vagotomy?
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yes, truncal vagotomy o prevent nerve stimulation of the stomach
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wat are complications of ulcer surgery?(6)
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1. early dumping
2. late dumping 3. diarrhea 4. bile reflux syndrome 5. marginal ulcers 6. afferent loop syndrome |
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when would you do surgery for an UGIB
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1. patient remains unstable (pulse, hct)
2. rebleeding using maximum medical therapy 3. if you use 6+ units of Packed RBC |
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how do we treat esophageal varicies?
|
1. sclerotherapy via EGD
2. Vasopressin 3. Sengstaken-Blakemore tube |
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what is the blood supply to duodenum?
|
primarily gastric duodedenal and SMA
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