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44 Cards in this Set
- Front
- Back
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Anatomy of the stomach
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-pliable saccular organ in the left hypochondrium and epigastrium
-has the ability to move (in contrast to the duodenum) |
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Proximal (low esophageal AKA esophageal distal hih pressure zone) Sphincter
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-epi changes from squamous to columnar
-purpose is to prevent reflux of gastric contents into esophagus |
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Distal (pyloric) Sphincter
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-along w/ the antral pump, the purpose is to control rate of gastric emptying, prevent reflux of duodenal contents into stomach (alkaline material)
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What are important aspects of the nervous system in the area of the stomach when it comes to surgical procedures?
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1. Right vagus - posterior branch to ciliac plexus
2. Left vagus - hepatic branch for GB, biliary tract, and liver 3. Vagus stimulates paarietal cells to secrete HCl as well as controls stomach motor activity |
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Where are parietal and chief cells only found?
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fundus
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Where are gastrin producing G cells only found?
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-Antrum
(significant for surgery) |
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***TQ MEchanisms of HCl secretion***
What are the 3 general phases of stimulates that cause HCl secretion from parietal cells? |
1. Cephalic phase: mediated by ACh released from vagus
2. Gastric phase: mediated by antral release of gastrin 3. Intestinal phase: mediated by GI peptides and Histamine released from SI |
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***Duodenal ulcers***
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-MC occur in first of duodenum since this is where the highest concentration of acid is
-Bacteria can cause ulcers (H. pylori) |
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**What are some of the clinical manifestations of having a duodenal ulcer?
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-burning epigastric pain (remember duodenum doesn't move) that is accentuated by fasting (more acid)
-pain often relieved by eating -pain can radiate to back |
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**What do posterior ulcers commonly present w/?
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-bleeding and massive hemorrhage
-this is because of the many vessels in the area -bleeding will spill into abd cavity and cause "board like" abd -acid will follow causing pt to be in pain |
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***Board question: What Xray is ncessary to make the diagnosis of pneumoperitoneum?
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-Upright chest Xray
-pneumoperitoneum = air under the diaphragm (usually from a perforated GI ulcer) -***it is pathognomonic for a perforated peptic ulcer |
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***Clinical presentation of duodenal ulcer disease
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-repeated bouts of acute ulceration may lead to gastric outlet obstruction
-pt presents w/ wt loss, n/v, chronic gastric dilation |
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What are indications for surgery for acute peptic ulcer disease?
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-hemorrhage, perforation, obstruction, intractibility
-if perforation is < 6 hr old, ulcer is plicated and acid reducing procedures are done -of >6 hrs, placation is done |
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What are indications for surgery for acute peptic ulcer disease?
Continued... |
-Upper GI hemorrhage -> decompress stomach, lavage and antacid tx
-coag needs to be ok, IV line should be good -make sure preload is nL so can judge amount of hypervolemia (if pt needs >6 units in 12 hrs surg) |
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Tx of Gastric outlet obstruction
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-stomach should be decompressed w/ NG tube
-NPO |
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****TQ Adenocarcinoma of the duodenum
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-RARE
-if there is a mass, only one biopsy is indicated -BUT gastric ulcers require multiple biopsies |
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Why is Gastric acid analysis done?
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-to differentiate benign ulcers
-ulcer pts will show an inc acid output upon stimulation -***when a Zollinger Ellsion pt is stimulated there will be NO RISE in acid secretion (diff from PU pt) |
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***TQ: What are surgical treatments of Peptic ulcers?***
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-basis is acid reduction.
-most critical aspect is interruption of paths responsible for acid excess -Truncal vagotomy: Heineke-Mikkulicz Pyloroplasty -Antrectomy and Billroth 1 -Billroth II -Roux en y Anastomosis |
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Truncal vagotomy: Heineke-Mikkulicz Pyloroplasty
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-slows down the GB
-slows down pancreatic secretion -slows down intestinal motility -GB not contracting - complication of gallstones |
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Antrectomy and Billroth I
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-cut out portion of stomach
-good for GUs, but not for ulcers inferior to the stomach -many complications but still acceptable for GU and gastric CA |
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Billoroth II
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-cut out part of stomach and close off duodenum
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Roux en y Anastomosis
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-Gold standard w/out vagotomy
-food rejoins w/ alkaline substances in isoperistaltic fashion resulting in no alkaline reflux |
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Zollinger Ellison
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-special variant of DU disease
-due to ind production of gastrin by a tumor arising in the pancreas or paraduodenal area -60% of ZE caused tumors are malig -pts w/ refractory PUD or virulent ulcer diatheresis have inc risk |
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***What should one think for pt presenting w/ recurring ulcers?
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-THINK ZE
-fasting serum gastrin levels are high -Secretin infusion test = rise in serum gastrin |
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***TQ and BQ: What are pathognomonic findings for ZE?***
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-fasting serum gastrin levels are high
-a secreting infusion test will show a rise in serum gastrin -highly sensitive and specific for ZE |
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Where is GU disease found?
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-on the lesser curvature of stomach w/in 1 cm of transition zone between antrum and body
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What is the mechanism of GUD?
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-defective mucous barrier, delayed gastric emptying, antecedent gastritis, inc H+ ion back diffusion, alkaline reflux, defective pyloric sphincter (or sphincter of Ode in diabetic)
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What are clinical manifestations of GUD?
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-pain in the epigastrium and may radiate through to the back
-produced by ingestion of food (OPPOSITE of duodenal) -wt loss is therefore common -nL/low pattern of gastric secretion |
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***When should you be suspicious of carcinoma?
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-if a pt has ACHLORHYDRIA
-if ulcer is found perform an endoscopy and multiple biopsies |
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What are surgical indications for GUs?
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-depends on gastric acid secretary status--> get ulcer out you are done
-*Distal gastrectomy w/ excision of ulcer (tx the complication not operating on any pt w/ GU) -success rate high, recurr low |
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What are postgastrectomy syndromes?
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-many complications, may need another surgery
-nutritional disturbances: pts commonly get anemia and require B12 treatment |
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***TQ Gastritis is the common cause of morbidity and mortality in what kind of patients?
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-burn pt (curling's ulcer)
-head trauma pts (cushing's ulcer) -or pt w/ ICU -the longer the pt is in the ICU, the more likely they are to get stress gastritis |
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Gastric polyps
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-Rare (Reagan had a polyp)
-Peutz Jegher syndrome --> multiple benign polyps in SI and melanous spots on the lips and buccal mucosa |
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Bezoar
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-accum of indigestible fibers in the stomach
-children, psych pts -trichobezoar -> mostly hair |
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What are s/s of gastric carcinoma
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-diff from ulcer systems
-wt loss, epigastric discomfort -pt may have dysphagia, hematemesis, melena -maybe anemia |
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How do you make a diagnosis of Gastric Carcinoma?
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-upper GI series
-GOLD STANDARD: ENDOSCOPY W/ BIOPSY -60% originate in distal end of stomach (can save some of stomach) |
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***TQ/BQ Where does gastric carcinoma metastasize?***
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-spread occurs to regional nodes, omentum, left supraclavicular area (Virchow's node), ovary peritoneum
-can metast to pelvis (felt during rectal exam: droplet aspects of carcinoma metast = Blumer's shelf) |
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Where are Krukenberg tumors?
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-ovaries
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Where are Sister Jeane Marie tumors?
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-umbilicus
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Leiomyoma and leimomyosarcoma
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-presents as submucosal mass, rigid abd, vague epigas GI pain
-endoscopy shows smooth raised lesion w/ central ulceration -tx surgery -a/w spicy diet, lesser curvature |
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Pyloric stenosis
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-common in newborns
-dilated stomach, but pyloris is not letting anything thru -tx: cut through and let mucous membrane come through, relieve tension from pyloris |
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***What is bariatric surgery?***
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-started as small bowel bypass, works well in diabetics
-***Pt must be at least 100lbs above ideal weight or BMI >40 -very strict criteria |
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Lap Band Procedure
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-restricting the food going in
-put band in area and increase/decrease fluid -(+'s): less trauma, adjustable -pt still needs to modify eating habits, diets, --> many complications |
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What is the Gold standard of combined restriction and malabsorptive procedures?***
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-"Roux en Y gastric bypass"
-makes the stomach volume less than 1 ounce, but pt can still stretch -staple stomach shut -need to B12 supplement |
