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100 Cards in this Set
- Front
- Back
What part of the stomach does the esophagus enter into? |
Cardia |
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What is the most superior part of the stomach? |
Fundus |
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What is the distal part of the stomach? |
Antrum |
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What is the part of the stomach that connects to the duodenum? |
Pylorus |
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What is the blood supply to the lesser curvature of the stomach? |
Left gastric artery (superior) Right gastric artery (inferior) |
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What is the blood supply to the greater curvature of the stomach? |
Short gastrics (from spleen) (superior) Left gastroepiploic artery (corner) Right gastroepiploic artery (inferior) |
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What space lies behind the stomach? |
Lesser sac; the pancreas lies behind the stomach |
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What is the opening into the lesser sac? |
Foramen of Winslow |
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What are the folds of gastric mucosa called? |
Rugae |
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What are the products of gastric parietal cells? |
- HCl - Intrinsic factor |
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What are the products of chief cells? |
PEPsinogen (PEPpy CHIEF) |
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What are the products of mucus neck cells? |
- Bicarb - Mucus |
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What are the products of G cells? |
Gastrin |
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Where are G cells located? |
Antrum |
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What is pepsin? |
Proteolytic enzyme that hydrolyzes peptide bonds |
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What is intrinsic factor? |
Protein secreted by parietal cells that combines with B12 and allows for absorption in terminal ileum |
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What is GERD? |
Excessive reflux of gastric contents into esophagus, "heartburn" |
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What is pyrosis? |
Medical therm for heartburn |
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What are the causes of GERD? |
- Decreased LES tone (>50% of cases) - Decreased esophageal motility to clear refluxed fluid - Gastric outlet obstruction - Hiatal hernia in ~50% of patients |
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What are the signs/symptoms of GERD? |
- Heartburn - Regurgitation - Respiratory problems/pneumonia from aspiration of gastric contents - Substernal pain |
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What disease must be ruled out when symptoms of GERD are present? |
CAD |
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What tests are included in workup of GERD? |
- EGD - UGI contrast study with esophagogram - 24-hour acid analysis (pH probe in esophagus) - Manometry, EKG, CXR |
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What is the medical treatment of GERD? |
- Small meals - PPIs or H2 blockers - Elevation of head at night and no meals prior to sleeping |
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What are the indications for surgery in patients with GERD? |
- Intractability (failure of medical tx) - Respiratory problems d/t reflux and aspiration of gastric contents (eg, pneumonia) - Severe esophageal injury (eg, ulcers, hemorrhage, stricture, +/- Barrett's esophagus |
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What is Barrett's esophagus? |
Columnar metaplasia from normal squamous epithelium as a result of chronic irritation from reflux |
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What is the major concern with Barrett's esophagus? |
Developing cancer |
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What type of cancer develops in Barrett's esophagus? |
Adenocarcinoma |
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What percentage of patients with GERD develop Barrett's esophagus? |
10% |
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What percentage of patients with Barrett's esophagus will develop adenocarcinoma? |
7% lifetime (5-10%) |
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What is the treatment of Barrett's esophagus with dysplasia? |
Nonsurgical: endoscopic mucosal resection and photodynamic therapy; other options include radiofrequency ablation, cryoablation (these methods are also often used for mucosal adenocarcinoma) |
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What are the surgical procedures for severe GERD? |
- Lap Nissen - Belsey mark IV - Hill - Toupet |
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What is a Lap Nissen? |
360 degree fundoplication - 2 cm long (done laparoscopically to treat severe GERD) PICTURE 273 |
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What is a Belsey Mark IV? |
240-270 degree fundoplication performed through a thoracic approach (tx for severe GERD) PICTURE 274 |
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What is a Hill procedure? |
Arcuate ligament repair (close large esophageal hiatus) and gastropexy to diaphragm (suture stomach to diaphragm) (Tx for severe GERD)
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What is the Toupet procedure? |
Incomplete (around 200 degree) posterior wrap (laparoscopic) often used with severe decreased esophageal motility (Tx for severe GERD)
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How does the Nissen wrap work? |
Thought to work by improving the lower esophageal sphincter: 1. Increasing LES tone 2. Elongating LES ~3 cm 3. Returning LES into abdominal cavity |
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In what percentage of patients does Lap Nissen work? |
85% (70-95%) |
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What are the post-op complications of Lap Nissen? |
1. Gas bloat syndrome 2. Stricture 3. Dysphagia 4. Spleen injury requiring splenectomy 5. Esophageal perforation 6. Pneumothorax |
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What is gas-bloat syndrome? |
Inability to burp of vomit |
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What is the incidence of gastric cancer? |
Low in US (10/100,000); high in Japan (78/100,000) |
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What are the associated risk factors for gastric cancer? |
- Diet: smoked meats, high nitrates, low fruits and vegetables, alcohol, tobacco - Environment: raised in high-risk area, poor socioeconomic status, atrophic gastritis, male gender, blood type A, previous partial gastrectomy, pernicious anemia, polyps, H. pylori |
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What is the average age at time of discovery of gastric cancer? |
>60 years |
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What is the ratio of male to female patients with gastric cancer? |
3:2 |
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Which blood type is associated with gastric cancer? |
Blood type A (there is an "A" in gastric, but no "O" or "B") |
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What are the symptoms of gastric cancer? |
WEAPON: - Weight loss - Emesis - Anorexia - Pain / epigastric discomfort - Obstruction - Nausea |
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What are the most common early symptoms of gastric cancer? |
Mild epigastric discomfort and indigestion |
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What is the most common symptom of gastric cancer? |
Weight loss |
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What are the signs of gastric cancer? |
- Anemia - Melena - Heme occult - Epigastric mass (in advanced disease) - Hepatomegaly - Coffee-ground emesis - Blumer's shelf - Virchow's node - Enlarged ovaries - Axillary adenopathy |
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What does the patient with gastric cancer have if he or she has proximal colon distention? |
Colonic obstruction by direct invasion (rare) |
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What is the symptom of proximal gastric cancer? |
Dypshagia (gastroesophageal junction / cardia) |
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What is a Blumer's shelf? |
Solid peritoneal deposit anterior to the rectum, forming a "shelf", palpated on rectal exam |
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What is a Virchow's node? |
Metastatic gastric cancer to the nodes in the left supraclavicular fossa |
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What is Sister Mary Joseph's sign? |
Periumbilical lymph node seen with gastric cancer metastases; presents as periumbilical mass |
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What is a Krukenberg's tumor? |
Gastric cancer (or other adenocarcinoma) that has metastasized to the ovary |
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What is "Irish's" node? |
Left axillary adenopathy from gastric cancer metastasis |
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What is a surveillance laboratory finding with gastric cancer? |
CEA elevated in 30% of cases (if +, useful for post-op surveillance) |
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What is the initial workup for gastric cancer? |
- EGD with biopsy - Endoscopic U/S to evaluate the level of invasion - CT of abdomen/pelvis for metastasis - CXR - Labs |
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What is the differential diagnosis for gastric tumors? |
- Adenocarcinoma - Leiomyoma - Leiomyosarcoma - Lymphoma - Carcinoid - Ectopic pancreatic tissue - Gastrinoma - Benign gastric ulcer - Polyp |
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What are the two histologic types of gastric cancer? |
1. Intestinal (glands) 2. Diffuse (no glands) |
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What are morphological types of gastric cancer? |
- Ulcerative (75%) - Polypoid (10%) - Scirrhous (10%) - Superficial (5%) |
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Are gastric cancers more common on the lesser or greater curvature? |
Lesser ("less is more") |
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What is more common, proximal or distal gastric cancer? |
Proximal |
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Which morphologic type of gastric cancer is named after a "leather bottle"? |
Linitis plastica: the entire stomach is involved and looks thickened (10% of cancers) |
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How do gastric adenocarcinomas metastasize? |
Hematogenously and lymphatically |
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Which patients with gastric cancer are NON-operative? |
1. Distant metastasis (eg, liver metastasis) 2. Peritoneal implants |
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What is the role of laparoscopy for gastric cancer? |
To rule out peritoneal implants and to evaluate for liver metastasis |
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What is the genetic alteration seen in >50% of patients with gastric cancer? |
P53 |
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How can you remember P53 for gastric cancer? |
Gastric Cancer = GC = P53 "GCP...53" |
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What is the treatment for gastric cancer? |
Surgical resection with wide (>5 cm checked by frozen section) margins and lymph node dissection |
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What operation is performed for gastric cancer tumors found in antrum? |
Distal subtotal gastrectomy |
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What operation is performed for gastric cancer tumors found in midbody? |
Total gastrectomy |
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What operation is performed for gastric cancer tumors found in proximal stomach? |
Total gastrectomy |
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What is a subtotal gastrectomy? |
Subtotal gastrectomy = 75% of stomach removed
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What is a total gastrectomy? |
Stomach is removed and a Roux-en-Y limb is sewn to esophagus
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What type of anastomosis is used with total gastrectomy? |
Billroth II or Roux-en-Y (never use a Billroth I) |
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When should splenectomy be performed for gastric cancer? |
When the tumor directly invades the spleen / splenic hilar adenopathy |
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Define "extended lymph node dissection"? |
Usually D1 and D2: - D1 are perigastric LNs - D2 include: splenic artery LNs, hepatic artery LNs, anterior mesocolon LNs, anterior pancreas LNs, crural LNs |
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What percentage of patients with gastric cancer are inoperable at presentation? |
~10-15% |
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What is the adjuvant therapy for gastric cancer? When is it indicated? |
Stages II and III: post-op chemotherapy and radiation |
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What is the 5-year survival rate for gastric cancer? |
25% of patients are alive 5 years after diagnosis in US (in Japan, 50% are alive at 5 years) |
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Why is it thought that the post-op survival is so much higher in Japan? |
Aggressive screening and capturing of early cancers |
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What is GIST? |
Gastro-Intestinal Stromal Tumor |
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What was GIST previously known as? |
Leiomyosarcoma |
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What is the cell of origin for GIST? |
CAJAL (interstitial cells of Cajal) |
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Where is GIST found? |
GI tract: "esophagus to rectum" - most commonly found in stomach (60%), small bowel (30%), duodenum (5%), rectum (3%), colon (2%), esophagus (1%) |
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What are the symptoms of GIST? |
- GI bleed - Occult GI bleed - Abdominal pain - Abdominal mass - Nausea - Distention |
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How is GIST diagnosed? |
- CT scan - EGD - Colonoscopy |
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How are distant metastases of GIST diagnosed? |
PET scan |
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What is the tumor marker for GIST? |
C-KIT (CD117 antigen) |
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What is the prognosis of GIST? |
- Local spread, distant metastases - Poor long-term prognosis: size >5 cm, mitotic rate >5 per 50 HPF (high power field) |
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What is the treatment for GIST? |
Resect with negative margins, +/- chemotherapy |
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Is there a need for lymph node dissection with GIST? |
No |
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What is the chemotherapy for metastatic or advanced disease of GIST? |
Imatinib - tyrosine kinase inhibitor |
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What is a maltoma? |
Mucosal-Associated Lymphoproliferative Tissue |
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What is the most common site for a maltoma? |
Stomach (70%) |
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What is the causative agent of maltomas? |
H. pylori |
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What is the medical treatment for maltomas? |
Non-surgical: treat for H. pylori with triple therapy and chemotherapy / XRT in refractory cases |
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What is gastric volvulus? |
Twisting of the stomach |
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What are the symptoms of gastric volvulus? |
Borchardt's triad: 1. Distention of epigastrium 2. Cannot pass an NGT 3. Emesis followed by inability to vomit |
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What is the treatment for gastric volvulus? |
Exploratory laparotomy to untwist, and gastropexy |
