stomach power point

7/29/2019 Stomach Power Point

1/29

StomachSurgery Review, Fairfax Residency


2/29

Stomach: Basic Anatomy


3/29

Blood Supply


4/29

Innervation


5/29

HSV


6/29

Parietal Cell Secretes acid and IF

Regulated by Ach, gastrin, histamine

Basal acid secretion 10% of maximal

Food bolus gastrin acid production luminal acid

inhibits gastrin


7/29

Cell Types & Locations


8/29

Abnormal Motility:

Gastroparesis Vagotomy

Hyperglycemia

H pylori

Common s/p Whipple

Anorexia & Bulimia

Connective tissue disorders

(Ehlers Danlos,

Scleroderma, parkinsons)

Tobacco?

1st line: treat with pro-kinetics

(reglan, erythro)

Dietary changes (plus

glucose control in DM)

Surgical (reversible):

jejunostomy, TPN, gastric

pacers, botulin

Surgical (irreversible):

Antrectomy, Distalgastrectomy


9/29

Vagotomy Loss of receptive relaxation and accommodation

Early satiety, bloating, accelerated emptying of liquids,

delayed emptying of solids

Pyloroplasty cuts pylorus, allows easier emptying of

food into duo (high incidence of recurrent ulcer)

Antrectomy removes gastrin-producing cells (less

chance of recurrent ulcer)


10/29

H pylori Found in 90% of duodenal ulcers & 75% of gastric

ulcers

Gram negative, microaerophilic bacteria

1st-line tx: PPI (Omeprazole = Prilosec) +Clarithromycin + Amoxicillin (or Flagyl if PCN-allergic)

Treat x 7 days

If refractory, add Bismuth (= Peptol Bismol)

Once eradicated, rarely recurs


11/29

Gastric Ulcers I: Lesser curve at incisura

(low to normal acid)

II: Gastric body with duo

ulcer (increased acidity)

III: Pre-pyloric (incr. acidity)

IV: High on lesser curve

(normal acidity)

V: Anywhere (normal acidity,NSAID-induced)


12/29

Gastric Ulcer Treatment


13/29

Gastric Cancer


14/29


15/29

Q1 68 yof on high-dose NSAIDs

from chronic low back pain,

early satiety, nausea,

vomiting; narrowing of lumen

at 1st portion of duo, almost

occluded; CT shows no

mass


16/29

Treatment? Pneumatic dilation

Anti-secretory meds

PEG Gastrojejunostomy

H pylori treatment


17/29

Whats Going On? Gastric outlet obstruction

Most likely cause: previous generations, ulceration

would have been most likely, now canceris most likely

Has cancer been ruled out? (CT negative)

High-dose NSAIDs, think ulcer (Type V)

Anti-secretory meds & H pylori eradication necessarybut not the firststep


18/29

Pneumatic Dilation Ulceration leads to

inflammation, scarring &

edema of pyloroduodenal

channel

90% success, can attempt x3, but if fails, proceed with

gastrojejunosomty

NEXT step is tx with anti-

secretory meds & H pylori

eradication


19/29

Treatment? Pneumatic dilation

Anti-secretory meds

PEG Gastrojejunostomy

H pylori treatment


20/29

Q2: Regarding gastroparesis:

Which is true?

More common in Type 2 than Type 1 diabetes?

Gastric electrical stimulation does not cause directcontraction of smooth muscle or entrain normal gastricelectrical rhythm

Receptive relaxation of fundus in diabetic patients is normal

Gastric electrical stimulation improves sx in idiopathic butnot diabetic gastroparesis

Idiopathic gastroparesis most common secondary tobacterial gastroenteritis


21/29

Gastroparesis Sx: slow emptying, nausea, vomiting, abd pain,

bloating, anorexia, weight loss; due to abnormalmyoelectrical activity

Seen in diabetics and after truncal vagotomy

In diabetics, 50% of Type I, 30% of Type II

Tx with reglan and erythro

40% of pts cannot tolerate pro-kinetic meds; anti-emetics are 2nd line

Medical success rate ~ 50%


22/29

Gastroparesis Surgical treatment includes gastro electric stimulation

Low-energy pulses delivered to greater curve 10 cm from

pylorus

Small amt of stimulation, not enough to cause directcontraction of smooth muscle

Does not always normalize emptying, but improves sx of

N&V and QOL.

Equally effective for diabetic and idiopathic gastroparesis


23/29

Q2: Regarding gastroparesis:

Which is true?

More common in Type 2 than Type 1 diabetes?

Gastric electrical stimulation does not cause directcontraction of smooth muscle or entrain normal gastricelectrical rhythm

Receptive relaxation of fundus in diabetic patients is normal

Gastric electrical stimulation improves sx in idiopathic butnot diabetic gastroparesis

Idiopathic gastroparesis most common secondary tobacterial gastroenteritis


24/29

Q348 yom, etoh abuse, presents with massive UGI bleed,endoscopy shows linear disruption of gastric mucosa high onlesser curvature at GE jct. Endoscopic treatment cannot controlbleeding. Pt gets 6 u PRBCs, HR is 115, SBP in 85.Treatment?

Embolize L gastric A.

Place Blakemore tube and inflate balloon

Anterior gastrostomy & oversewing bleeding site

Vagotomy, Antrectomy & biopsy of bleeding site

Total gastrectomy


25/29

Whats Going On? Mallory-Weiss Tear, pt unstable

Source of ~ 10% of admission for UGI bleed

Endoscopy 1st line

If pt unstable, tx is proximal anterior gastrostomy withoversewing of tear

Bleeding stops in 90% with resuscitation only. LGA

embolization and vasopressin useful if pt not opcandidate

Lesion not malignant, not due to incr acid


26/29

Q348 yom, etoh abuse, presents with massive UI bleed,endoscopy shows linear disruption of gastric mucosa high onlesser curvature at GE jct. Endoscopic treatment cannot controlbleeding. Pt gets 6 u PRBCs, HR is 115, SBP in 85.Treatment?

Embolize L gastric A.

Place Blakemore tube and inflate balloon

Anterior gastrostomy & oversewing bleeding site

Vagotomy, Antrectomy & biopsy of bleeding site

Total gastrectomy


27/29

Q4: Pathology of stress-related gastric

mucosal injury

Elevated gastric acid

Bile reflux

Reduced gastric blood flow

H pylori infection

NSAIDs


28/29

Stress related gastric injury ICU patients

Seen in fundus and body of stomach

Rarely in distal stomach

Diagnose with endoscopy

Tx: Resuscitate, correct coagulopathy, NG lavage, H2

blockers (Ranitidine = Zantac)

Source is reduced mucosal perfusion acid damages

gastric mucosa


29/29

Q4: Pathology of stress-related gastric

mucosal injury

Elevated gastric acid

Bile reflux

Reduced gastric blood flow

H pylori infection

NSAIDs

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