as given by Dr. Ellis

1. Stomach
ABSITE Prep

2. Anatomy
• Cardia
• Mucosal Cells
• Fundus
• Mucosal, Parietal, Chief Cells
• Body
• Mucosal, Parietal, Chief, D, ECL Cells
• Antrum
• Mucosal, G, D Cells

3. Cell Functions
• Chief Cells – 40% - Pepsinogen  Pepsin at pH <5
• Parietal Cells – HCl, Intrinsic Factor
• Pernicious anemia – autoimmune disease against Parietal Cells, no IF  B12
deficiency
• Mucous Cells – Mucous, Bicarb
• G Cells – Gastrin
• D Cells – Somatostatin
• ECL – Serotonin
• ECL-Like – Histamine
• Increases HCl production through cAMP (‘Happy cAMPer’)

4. Blood Supply

5. Gastritis
• Stress
• Curling - >30% TBSA Burns, due to mucosal ischemia
• Curling Iron Burns – Curling ulcer
• Cushing – Severe head trauma, due to increased gastrin and HCl
hypersecretion
• Cushing was neurosurgeon, Head trauma – Cushing ulcer
• Alkaline Reflux
• Bile reflux in the stomach – s/p pyloroplasty or Billroth II
• Sx – Post-prandial abdominal pain,
• Dx – EGD
• Tx - RnY

6. Peptic Ulcer Disease
• H. pylori infection - #1 RF
• MCC: H. pylori, followed by NSAIDs
• H. Pylori Tx – PPI, Amoxicillin with Clarithromycin or Flagyl
• ‘CAP’ or ‘CAMO’
• Confirm eradication with urea breath test
• Presents with bleeding – ALWAYS EGD with some adjunct
• Indications for surgery: perforation, bleeding despite endoscopic
therapy, obstruction

7. Gastric Ulcer Types
• Type I
• Distal lesser curvature
• Normal, decreased acid
• Type II – ‘two spots’
• Distal lesser curvature and duodenal
• Acid hypersecretion
• Type III
• Pre pyloric/pyloric
• Acid hypersecretion
• Type IV
• Proximal lesser curvature
• Normal, decreased acid
• Type V – Anywhere, NSAIDS

8. Surgical options
• Perforated GASTRIC ulcer- antrectomy with truncal vagotomy (RISK OF
GI CA)
• Perforated DUODENAL ulcer – graham patch or if bleeding
duodenotomy w/ GDA ligation
• Highly selective vagotomy – highest ulcer recurrence rate
• Best reconstruction is RY – less dumping syndrome and bile reflux
• R. Vagus gives off criminal nerve of grasso – if undivided have recurrent
ulcers
• R vagus is posterior, L vagus is anterior
• Always send ulcer tissue to path

9. Vagotomy

10. UGI Bleeding
• Dx/Tx: reverse anticoagulation, EGD w/ adjuncts
• Active pulsatile bleeding and visible vessel are highest re-bleeding risks
• If liver failure and from esophageal varices --> EGD w/ banding, TIPS if
local therapy fails
• If unable to find source --> angiography --> tagged RBC scan
• Gastric varices w/o esophageal varices – hx of pancreatitis – thing splenic
vein thrombosis. Dx with US. For symptomatic pts ---> splenectomy

11. Post-gastrectomy complications• Dumping
• Early – 15-30 minutes due to rapid passage of high osmolarity food – H2O shift – add fiber avoid hyperosmolar foods
• Late – 2-3 hours due to hyperactive insulin release
• Persistent sx – convert to RNY
• Diarrhea
• 10% post gastrectomy patients, treatment is antimotility agents
• Afferent loop syndrome (blind loop syndrome)
• Poor motility and stasis in the afferent limb
• Bacterial overgrowth --> B12 depletion ---> megaloblastic anemia
• Duodenal stump blowout
• Emergent operation, lateral duodenotomy tube
• Bile Reflux
• Nausea, epigastric pain, bilious emesis, Tx PPI, cholestyramine, metoclopramide
• Gastroparesis
• Associated with RNY, Dx – EGD UGI, Gastric emptying study, Tx - Erythromycin
• Marginal/recurrent ulcers
• Stop NSAIDS, treat H Pylori, PPI, Carafate
• Iron deficiency
• MC nutritional disorder s/p gastrectomy
• Gastric remnant cancer
• 15 years post resection, advanced at Dx, poor prognosis

12. GIST
• Sx – early satiety, bleeding – tumor necrosis,
perforation or incidental discovery
• Interstitial cell of Cajal
• Pacemaker of GIT
• C-kit pos
• Early recurrence/met spread
• Size >10cm, Mitotic Rate >5/50 hpf, small intestine
• Tx
• w/o met spread - resect with 1-2cm margins, Gleevec
(tyrosine kinase inhibitor) if high risk features (above)
• w/ met spread – Gleevec

13. Adenocarcinoma
• Risk Factors – Nitrosamines (smoked meat), Chronic H. pylori/Ulcer
Dx, Pernicious anemia, Atrophic gastritis, Smoking, HNPCC
• Intestinal or diffuse
• Sx – Abdominal pain/Weight loss
• Dx – EGD, CT, Laparoscopy – disease staging
• Tx - Resection, negative margins, en bloc with greater omentum and
lymph nodes. Goal is 16 nodes.
• D1 – Perigastric
• D2 – Perigastric + Celiac + Hepatic + Splenic lymph nodes
• Chemo – if N+, T3, T4 – epirubicin, cisplatin, 5-FU

14. Gastric Lymphoma
• Sx – pain, weight loss, fatigue/anemia
• Dx – PE, LDH, Microglobulin, CT of Chest Abd/Pelvis
• MALToma
• Early Stage – Treat with eradication of H Pylori
• Late Stage – treat as NHL
• Non Hodgkin
• Doxorubicin and cyclophosphamide
• Surgery +/- XRT for non responders, recurrent disease, or complication with
chemo