1. The stomach has several cell types that secrete different substances like pepsinogen, HCl, intrinsic factor, mucus, gastrin, and somatostatin. Diseases can affect these cells and their secretions. 2. Common causes of peptic ulcer disease include H. pylori infection and NSAID use. Treatment involves eradicating H. pylori and managing risk factors. Surgery may be needed for complications like bleeding or perforation. 3. Other diseases discussed include gastritis, gastric cancer, GIST tumors, dumping syndrome, and lymphomas. Diagnosis involves endoscopy, imaging, and biopsies. Treatment depends on the specific disease but

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