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MALT:

  • Is a precursor to gastric lymphoma
  • It regresses with H. pylori Tx
  • If does not regresses = chemotherapy (CHOP)

CLO test: Detects urease from H. pylori

H. Pylori Treatment options:

  • Triple therapy : 1. PPI (antisecretory) , + 2 antibiotics (clarithromycin and Amoxillin)
  • Triple therapy : 1. PPI (antisecretory + 2 antibiotics (Clarithromycin + Flagyl)
  • Quadruple therapy 1 PPI (antisecretory) + 2 antibiotics as above + Bismuth Salt .

Gastric Ulcers Types:

  • Type I: On lesser curve (ê Mucosal protection)(Type A blood)
  • Type II: 2 ulcers (lesser curve and duodenal)(é Acid secretion) (Type O blood)
  • Type III: Prepyloric (é Acid secretion)
  • Type IV = High lesser curve (ê Mucosal Protection) (Type O blood)
  • Type V: Anywhere a/w NSAID use

Upper GI Bleed:

  • First: NGT & EGD to confirm bleeding is from ulcer
  • Patient hypotensive despite resuscitation= OR
  • Trouble localizing bleeding source= Tagged RBC scan
  • Biggest Risk factor for re-bleeding at time of EGD:
  1. 1 Spurting blood vessel (60% chance of re-bled)
  2. 2 Visible blood vessel (40% chance of re-bleed)
  3. 3 Diffuse oozing (30% chance of re-bleed)

Duodenal Ulcers:

  • Most common in anterior wall
  • Anterior ulcers: Perforate
  • Posterior ulcers: Bleed from gastroduodenal artery
  • Tx: PPI, Sx if medical therapy fail
  • Perforations:
    • If pt not in PPIs: Graham patch + PPIs
    • If pt already on PPIs: Graham patch + highly selective vagotomy.


Billroth I: Gastro-duodenal anastomosis

Billroth II: Gastro-jejunal anastomosis


Gastric adeno CA:

  • Risk Factors:
    • Adenomatous polyps(10-20% risk), type A blood, nitrosamines, chronic atrophic gastritis/pernicious anemia
    • Has intramural spread so 6 cm margin necessary.

Gastric Leiomiyomas (GIST):

  • Most are C-Kit (positive)
  • Chemotherapy: Gleevec = Tyrosine kinase inhibitor

Gastric lymphoma:

  • Chemo and RT are the Tx of choice
  • Surgery for complications

Bowel rest, NPO/NGT:

  • Cures 65% of partial SBO, 20% of complete SBO

Bowel Anastomoses:

  • Ischemia: most common cause of leak
  • Signs of Leak: éHR, éRR, éWBCs, Pain, Fever

Terminal ileum resection:

  • Decrease bile salt absorption -> less colonic H2O absorption -> diarrhea
  • Decrease B12/intrinsic factor absorption
  • Decrease binding of oxalate -> more oxalate absorbed in colon -> more oxalate stones

Pts w/Crohn's dz with numerous strictures:

  • Avoid resection (and short gut), perform stricturoplasties

Carcinoid:

  • Tryptophan -> serotonin -> 5-HIAA (measure in urine)
  • Tryptophan diversion can cause pellagra (3 D's: dermatitis, dementia, diarrhea)
  • Serotonin is secreted by argentafin staining cells (enterochromaffin cells) only.
  • 9% of patients with mets get Carcinoid syndrome:
    • ​(Flushing, asthma, diarrhea, R sided heart valve disease)
    • Octreotide helps:
      • ​1/3 of pts w/SB carcinoid have multiple primary sites
      • 1/4 have metachronous adenocarcinoma
  • ​Palliative chemo for carcinoid:
    • ​Streptozocin, doxorubicin, 5 FU


Fistulas:

  • Less likely to heal with FRIENDS:
    • Foreign body
    • Radiation
    • IBD
    • Epitheliazation
    • Neoplasm
    • Distal obstruction
    • Sepsis/infection

TPN: Proven to increase closure rate of fistulas, but not shown to increase survival


Gallstone ileus:

  • SBO d/t gallstones (from cholecysto-enteric fistula):

  • SBO w/ pneumobilia.
  • Remove stone to relieve SBO but leave GB and fistula to ê mortality.


Medical Management of Crohn’s:

  • Corticosteroids
  • Aminosalicylates:
    • ​5-ASA, mealamine
  • ​Immunomodulators:
    • ​Azathiprine, 6-MercaptoPurine: (Inhibit DNA synthesis, Suppression of cytotoxic T cell and NK function)
  • Metronidazole

  • Tumor Necrosis Factor Antibody (Infliximab (Remicade))

Pages in category "Stomach/Small Bowel"

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