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Flashcards in stomach and duodenum Deck (186):

esophageal motility disorder characterized by failure of the circular esophageal muscle in the distal 2cm of the esophagus to relax



definite mucosal change from gastric epithelium to intestinal epithelium (striated columnar cells w interspersed goblet cells) and 1-3cm long smooth muscle valve known as pylorus

gastroduodenal junction


what does the pylorus do

prevents reflux of duodenal contents into stomach; controls gastric emptying



distal gastric resection that removes the gastrin producing cells of the stomach


basal acid secretion

circadian rhythm w highest levels at night and lower levels in the morning


what is responsible for creating the concentrated acid environment within the lumen of the stomach

H for K, ATPase


diffuse erythema and disruption of the mucosa of the stomach; assoc w ingestion of irritating agents



Schilling test

used to determine cause of bit B12 def: pernicious anemia or small intestinal bacterial overgrowth


what two things promote ulcer formation by altering the balance between the protective and potentially harmful components of the gastric environment

H. pylori and NSAIDs


causes a chronic active gastritis w dysregulation of gastrin and acid secretions

h. pylori


inhibit cox1 which is essential for prostaglandin synthesis, thereby altering local blood flow, mucus production,and bicarb secretion in the stomach



mc cause of benign gastric ulcer ds

h pylori and nsaids


type 1 gastric ulcers

most frequent, occur along lesser curvature of the stomach in the zone above the antrum; normal or low acid output


type 2 gastric ulcers

arise in combo w duodenal ulcers; acid hyper secretion


type 3 gastric ulcers

dev in prepyloric region; acid hypersecretion


type 4 gastric ulcers

least frequent, occur high on lesser curvature near GE junction; normal or low acid output


how is h pylori spread

gastrooral or fecal oral


s/sx of uncomplicated gastric ulcers

gnawing epigastric pain that can radiate to back; anorexia and wl because assoc w ingestion of food


s/sx complicated gastric ulcers

may or may not have any prior to perforation or bleeding


what confirms the presence of an ulcer

EGD; any gastric ulcer found needs to be bx for malignancy; always bx for h pylori


endoscopic features suggestive of malignancy

bunched up ulcer border or large (>3cm) ulcer size; presence of achlorhydria


besides EGD another dx study gastric ulcer

barium upper GI contrast; con is can't bx


first line therapy for uncomplicated gastric ulcer disease

cessation of all potential ulcerogenic agents (tobacco, nsaids, aspirin, steroids, alcohol); tx h pylori w abx; acid suppression therapy; cytoprotective agents (sucralfate, misoprostol)


abx to tx H pylori

clarithromycin, amoxicillin, metronidazole, tetracycline, bismuth, omeprazole


what is mandatory after initiating medical tx for gastric ulcer

repeat endoscopy; after 6 weeks ulcer should show healing


surgical tx for nonhealing, obstructing or refractory gastric ulcers types 1-3

excision; antrectomy (50% gastrectomy, mc performed), GI continuity restored to either proximal duodenum (Billroth 1), loop of proximal jejunum (billroth 2) or transposed limb of jejunum isolated from biliopancreatic secretions (Roux en y)


Which gi reconstruction may be assoc w impaired gastric emptying and intestinal transit

roux en y


pts w type 2 and 3 often receive what n addition to antrectomy for further dec gastric acid secretion

truncal vagotomies


surgical tx type 4

may require near total gastrectomy w roux en y reconstruction


tx emergent operation for perforated pyloric channel ulcer prev unrecog

oversew and omental patch without resection


inflammation of the stomach mucosa that may be assoc w erosions and hemorrhage

acute gastritis


s/sx acute gastritis

n, v, hematemesis, melena, or hematochezia


causes of acute gastritis

h pylori, nsaid, aspirin, bile reflux, alcohol irradiation, local trauma


tx acute gastritis

acid suppression, removal of noxious agent, occasional gastric decompression, nutritional support


pts can develop mucosal erosions beginning in the proximal stomach and progressing rapidly throughout the rest of the organ

stress gastritis


ulcer formation in major burn victims (curling's ulcer) and patients w cns injury (cushing's ulcer)

stress gastritis


prophylaxis in critical ill pt since stress gastritis can dev within 48hr

PPI, h2 rec blockers, sucralfate, misoprostol


intraluminal ph should not dec below



mc complication of stress gastritis

hemorrhage; watch for blood per rectum, blood in ng aspirate, or drop in blood ocunt


what confirms the dx of stress gastritis



hypertrophic gastritis (menetrier's ds)

rare disorder of the lining of the stomach characterized by massive hypertrophy of the gastric rugae


s/sx hypertrophic gastritis (menetriers)

epigastric pain, n, v occult hemorrhage, anorexia, wl, diarrhea; hypoproteinemia and peripheral edema


tx hypertrophic gastritis (menetriers)

acid suppression w ppi, h2 or antacids; high protein diet


upper GI hemorrhage secondary to linear tearing of the mucosa at the GE junction

mallory weiss syndrome


when do mallory weiss tears usually occur

after episodes of strong valsalva maneuver causes mechanical stress on mucosa in region; retching, heavy lifting, childbirth, vomiting, blunt abd trauma, seizures


eval of mallory weiss tear

ng tube and gastric lavage; if blood then endoscopy, nuclear scintigraphy or selective angiography


tx mallory weiss tear

fluid resuscitation, stabilization; acid suppression; if bleeding persists then electrocautery, heater probe or injection therapy


gastric polyp

hyperplastic or adenomatous in nature. Hyperplastic polyps are more common and are typically benign, although rare cancerous transformation has been reported. Adenomatous polyps have a higher risk of malignant degeneration, especially those >1.5 cm. When a gastric polyp is diagnosed, the physician should consider the possibility of other polyps within the GI tract and polyposis syndromes.


presence of multiple benign polyps in small intestine and sometimes portions of gi tract, melanin spots on lips and buccal mucosa

peutz jeghers syndrome- auto dom


accumulation of lg mass of indigestible fiber within the stomach

bezoar (vegetable=phytobezoar) (hair=trichobezoar)


mc stomach cancer



risk factors for gastric adenocarcinoma

h pylori infx, pernicious anemia, achlorhydria, chronic gastritis; caustic injury from lye ingestion; adenomatous polyps


mc category of gastric adenocarcinoma

ulcerative carcinomas


two histologic types of gastric adenocarcinoma

intestinal (older pt and spreads hematogenously) and diffuse (signet ring cells, younger, type A blood, spreads lymphatics and local extension)


term used to describe complete infiltration of the stomach w carcinoma

linitis plastica; stomach looks like a leather bottle


s/sx of later stages of gastric carcinoma

epigastric pain, wl, dysphagia, hematemesis, melena, n, v; iron def anemia or guaiac positive stools


dx imaging gastric carcinoma

upper endoscopy, bx, endoscopic us, cxr, ct abd/pelvis;PET


dx lab gastric carcinoma

cbc, electrolytes, creatinine level, lfts


what do pts undergo who don't have any evidence of metazoic ds on initial workup

laparoscopic staging


surgical tx of gastric carcinoma

Complete surgical resection in an attempt to cure gastric adenocarcinoma should only be undertaken in the presence of localized disease. Considerable debate exists regarding the extent of such a resection. For most distal lesions, many surgeons favor a radical subtotal gastrectomy. In this procedure, approximately 85% of the stomach is removed, including the omentum. The proximal portion of the resected specimen is then immediately examined by the pathologist (i.e., frozen section) to verify that it is free of tumor involvement. Only after such verification is GI continuity restored by means of a Roux-en-Y gastrojejunostomy. Total gastrectomy is reserved for either large distal lesions or more proximal tumors. Splenectomy or pancreatectomy may also need to be included in the operative procedure. They should, however, be avoided unless absolutely necessary.


NCCN guidelines of chemo w gastric carcinoma

perioperative chemo using epirubicin, cisplatin, and 5 fluorouracil for lesions invade beyond lamina propria or have positive nodes


is chemoradiotherapy necessary for less invasive lesions (only invade submucosa)

no can be excised without but 5 fluorouracil w or without leucovorin is recommended after


indications for palliative surgical intervention of gastric carcinoma

proximal or distal tumor obstruction and bleeding


gastric carcinoma stage 1

mucosa, muscularis mucosa, submucosa


gastric carcinoma stage 2

mucosa, muscularis mucosa, submucosa, muscularis propria


gastric carcinoma stage 3

mucosa, muscularis mucosa, submucosa, muscularis propria, lymph nodes


gastric carcinoma stage 4

mucosa, muscularis mucosa, submucosa, muscularis propria, lymph nodes, distant metastases or contiguous spread


primary source of almost 2/3 of all gi lymphomas

stomach; older and nonhodgkins predominates


s/sx gastric lymphoma

upper abd pain, lw, fatigue, bleeding


dx gastric lymphoma

tissue bx during upper endoscopy; sometimes during surgical exploration


if dx is made prop what workup should be done for gastric lymphoma

cxr, abd ct, bone marrow bx


tx gastric lymphoma

chemo but has risk of gastric perforation or hemorrhage; or resection followed w chemo or radiation


submucosal growths of the GI tract arising from variety of cell types

formerly known as leiomyomas and leiomyosarcomas but now gastrointestinal stromal tumors (GISTs)


what suggests malignancy with GISTs

large tumor size >6cm and tumor necrosis


s/sx GISTs

asyp; nonspecific abd pain, but bleeding and obstruction can manifest; may present w abdominal mass


eval of GISTs

upper endoscopy, endoscopic us, abdominal ct


most common site of GIST and mc site for disseminated disease

stomach; liver



local excision w margin of 2-3cm included; if aggressive chemo using imatinib mesylate


two ucergenic agents for duodenum

h pylori and nsaids; maybe tobacco


s/sx uncomplicated duodenal ulcers

burning epigastric abd pain that is gnawing in character; can radiate to back; occur 1-3hrs after food and accentuated by fasting; awaken from sleep; relief w acid suppressants; food intake can also improve pain


older dx imaging uncomplicated duodenal ulcer

upper gi series (not used as much), gastric acid analysis (ng tube placed in stomach for samples of gastric aspirates for 1 hr, >4 basal acid output)


noninvasive dx testing for uncomplicated duodenal ulcer

quantitative and qualitative serologic antibody,urease tests, and fecal antigen test for h pylori; upper endoscopy*


tx uncomplicated duodenal ulcer

stop ulcerogenic agents, acid suppression therapy, abx h pylori


4 main manifestations of complicated PUD

perforation, hemorrhage, gastric outlet obstruction, intractability


s/sx pt w perforated ulcer

acute onset of severe epigastric pain, tachycardia, rigid abdomen; may have rlq rebound tenderness


eval of perforated ulcer

upright chest radiograph- evidence of free intraperitoneal air (pneumoperitoneum) outlining diaphragm or liver, cbc and bmp


s/sx bleeding ulcer

hematemesis, melena, blood per rectum, hypotension,tachycardia, pallor, mental status changes, active bleeding


eval bleeding ulcer

ng tube w gastric lavage, endoscopy, serial hematocrits and coag parameters, blood type and cross match


s/sx gastric outlet obstruction resulting from chronic ulcer scarring

inability to tolerate oral intake, projectile vomiting shortly after eating, lw, dehydration, upper abd fullness, dec skin turgor, dry mucus membranes, epigastric peristaltic waves


eval gastric outlet obstruction

electrolyte and creatinine levels- often have hypokalemic, hypochloremic metabolic alkalosis


s/sx intractable ulcers

persistent ds after adequate nonop therapy, pe same as pt w uncomplicated PUD


tx complicated pud

initial stabilization phase (resuscitation and nonop therapy) if doesn't work then surgery


tx perforated ulcer

surgical emergency; fluid resuscitation and nasogastric decompression; oversewing the ulcer w buttressing w a tag of momentum is performed followed by intensive tx w PPIs and abx


tx hemorrhage ulcer

volume resuscitation then Advanced Trauma Life Support (ATLS) guidelines: 2L crystalloid followed by whole blood; stomach decompressed using NG tube; high dose PPI therapy, then coag abnorm corrected; upper endoscopy w electrocautery; surgery for refractory bleeding (>6u in first 12hr)


tx gastric outlet obstruction

stomach is decompressed w an NG tube for 5-6d or until returns to normal size, NPO, nutrition/fluids through IV w normal saline crystalloid and total parenteral nutrition; surgery


tx intractable ulcers

surgical intervention to dec acid secretion through interruption of the vagal neural pathway w or without removal of gastrin producing cells in antrum usually by truncal vagotomy and pyloroplasty


proximal gastric vagotomy

antiulcer operations; selectively denervates vagal stimulation to the parietal cells; maintains function of the pyloric sphincter


dumping syndrome

complex myriad symptoms; may include cramps abd pain and diarrhea; secondary to ablation of the pyloric sphincter mechanism


familial adenomatous polyposis

auto dom dev w polyps in the colon and gastroduodenal region; possible malig so close monitoring


Zollinger-Ellison syndrome

severe variant of duodenal ulcer ds; results from the independent production of gastrin by a tumor (gastrinoma) that arises in the pancreas or paraduodenal area


ZE syndrome has strong assoc w what endocrine neoplasm

multiple endocrine neoplasia type 1 syndrome (MEN 1)


characteristics of MEN 1

pituitary adenomas, hyperparathyroidism, pancreatic islet cell tumors


s/sx ZE syndrome

ulcer like symptoms w concomitant chronic or severe diarrhea


dx ZE syndroma

establishing presence of hypergastrinemia w hyper secretion of acid so a fasting serum gastrin level is necessary; make sure PPI discontinued stopped 1 week prior; >1000 is dx; secretin stimulation test inc >200; gastric ph


tx ZE syndrome

total gastrectomy w esophageal anastomosis; high dose PPI or H2 rec antag; hormonal manipulation w somatostatin octreotide


tx ZE syndrome w MEN1

parathyroidectomy +/- surgical exploration


mc site for adenocarcinoma in the small bowel

duodenum; 2/3 in the second part in the periampullary region


s/sx adenocarcinoma of duodenum

nonspecific abd pain w wl to intestinal/gastric outlet obstruction; melena or hematochezia due to ulceration of the lesion; pe unremarkable


dx adenocarcinoma of duodenum

upper endoscopy w tissue bx; ct


tx adenocarcinoma of duodenum

surgical excision; pancreaticoduodenectomy is in 1/2 part of duodenum; duodenojejunostomy if in 3/4 part; unresectable have diverting gastroenterostomy; postop radiation


what happens when the stomach is denervated

control of gastric emptying is abolished


if someone is having a complicated postop course what is used for eval

upper GI series- doc extent of gastric resection and type of reconstruction, determine cause of vomiting, asses gastric emptying and motility


symptoms that occur after ingestion of food of high osmolarity

early dumping syndrome


15m after eating pt presents w anxiety, weakness, tachycardia, diaphoresis, and palpitations; extreme weakness and wants to lie down; cramps abd pain, borborygmi heard

early dumping syndrome


what is happening during early dumping syndrome

uncontrolled emptying of hypertonic fluid into small intestine which moves rapidly from intravascular space into intraluminal space leading to intravasc vol depletion


tx early dumping syndrome

avoid hypertonic liquid meals, alter vol of each meal, ingest fat w each meal to slow gastric emptying; ingest liquids 30min before or after meal; frequent small meals; if doesn't work roux en y gastrojejunostomy may be necessary


late dumping syndrome

same symptoms of early but begin within 3 hours after meal and not assoc w borborygmi or diarrhea


cause of late dumping syndrome

rapid changes in serum glucose and insulin levels leading to hypoglycemia


tx late dumping syndrome

small snack 2 hr after meals (crackers/pb); acarbose; if all else fails surgery


what do almost half the pts who undergo a truncal vagotomy experience

change in bowel habits (inc freq, more liquid)


causes of postvagotomy diarrhea

enhanced intestinal motility (vagal denervation), rapid gastric emptying, bile malabsorption, and bacterial overgrowth


tx postvagotomy diarrhea

fluid intake restricted; food w low fluid content; antidiarrheal/antimotility agents (codeine, diphenoxylate hydrochloride, loperamide); cholestyramine or somatostatin; if refractory to med man then reversed 10cm set of jejunum inserted 100cm distal to ligament of treitz


afferent loop obstruction occurs after which reconstruction

gastrectomy w billroth 2


cause of afferent loop obstruction

kink in afferent limb adjacent to anastomosis; pancreatic and biliary secretions are trapped in limb and cause distention


s/sx afferent loop obstruction

severe abd cramping mimed after ingestion of meal; pain as crushing; within 45 min feel abd rush assoc w inc pain then n and v of dark brown bitter tasting material; symp resolve w vomiting; wl


tx afferent loop obstruction

exploration of the abdomen and conversion of billroth 2 anastomosis to either a roux en u gastrojejunostomy or billroth 1 gastroduodenostomy


blind loop syndrome is more common after what procedure

billroth 2; bypass of small intestine secondary to radiation injury or morbid obesity


assoc w bacterial overgrowth in the limb of intestine that is excluded from the flow of chyme; interferes w folate and bit b12 metab

blind loop syndrome


a def of vit b 12 leads to

megaloblastic anemia


s/sx blind loop syndrome

steatorrhea, diarrhea, wl, weakness


dx blind loop syndorme

schilling test using cobalamin found to IF is abnormal


tx blind loop syndrome

oral broad spectrum abx cover aerobic and anaerobic bacteria (tetracycline); conversion to billroth 1 gastroduodenostomy


alkaline reflux gastritis is seen in pts in which what contents reflux into the denervated stomach

duodenal, pancreatic, and biliary contents


s/sx alkaline reflux gastritis

weakness, wl, persistent n, epigastric abd pain radiates to back, anemia


what will an upper endoscopy reveal w alkaline reflux gastritis

edematous, bile stained gastric epithelium that is atrophic and erythematous;inflammatory changes w corkscrew appearance of submucosal blood vessels; need to take bx


inflammatory changes w corkscrew appearance of submucosal blood vessels

alkaline reflux gastritis


tx alkaline reflux gastritis

surgical correction consists of diverting duodenal contents away from stomach w long limb roux en y gastrojejunostomy; minimum distance between gastrojejunostomy and entry point of biliopancreatic limb draining the digestive juices into intestine is 40cm (18in)


where do marginal ulcers develop

jejunal side of gastrojejunostomy anastomosis


why do marginal ulcer develop

secondary to ischemia but also smoking


s/sx marginal ulcers

abd pain during eating along w n/v


what does upper endoscopy show for marginal ulcer

ulcer on jejunal side no more than 2cm distal to anastomosis


conservative management of marginal ulcer

stop tobacco use and start PPI; severe NPO and TPN; surgery


recurrent ulcer ds following surgical intervention in benign PUD is most commonly due to

incomplete vagotomy; posterior vagal trunk or branch of right posterior nerve (criminal nerve of Grassi) is left intact


dx recurrent ulcer ds

upper endoscopy is used to help confirm persistent vagal innervation to the stomach. Congo red is used to demonstrate areas of pH drop in the gastric mucosa after the administration of an acid secretagogue (pentagastrin). Such regions have intact vagal innervation


what should be eval for pts w recurrent ulceration and verified complete vagotomy

search for endocrine etiology; fan hx MEN1; calcium and parathyroid hormone levels for hyperparathyroidism; gastrin levels


mc metabolic abnorm after gastric resection



medication for late dumping syndrome

acarbose- alpha glucosidase hyrolase inhibitor


medication for postvagotmy diarrhea and alkaline reflux gastritis

cholestyraime- bile salt binding agent


medication for postvagotomy diarrhea and dumping syndrome

somatostatin- secretory inhibitor


medication for gastric atony

metoclopramide- promotility agent


medication for marginal ulcer and alkaline reflux gastritis

sucralfate- gi protectant


medication for postvagotomy diarrhea

diphenoxylate hydrochloride or loperamide


10kcal/day of extra energy can result in how much weight gain over the course of a year



what 3 things play an important role in appetite regulation within the body

hypothalamus, stomach, adipocyte:Food intake is triggered by the release of the hormone ghrelin from gastric oxyntic cells. This compound stimulates the release of neuropeptides in the “hunger center” of the hypothalamus, increasing caloric consumption. To signal adequate caloric load, the adipocyte releases the hormone leptin, which activates the “satiety center” of the hypothalamus. In this manner, food intake is decreased.


bmi=weight (kg)/ height (m)(squared) ranges

40 (severely obese)


3 categories for tx for overweight and obese ppl

behavior modification (all BMIs), pharmacotherapy (all BMI except underweight), surgical intervention (obese or severely obese)


calorie range for low calorie diet

500-1000kcal/day so for women this is reached at 1000-1200kcal/day and men 1200-1500kcal/day; will lose 0.45-.9kg/week


goal of low calorie diet

10% weight loss over 6 months


long term weight reduction agent that is FDA approved

sibutramine and orlistat


3 different bariatric procedures that limit food intake by forcing the pt to eat smaller portions

adjustable gastric banding (AGB), sleeve gastrectomy (SG) and vertical banded gastroplasty (VBG)


malabsoprtive operation that alters food processing by limiting its absorption in the intestines

biliopancreatic diversion (BPD) w or without duodenal switch (BPD/DS)


combined restrictive and malabsorptive operation for bariatric procedures

roux en y gastric bypass


roux en y

creation of small proximal gastric pouch by transecting the stomach; roux limb measures 75-150cm in length


adjustable gastric banding (AGB)

creation of proximal gastric pouch using inflatable band and placement of access port;A pars flaccida technique is used to create a posterior gastric tunnel from the lesser curve to the angle of His. The band is then positioned and secured by imbricating its anterior aspect. The distal fundus is sutured to the proximal gastric pouch. The port is placed on the abdominal muscle fascia. Adjustments of the band are made by instilling sterile solution percutaneously via the access port.


sleeve gastrectomy (SG)

surgeon removes approximately 85% of the stomach laparoscopically so that the stomach takes the shape of a tube or “sleeve” This procedure is not reversible. Unlike many other forms of bariatric surgery, the pylorus and stomach innervation remain intact.



BPD is basically a subtotal gastrectomy with a very distal Roux-en-Y reconstruction. BPD/DS involves SG, duodenal transection with duodenojejunostomy creation, and very distal jejunoileostomy


vertical banded gastroplasty

reation of a proximal gastric pouch by stomach partitioning and the reinforcement of the stoma with banding. Partitioning is usually via gastric stapling, and polypropylene is a popular banding material


early complication of bariatric procedures (periop or before pt discharged)

anastomotic leak (roux), dvt and pe (roux, ABG, SG), bleeding (roux, abg, sg), infection (roux,abg, sg), splenic or visceral injury (roux, abg, sg)


late complications of bariatric procedures (after discharge)

nutritional disturbances (roux, abg, sg), marginal ulcers and anastomotic strictures (roux), internal hernia (roux), afferent limb syndrome (roux), cholelithiasis (roux, sg), band slippage (sg), esophageal dilation (ABG, sg), band erosion (abg)


mc site of anastomotic leak



s/sx of anastomotic leak

abd pain, unexplained tachycardia, tachypnea, hypoxia


dx anastomotic leak

upper gi series or abd ct w oral contrast


tx anastomotic leak

percut drainage and parenteral nutrition; if not surgery


tx dvt or pe after bariatric surgery

enoxaparin or unfractionated heparin for initial tx then oral anticoag w warfarin for 6m


bariatric surgical patients are instructed to consume extra what after surgery so don't dev nutrition disturbance

protein (60-80g/d)


mc def of gastric bypass pts

iron def (65mg/d plus vit c) then b12 (IM or subling)


pt complain of progressive intolerance of solids/liquids w postprandial abd pain and vomiting

stricture after bariatric surgery


pt w abd pain, n, nonbilious vomiting after bariatric surgery

biliopancreatic limb obstruction


since cholelithiasis can occur due to rapid wl following gastric bypass surgery what is taken for 6m postop

ursodeoxycholic acid 300mg BID


tx for pt for has roux en y done and regained weight due to pouch or pouch outlet enlargemnt



guidelines for adolescents to receive bariatric surgery

tried for 6m to lose weight w no success, vmi >40, reached adult height, serious obesity related health problems, psych eval pt and parents


A 60-year-old man comes to the emergency room because of hematemesis and bright red blood per rectum. He reports a history of gnawing epigastric pain radiating to the back and improved with eating. His past medical history is significant only for frequent headaches and back pain, for which he takes nonsteroidal anti-inflammatory drugs (NSAIDs) and over-the-counter medications. On physical exam, he is pale, hypotensive, and tachycardic. After resuscitation, initial upper endoscopy reveals evidence of an upper gastrointestinal hemorrhage and an ulcer in the posterior duodenal bulb. Which blood vessel is the most likely source of bleeding?

The patient presents to the emergency room with evidence of a massive upper gastrointestinal hemorrhage (hematemesis with bright red blood with hypotension and tachycardia). His symptoms of gnawing epigastric pain radiating to the back and Improved with eating suggest a posterior bulb duodenal ulcer. Ulcers in this location can erode into the gastroduodenal artery as It passes behind the first portion of the duodenum, causing massive gastrointestinal hemorrhage. The left gastric artery arises from the celiac axis. The common hepatic artery divides Into the gastroduodenal and proper hepatic arteries. The right gastric artery arises from the proper hepatic artery. The superior mesenteric artery is a branch off the aorta.


A 63-year-old man came to the office because of epigastric pain of 2 months’ duration not relieved with antacids. He has a history of an adenomatous gastric polyp removed 3 years ago. At upper endoscopy, he was found to a have another gastric polyp in his antrum that, on endoscopic ultrasound, appeared to be superficial and not associated with any enlarged lymph nodes. Pathological analysis of the polyp reveals evidence of adenocarcinoma invading into the submucosa. On clinical staging, there Is no evidence of distant metastasis. The next step in therapy for this patient is

subtotal gastrectomy

This patient has an early stage gastric cancer (i.e., no evidence of metastasis or perigastric lymph nodes) on clinical staging and is a candidate for potentially curative resection. Patients with minimal evidence of gastric wall invasion (i.e., mucosal or submucosal invasion) do not require any preoperative therapy and should proceed straight to surgical resection. In this patient with an antral lesion, a subtotal gastrectomy is Indicated with frozen section analysis of surgical margins to ensure adequate resection. Wedge resection is not recommended. In patients with evidence of greater gastric wall invasion (I.e., invasion to and beyond the lamina propria), perioperative chemotherapy with epirublcin, clsplatln, and 5-fluorouracil has been demonstrated to provide a survival benefit.


A 34-year-old woman is being evaluated for epigastric pain and Is found to have an ulcer In the anterior duodenal bulb on upper endoscopy. Rapid urease testing of a mucosal biopsy of the antrum of the stomach is positive. In addition to omeprazole, appropriate therapy at this time would include a 2-week course of omeprazole, metronidazole, and

All patients presenting with duodenal ulceration should undergo testing for the presence of Helicobacter pylori Infection. The rapid urease test can be performed on antral stomach biopsies and Is Indicative of infection if positive. If H. pylori infection is present, it should be eradicated. First-line therapy includes acid suppression with clarithromycin and amoxicillin or clarithromycin and metronidazole for a minimum of 7 days. Traditional quadruple therapy Is a second-line treatment and consists of acid suppression with bismuth, metronidazole, and tetracycline for a minimum of 7 days.


A 53-year-old woman comes to clinic for evaluation for weight loss. She has recently diagnosed diabetes, asthma, sleep apnea, and hypertension. Her BMI is 38 kg/m2. Which of the following weight loss options Is most appropriate for this patient?

This patient has type II obesity with the life-threatening comorbidity of sleep apnea. As such, she qualifies for surgical intervention according to 1998 NIH guidelines. Weight loss surgery is the only treatment option to demonstrate sustained, substantial weight loss. Gastric bypass, therefore, is Indicated. Very low calorie diets are not recommended for weight loss by the NIH guidelines. Although low-calorie diets, sibutramine, and orlistat are all options in treating obese patients, those individuals who qualify for surgery should undergo it if they are deemed appropriate candidates.


A 42-year-old woman comes to the emergency room with epigastric pain radiating to right upper quadrant. She underwent a laparoscopic adjustable gastric band 6 months ago. She has lost approximately 80 lbs over the 6 months. She is afebrile with stable vital signs. A right upper quadrant ultrasound is shown below. Which of the following medications would have been most effective In preventing this complication?

This patient has developed symptomatic cholelithiasis following rapid weight loss after a bariatric procedure. The ultrasound shows several echogenlc stones within the gallbladder. Without pharmacotherapy, the risk of gallstone formation during this period approaches 30%. The prophylactic use of ursodeoxycholic acid decreases the risk of gallstone formation to approximately 2%. Sucralfate is used to promote healing of anastomotic ulcers. Cholestyramine Is used in the treatment of alkaline reflux gastritis to bind bile salts. Calcium citrate Is given to bariatric patients to prevent calcium deficiency and subsequent osteoporosis. Omeprazole is a proton pump Inhibitor used in the treatment of anastomotic ulcers.