Gastric CA RF
Modifiable
- lifestyle: diet (preserved, smoke, nitrosamine), smoking
- low SES
- chronic gastritis, prev H pylori, barrett esophagus
- prev OGD: polyp
- prev stomach lymphoma
- smoking
- obesity
- atrophic gastritis
- pernicious anemia
- Menetrier dz (hypertrophic gastropathy)
Non modifiable
- age >50
- gender: males
- previous gastric resection (partial gastrectomy with bile reflux)
- type A blood
- family history
- familial diffuse gastric cancer (e-cadherin, CDH 1)
- FAP (Apc gene), HNPCC/ Lynch syndrome, BRCA1/2, PJS, Li-Fraumeni syndrome
- common variable immune deficiency (CVID)
protective factors: aspirin, fresh fruits/ vegetables, vit C
Forrest classification
Acute hemorrhage Ia: spurting Ib oozing Signs of recent hemorrhage IIa: non bleeding visible vessel IIb: adherent clot IIc: flat pigmented spot no active bleed: III: clean ulcer base
Prognostication for acute UGI bleed
Rockall Blatchford AIMS 65 - Albumin <30 - INR >1.5 - Mental state GCS<14 - SBP <90 - age >65
CLO positive?
- treatment of H pylori
- test for eradication
Clostridium like organism: urease producing org that cleaves urea to ammonia and HCO3, decreasing the PH (yellow > red)
H pylori tx: TRIPLE THERAPY
- amoxicillin (1g BD) 2w
- clarithromycin (500mg BD) 2w
- omeprazole 6w
sub amox for metronidazole only in penicillin allergic individuals
BISMUTH QUAD THERPAY
- omeprazole 20mg BD
- bismuth subsalicylate (120mg QDS)
- 2 Abu: metronidazole 400mg BD + tetracycline 500mg QDS
ERADICATION TESTS
- urea breath test
- fecal antigen test
- OGD >4w after completion of abx therapy (PPI withheld 1-2w prior to testing)
Indications for repeat endoscopy for gastric ulcers
surveillance endoscopy after 12w of antisecretory therapy if gastric ulcer with
- symptoms despite med therapy
- unclear etiology
- giant ulcer >2cm
- presented with bleeding
- RF for gastric ca
- first endoscopic shows suspicious ulcer
- biopsies not taken in first endoscopy
Definition of orthostatic hypotension
a decrease in the systolic blood pressure of more than 20 mmHg and/or an increase in heart rate of 20 beats per minute when moving from recumbency to standing
ddx UGBIT
variceal - GEJ non variceal - eso: mallory weiss - gastric: PUD, gastritis, dieulafoy - duodenum: duodenitis, aorto-enteric fistula
classes of shock
I: <15%
II: 15-30%: resting tachycardia, urine output 20-30, decreased pulse pressure, orthostatic hypotension
III: 30-40%: resting hypotension, anxious, urine 5-15, tachypnea
IV: >40%: negligible urine output, confused lethargic
Indications for emergency OGD
- role of OGD
- shock/ hemodynamic instability
- active BGIT (hemetemesis, fresh Malena)
- suspected variceal bleed
diagnostic - confirm UGBIT, identify source of bleed, biopsy (clo + 6 bites for gastric ulcer)
therapeutic: stop bleed
prognostic: forest classification
Types of gas used to scopes and differences
types of gas infused
- CO2: need more vol to distend bowel but body can resorb
- air (more nitrogen): not absorbed by mucosa, helps distend bowel with less volume, but more problems if perforated bowel - cannot be resorbed by body
complications of OGD
Anesthetic risk - sedation: resp depression - CVS risk - ami, cva Procedural related risk - bleeding and perforation - failure of endoscopic hemostasis - failure of complete scope
Mgx of rebleeding of UGBIT
repeat OGD and endoscopic hemostasis
if fail:
- surgery
- radio: CTMA or mesenteric angiogram KIV embolisation
Prognostication for UGBIT
Rockall score
Blatchford scoring
AIMS 65: albumin <30, INR >1.5, Mental status <14, SBP<90, age>65
Hepatic venous pressure gradient
- normal value
- risk of variceal devt
- risk of variceal bleed
n: 1-5mmhg
devt: >10mmhg
bleed/ ascites: >12
What is Zollinger Ellison syndrome?
- how to diagnose
- how to mgx?
hyper secretion of gastric acid due to a gastrinoma (rare cause of PUD)
triad of: recurrent PUD in unusual locations, massive gastric acid hyper secretion, gastrinoma
dx: high fasting serum gastrin levels with high acid secretion
mgx: PPI + sx
Endoscopic methods of stopping bleeding
- injection of adrenaline 1:10,000 dilute to 10ml (cx: perforation, bleed, necrosis, arrhythmia)
- coagulation (heater probe - thermal/ argon plasma)
- haemostatic clipping (endocrine clip), hemospray
dual modality
sx management of duodenal ulcers
- truncal vagotomy with pyloroplasty
- truncal vagotomy with antrectomy and bilroth 1/2
- highly selective vagotomy
options for gastric ulcer bleeding refractory to endoscopic therapy
transcatheter arterial embolisation (TAE)
surgical: oversewing of bleeding vessels/ wedge excision of ulcer
DU posterior: GD artery
Causes of pneumoperitoneum
suggestive of perforated viscus: GU, DU, appendix, GB
sx mgx of perf gastric/ duodenal ulcer
Duodenal:
lap omental patch repair
peritoneal debridement/washout
H pylori eradication
Gastric:
wedge excision - TRO CA
if perf too big > gastrectomy (bilroth II) or serial patch/ mental patching
mgx of gastric outlet obstruction
correct volume/ electolytes
NG suction
IV antisecretory agents
OGD
endoscopic hydrostatic balloon dilatation
surgical if recurrent/ refractory after endo balloon
- antrectomy with bilroth I/II reconstruction
OGD classification of gastric cancer
Borrmann classification I: polypoid/ protruded type II-V: depressed type 2 ulcerative 3 infiltrative ulcerative 4 diffuse infiltrative aka linitis plastica (signet ring cells) 5 can't be classified
Classification of biopsy findings in gastric ca
Adenocarcinoma (Lauren classification)
- intestinal (expanding): elderly male, distal stomach, GOO, hematogenous spread
> papillary
> tubular
> mucinous
- diffuse (infiltrative): signet cell, younger, female, proximal stomach, transmural and lymphatic spread with early mets, CDH1 mutation (E-cadherin)
Non-adenoCA
- gastric neuroendocrine tumour (carcinoid)
- gastric lymphoma
- gastrointestinal stomal tumour
what are signet ring cells
large cytoplasmic mucin vacuoles and peripherally displaced crescent shaped nuclei
