Stomach/Gallbladder

Stomach/Gallbladder

1. Peptic ulcer/Gastritis/Duodenitis

   • Causes
     • NSAIDS
     • ETOH
     • stress=CNS event,sepsis,burns,post-op
     • H. pylori
     • Pernicious anemia
     • Gastrinoma (Zollinger-Ellison syndrome)
       • 20% part of MEN type 1
         • Multiple Endocrine Neoplasm
       • gastrinoma
         • in pancreas/duodenum
           • causes hypergastrinemia
             • fasting gastrin lvl>150
       • Dx
         • secritin test confirms
       • Rx
         • omeprazole controls gastrin secretion
         • surg resection
   • S/S
     • epigastric pain poss radiate to back or LUQ
     • N/V
     • hematemesis/melena
     • severe pain
       • perforation
     • worse pain w/ food
       • gastric
     • decrease pain w/ food
       • duodenal
     • Complications
       • bleeding
       • perforation
         • peritonitis
         • sepsis
       • obstruction w/pyloric stenosis
       • malignancy
   • Dx
     • H. pylori lab
     • urea breath test
     • vit B12, CBC
       • pernicious anemia
     • CXT air under diaphram/CT for free air
       • perforation
     • *EGD w/ bx
   • Rx
     • Gastritis/duodenitis
       • H2 blockers
       • PPI
     • PUD
       • triple Rx
         • PPI, clarithromycin, amoxicillin (or metronidazole) BID x 14d
     • bleeding
       • in pt.
       • IV PPI, NPO, NGT, IVF, Blood tx prn, endo for sclerotherapy
     • perforated
       • IV antibiotic, supportive, surg Graham patch
         • if fail med rx= poss vagotomy to stop acid production
     • D/C NSAIDS/smoking
     • prophylax if in ICU

2. Gastric CA

   • adenocarcinoma
     • very common
     • Men>women
     • decr in US
     • risks
       • smoking, ETOH, nitrites, H pylori
     • S/S
       • asymp until late
       • dyspepsia, epigastric pain
       • anorexia, wt. loss
       • early satiety & vomit
       • bleeding
       • sx despite med rx w/ PPI
       • metastatic
         • Virchow node
           • L supraclavicular
         • Sister Mary Joseph nodule
           • umbilical
   • lymphoma <2%
     • NHL (non-hodgkins) common extranodal site
   • Gastrointestinal Stromal tumors (GIST)
     • rare
       • 50-70% originate in stomach
   • Dx
     • labs
       • Fe deficiency anemia
     • UGI
     • *endo w/bx
     • CT to stage
   • Rx
     • resect w 6cm margin & nodes
     • total gastrectomy if extensive, proximal tumors or lymphoma
     • post-op rad
     • 5yr survival 12%

3. Pyloric stenosis

   • hypertrophy of pyloric muscle
   • develops 4-6wk old
   • projectile vomit
   • *mobile,"olive" mass epigastrium on exam
   • barium swallow
     • string sign
   • Rx
     • pyloromyotomy
   • *first born males

4. Cholecystitis/Cholelithiasis

   • inflam of lining
     • stone, sludge, infection
       • stones are cholesterol, bilirubin
   • *4 Fs = risks
   • S/S
     • fatty food intolerance
     • intermittent epigastric/RUQ pain, may radiate R shoulder
     • N/V
     • F/C
     • Murphy's sign
       • abrupt stop inspiration due to pain w/ palp RUQ
   • Dx
     • *US= thick wall,pericystic fluid, dilated duct, stones
     • HIDA (hepato-iminodiacetic acid) scan
     • CBC (leukocytosis), LFTs, amylase, lipase
     • ERCP (endoscopic retrograde cholangiopancreatography)
       • stones
   • Rx
     • IV antibiotic, IVF, NPO
     • analgesia
     • low fat diet
     • cholecystectomy
       • laparoscopic
     • asympt stone= no Rx
   • Complications
     • Charocot's triad
       • RUQ pain,fever, jaundice
       • critical/septic
       • stone stuck in duct
       • antibiotics & urgent ERCP
     • ascending cholangitis