Gastric conditions😍

Layers of the GI Tract

• GI tract has four layers:
• Mucosa (epithelium)
• Lining epithelium,
• Lamina propria (Whipplei PAS +ve)
• Muscularis mucosae.
• Submucosa
• Meissner plexus.
• Missed (Meissner) → Submucosa
• Muscularis propria
• Auerbach/myenteric plexus.
• Backilum/ my enteric → muscles
• Serosa (outermost)

• Exceptions:
• Esophagus: No serosa.
• Gallbladder: No submucosa.

Cells of Cajal

• Pacemaker cells of GIT: 

• Tumors: GIST (Gastrointestinal Stromal Tumor).

Peptic Ulcer Disease (PUD)

Features

• M/C type: Duodenal ulcers (90% a/w H. Pylori & ↑acid production).

• M/C complication: Bleeding.

• M/C cause of upper GI hemorrhage.

Duodenal Ulcers

Anterior ulcers

• M/C complication: Perforation → Perforation peritonitis.

• C/F:
• Pain, ↑HR, ↓BP.
• Rebound tenderness.
• Board like rigidity.

• Investigation: X-Ray → Gas under diaphragm (Hollow viscus perforation).

Treatment (for perforated DU)

• NPO, I.V. Antibiotics, Painkillers.

• Urgent Surgical exploration
• Emergency exploratory Laparotomy +
• Omental patch repair/Graham patch repair

• Don't wait for any other imaging

• No NPO, no antibiotics → Urgent surgical exploration

Gastric Ulcers

• 60% a/w H. Pylori.

Johnson Criteria (Gastric Ulcer Type & Features)

Gastritis Types

Management (for Gastric Ulcers)

• Biopsy must be done to rule out malignancy.

• Antrectomy.

• Pauchet's procedure (Type IV ulcers).

• Mnemonic: Johnson and johnson () powder um Pochayum (Pauchet) parich Gastric Ulcer nte mukalil idam

H. Pylori

• CAG-A & VAC-A genes: Toxins.

• Urease: Helps it survive in acidic environments.

• A/w:
• Peptic ulcers
• Gastric cancer
• Type B gastritis
• MALToma

• Slightly protective against adenocarcinoma esophagus & Barrett's esophagus.

Gastric Reconstruction

Procedures

• Roux-en-Y gastrojejunostomy (m/c):



• Close duodenal stump
• End-to-side gastrojejunostomy (GJ)
• End-to-side jejunojejunostomy (JJ)

Vagotomy

• Replaced by PPIs currently.

Types & Features

• Left Vagus N → Anterior N of Latarjet → Crows foot =

Truncal vagotomy	Highly selective vagotomy
Vagus N trunk	Crows foot
Maximal acid reduction	Least acid reduction
Least ulcer recurrence	Max ulcer recurrence
Max vagotomy related complication	ㅤ

Complications of Vagotomy & Reconstruction

Nutritional Deficiencies

• M/C: Iron deficiency.

• Other deficiencies: Vit B12, Vit D3.

Internal Hernia

Petersen's hernia:

• Bowel loop herniates behind Roux limb.

• Antecolic reconstruction

• Mnemonic: Peter is behind

Stemmer hernia:

• Bowel loops herniate through the transverse mesocolon.

• Retrocolic reconstruction.

• Mnemonic: Stem through

Dumping Syndrome

Dumping Syndrome: Prevention

• Small frequent meals.

• Avoid liquid with meals.

• Avoid sugar rich liquids.

• Avoid simple sugars → TAKE COMPLEX CARBS

• Take high protein/fat diet.

• Resistant cases: Try octreotide.

Upper GI Hemorrhage

• Bleeding proximal to ligament of Treitz.

Causes

1. Non-variceal bleeding (m/c):
• Peptic ulcer (m/c): Duodenal > Gastric.
• Mallory Weiss tear.
• Gastritis.

2. Variceal bleeding.

Nutcracker Syndrome

• Compression of left renal vein between aorta and SMA.

• Present with hematuria

• Leads to:
• Dilatation of left testicular vein.
• Dilatation of left pampiniform plexus.
• Varicocele (bag of worms appearance).

Superior Mesenteric Artery Syndrome (SMAS)

• Also known as Wilkie's Syndrome

• Normal angle b/w aorta & SMA: 
• 25-45°

• Angle <22° compresses D3
• 3rd part of duodenum

• Causes:
• Rapid weight loss
• spinal cast.

• C/F:
• Bilious vomiting after meals.

• IOC:
• CT Angiography.

• Rx:
• Encourage weight gain.
• Strong's procedure.
• Duodenal derotation (Cut ligament of Trietz).
• Duodeno-jejunostomy.

• Wilkie (Wilkie) tried to reduce weight in 3 days (D3) → to get strong (strong procedure) → got duodenal obstruction

Mallory Weiss Tear

• Longitudinal tear in mucosa/submucosa.
• (GE junction → Cardia).

• m/c in alcoholics: After bout of forced vomiting.

• Vessel: Left gastric artery.

• Rx: Self limiting.

• D/D: Boerhaave syndrome.

GAVE (Gastric Antral Vascular Ectasia)

• Seen at antrum.

• Autoimmune.

• Endoscopy: Watermelon stomach (D/t dilated venules).

• Mx: Argon photocoagulation.

Portal Gastropathy

• Seen in portal hypertension.

• Endoscopy: Strawberry stomach (Reddish nodules).

Menetriers Disease

• Gender: More common in men.

• Hypertrophy of gastric mucosal folds.
• D/t overexpression of TGF ɑ.
• ↑ Risk of cancer.

• C/F:
• Protein losing enteropathy (Earliest) → intermittent edema.
• Upper GI hemorrhage.

• Gross: Stomach looks like a brain or walnut with cerebriform rugae.

• Microscopy: Foveolar cell hyperplasia.

• Mx:
• Cetuximab (monoclonal ab against EGFR) 
• Gastrectomy (Severe cases).

• Mnemonic: Menetrier → Men tried to destroy KGF (TGF)→ α man (KGF α) saved KGF and became Favourite (Foveolar cell) of everyone → He later had protein losing enteropathy → and stomach started looking like a brain

Stress Ulcers

Helicobacter pylori (H. pylori)

• Urease positive organism (gives pink color).

• Stains for identification:
• Most important: Warthin-Starry silver stain (organisms appear black).
• Less important: Modified Giemsa stain.

Drugs

• Amoxycillin

• Metronidazole

• Clarithromycin

Triple Drug Therapy:

• Used for H. pylori associated PUD.

• Components: PPI + 2 Antibiotics
• C: Clarithromycin (Preferred therapy)
• A: Amoxycillin / Metronidazole
• P: PPI
• CAP regimen

• Duration: Given for 2 weeks.

Gastric Volvulus

Characteristics

• Twisting of stomach → Borchardt's triad:
• Unproductive retching
• Inability to pass Ryle's tube
• Epigastric pain

• Mnemonic: Boche chadiyapo (Borchardts) → Stomach rotated

Types

Management

• IOC: CECT.

• Derotate stomach.

• Fix underlying cause.

• Tighten the diaphragmatic defect

Trichobezoar:

• Hairball in stomach.
• 2o to trichophagy (Eating one's own hair).
• Mx: Surgical removal → Psychiatry reference.

Bariatric Surgery

• 35 → 40 → 45 → 50

Indications

• BMI >40 kg/m ².

• BMI >35 kg/m ² with obesity complications:
• Arterial hypertension.
• Diabetes.

• Asian population: Lower cutoff for surgery.

Features of Bariatric Surgery

• AKA metabolic surgery:
• Weight loss + improvement in DM/HTN/hyperlipidemia.

• m/c cause of death: DVT → Pulmonary embolism.

• Nutrient replacement:
• Iron.
• Vit B₁₂
• Vit D₃ & Ca²⁺
• Fat soluble vitamins:
• In sleeve gastrectomy & Roux-en-Y bypass

Types

Irreversible Procedures

Biliopancreatic Diversion (BPD) & Duodenal Switch (DS)

• Common channel: 
• BPD: 50 cm
• DS: 100 cm

• Maximum weight loss d/t malabsorption

• Disadvantage: maximum surgical complications.

Roux-en-Y Gastrojejunostomy

• Roux limb length: 100 cm.

• Nutritional deficiencies:
• iron (m/c).
• Due to ↓ breakdown into Iron from food by HCl
• Vit D₃ & Ca²⁺.
• vit B₁₂.

Lap. Sleeve Gastrectomy

• m/c done procedure.

• Restrictive surgery.

• Greater curvature of stomach removed.

Complications:

• m/c: Bleeding from staple line.

• GERD → Barrets Oesophagus

• Nutritional deficiencies.

• Leak from angle of His:
• most distressing → Peritonitis.

• Redistention of sleeve
• Mx: TOGA → NOTES Procedure

Reversible Procedures

Gastric Banding

• Band placed 6cm from the GE junction.

• Reversible pressure adjustable balloon.

• Weight loss can be titrated.

• Complications:
• Prolapse (m/c).
• Nutritional complications.
• Erodes into stomach.
• Rupture.

Intragastric Balloon Placement

• Balloon distended in stomach.

• Removed after weight loss achieved.

• Self-dissolvable balloon: Dissolves after 3 months.

Pneumoperitoneum

Signs on X ray:

• Air in peritoneal cavity due to ruptured hollow viscus organ (perforation, post laparoscopy).

• On CT, jet black appearance shows air.

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1. On erect chest X ray:

• Free air under the diaphragm.

2. Decubitus abdomen sign:

• Left lateral decubitus position with horizontal X-ray beam.

• Provides good contrast against liver.

• Air around lesser sac can escape through epiploic foramen.

• Black air seen above liver.

3. Football sign:

• Patient supine.

• In neonate

• Air beneath anterior abdominal wall.

• Suggestive of Massive pneumoperitoneum.

4. Rigler's sign

• Double bowel sign.

• Air inside and outside the bowel makes bowel loops clearly visible.

• Important Information:
• Rigler's triad: Seen in gall stone ileus.

5. Cupola sign:

• Air beneath the central diaphragm.

Ligament sign:

• Falciform ligament seen



• Falciform ligament connects anterior abdominal wall and liver.
• Ligament visualized due to air on either side.
• All ligament signs are seen in pneumoperitoneum.

7. Inverted V sign:

• Paired umbilical ligament sign (seen due to air around the ligament).

Pseudo Pneumoperitoneum

• Air in the bowel beneath the diaphragm.

• Bowel markings are seen.

Chilaiditi syndrome:

• Presence of colonic loop between diaphragm and liver.

• Colonic interposition.