University:
Texas Lutheran University
Course:
NURS 332 | Fundamental Nursing Concepts & Practice
Academic year:

2020
Views:

262

Pages:

21
Author:

FreestyleLava

Stomach Proximal part secreted mucus Blood supply: Celiac Branches Greater Curvature Rt and Lt gastroepiploic artery Lesser Curvature Rt gastric artery Branches from hepatic artery Pylorus Gastroduodenal artery Fundus short Gastric artery. Innervation Q Anterior gastric wall Left Vagus wall (give branches to liver) Posterior Gastric wall Rt Vagus wall (give branches and the cranial nerve G cells Gastrin function: Pepsinogen and Gastric Acid and mucosal Growth (trophic action) Peptic (chief) Pepsinogen It's activated by HCL to form Pepsin to Digest Protein Oxyntic (parietal) HCL + Intrinsic factor for B12 absorption HCL is from Parietal Cells activated by Vagus nerve, Histamine Gastrin to Digest Protein Function of stomach Digest protein. Vit B12 absorption Reservior. Notes Causes of vit B12 defs Gastrectomy Disease or resection of terminal ilium. Insufficient dietary intake Gastric mucosal barrier: protective gel layer is enhanced by prostaglandin E (PGE₂) and damaged by NSAIDs Gastric bicarbonate: Secretion into mucous gel is Inhibited by NSAIDs Acetazolamide, alpha blocker and alcohol Penicious anemia. Cardica O Pylorus Antrum Fundus/ Body Gastroepiploic artery Left gastroepiploic artery G cells Gastrin function: Pepsinogen and Gastric Acid and mucosal Growth (trophic action) Peptic (chief) Pepsinogen It's activated by HCL to form Pepsin to Digest Protein Oxyntic (parietal) HCL + Intrinsic factor for B12 absorption HCL is from Parietal Cells activated by Vagus nerve, Histamine Gastrin to Digest Protein Function of stomach Digest protein. Vit B12 absorption Reservior. Notes Causes of vit B12 defs Gastrectomy Disease or resection of terminal ilium. Insufficient dietary intake Gastric mucosal barrier: protective gel layer is enhanced by prostaglandin E (PGE₂) and damaged by NSAIDs Gastric bicarbonate: Secretion into mucous gel is Inhibited by NSAIDs Acetazolamide, alpha blocker and alcohol Penicious anemia. Cardica O notes 8 opening into lesser sac => foramen of winslow folds of gastric mucosa called => Rugae mucous neck cells => mucous - Bicarb ulcer (burn) => Curling ulcer ulcer (head) => Cushing ulcer Gastric ulcer Decrease protection against acid Can be caused by duodenal Reflex (pyloric sphincter dysfunction) Can occur with a chlamydia RF: Smoking - decrease mucous & Bicarbonate production. H. pylori - most commonly in Lesser curvature NSAIDS Most imp RF 3-4 folds Stexolds Sign & symptoms Burning, grawing epigastric pain occur with anything in stomach. ↑ with eating ↓ with eating anxexia wt loss. Vomiting associated with Blood type A Diagnosis: Double Contrast barium swallow Endoscopy * + Biopsy (H.pylori-Cancer) notes: other Types of ulcer Cushing ulcers PUD/gastritis associated with CNS tumor or trauma (Head) curling's ulcers major burn injury. marginal ulcer: ulcer of the margin of fil anastomosis Dieulafoy's weer pinpoint gastric mucosal defect bleeding from underlying Vascular malforma Kissing ulcer? 2 ulcers each on opposite sides of the lumen so that they can meet. *Cont notes: *Gastric ulcer associated with ↑ gastric acid *Duodenal ulcer → يشابه كل من *Coexist with duodenal ulcer Bariatric surgery → See last page in this chapter BMI=wt in kg/(height in m)² *Indications *BMI > 35 with Comorbidity (COM-HTN) *BMI > 40 with or without Comorbidity *Prerequisites: participating dietary program without success Surgery Restrictive ↓ (Reduction of quantity) *Vertical band Gastroplasty *Sleeve Gastric resection *Laprascopic adjustable band placement Malabsorptive (Limit nutritional absorption by bypassing duodenum and small intestine) *Biliopancreatic diversion with or without duodenal switch *Roux-en-Y gastric bypass with restrictive Component Gastric outlet obstruction Common Causes Malignant tumor of stomach or (head of pancreas with obstruction of common bile duct (mostly with jaundice) Chronic ulcers causing secondary edema or scarring (which occlude lumen) Early Symptoms Early satiety Gastric reflux Abdominal distension Late Vomiting Dehydration Hypochloremic, hypokalemic metabolic alkalosis with paradoxic acid urine wt loss Infusion of 0.9% normal saline to correct hypovolemia Diagnosed by Endoscopy Treated by medical compression then gastrectomy or truncal vagotomy + pyloroplasty Gastritis Acute or chronic inflammation of stomach lining Etiology: Gastric reflux Nicotine Alcohol H. pylori NSAIDs Ischemia Glucocorticoids Sign and symptoms: similar to PUD Diagnosis by endoscopy Treatment as GIU Complications: Gastric atrophy Gastric metaplasia Pernicious anemia decrease production of intrinsic factors from gastric parietal cells due to idiopathic atrophy of gastric mucosa and subsequent mal absorption of vit B12. Chronic gastritis (associated) fundal (Type A) Antral (Type B) Pernicious anemia H. pylori Parietal cell antibody Achlorhydria Autoimmune disease Malignant Tumors Adenocarcinoma MC 95% Elderly > 60y, men > women, whites > black MC in lesser curvature MC in proximal part of stomach Mets by blood & lymphatic Squamous cell carcinoma Due to chronic irritation Smoking, spray lead Lymphoma Second most common MALT (Mucosa-Associated Lymphoid Tissue) lymphoma (from mesenchymal cells of Cajal) All considered malignant GIST (Gastrointestinal Stromal Tumors) Risk Factors Environmental factors: diet & preserved meat or fish, ↑ nitrate, preserved, smoked, cured, smoking, socioeconomic status, occupational hazards, obesity Genetic factors: p53, BRCA1, BRCA2, CDH1 gene, familial adenomatous polyposis, blood type A, hereditary Infectious factors: H. pylori infection (has Cag A which become intracellular and activate oncoprotein SHP2) (6x increased risk), Epstein Barr Virus Others: DM, GERD, post partial gastrectomy (15+ years), pernicious anemia Pathology morphology Polypoid: 25-50%, non-substantial necrosis or ulcer Ulcerative: 25-50%, sharp margins Superficial spreading: 3-10%, involve mucosa & submucosa only, best prognosis Linitis plastica: 8-10%, leather bottle type, involves all layers, extremely poor prognosis Sign & symptoms: Early → mostly asymptomatic late wt loss (mc), anorexia, nausea, vomiting, dysphagia (if proximal) usually constant vague pain, non radiating, bloating, weakness, ↑↑food after 6-12 fatigue, melena, hematemesis, gastric outlet obstruction (distal) anemia metastatic → (By blood & lymphatic) Krukenberg’s tumor: mets to ovaries Blumer’s shelf: mets to pelvis Cul-de-sac - felt on DRE Virchow’s node: mets to LV palpable in left supraclavicular - from thoracic Duct) Sister mary joseph’s nodule: Pericumbilical metastatic nodules. Irish’s nodes: left axillary adenopathy from gastric Cancer. others: ascites, hepatosplenomegaly, cachexia. Diagnosis and Staging: *Blood: CBC, U&E, LFT, coagulation profile) *Diagnosis: Endoscopy + Biopsy (Best) Q or Diagnostic laparoscopy *Staging: imp to say CTCAP (chest-abdomen-pelvis) Endoscopic US (to know tumor size, thickness, nodes, invasion) Prognosis Treatment is major prognostic factor. Proximal gastric cancer has less favorable prognosis than distal lesion. ↑ serum carcinoembryonic antigen (CEA) has less favorable prognosis Other: Histological grade, regional lymphatic spread Treatment multimodality (tumor board) + surgical resection (only) Early Disease & confined to superficial layer Radical subtotal gastrectomy (Remove stomach + LN) Proximal Cancer Total gastrectomy with Roux-en-Y reconstruction Chemo In palliative for non-surgical candidates Marginal benefit in adjuvant setting Stage 2, 3 Adjuvant (post-operative chemo & radiation) Stage 4 Palliative Follow up Every 3m for 1y Every 6m for 2y Then annually Gastric lymphoma 2nd mc malignancy of stomach (MC in stomach) Majority are B cells non-Hodgkin's type ↑ Risk with H. pylori SSS: not specific, abdominal discomfort, nausea, vomiting, anorexia, wt loss, hemorrhage (occult bleeding & anemia) in 50% Diagnosis by endoscopy + biopsy + formals bone marrow aspiration and gallium bone scan Treatment: MALT (low grade) treat as H. pylori MC treatment. Mucosal associated lymphoid tissue MALT (high grade) or non-malt Radiation/chemo ± surgical resection Pt with bleeding and Gastrointestinal Stromal Tumor (GIST) Previously known as leiomyosarcoma. Mesenchymal (smooth muscles / Interstitial cells of Cajal) tumor arising from gastric stroma, submucosal and slow growing. MC in stomach Causing GI bleeding, abdominal pain, distention, nausea, abdominal mass Variable histology - from spindle cell tumors to epithelioid to pleomorphic but All GISTs are regarded as malignant Approximately 45% of GISTs have C-Kit (CD117) expression leading to constitutively active receptor tyrosine kinase Diagnosis by: CT scan, endoscopy, biopsy, colonoscopy Prognosis depends on completeness of resection, presence of mets, mitotic index Treatment: surgical resection and Gleevec (Imatinib) inhibit tyrosine kinase receptors

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