Nir Hus Q july 7 09

Q:

Precursors Gastric AdenoCA

Gastric adenocarcinoma is among the most common malignancies worldwide (~50% of CA related deaths in Japan).

Its etiological pathogenesis is complex and, as yet, incompletely understood; however: Diet, Infection with Helicobacter pylori, Genetic factors are involved.

It may be classified into two main types: Intestinal. Diffuse (Linitis plastica).

Precursors Gastric AdenoCA

The intestinal type has decreased in incidence, whereas the diffuse tumors as well as those confined to the cardia are increasing.

Numerous conditions, such as gastritis, adenomatous polyps, tobacco, gastric atrophy, and intestinal metaplasia (IM), type –A blood, and nitrosamines are associated with intestinal type gastric cancer in retrospective studies.

Only epithelial dysplasia has a positive predictive value for malignancy.

Tx of gastric adenoCa – subtotal gastrectomy w/ 5cm margines.

Rx Carcinoid Tumor Rectum

Metastases is related to size of tumor.

Low rectal carcinoids Tx: < 2cm – wide local excision w/ negative margins > 2cm – or invasion of muscularis propria APR

Colon or high rectal carcinoids – formal resection w/ adenectomy.

Rx GistAKA Gastric Leiomyomas

Most common benign gastric neoplasm

Usually asymptomatic but obstruction and bleeding can occur

Hypoechoic on US with smooth edges.

Dx – Bx.

Tx – resection

If >5cm or 5-10 mitoses/HPF then consider chemo

Need 1cm margeens

Most are c-kit positive.

Rx GistTx – resection

If >5cm or 5-10 mitoses/HPF then consider chemo

Need 1cm margeens

Most are c-kit positive.

Chemo gleevec (TK-inhibitor)

Rx Hiatal HerniaFour types:

I. - Most common. Sliding hernia from dilation of hiatus. Associated w/ GERD

II. - Paraesophageal. Normal GE junction. Symptoms – chest pain, dysphagia, early satiety.

III. Type I & II combined

IV. Entire stomach in the chest plus another organ (i.e., colon, spleen).

Rx Hiatal HerniaType II still requires Nissen because:

1. diaphragm repair only might affect the LES.

2. Nissen better anchors the stomach.

3. High risk of incarceration

4. Ischemia – organoaxial rotation.

Schatzki’s ring: Almost all pt have assoc. hiatal hernia. Symptoms – short episodes of dysphagia

following rapid swallowing. Tx – dilation, may need Sx.

Rx Perforated Duodenal Ulcer

80% will have free air

Sudden sharp epigastriv pain, generalized peritonitis.

Pain might radiate to the pericolic gutters with dependent drainage of gastric contents.

Elderly – some believe inobservation. Need UGI to confirm that the perforation healead.

Sx – Graham patch only or in addition to highly selective vagotomy – if pt. failed H-pump inhibitors.

Rx Pyogenic Liver Abcess

Account for 80% of all liver abscesses.

Symptoms: fever, chills, weight loss, RUQ pain, Inc. LFTs, WBC, sepsis.

Higher rate found I Right lobe.

15% mortality if pt. developed sepsis.

GNR specifically E. coli – most common organism.

Commonly 2nd to contiguous biliary tract infections.

Can occure following bacteremia such as diverticulitis and appendicitis.

Rx Pyogenic Liver Abcess

Dx – aspiration.

Tx – CT—guided drainage & abx.

Sx for continued signs of sepsisor hemodynamically unstable.

May also need biliarry decompression.