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EXAM-ORIENTED NOTES: GASTRIC DISORDERS

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PART 1 — GASTRITIS

Classification

• Causes: NSAIDs/aspirin (COX-1 inhibition → reduced prostaglandins), alcohol, corticosteroids, stress (Curling's ulcer = burns; Cushing's ulcer = head injury), H. pylori

H. pylori - High-Yield Facts

• Gram-negative, spiral, microaerophilic; colonises antrum; produces urease
• Associated: Type B gastritis, PU (90–95% DU, 70–80% GU), gastric Ca, MALT lymphoma
• Tests: CLO test, 13C-urea breath test, stool antigen, serology
• Eradication: Triple therapy - PPI + clarithromycin + amoxicillin × 7–14 days

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PART 2 — PEPTIC ULCER

Definition

Sites: Gastric (lesser curvature/antrum) | Duodenal (1st part) | Oesophageal | Meckel's | Anastomotic

Gastric Cells

Chronic GU vs DU Comparison

Complications

1. Haemorrhage (most common) - posterior DU erodes gastroduodenal artery
2. Perforation - anterior DU/lesser curvature GU; gas under diaphragm on erect CXR; Graham's omental patch
3. Pyloric stenosis - cicatricial fibrosis from chronic DU
4. Malignant change - GU only; greater curvature/pyloric segment most prone
5. Penetration - posterior GU/DU → pancreas → constant back pain

Surgical Operations

Post-gastrectomy Complications

• Early dumping: 15–30 min after meal; palpitations, sweating, diarrhoea
• Late dumping: 2–3 hrs; hypoglycaemia from insulin rebound
• Alkaline reflux gastritis: Bile reflux; burning pain aggravated by food; Roux-en-Y
• Iron deficiency: 40% if duodenum bypassed
• Megaloblastic anaemia: B12 deficiency; 5–10 years post-op; IM cyanocobalamin
• Calcium deficiency: 40% with duodenal bypass
• Post-vagotomy diarrhoea: 5–20%; Henley loop if severe

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PART 3 — PYLORIC STENOSIS

Two Distinct Conditions

IHPS - Key Points

• Visible gastric peristalsis left → right
• "Olive" mass in right hypochondrium on test feed
• Paradoxical aciduria: metabolic alkalosis but acidic urine (kidneys conserve H+, excrete K+)
• Correct metabolic state first: IV 0.45% NaCl + 30 mEq KCl/L - NOT a surgical emergency
• Ramstedt's pyloromyotomy: Grid-iron incision, superior surface of pylorus, split muscle until mucosa bulges freely, preserve mucosa. Result: ~100% cure, no mortality

Adult Pyloric Stenosis - Succussion Splash

• Audible splash on shaking patient 5+ hours after last meal = retained food/fluid in stomach
• Barium meal: dilated stomach, food residue, delayed emptying

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PART 4 — HAEMATEMESIS

Definition

Haematemesis vs Haemoptysis

Causes

1. Peptic ulcer - most common overall
2. Oesophageal varices - most dangerous (30–40% mortality/episode)
3. Mallory–Weiss tear - mucosal tear at OGJ after retching
4. Acute erosive gastritis
5. Gastric carcinoma
6. Leiomyosarcoma (massive haematemesis = only symptom)

Management

1. Airway + large-bore IV access × 2
2. Bloods: FBC, U&E, coagulation, group + crossmatch
3. IV fluid resuscitation → blood transfusion
4. NG tube + iced saline lavage
5. Nil by mouth; urinary catheter for urine output
6. High-dose IV PPI (80 mg omeprazole bolus then 8 mg/hr)
7. OGD within 24 hrs - gold standard; identifies source + therapeutic

Indications for Surgery

• Rebleeding after admission
• Age >45
• Requires ≥5 units blood
• Conservative treatment failing
• Possible associated perforation
• Previous bleeding within a few months

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PART 5 — GASTRIC CARCINOMA

Epidemiology

• 2nd most common cancer death worldwide; highest in Japan
• Male predominance (2–3:1); peak age 50–70 years; blood group A

Predisposing Conditions

1. Chronic atrophic gastritis + intestinal metaplasia (10% → Ca over 20 yrs)
2. H. pylori (Group 1 carcinogen)
3. Pernicious anaemia (10% → malignancy)
4. Chronic gastric ulcer (greater curvature, pyloric segment)
5. Adenomatous gastric polyps
6. Post-gastrectomy stump (15–20 yrs later)
7. Family history / blood group A

Pathology

• I = Polypoid | II = Ulcerating with elevated edges | III = Ulcerating + infiltrating | IV = Linitis plastica (leather-bottle stomach)

Spread

• Virchow's node (Troisier's sign) = left supraclavicular node
• Krukenberg tumour = bilateral ovarian metastasis
• Sister Mary Joseph's nodule = periumbilical nodule
• Blumer's shelf = pelvic deposits on PR exam
• Trousseau's sign = phlebothrombosis of leg veins

Six Clinical Presentations (Groups I–VI)

1. Dyspeptic/early - anorexia, weight loss (often asymptomatic early)
2. Insidious - haematemesis/melaena/anaemia; body/greater curvature tumour
3. Pain - continuous, no periodicity, not relieved by food; coffee-ground vomit; found in 95% at diagnosis
4. Obstructive - pyloric → vomiting/fullness; cardiac → dysphagia
5. Lump - epigastric mass (1/4 of cases)
6. Metastases - ascites, jaundice, Virchow's node, Krukenberg, back pain

Investigations

• OGD + biopsy (gold standard)
• CT chest/abdomen/pelvis (staging)
• Barium meal: shouldered ulcer, leather-bottle, filling defect
• EUS (T + N staging)
• Staging laparoscopy before curative surgery
• Bloods: High ESR (~80% of patients), low Hb, faecal occult blood +ve

Treatment

• Chemotherapy: Cis-platinum + 5-FU + epirubicin (ECF) - best results
• Radiotherapy: Disappointing; palliative for bone pain only
• 5-year survival: West 25–50% | Japan 50–70% | Early gastric cancer >90%

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MASTER QUICK REFERENCE

High-Yield "Most Common/Important" Facts

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