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Miscellaneous

Stress Gastritis

  • Location: Usually occurs in the body of the stomach.
  • Characterized by multiple non-ulcerogenic erosions.
  • Caused by a combination of hypoperfusion and acid/pepsin digestion.
  • Examples:
    • Curling's ulcer: Associated with burns.
    • Cushing's ulcer: Caused by acid hypersecretion in head injury, usually large and solitary.
  • Onset:
    • 50% of stress gastritis cases present within 1–2 days of the inciting event.
    • Profuse hemorrhage is rare.
  • Prophylaxis:
    • PPI is the prophylactic agent of choice.
    • Overuse of PPIs without indication may lead to pneumonia.
    • Indications for PPI prophylaxis in a critical care setting:
      • Coagulopathy.
      • Ventilation required for >48 hours.

Treatment of Bleeding in Stress Gastritis

  1. Conservative management with PPIs.
  2. If bleeding persists, consider endoscopic measures (though not highly successful).
  3. Angiographic injection of vasopressin into the left gastric artery or its embolization.
  4. Surgical intervention (rare):
    • Anterior gastrotomy with multiple figure-of-8 stitches on bleeding points.
    • Vagotomy with pyloroplasty.
    • In extreme cases, total gastrectomy may be necessary.

MCQ 51: Prevention of Bleeding in Stress Gastritis – False Statement

Question:

All of the following factors help in preventing bleeding in high-risk cases of stress gastritis except:

a. Routine use of ventilators

b. Maintain perfusion

c. Treat sepsis

d. Enteral feeding

Answer:

a) Routine use of ventilators

Explanation:

  • Routine use of ventilators does not prevent bleeding in stress gastritis. In fact, prolonged mechanical ventilation increases the risk of stress-related mucosal damage, which is why PPI prophylaxis is indicated in these cases.

Mallory-Weiss Tears

  • Nature of the tear:
    • A tear of the mucosa and submucosa.
  • Location:
    • Occurs near the gastroesophageal junction (GEJ), typically along the lesser curvature of the stomach.
  • Prevalence:
    • Responsible for 5-10% of upper gastrointestinal (UGI) bleeds.
  • Risk factors:
    • Commonly associated with alcoholism.
  • Pathophysiology:
    • Caused by forceful contraction of the abdominal muscles, leading to increased intragastric pressure with an unrelaxed cardia.
  • Treatment:
    1. Endotherapy (first-line).
    2. If bleeding persists, angiographic embolization.
    3. In rare cases, surgical intervention may be required.

MCQ 52: Mallory-Weiss Tear – False Statement

Question:

Which of the following is false regarding Mallory-Weiss tear?

  1. Caused by increased intra-abdominal pressure or vomiting.
  2. Often associated with alcoholism.
  3. Often requires blood transfusion.
  4. Diagnosed by endoscopy.

Answer:

3) Often requires blood transfusion

Explanation:

  • 90% of Mallory-Weiss tears are self-limiting and do not often require blood transfusions. Treatment is usually conservative, with endoscopic intervention as the primary therapy if necessary.

Dieulafoy's Lesion

  • Type of bleeding:
    • Arterial bleeding due to a malformation of a submucosal artery.
  • Location:
    • Typically occurs along the lesser curvature within 6 cm of the gastroesophageal (GE) junction.
  • Pathophysiology:
    • The artery in the submucosa pulsates, leading to mucosal ulceration.
  • Demographics:
    • More common in males.
  • Clinical presentation:
    • Sudden onset of massive, painless bleeding.
  • Management:
    1. Endotherapy (first-line treatment).
    2. If bleeding persists, consider angiographic measures.
    3. Surgery (wedge resection) in rare, refractory cases.

MCQ 53: Cause of Bleeding in Dieulafoy's Lesion

Question:

Bleeding from a Dieulafoy gastric lesion is due to:

a) Antral vascular ectasia

b) Abnormal gastric rugal folds

c) Ingested foreign material

d) An abnormal submucosal vessel

e) A premalignant lesion

Answer:

d) An abnormal submucosal vessel

Explanation:

  • Dieulafoy's lesion is characterized by an abnormal submucosal artery, which can lead to significant arterial bleeding.

MCQ 54: Dieulafoy Lesion – False Statement

Question:

Which of the following is false about Dieulafoy lesion?

A. It involves the greater curvature of the stomach

B. Involves the gastroesophageal junction

C. Submucosal lesion often not seen in endoscopy

D. Endotherapy is first-line management

Answer:

A) It involves the greater curvature of the stomach

Explanation:

  • Dieulafoy's lesion is most commonly found along the lesser curvature of the stomach near the gastroesophageal junction. It does not typically involve the greater curvature.

Ectopic Pancreas

  • MCQ 55: Most Common Site of Ectopic Pancreas

Question:

The most common site of ectopic pancreas is:

a. Stomach

b. Meckel's diverticulum

c. Omentum

d. Appendix

Answer:

a) Stomach

Explanation:

  • The stomach is the most common site of ectopic pancreatic tissue, followed by Meckel's diverticulum.

Menetrier’s Disease

  • Pathology:
    • Premalignant condition characterized by massive mucosal folds in the fundus and corpus of the stomach.
  • Appearance:
    • The stomach has a cerebriform, cobblestone appearance due to foveolar hyperplasia (hyperplasia of surface mucous cells).
  • Key Features:
    • Mucus hypersecretion.
    • Achlorhydria (lack of stomach acid).
    • Protein-losing enteropathy.
    • Foveolar hyperplasia is a hallmark.
  • Associated Infections:
    • H. pylori in adults.
    • CMV in children.
  • Molecular Aspect:
    • TGF-alpha is found in the gastric mucosa of patients with Menetrier’s disease.
  • Management:
    • Total gastrectomy is indicated in cases of dysplasia, malignancy, or excessive protein loss.

Gastric Volvulus

  • Definition:
    • A rotation of the stomach by at least 180 degrees, which can lead to obstruction or ischemia.

Classification of Gastric Volvulus (Singleton’s Anatomical Classification):

  1. Organoaxial:
    • 2/3 of cases (transverse rotation).
  2. Mesenteroaxial:
    • 1/3 of cases (longitudinal rotation).
  3. Mixed:
    • Combination of both types.

Types of Gastric Volvulus:

  1. Primary Gastric Volvulus:
    • 10–30% of cases.
    • Caused by laxity of ligaments.
    • Often associated with congenital asplenia or a wandering spleen.
    • Typically mesenteroaxial, where the pylorus rotates anteriorly (more common) or posteriorly.
    • May be incomplete (<180 degrees).
    • Symptoms are usually chronic or intermittent.
  2. Secondary Gastric Volvulus:
    • Most common type.
    • Associated with diaphragmatic hernias:
      • Paraesophageal hernia (in all age groups).
      • Congenital diaphragmatic hernia (Bochdalek) in children.
    • Typically organoaxial, where the greater curvature rotates anteriorly (more common).
    • Usually complete, resulting in the stomach being "upside-down" in the chest.
    • Can occur after procedures like Nissen fundoplication.

Borchardt’s Triad (Seen in 70% of Acute Organoaxial Volvulus)

  1. Epigastric pain.
  2. Retching but inability to vomit.
  3. Inability to pass a Ryle’s tube.
  4. Ryle’s tube may be passed initially in mesenteroaxial volvulus.

MCQ 56: Investigation of Choice for Acute Gastric Volvulus

Question:

What is the investigation of choice for acute gastric volvulus?

  1. Gastrograffin study
  2. CT abdomen
  3. Fulfilling Borchardt's triad
  4. Plain X-ray abdomen

Answer:

2) CT abdomen

Explanation:

  • CT abdomen is the investigation of choice as it helps visualize the volvulus and associated pathologies (e.g., hernias or ischemia).

Treatment of Gastric Volvulus

  • Acute setting:
    • Laparotomy.
    • Anterior gastropexy (fixation of the stomach).
    • Gastrostomy.
    • Seromuscular gastrojejunostomy or fixation to the transverse colon.
  • Primary chronic volvulus:
    • May be managed conservatively if stable.
  • Secondary volvulus due to hiatus hernia:
    • Early surgery is recommended to prevent emergency thoracic complications.

Gastric Antral Vascular Ectasia (GAVE)

  • Also known as: "Watermelon stomach."
  • Typically found in the antrum of the stomach.
  • Characterized by dilated venules in the submucosa, leading to bleeding.
  • Endoscopic Argon Plasma Coagulation (APC) is the first-line management.
  • Severe bleeding is not common in GAVE.
  • Parchment or snakeskin appearance is not typically associated with GAVE.

MCQ 57: GAVE – False Statement

Question:

Which of the following is false about GAVE?

  1. Parchment or snakeskin appearance of the stomach
  2. Antrum
  3. Endoscopic APC is the first-line management
  4. Severe bleeding usually present
  5. Dilated venules in the submucosa are responsible

Answer:

1) Parchment or snakeskin appearance of the stomach

4) Severe bleeding usually present

Explanation:

  • GAVE is characterized by dilated venules, and APC is the first-line treatment. However, GAVE is not typically associated with severe bleeding or a snakeskin appearance.

Aortoduodenal Fistula (ADF)

  • ADF occurs when there is a communication between the aorta and the duodenum.
  • Typically occurs after repair with a graft, especially with an infected graft.
  • Sentinel bleeding (a small episode of bleeding that precedes massive hemorrhage) is a hallmark sign.
  • Most often affects the D3 and D4 portions of the duodenum.
  • Median time after surgery: 3 years.

MCQ 58: Aortoduodenal Fistula – False Statement

Question:

Which of the following is false regarding an aortoduodenal fistula?

  1. Usually after repair with graft
  2. Pseudoaneurysm first at the inferior level of the graft
  3. Median time after surgery is 3 years
  4. 'Sentinel bleeding'
  5. Bleeding in D3, D4

Answer:

2) Pseudoaneurysm first at the inferior level of the graft

Explanation:

  • Aorto-duodenal fistulas occur due to erosion or infection, not primarily due to a pseudoaneurysm at the inferior level of the graft.

MCQ 59: Aortoduodenal Fistula – False Statement

Question:

Which of the following is false regarding an aortoduodenal fistula?

A. Single episode of massive GI hemorrhage

B. D3 and D4 junction

C. Air around aortic graft in CT abdomen

D. Occurs in less than 1% of graft repair cases

Answer:

A) Single episode of massive GI hemorrhage

Explanation:

  • A sentinel bleed usually precedes a massive hemorrhage in ADF, not a single massive episode.

Treatment of Aortoduodenal Fistula (ADF)

  • Ligation of the aorta proximal to the graft.
  • Removal of the infected prosthesis.
  • Extra-anatomic bypass.
  • The defect in the duodenum is often small and can be repaired primarily.
  • This is a complex and morbid procedure.