First successful culture of H pylori was done by?
Marshall and WarrenQ
Association of H pylori with peptic ulcer?
Around 90% of duodenal ulcers and 75% of gastric ulcer are associated with H. pylori infectionQ.
MC site of colonizationQ of H pylori?
- Gastric antrum.
- Can live only in gastric epithelium - only gastric epithelium expresses specific adherence receptors that can be recognized by organism
Sites where heterotropic gastric mucosa are present?
- Proximal esophagus
- Barrett’s esophagus
- Gastric metaplasia in the duodenum
- Meckel’s diverticulum, and
- Heterotopic gastric mucosa in the rectumQ
Characteristic of H. pylori?
Spiral shaped, gram (-)ve rod, motile with lophotrichous flagellaQ
Biochemical reactions of H. pylori?
- Catalase, oxidase and urease positiveQ
- Urease provides ammonia to buffer acidQ
Media used for H. pylori?
- Skirrow’s medium
- Chocolate mediumQ
Optimally pH for growth of H pylori?
Pathophysiology of ulceration in H. pylori?
H. pylori colonization decreases somatostatin producing cells →↑ Gastrin →↑Acid → Gastric metaplasia in duodenum → UlcerationQ
Extra-gastrointestinal pathologies of H. pylori?
Ischemic heart disease and cerebrovascular diseaseQ
Diagnosis of H. pylori?
- If endoscope is employed - Rapid urease testQ.
- When endoscopy is not required - Serology is the test of choice
- After treatment - Urea breath test is the method of choice but should be performed after 4 weeks of therapyQ
Accuracy of Diagnostic Methods in H. pylori?
- • Chronic inflammation on a gastric mucosal biopsy specimen is 100% sensitive testQ
- • Rapid Urease test on a gastric mucosal biopsy specimen is 100% specific testQ
Diseases associated with H. pylori?
- • Duodenal ulcerQ
- • Gastric ulcerQ
- • Gastric adenocarcinomaQ
- • MALT lymphomaQ
Types of Chronic gastritis?
- Type A – Autoimmune, involves body and fundusQ
- Type B – Bacteria induced (H. pylori), involves antrum
MC Site of gastric and duodenal ulcer?
- Gastric - Lesser curvature along the incisura angularis (Type 1)Q
- Duodenal - 1st part of duodenum (overall MC site for peptic ulcer)Q
Most common complication of gastric and duodenal ulcer?
- Perforation: MC complication of gastric ulcer (Into lesser sac)Q
- Bleeding: MC complication, on posterior wall, gastro¬duodenal arteryQ is most commonly involved
Modified Johnson classification of Gastric ulcer?
- I - Lesser curvature, near incisura angularis (MC)Q - Low
- II - Body of the stomach and duodenumQ - HighQ
- III - PrepyloricQ (within 2-3 cm of the pylorus) - HighQ
- IV - High on the lesser curve, near GE junctionQ - Low
- V - Anywhere, induced by medication (NSAIDs) – Low
Blood group association of Gastric ulcer?
- Type I: Blood group ‘A’Q
- Type II, III, and IV: Blood group ‘O’Q
Treatment of bleeding duodenal ulcer?
- Endoscopic measures
- Pyloroduodenotomy and ligation of GDA
- Even in the era of H. pylori and our ability to eradicate it, a TV perhaps should be performed in those patients with a bleeding duodenal ulcer
Location of pyloric vein of Mayo?
Anterior surface of the inferior pylorusQ
Most common surgery for bleeding duodenal ulcer?
Truncal vagotomy and Q
What percent of patients show gas under diaphragm in upright chest x-ray?
MOA of PPI?
Inhibition of acid secretion is also more prolonged because of the irreversible inhibition of the enzyme caused by the covalent bond to the proton pumpQ, requires acidic environment
What is highly selective vagotomy?
Nerves of Latarjet supplying the antrum are preservedQ (and hence gastric motility)
What is Polya Gastrectomy?
- Posterior gastroenterostomy which is a modification of Billroth II operation.
- Resection of 2/3 of the stomach with blind closure of the duodenal stump and retrocolic anastomosis of the full circumference of the open stomach to jejunumQ.
Drainage Procedures in Peptic Ulcers?
- Heineke-Mikulicz Pyloroplasty
- Finney Pyloroplasty
- Jaboulay Gastroduodenostomy
Association of H pylori withPeptic ulcer?
75% GUs and 90% DUs
Elective Gastric Ulcer Operations?
- Type I - Distal gastrectomy with Billroth I or II reconstructionQ
- Type II and III - Truncal vagotomy plus antrectomyQ
- Type IV - Schoemaker procedureQ, • Pouchet procedureQ, • Kelling-Madlener procedure (For unstable patientsQ), Csendes procedure (For stable patientsQ)
Malignancy in gastric ulcer?
- Chronic duodenal ulcer never turns malignant
- < 1% of chronic gastric ulcer may transform into carcinoma
Location of benign and malignant gastric ulcer?
- Benign - Generally at lesser curvatureQ
- Malignant - At greater curvatureQ
Mucosal rugae in benign and malignant gastric ulcer?
- Benign - Mucosal rugae projects outwards from the margins of ulcerQ
- Malignant - Mucosal rugae stop far of the ulcerQ
Morphology of benign and malignant gastric ulcer?
- Benign - Smooth radiating foldsQ with Hampton line and collarQ, Overhanging marginsQ showing regeneration, Benign BPH: (Benign ulcer- Penetrating sign and Hampton’s hump)
- Malignant - Interrupted nodular, clubbed folds with Lasman Kirklin complexQ (malignant ulcer with no mass) • Eccentric with heaped up and everted marginsQ, Malignant CIK: (Carman’s meniscus sign, Intraluminal crater, Kirklin complex)
Hill and Baker procedure?
Posterior truncal vagotomy with anterior HSVQ.
Posterior truncal vagotomy with anterior lesser curve seromyotomyQ. The technique is very suitable for a laparoscopic approach
Secondary to gastric resection - Dumping syndromeQ • Metabolic disturbancesQ
- Secondary to gastric reconstruction - Afferent loop syndromeQ • Efferent loop obstructionQ • Alkaline reflux gastritisQ • Retained antrumQ syndrome
- Postvagotomy syndrome - Postvagotomy diarrheaQ • Postvagotomy gastric atonyQ • Incomplete vagal transectionQ
MC metabolic defect appearing after gastrectomy?
AnemiaQ, Iron deficiency anemia (IDA) is more common than vitamin B12 deficiency anemiaQ
What is early dumping syndrome?
Occurs immediately after meals (after 15-30 minutes) Q, Dumping of hyperosmolar contents into the small bowelQ results in rapid fluid influx from the circulation into the gastrointestinal tract - leads to acute intestinal distention and peripheral and splanchnic vasodilatationQ. - gives rise to vasomotor and abdominal symptoms.
Late dumping syndrome?
Is seen 2-3 hrs after mealQ, due to reactive hypoglycemiaQ. • The carbohydrate load in the small bowel causes a rise in plasma glucose, which in turn, causes high insulin levels leading to hypoglycemia.• Symptoms are relieved by administration of sugarQ
Surgical procedures for dumping syndrome?
- Use of an antiperistaltic loop of jejunum between the residual gastric pouch and intestine
- Conversion of Billroth II to Billroth I anastomosis
- Conversion to Roux-en-Y-anastomosis
Timing of duodenal stump blow out?
4th to 7th post-operative dayQ.