Stomach

Stomach short note by S.Wichien (SNG KKU)

Anatomy

Angle of his -fundus meet lt side GEJ

Angularis incisura -lesser curve---beginning antrum

Artery 1.Lt gastrric a--largest --celiac trunk

-15%--lt hepatic a

2.Rt gastroepiploic a--2nd large--GDA

3.Lt gastroepiploic a--splenic a 4.Rt gastric a--hepatic a

5.short gastric a--splenic a

¤¤at least 2/4 a may be ligated

¤¤eso.replace--rt gastric/rt GE

Vein

-lt/rt gastric--portal v -rt gastroepiploic--SMV

-lt gastroepiploic--splenic v

Innervation Parasym

Ant vagus n

-hepatic br -n of Latarjet--crowfoot--terminal br

Post vagus n

-criminal n of Grassi--post fundus

-celiac br

Sympathetic

-T5-10--celiac gg

¤submu--meissner plexus muscularis--Aurbach plexus/Cajal cell

Histology Epithelial cell

1.chief cell (zymogenic cell)--44% -fundus/body

-pepsinogen I,II

2.surface mucous epi cell (SEC)--40%

-all stomach

-bicarbonate/glycoprot--neutral HCL

3.parietal cell (oxyntic cell)--13%

-fundus/body -HCL/intrinsic f/bicarbonate

4.G cell/D cell--3%

-antrum -G cell--gastrin

-D cell--somatostatin

5.ECL cell

-fundus/body -H2 secreting

Acid secretion

-hcl--ingest pathogen -long term PPI--clostri.difficile colitis

Parietal cell -+ve=ach/gastrin/H2

--ve=somatostatin

-H+/K+ ATPase--proton pump -H pylori--inh D cell

Pepsinogen secretion

-+ve=ach --ve=somatostatin

Intrinsic factor -parietal cell

-bind B12--absorb in terminal ileum

Mucosal barrier

-SEC--mucus barrier/bicarbonate -parietal cell--bicarbonate

-Epi barrier

:hydrophobic phospholipid

:Tight jxn :Restitution-replaced SEC by adja cell

-microcircu--back diffuse H+

-mediator--PG,NO,EDGF,peptide

Gastrin hormone

Gastrin

-G cell--antrum

Hypergastrinemia

-pernicious anemia, acid suppress

Gastrinoma,retain antrum follow distal gastrec/billoth2/vagotomy

Somatostatin

-D cell -inh acid, gastrin, H2

Gastrin releasing peptide--GRP -+ve gastrin/somatostatin

-binding G/D cell receptor

Leptin

-by adipocyte/chief cell

-satiety hormone

Ghrelin

-by stomach -+ve appetite


PU

-imbalance of acid-mucosa defense -GU : aware cancer

-DU : rare cancer

Causes

1st--h.pylori 2nd--Nsaid use

Other--ZES, G cell hyperfxn/hyperpla

trauma, burn, stress

DU GU

Periodicity yes no

pain releif by meal no vomit less more

GI bleed melena hematemesis appetite normal afraid to eat

diet all milk,fish

wt inc dec M:f 2:1 1:1

GU Johnson classification

1--angularis incisura 2--1+DU

3--prepyloric

4--hi lesser curve/near EGJ 5--Nsaid induce--anywhere

¤2/3--acid hypersecretion

Nsaid

Who need PPI

-60yr

-Hx of acid/peptic dz -concurrent steroid intake

-concurrent anticoag intake

-hi-dose Nsaid/ASA

EGD ->45 yr

-Alarm symp--wt loss,dysphagia,

bleeding,anemia,recurrent vomiting

PU c/p

1.bleeding -3/4--Tx improve

1/4--continue bleed/re-bleed

Rockall score (Score 0-11)

0 1 2 3 1age <60 60-79 >80

2shock no PR>100 SBP<100

3comor IHD,HF RF,LF

4EGD mallory PU GI ca dx no lesion

5EGD clean base blood

spot clot spurting

<3=good prog >8=hi risk motality

Blatchford score (Score 0-23) 1SBP

:100-109=1 90-99=2 <90=3

2.BUN

:6.5-7.9=2 8-9.9=3 10-24.9=4 >25=6 3.Hb

men:12-12.9=1 10-11.9=3 <10=6

women:10-11.9=1 <10=6 4.other

pulse:>100=1 melena=1

syncope=2 hepatic ds=2

HF=2

2.perforate

-free air 80%

3.GOO

->5% of PUD -DU/prepyloric ulcer

-acute--inflam swelling chronic--cicatrix (scar)


PU sx

1.highly selective vagotomy -HSV

-parietal cell vagotomy -proximal gastric vagotomy--2/3

-all parietal cell located

-preserve vagal to antrum,pylorus -dec acid secretion 70%

-hi recurrence than vago/antrectomy

-gastric emptying time

solid : normal liquid : normal

-not well perform for typeII/III

2.vagotomy and drainage : V+D

-s/e=dumpling,diarrhea,recurrence

1.truncal vagotomy+pyloroplasty

:post bleeding DU :limit or focal scarring in pylorus

2.truncal vagotomy+gastrojejunos

:GOO, severe ds prox duodenum

:s/e=marginal ulceration

Pyloroplasty

a.Heineke Mikulicz :close longitu transpyloric incision in

transverse fashion

b.Finney pyloroplasty

:inverted U incision

:pylorus-duodenotomy

c.Jaboulay pyloroplasty

:pylorus-duodenotomy

3.vagotomy and antrectomy

-V+A -low ulcer recurrence

-higher morbidity -avoid in unstable pt

Anastomosis

1.Billoth 1 gastroduodenotomy

2.Billoth 2 loop-gastrojejunostomy

3.Roux en Y gastrojejunostomy

-keep duodenum out of stomach/eso

-avoid in gastric remnant 60-70% -large gastric remnant--marginal ulcer

4.distal gastrectomy -without vagotomy

-usually 50%gastrectomy include ulcer

-procedure of choice for type1 GU -Billoth 1/2 -type 2,3 GU--add truncal vagotomy

PU Sx option

° operation of choice in low risk ¤ shock

1.Bleeding PU

IC for sx

-massive hmg unrxn endo.control -recurrent hmg after endo attempt

-PRC>4-6/day

-lack of endoscopist

-repeat hospitalize for bleeding ulcer -perforate/obstruct

Early operation

-hi risk lesion :post DU (GDA)

:lesser curve (lt gastric a) ->60 yr

-ulcer >2cm

DU GU

1.overesew¤ oversew,bx¤

2.oversew,V+D oversew,bx,V+D

3.V+A distal gastrec°

2.Perforation

DU GU 1.patch¤ bx,patch¤

2.patch,HSV° wedge resect,V+D

3.patch,V+D distal gastrec°

3.Obstruction

DU GU

1.HSV+GJ bx,HSV+GJ 2.V+A distal gastrec°

4.Intractable,nonhealing DDx

Ca--gastric,pancreatic,duodenum Persistent H.pylori--false-ve

Non-compliance

ZES

DU GU

1.HSV° HSV,wedge

2.V+D distal gastrec 3.V+A


Gastrectomy complication

1.dumping syndrome -5-10% after sx

Early -15-30 min after meal

-abrupt delivery of hyperosmolar load

into small bowel -neuroendocrine rxn

-periphera/splanchnic vasodilate

-diaphoretic,weak,light-head,

tachycardia -imp by lay down,saline infusion

Late

-2-3 hr after meal -hyperinsulinemia

-post pandrial hypoglycemia -imp by sugar

Tx

-avoid liquid during meal -avoid hyperosmolar liquid

-add dietary fiber

-if dietary fail,octreotide 100 mcg sc twice daily,can inc up to 500 mcg -alpha glucosidase inh(acarbose) may helpful in late synd

2.diarrhea

-result of truncal vagotomy,dumping,

fat malabsorption

3.Gastric stasis

-gastric motility abnormality

-obstruction a.mechanical:anastomosis stricture,

eff limb kink,prox small bowel obstr

b.functional:retrograde peristalsis in roux limb

4.bile reflux gastritis

5.Roux synd

6.gall stone

7.wt loss

8.anemia

-iron def: absorp primary in prox GI

-B12,folate def -parietal cell=intrinsic f.=absorb B12

9.bone disease

-disturbed ca,vit D metaolism -ca absorp in duodenum

-fat malabsorb=vit D def

H.pylori

-urease enz -urea --> ammonia + bicarbonate

Mechanism that damage mucosa

Local effect

-toxin : vac A,cag A Immune rxn

-elaboration cytokine--IL-8

-recruitment inflam cell

-release inflam mediator -production of Ig

Acid secretion

-inc gastrin--hypergastrinemia -dec somatostatin Duodenal bicarbonate secretion -dec duodenal bicarbonate

H.pylori test histo exam of antral bx=gold std

1.serologic test

-non invasive

-sense 80%,spec 90% -not confirm eradication,because

sero scar remain after cure

2.urea breath test -std test to confirm cure of infection -sense/spec 90-99%

(ingest urea--urease--CO2+ammonia)

3.histologic test

-sense 85-100%,spec >95%

-hematoxylin-eosin and Diff-Quik stain

-Genta stain 4.rapid urease test

-simplest method

-one bx specimen -sense 80-95%,spec 95-100%

5.culture -when repeated failure of ATB tx

Tx

Tripple tx

-PPI+clarithro+amoxy/metro 14d

Fail

-PPI+amoxy+levoflox 10d -PPI+bismuth 525mg qid+

metro+tetracycline 10-14d


Bezoars

-young women -undigestible accumulate in stomach

-trichobezoar=hair -phytobezoar=vegetable

-asso gastroparesis,GOO

Rx -enzyme therapy

-endoscopic remove,sx remove

Mallory weiss syn -longitudinal tear in mucosa--GEJ

-forceful vomiting

-alcoholic -UGIB

-90% stop spontaneous Tx

-endoscopic confirm dx and Tx

-balloon tamponade -angiographic embolization

-vasopressin

-Sx--overesewing through gastrotomy

Vascular ectasia

Watermelon stomach

-gastric antral vascular ectasia -parallel red strip atop mucosal fold

-distal stomach

-elderly women

-chronic Gi bl loss

-resemble portal HTgastropathy

:but PHG -- proximal stomach

Histo -dilate mucosal blood vv

-often contain thrombi in lamina p.

-mucosal fibromascular hyperplasia Tx

-estrogen/progesterone -endoscopic--Nd:YAG/ argon plasma

-antrectomy--require to control bl loss

Menetrier ds

-hypertrophic gastropathy -large rugal fold in prox.stomach

:spare antrum -overexpress of TGF alpha

:+ve EGFR,TKR

:surface mucus secreting cell -Bx--diffuse hyperplasia of SEC

-inc risk of gastric ca

Clinical

-middle age men -epigastric pain,wt loss,diarrhea

-hypoproteinemia

Asso 1.protein losing gastropathy

2.hypochlorhydria Tx

-EGFR blocking monoclonal ab

:cetuximab -gastric resection in

:bleeding, severe hypoproteinemia

Dieulafoy lesion -congen AVM

-large tortous submucosa a.

-if a.erode=bleeding -middle aged/elderly men

-endoscopic can miss lesion if not

active bleeding--normal mucosa

Tx

-endoscopic hemostatic therapy

-angio embolization

-sx--oversew/resect

Isolate GV

-T1--fundus T2--distal to fundus

-asso portal HT/ splenic v thrombosis -no I/C for prophylaxis

Tx

-octreotide

-sengstaken blakemore tube--T1

-endo.Tx--sclerotherapy/EVL

:less success than EV

-splenic v thrombosis--splenectomy -liver transplant--cirrhotic pt


Diverticula

-usually solitary -congen--true diverterticula

-acquired--pulsion -most--post cardia or fundus

-most asymptomatic

:can inflam--pain,bleed Tx

-symtomatic pt

:should be removed--laparoscopic

Volvulus

-asso large hiatal hernia

1.organoaxial volvulus

-typical -twisted along long axis

2.mesenteroaxial volvulus

-twisted around transverse axis

Clinical

1.asymptomatic

-no sx -rare strangulation

2.symptom

-pain -pressure effect

:lungs--dyspnea

:pericardium--palpitation

:eso--dysphagia

-gastric infarction=sx emer

Tx

-elective sx :reduction of stomach and

repair hernia c/co gastroplexy

Gastroparesis

-delay gastric emptying time -n/v,bloating,early satiety,abdo pain

-80% = women -should r/o mecha GOO,gut obs

-upper GI study:slow gastric emptying

Dx

-upper GI--slow gastric emptying

-EGD--bezoars, normal

-gastric emptying scintigraphy--DGE

Etiology

Idiopathic Endocrine/metabolic DM/thyroid/CKD

After sx resection/vagotomy CNS BS lesion/parkinson

Peripheral nm ds

-duchenne m dystrophy -myotonia dystrophica

CNT scleroderma/PM,DM

Infiltrative lymphoma/amyloidosis

Medication Elyte k,ca,mg

Diffuse GI motility ds

Miscellaneous infection,viral paraneoplastic,ischemia,GU

Rx

1.medication

-prokinetic,antiemetic

2.sx 2.1 severe diabetic gastroparesis

-pancreas transplantation

-if can't gastrostomy (decompress) + feeding jejunostomy

2.2 others

-Implant gastric pacemaker

-1° gastroparesi--gastric resection


Lymphoma

-4% of gastric ca -most common of 1°GI lymphoma

-95% = NHL (1/2 of NHL involve GI tract) -most are B cell type--in MALT

-usually also H.pylori infection

Low grade MALT lymphoma

-arise from chronic gastritis -asso H.pylori -if eradicate H.pylori :low gr lymphoma--often disappear

Tx -not sx lesion--careful f/u is necessary

-persist after tx H.pylori :stage1=RT

:stage2,3=CMT+RT

Hi grade gastric lymphoma

-require aggressive onco tx

-systemic symptom

:fever,wt loss,night sweats -lymphadenopathy/organomegaly

-Dx=endoscope+bx

1°lympho : nodular c enlarged fold 2°lympho : diffuse infiltrative

-EUS,CT chest-abdomen,BM

Tx

-Limit to stomach+region LN

:radical subtotal D2 gastrectomy

-CMT,RTX

Japanese numeric classification

1-rt paracardia 2-lt paracardia

3-lesser curvature 4a-greater curvature,upper

4b-greater curvature,lower

5-suprapyloric 6-infrapyloric

7-lt gastric

8-common hepatic a.

9-celiac a 10-splenic hilum

11-splenic a

12-hepatoduodenal lig 13-post pancreatioduodenal

14-SMA 15-middle colic a

16-paraaortic

17-ant pancreatioduodenal

D1=3-6

D2=1,2,7,8,11

D3=9,10,12


Carcinoid Tumor

-rare -1% of carcinoid

-ECL cell -malignant potential

Type1 -most common--75%

-chronic hypergastrinemia

-2° to pernicious a.,atrophic gastritis

-women -often multiple, small

-malignant potential <5%

Type2 -asso MEN1, ZES

-malignant potential 10% Type3

-Sporadic

-solitary >2cm -men

-most--metas at dx time

Dx -endoscope+bx

-EUS in size,dept

-plasma chromogrannin A -CT

-octreotide scan

Tx

1.small lesion (T1,2)

confine mucosa,<5lesion

-EMR -careful follw up

2.larger lesion -D1/D2 gastrectomy

3.metastatic dz

-somatostatin

-sx debulking

GIST

-interstitial cell of Cajal--ICC -2/3 occur in stomach -epithelial cell stromal GIST :most common cell type

-GIST--CD117 (c-KIT), CD34

-smooth m tumor--desmin -hematogenous (liver,lungs)

-most--body of stomach

-almost solitary

-prognosis=size,mitotic count,metas Clinical

-submucosa tumor--slow growing

-large lesion--wt loss,abdo pain, fullness,bleeding,abdo mass

Tx -wedge resection c clear margin

-invade adjacent organ--en bloc R

Imatinib -block tyrosine kinase

(product of c-kit)

-metas/unresect pt

Benign tumor

1.polyps

-most common benign tumor 5 type

1.Adenomatous

2.Hyperplastic (regenerative)

:most common--75%

1,2 -- malignant potential

3.Hamartomatous

4.Inflammatory 5.Heterotopic (ectopic pancrease)

3,4,5 -- negligible malignant potential

Tx -symptomatic

->2cm,adenomatous :endoscopic snare polypectomy

2.Leiomyoma

-submucosa

-if ulcerate--umbilicated appearance

-<2cm--asymp/benign

>2cm--greater malignant :should remove by wedge resect

:often possible lap

3.Lipoma

-found incidentally


Ca stomach

-adenoca 95%,lymphoma 4% GIST1%,carcinoid,angiosarcoma,SCC

-metastasic (melanoma,breast) -direct invasion:ca colon,pancrease

Adenocarcinoma -elderly

-male:female = 2:1

-low economic status

-black > white

Factor

Increase risk -fam hx

-bl gr.A -pernicious anemia -hi fat,salt,nitrate diet

-FAP(10x) -gastric adenoma

-hereditary nonpolyposis colorectal ca

-H.pylori (3x) :atrophic gastritis-->intes.metaplasia -previous gastrec/gastrojeju >10yr

-tobacco

-EBV -menetrier dz Decrease risk

-aspirin

-vegetable/fruit diet

-vit c,e

Genetic factor -p53 and COX-2 gene :deletion or suppression of p53 :overexpression of COX-2

Premalignant lesion

1.Polyps--5 type 1.inflam

2.harmartomatous 3.heterotopic

¤¤no malignant potential

4.hyperplastic 5.adenoma, FAP(10x) 2.Atrophic gastritis

-most common precursor for ca

-intestinal type 3.Intestinal metaplasia

4.Benign gastric ulcer

5.Gastric remnant cancer -s/p distal gastrec in PUD >10yr

Pathology

Dysplasia

-mild dysplasia : f/u bx -severe dysplasia

:multifocal=gastric resection

:localized=EMR

Early gastric ca

(Adenoca limited to mucosa/submu) Type1:exophytic Type2:superficial variant

2a:elevate lesion

2b:flat lesion

2c:depressed lesion

Type3:excavated lesion

Gross morphology : 4 form 1.polypoid

2.fungating--intraluminal+ulcer

3.ulcerative 4.scirrhous (linitis plastica) :poor prog


Clinical manifestation

-wt loss -dec food intake:anorexia,satiety

-abdo pain -n/v -bloating -acute GI bleeding : 5%

-chronic occult bl loss : iron def

-dysphagia if involve cardia -paraneoplastic syn

1.trousseau sign = thrombophlebitis

2.acanthosis nigrican

3.peripheral neuropathy -metas pleural effusion

-krukenberg tumor

-sister joseph node -rectal shelf/drop metastasis

Dx 1.endoscope -- gold std

-if suspicion for ca is hi and bx=neg

:re endoscope and aggressive bx 2.CT abdo,pelvic CT

-preoperative staging

3.EUS

-best way to stage tumor -tumor dept/can FNA LN

-distinguished early ca vs advance 4.PETs scanning -evaluate distant metastasis

5.Staging laparo+peritoneal cytology

-evaluate peritoneal/liver metas

Ca stomach staging

Tis-no lamina propia

T1-lamina propia/submu T2-muscularis propia

T3-serosa

T4-adjacent organs N1-1-6 LN

N2-7-15 LN N3->15 LN

1a T1 NO

1b T1 N1

T2 N0

2 T1 N2

T2 N1 T3 N0

3a T2 N2

T3 N1 T4 N0

3b T3 N2

4 T4 N1-3

anyT N3 anyT anyN M1

Ca stomach Sx

-Sx is only curative tx

Curative Sx goal -resect all tumor,free margin (R0)

-adequate lymphadenectomy

-grossly -ve margin at least 5 cm

Extent of gastrectomy

-std sx=radical subtotal gastrectomy

-remove 75% stomach :include pylorus, 2cm doudenum

-greater/lesser omentum

-all asso lymphatic tissue -Billroth-2 gastrojejunostomy

:if remnant <20% : Roux-en-Y -Total gastrectomy c Roux-en-Y

esophagojejunostomy

:prox.gastric ca

Extent of lymphadenectomy

-D1:station 3-6

D2:station 1,2,7,8,11 D3:station 9,10,12

USA

:D1 resection Asia

:D2 gastrectomy

:resect peritoneal over pancrease,

ant mesocolon

:hi M&M

CMT,RTX -adjuvant tx c CMT (5FU,LV) and RTX

benefit in resected pt c stage II,III

-no indication for RTX alone :can be effective in bleeding or pain

Endoscopic resection

-early gastric ca, <2cm, -ve LN

EUS:confined mucosa

:LN metas <1%

Screening

-FAP,adenoma,intes meta/dysplasia HNPCC,Menetrier ds,remote gastrec


Postgastrectomy syndrome

1.dumping syndrome -abrupt delivery of hyperOsm load

Mech 1.bypass pylorus

2.accelerate emptying of liquid--HSV

Early dumping -15-30 m after meal

-sweating,light-head

-relief--NSS

Late dumping -2-3 hr after meal

-relief--sugar

-hypoGlycemia -hyperinsulinemia

Tx -diet mx

:avoid liquid during meal

:not hyperosm liquid :dietary fiber

-octreotide

-acarbose--late dumping

Sx--rare -pylori recons

-take down GJ

-converse billoth2-->1 -converse to Roux en Y--sx of choice

:large gastric remnant--marginal U

-interposition 10cm reverse intes

:between stomach/duodenum

:rarely use

2.diarrhea cause

1.truncal vagotomy

-intes dysmotility -accelerated transit

Tx--cholestyramine,loperamide Sx--10cm reverse jejunal interposition

2.dumping

3.fat malabsorption

3.gastric stasis

1.Mechanical -anastomosis stricture

-efferent loop kink -prox SB obstruct

Sx

-re-operation

2.Fxn

-retrograde peristalsis in Roux limb

-should r/o mechanical Tx

-Medical tx/diet mx

Sx After V+D

-subtotal gastrectomy -Billoth2 anas c braun enteroenteros

After subtotal gastrectomy

-near total gastrectomy/total gastrec c Roux en Y reconstruction

4.bile reflex gastritis

-s/p resect pylorus -develop mo-yr

-billoth 2 gastrec,GJ

DDx -aff/eff loop obstruct

-gastric stasis

-SMB obstruct

Sx

-Roux eu Y GJ

:Roux limb at least 45 cm

-Billoth2 c braun enteroenteros -interposition 40 cm isoperistatic

jejunal loop between gastric--duo

(Henley loop) 1°bile reflux--no previous sx--rare

Tx -duodenal switch operation

:have marginal ulcer

:combined w HSV


Postgastrectomy syndrome (cont)

5.Roux synd

-s/p Roux en Y -DGE, no mech obstruct

-vomiting/epi pain/wt loss

Med -prokinetic drugs

Sx

-subtotal gastrctomy

-resected Roux limb--if dilate/flaccid -Billoth2 c braun enteroenteros or

Henley loop

6.gall stone

-vagal denervation--GB dysmotility -stasis of GB

Prophylactic cholecystectomy

-not justified in most case -but appear abnormal GB--yes

or GS/sludge

7.wt loss

8.anemia

-iron def--absorb in prox GI -B12--no intrinsic f

-folate def

9.bone disease

-ca--absorb in duodenum

-vit D--fat malabsorpt

Gastrostomy

-alimentation or decompression methods

1.Percu--PEG 2.Open

-Stamm--most common

-Witzel -Janeway--create permanent stroma

3.laparoscopic

C/P

-infection -dislodgement

-aspirate pneumonia

DDx of hypergastrinemia 1.With excessive gastric acid (ulcerogenic)

-Zollinger Ellison syn

-GOO -retained gastric antrum

(after BillrothII reconstruction )

-G-cell hyperplasia

2.Without excessive gastric acid

(nonulcerogenic)

-pernicious anemia -atrophic gastritis

-renal failure

-post-vagotomy

-short gut syn


Zollinger Ellison synd--ZES

-uncontrol secrete of abnormal gastrin by duodenal or pancreatic NE tumor

-80%=sporadic--solitary-->90% cure -80% in gastrinoma triangle

(cystic d--jxn 2/3 duo--jxn neck/body)

20%=inherited--MEN1--multiple -50%=malignant

2clinical syndrome by

epi hyperplasia & giant gastric fold 1.ZES

2.Menetrier disease

Symptom

-epigastric p. -GERD

-diarrhea

-PU=90% of pt Typical ulcer=proximal duodenum Atyp ulcer=distal duo,jejunum,multi

DDx -recurrent PU

-secrete diarrhea

-gastric rugal hypertrophy -esophagitis c stricture

-bleeding or perforate ulcer

-familial ulcer

-ulcer w hyperca

-gastric carcinoid

Dx -gastrin level (false+ve=antisecrete)

-BAO>15mEq/h, >5mEq/h (PU sx)

-secretin stimulation test :confirm test

:iv bolus of secretin (2u/kg) :gastrin level before/after injection

:inc serum gastrin of 200 pg/ml

-serum ca,parathyroid level r/o men1

Imaging

1.u/s--not very sensitive 2.CT--detect lesion>2cm

3.MRI 4.EUS

-more sensitive

-may miss smaller lesion -confuse normal LN

5.Somatostatin R.Scintigraphy--SRS

-octreotide scan

-imaging of choice -gastrinoma cell--type2 somato R

6.Dx angiography and transhepatic

selective venous sampling of portal s. -a.catheter--gastroduodenal,splenic

-v.catheter--hepatic v -inject secretin--gastrin in hepatic v

-signi elevate in hepatic v gastrin

indicate tumor is supplied by inject a.

*most important locate tumor is

intraop exploration

Rx

1.sporadic (nonfamilial) gastrinoma

-usually solitary -intra op u/s

-should sx resection--possible cure

-explor gastrinoma triangle+pancreas

-other site

:liver,stomach,SMB,mesen,pelvis

-if can't locate, should consider

:longitudinal duodenotomy

2.MEN1

-rarely cure by operation -multiple lesion

-HSV in unresectable gastrinoma

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Stomach