Apatient with a known family history of multiple endocrine neoplasia (MEN) I, now presents with intractable ulcer disease.Which of the following statements about his condition is most accurate?
Answer(s): A
The Zollinger-Ellison syndrome was described in 1955, in two patients with the triad of gastroduodenal ulcerations, gastric hypersecretion, and nonbeta islet cell tumors of the pancreas. Gastrinomas arise from neuroendocrine cells and represent the third most common neuroendocrine tumors (after carcinoids and insulinomas). These tumors are associated with MEN I. These tumors occur predominantly in the pancreas, duodenum, antrum, and peripancreatic lymph nodes, but can also occur at distant sites like the ovary. Isolated tumors are found in 50%, and multiple tumors in 50%, but there is a higher incidence of multiple tumors in MEN I. Tumors are malignant in 50%, with metastases to the regional lymph nodes and the liver. Once the diagnosis has been established, tumor localization can be achieved with indium-labeled octreotide scan, CT with fine cuts through the pancreas, ultrasound, MRI, or selective angiography. None of these tests are highly sensitive, and often the tumors are not localized until the time of exploration and intraoperative-directed ultrasonography.
A 60-year-old Asian male presents with early satiety and 40-lb weight loss over 3 months.Upper endoscopy shows an irregular mass in the antrum of the stomach. What can you tell him and his family about his situation?
Answer(s): D
Gastric adenocarcinoma is associated with dismal overall prognosis, with long-term survival seen only in patients with early stage disease. Surgical resection remains the mainstay of potentially curative therapy, with poor responses to chemotherapy in the majority of clinical trials. Patients often present with vague epigastric discomfort, occult GI bleeding/anemia, anorexia, weight loss, and even hematemesis/ vomiting. Patients are staged with endoscopic ultrasound, which is the most effective imaging modality for determining T and N stage. CT may also be useful for determining nodal metastases, but is more accurate for determining distant metastases (liver). Antral tumors may have a better prognosis than more proximal gastric tumors, with a decreased incidence of nodal metastases. Five-year survival rates for stage I disease is excellent, approaching 8090% in both the Western countries and in Asia. However, 5-year survival rates are dismal for stage III and stage IV disease, and most Western series report overall 5-year survival rates for gastric cancer of 1021%.In contrast to gastric adenocarcinoma in the United States, the incidence of gastric lymphoma is rising. Gastric lymphoma accounts for two-thirds of GI lymphomas. Symptoms are similar to gastric adenocarcinoma, but obstruction, perforation, and massive bleeding are very uncommon symptoms. Because gastric lymphoma spreads by submucosal infiltration, mucosal biopsies at the time of upper endoscopy can often be nondiagnostic. Repeated biopsies to obtain submucosal tissue are needed to establish a diagnosis. Treatment protocols vary among institutions, but most often center on chemotherapy; surgical resection of isolated or localized gastric lymphoma can be curative, but is rarely seen. Fortunately, survival rates for gastric lymphoma are much better than those seen in gastric adenocarcinoma, with cure rates of 70% seen in patients with stage IE and IIE disease treated with chemotherapy alone.
A 60-year-old Asian male presents with early satiety and 40-lb weight loss over 3 months.Upper endoscopy shows an irregular mass in the antrum of the stomach. He follows up in the clinic a few days later, and you see that the results of the endoscopic biopsies are suggestive of a gastric lymphoma. Which of the following is true regarding this condition?
You perform an upper endoscopy on a patient and find changes suggestive of Barrett's esophagus. How do you explain this to the patient and his family?
Barrett's esophagus is related to GERD. It is found proximal to the LES and is thought to be a result of constant acidic exposure. It is a condition where the normal esophageal squamous cell epithelium is replaced by columnar epithelium, similar to intestinal metaplasia. A single biopsy is all that is needed to confirm the diagnosis. In fact, many biopsies should be taken during endoscopy if the diagnosis is suspected in an effort to find dypslasia. The risk of malignant degeneration is the most important risk associated with Barrett's esophagus.
On your surgery rotation you are assisting in a gastric surgical procedure. The attending surgeon asks you to describe the vascular supply to the stomach. You reply with which of the following?
The main blood supply to the stomach comes from the right gastric artery (from the hepatic artery), the left gastric artery (from the celiac axis), the right gastroepiploic artery (from the gastroduodenal artery), the left gastroepiploic (from the splenic artery), and the short gastric arteries from the splenic artery.
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