Disorders Of Upper Gi

Question 1

What investigations are done for duodenum perforation

Answer 1

CXR
AXR
WCG
Crp
Wcc
Lfts

Question 2

Why do we do CXR AXR for duodenal perforation

Answer 2

• Want to see if they have air under diaphragm in CXR
• Want to look for free air in AXR but also to check small and large bowel

Question 3

What do you see in perforated duodenum

Answer 3

• Rigler’s sign- free intraperitoneal air (right pic)
• Free subdiaphragmatic air (left pic)

Question 4

How do we manage peritonitis pre-operatively then operatively?

Answer 4

Pre-operatively

• Put NG tube in to empty gastric contents to stop them leaking into abdomen
• NBM or else anything that goes in will go through the hole
• IV fluids
• Antibiotics

Operatively

• Identify aetiology of peritonitis (where hole is)
• Eradication of peritoneal source of contamination
• Peritoneal lavage and drainage

Question 5

What are the common sites of perforation for duodenal ulcers?

Answer 5

• Most commonly anterior/superior surface of first part of duodenum or pylorus- anterior ulcers typically perforate at D1
• Rarely on pre-pyloric antrum
• Less frequently in stomach (lesser curvature, fundus)
• Rarely found on posterior surface of first part of duodenum or the stomach
• Duodenal perforation is 10x more frequent than gastric perforation

Question 6

What is the problem with posterior duodenal ulcers?

Answer 6

These are retroperitoneal and can perforate into arteries and bleed

Especially gastroduodenal artery which is a big one

Question 7

What is a laparoscopic omental patch?

Answer 7

We take a bit of omentum and stitch it on top of perforation- not too tight or else it’ll make duodenum ischaemic

Then lavage and clean it a lot to get rid of any contamination which could later become infected

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Question 8

Gallstone pancreatitis

Answer 8

Where gallstones obstruction ampulla of voter where the bile duct and pancreatic duct end it into duodenum
Causes enzymes to back up and activate

Question 9

How do we assess severity of pancreatitis

Answer 9

P – PO2 <8KPa

A – age >55yrs

N – WCC >15

C – calcium <2mmol/L

R – renal: urea >16mmol/L

E – enzymes: AST >200iu/L, LDH >600iu/L

A – Albumin <32g/L

S – sugar >10mmol/L

Question 10

Management for pancreatitis

Answer 10

• 4 principles of management:
  
  • Fluid resuscitation (IV fluids, urinary catheter, strict fluid balance monitoring)
  • Analgesia
  • Pancreatic rest (with or without nutritional support if prolonged recovery e.g. NJ feeding or PN)
  • Determine underlying cause
• 95% settle with conservative treatment

Question 11

What other IX for pancreatitis/gallstones

Answer 11

USS abdomen
Then MRCP to look for stones
Then ERCP LAST to push stone out

Question 12

Murphys sign

Answer 12

Looks for cholecystitis

Put 2 fingers under patient’s right subcostal margin and ask them to breathe in- this pulls liver and gallbladder down and if gallbladder is inflamed when gallbladder hits finger the patient is in a lot of pain