Disorders of Upper GI Tract Tutorial Flashcards
What are the surgical and non-surgical causes of upper abdominal pain?
Surgical: Pancreatitis Biliary pathology Abdominal wall Vascular - e.g. aortic aneurysms Small bowel Large bowel
Noon-surgical: Cardiac - e.g. MI Gastroenterological - e.g. colitis Muscoloskeletal Diabetes Dermatological
Case 1:
45M - 1 year history of intermittent upper abdominal pain
Abdo pain worsening for last 3 hours
1 vomit of gastric contents
PMH - lower back pain
SH - smoker
DH - ibuprofen for abdo pain for the last 2 yrs
Observations / examinations (O/E)L
BP normal, HR normal, abdo soft and tender in epigastrium
Bloods: Urine - NAD WCC 13.4 (little high) Hb 15.1 Plts 250 INR & APTR Normal LFTs Normal CRP 15 Amylase 71
Ivestigations:
ECG - sinus rhythm
What is the next line of investigation? CXR AXR USS CT MRI Laparoscopy Laparotomy
CXR and AXR
Erect chest x-ray to:
Look for air under the diaphragm (performation)
Look for chest problems
Abdominal x-ray
What does his AXR show?
Completely normal - normal bowel gas patterns
What is the patient diagnosed with and how is he treated?
Patient is given IV fluids and paracetamol
Diagnosed with gastritis
Discharged home with no follow-up (patient just wanted to go home)
More history: He comes back 2 days later with: Been taking double dose ibuprofen as the pain has not got better Worsening epigastric pain Started vomiting Pain now constant
O/E:
Looks unwell, sweating
Temp 379, HR 110, BP 100/60
Abdomen rigid with four quadrant tenderness
Bloods: Urine - NAD WCC 16.4 Hb15.1 Plts 250 INR & APTR Normal LFTs normal CRP 180 Amylase 105
Investigations:
ECG - sinus tachycardia
What is the next line of investigation?
Erect CXR and AXR again
What did the patient’s CXR and AXR show?
AXR shows Rigler’s Sign - see the outline of the small / large bowel clearly due to air on the inside and outside of the bowel
- Free intraperitoneal air
CXR shows free subdiaphragmatic air - AKA air under the diaphram
- This is an erect chest x-ray so air goes upwards, so there is air above the liver
What is the most likely diagnosis combining the results from the x-rays and his medical history?
Pancreatitis Gastritis Pneumonia Small Bowel Obstruction Large Bowel Obstruction Perforated Viscus
Perforated Viscus
What is the likely perforated organ? Duodenum Stomach Sigmoid diverrticular disease Appendix Small bowel Colon from colitis
Due to drinking and smoking history - most likely duodenum or stomach
What is the next line of investigation for the patient?
On a CT scan what colour does free air show up?
What does the patient’s CT scan show?
CT Scan
Black - normally only in the (large) bowel etc.
But in this patient, there is black outside the duodenum and stomach
He has a posterior duodenal perforation
What is a consequence of the perforation?
Acute peritonitis - duodenum contents fall out and into the abdominal cavity
What is the management of acute peritonitis?
Pre-op: NGT - want all the fluid there to come out into a bag rather than his abdomen NBM IV fluids - due to dehydration Antibiotics
Operative:
Identification of aetiology of peritonitis
Eradication of the peritoneal source of contamination - operation to sort out the hole and close it up
Peritoneal lavage and drainage - wash out the abdomen
What are the treatments for perforated ulcer:
Conservative treatment (Taylor's approach) - for old, frail patients with contained perforation Radical surgery (vagotomy, gastrectomy)
Where is the most common site of perforation for duodenal ulcer disease?
Most commonly anterior/superior surface of first part of duodenum or pylorus, rarely on the pre-pyloric antrum
Less frequently in the stomach (and if it does occur, then in the lesser curvature, fundus)
Rarely found on the posterior surface of the first part of the duodenum or the stomach
Duodenal perforation is 10x more frequent than gastric perforation
Acute ulcers occur in patients with no history of ulceration in 25-30% of cases
How do anterior and posterior duodenal ulcers differ?
Anterior ulcers tend to perforate
Posterior ulcers tend to bleed
Are gastric or duodenal perforations more common and why?
Duodenal = 10x more likely than gastric perforation
Because the stomach has many more protective mechanisms for its lining compared to the duodenum
What is the first step for a perforated stomach?
You must think - ‘have they got a cancer that has perforated?’
Take biopsy if you come across it during a surgery
How are perforations normally amended surgically?
Laparoscopic omental patch - cannot only stitch together the hole
Place stitches around hole, then use fat from omentum to cover hole and stitch it over the hole
What do you do post-operatively for the patient?
Lavage - fluid washouts to get rid of contamination
Take observations often
More History - post-operatively: Stable and normal observations for first 48 hrs Day 3 post-op Complaining of SOB O2 sats drop from 99% to 87% on 2L nasal specs Spike of temperature to 385 Sinus tachycardia 100 (no ECG changes) Bibasal creps on auscultation R>L pO2 8.2 on FiO2 of 0.35
X-ray also conducted
What is the most likely diagnosis? Pulmonary oedema Pneumonia Pulmonary embolism Leak / collection
Pneumonia - look for explanation
Any upper GI surgery is just beneath the diaphragm
The incision is painful, so the patient needs adequate pain relief to be able to take in deep breaths
Due to lack of deep breathing - if they do not expand their lungs full of air, their lungs fill with fluid instead
Fluid becomes infected - leading to pneumonia
Improves with IV antibiotics and discharged on day 6
Comes back 2 days later with more abdominal pain and vomiting
Represents 2 days later with abdominal pain & vomiting
Febrile 38, HR 110, BP 100/60, Sats 98% RA
Abdomen soft but tender & guarding in epigastrium
Hb 14.1, WCC 18 (raised), CRP 209 (high), LFTs & U&Es normal
ECG sinus tachycardia
CXR & AXR unremarkable
CT scan
What is the most likely diagnosis? Leak from repair site Peristent pneumonia Constipation Intra-abdominal collection
Persistent pneumonia or intra-abdominal collection (cavity not washed out properly)
Most likely intra-abdominal collection - from the CT
Collection is not a leak from the repair site, it is from the abdominal lavage not bbeing carried out properly
e.g. lavage not carried out properly in difficult ares such as in the lesser sac, behind the stomach - fluid accumulates there and becomes infected
Leak unlikely - as repair site has usually healed by day 5 post-op
How is an intra-abdominal collection treated?
Put in a drain, flush it to get the debris out
If the leak / ulcer was there, then anything put in the stomach would come out of the drain - but this didn’t happen
What is the difference between a leak and a collection?
Leak = from the GI tract
Collection is not a leak from the repair site, it is from the abdominal lavage not bbeing carried out properly
Case 2
45F - upper abdo pain intermittently 1y, esp. after eating Mars bars
Now 2/7 severe upper abdominal pain associated with vomiting
Overweight but otherwise fit and well
O/E: Temp 378, HR 100, BP 110/65 Tender & guarding in epigastrium No J/ Cl / An / Cy CVS, RS, CNS –NAD
Bloods: Urine - NAD WCC 20, neutrophila Hb 14 Plts 230 MCV 80 INR & APTR Normal LFTs bilirubin 35 (high), Alk phos 366 (high) CRP 150 (high) Amylase 2150 (high)
Investigations:
ECG –sinus tachy 100
CXR erect –no free air
AXR –nil diagnostic
What is the most likely diagnosis? Appendicitis Biliary colic Cholecystitis Perforated duodenal ulcer Gallstone Pancreatitis Gastritis
Gallstone pancreatitis - liver function tests are only mildly elevated, but her super high amylase = pancreas issue
How is acute pancreatitis assessed for severity?
Modified Glasgow criteria (alternative is Ranson’s criteria): 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
Score of 3 or > within 48hrs of onset - suggests severe pancreatitis
CRP is an independent predictor of severity
>200 suggests severe pancreatitis
How is acute pancreatitis managed?
ABC
Management for anyone with pancreatitis is conservative - 4 principles of management:
Fluid resuscitation (IV fluids, urinary catheter, strict fluid balance monitoring)
Analgesia - pain relief
Pancreatic rest (+/- nutritional support if prolonged recovery [NJ (nasojegunal) feeding or PN]) - every time food enters the stomach, the pancreas is put to work so it is important to give the pancreas a rest
Determining underlying cause
95% settle with conservative treatment
If severe pancreatitis on scoring –> HDU (high dependency unit) with one to one nursing as they can get unwell very quickly
Antibiotics controversial –> commence if necrotic pancreatitis/infected necrosis, but not routinely
Surgery only very rarely required
What is the next line of investigation for the patient? CT USS (ultrasound scan) MRCP HIDA scan ERCP
Suspected gallstones, so need imaging to confirm gallstones
USS - can see gallstones on this, and can check the bile duct
What does her USS show?
Shows gallbladder (big dark round black circle thing) and the 2 stones Stones give off acoustic shadows (beneath the stones projecting down) - the rest of the tissue is greyish white
Day 5 of in-patient admission
Her LFTs still remain high even though they should be going down
What is the next line of investigation? CT abdo/pelvis USS abdomen MRCP HIDA scan ERCP
MRCP - Magnetic resonance cholangiopancreatography
Worried about stones within their common bile duct
MRCP can confirm gallstones in the common bile duct
Not appropriate to skip straight to ERCP as there may not be gallstones there
MRCP shows gallstones
What is the next line of investigation? CT abdo/pelvis USS abdomen MRCP HIDA scan ERCP
ERCP - helps take out the stones
Scope is passed through the stomach, through the ampulla
Wire placed in first, then balloon
Balloon is blown up just proximal to where the stones are
And the stones are pulled out
How can you tell when a stone has passed?
When patient comes in with gallstones, LFTs are high
But once the stone has passed, the LFTs return to normal
Day 7 of in-patient admission Things get worse On HDU In pain Urine output 10mls/hr despite +ve fluid balance of 3L p02 of 7.9 on Fi02 0.35 HR 110, BP 110/65 Modified Glasgow Criteria score of 3 (LDH, WCC, p02)
What is the next line of investigation? CT abdo/pelvis USS abdomen MRCP HIDA scan ERCP
CT - can show the complications from pancreatitis
What does the patient’s CT scan show?
Patient’s CT showed changes consistent with pancreatitis - pancreatic juice munching away at fat = inflammatory response
Clinically much improved by day 10
Discharged home with elective laparoscopic cholecystectomy set for 6/52
Unfortunately readmitted following 10 days after discharge:
Severe RUQ pain 3/7
Constant
Sweats and rigors
Bloods:
WCC 18 (raised)
Bili 17, ALP 130, AST 100, Amylase 75
CRP 95
O/E:
Temp 379, HR 115, BP 100/60
Abdomen soft, tender and guarding RUQ
Positive Murphy’s sign
What is the most likely diagnosis?
Cholecystitis - blocked stone WITH inflammation and constant pain (unlike biliary colic = no inflammation and colicky pain)
CT scan shows: inflammed gallbladder
What is the treatment for cholecystitis?
No acute laparoscopic cholecystectomy because of duration of symptoms - need ot let cholecystitis settle
Treated conservatively with fluid resuscitation & IV ABx
Pain improving
Inflammatory markers coming down (CRP 10)
No fevers or tachycardia for 24 hrs
Discharge with laparoscopic cholecystectomy set for 6/52
Which are the two structures that need to be identified and divided during a laparoscopic cholecystectomy?
Cystic duct and cystic artery
Need to be careful not to cut through the hepatic ducts or arteries as it will be compromising blood flow to the liver
What are some biliary and vascular anamolies?
Hilum for liver is different in about 25% of patients
What are some common complications during a laparoscopic cholecystectomy?
Biliary complications: damaging common bile duct or right hepatic duct
OR
Vascular complications: issues with vessels / bleeding
Post-operatively Well No pain Drain removed by nurse 12 hrs later, prior to discharge The drain snapped
Where is drain tip?
CT scan shows the drain tip is still inside the patients body
What is the next line of treatment for the snapped drain?
Relaparoscoped
To take out drain tip
Patient went home the next day
