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Y2 - BRS - GI > Disorders of Upper GI Tract Tutorial > Flashcards

Disorders of Upper GI Tract Tutorial Flashcards

1
Q

What are the surgical and non-surgical causes of upper abdominal pain?

A 
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
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2
Q

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
A

CXR and AXR

Erect chest x-ray to:
Look for air under the diaphragm (performation)
Look for chest problems

Abdominal x-ray

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3
Q

What does his AXR show?

A

Completely normal - normal bowel gas patterns

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4
Q

What is the patient diagnosed with and how is he treated?

A

Patient is given IV fluids and paracetamol
Diagnosed with gastritis
Discharged home with no follow-up (patient just wanted to go home)

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5
Q 
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?

A

Erect CXR and AXR again

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6
Q

What did the patient’s CXR and AXR show?

A

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

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7
Q

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
A

Perforated Viscus

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8
Q 
What is the likely perforated organ?
Duodenum
Stomach
Sigmoid diverrticular disease
Appendix
Small bowel
Colon from colitis
A

Due to drinking and smoking history - most likely duodenum or stomach

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9
Q

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?

A

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

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10
Q

What is a consequence of the perforation?

A

Acute peritonitis - duodenum contents fall out and into the abdominal cavity

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11
Q

What is the management of acute peritonitis?

A 
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

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12
Q

What are the treatments for perforated ulcer:

A 
Conservative treatment (Taylor's approach) - for old, frail patients with contained perforation
Radical surgery (vagotomy, gastrectomy)
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13
Q

Where is the most common site of perforation for duodenal ulcer disease?

A

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

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14
Q

How do anterior and posterior duodenal ulcers differ?

A

Anterior ulcers tend to perforate

Posterior ulcers tend to bleed

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15
Q

Are gastric or duodenal perforations more common and why?

A

Duodenal = 10x more likely than gastric perforation

Because the stomach has many more protective mechanisms for its lining compared to the duodenum

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16
Q

What is the first step for a perforated stomach?

A

You must think - ‘have they got a cancer that has perforated?’
Take biopsy if you come across it during a surgery

17
Q

How are perforations normally amended surgically?

A

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

18
Q

What do you do post-operatively for the patient?

A

Lavage - fluid washouts to get rid of contamination

Take observations often

19
Q 
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
A

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

20
Q

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
A

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

21
Q

How is an intra-abdominal collection treated?

A

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

22
Q

What is the difference between a leak and a collection?

A

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

23
Q

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
A

Gallstone pancreatitis - liver function tests are only mildly elevated, but her super high amylase = pancreas issue

24
Q

How is acute pancreatitis assessed for severity?

A 
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

25
Q

How is acute pancreatitis managed?

A

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

26
Q 
What is the next line of investigation for the patient?
CT 
USS (ultrasound scan)
MRCP
HIDA scan
ERCP
A

Suspected gallstones, so need imaging to confirm gallstones

USS - can see gallstones on this, and can check the bile duct

27
Q

What does her USS show?

A 
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
28
Q

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
A

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

29
Q

MRCP shows gallstones

What is the next line of investigation?
CT abdo/pelvis
USS abdomen
MRCP
HIDA scan
ERCP
A

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

30
Q

How can you tell when a stone has passed?

A

When patient comes in with gallstones, LFTs are high

But once the stone has passed, the LFTs return to normal

31
Q 
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
A

CT - can show the complications from pancreatitis

32
Q

What does the patient’s CT scan show?

A

Patient’s CT showed changes consistent with pancreatitis - pancreatic juice munching away at fat = inflammatory response

33
Q

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?

A

Cholecystitis - blocked stone WITH inflammation and constant pain (unlike biliary colic = no inflammation and colicky pain)

CT scan shows: inflammed gallbladder

34
Q

What is the treatment for cholecystitis?

A

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

35
Q

Which are the two structures that need to be identified and divided during a laparoscopic cholecystectomy?

A

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

36
Q

What are some biliary and vascular anamolies?

A

Hilum for liver is different in about 25% of patients

37
Q

What are some common complications during a laparoscopic cholecystectomy?

A

Biliary complications: damaging common bile duct or right hepatic duct
OR
Vascular complications: issues with vessels / bleeding

38
Q 
Post-operatively
Well
No pain
Drain removed by nurse 12 hrs later, prior to discharge
The drain snapped

Where is drain tip?

A

CT scan shows the drain tip is still inside the patients body

39
Q

What is the next line of treatment for the snapped drain?

A

Relaparoscoped
To take out drain tip
Patient went home the next day

Y2 - BRS - GI (14 decks)

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