Foregut Flashcards
1
Q
Complications of peptic ulceration
A
- Haemorrhage
- Perforation
- Gastric outlet obstruction
- Recurrent ulceration
2
Q
Nerves of Laterjet
A
Gastric divisions of both anterior and posterior gastric nerves
3
Q
Role of CCK
A
- Secretion of enzyme-rich fluid from pancreas
- Contraction of GB
- Relaxation of Sphincter of Oddi
- Induces satiety
4
Q
Gastric ulcers associated with Burns
A
Curling’s ulcers
5
Q
Gland predominance in antrum and pylorus
A
Mucus and neuroendocrine
6
Q
Level of oesophogastric junction
A
T11 (passes the tip of the xiphoid process)
7
Q
Clinical features of gastric ulcers
A
- Epigastric pain induced by eating
- Weight loss
- N+V
- IDA is common
8
Q
Incidence of Barrett’s
A
1%
9
Q
Branches of coeliac trunk
A
- Right gastric
- Common hepatic
- Splenic
10
Q
Management of Boerhaave syndrome
A
Surgical repair urgently due to extensive contamination
11
Q
Length of oesophagus
A
25cm
12
Q
Barium swallow appearance of achalasia
A
‘Birds-beak’ appearance
13
Q
Describe the course of B12 absorption
A
- Enters stomach bound to salivary R protein
- In the duodenum pancreatic trypsin hydrolyses the R protein
- B12 then binds to intrinsic factor
- Complex absorbed in terminal ileum
14
Q
Gastric ulcers associated with brain damage
A
Cushing’s ulcers
15
Q
Three phases of gastric acid secretion
A
- Cephalic phase
- Gastric phase
- Duodenal phase
16
Q
Name the two classic gastric ulcer operations
A
- Bilroth 1
2. Bilroth 2
17
Q
Describe the cephalic phase of gastric secretion
A
Vagal activity caused by site and smell of food causes:
- Gastric glands stimulated by Ach
- Gastrin released by G cells
- Histamine released from mast cells which stimulates parietal cells
18
Q
Describe the gastric phase of acid secretion
A
- Food enters stomach
2. Stretch causes Ach release from vagus
19
Q
Age cut off for OGD in GORD
A
55
20
Q
Laparoscopic GORD procedure
A
Nissen 360 fundoplication - fundus is wrapped around lower oesophagus
21
Q
Outline the superior and inferior bounds of the oesophagus
A
- Superior = lower border of cricoid cartilage
- Inferior = cardiac orifice of the stomach
22
Q
Origin of left gastro-omental artery
A
Splenic artery
23
Q
Where do peptic ulcers most commonly occur
A
Duodenum (80%)
24
Q
Incisura angularis
A
- Most inferior part of lesser curvature
- Junction between body and pyloric part
25
Complications of achalasia
- Squamous cell carcinoma
- Bronchiectasis
- Lung abscess
- Nocturnal aspiration
26
Describe the 4 natural oesophageal constrictions
1. Cervical caused by cricopharyngeus muscle
2. Crosses arch of aorta
3. Crosses left main bronchus
4. Pierces the diaphragm
27
Complication of gasrectomy
- Dumping syndrome
- Anaemia and malnutrition
- Carcinoma of gastric remnant
- Pancreatitis
- TB
- Osteomalacia
28
What is contained within the hepatogastric ligament
Right gastric vessels
29
Normal resting LES tone
>5mmHg over a distance of >1cm
30
How does Barrett's develop into cancer
Dysplasia to adenocarcinoma
31
GOLD standard investigation of oesophageal rupture
Contrast study
32
GIST origin
Intestinal pacemaker cells of Cajal
33
Pattern of stomach venous drainage
Run parallel to arteries
34
Most common site of spontaneous oesophageal rupture
Left aspect just above the cardia
35
Describe the course of the abdominal oesophagus
- Pierces diaphragm at T10 in the right crus
- Attached to oesophageal hiatus by phrenico-oesophageal ligament
- Lies in groove on posterior surface of left lobe of liver
- Covered anteriorly and to the left with peritoneum
36
Gland predominance in cardia
Mucus cells
37
GOLD standard reflux investigation
pH monitoring
38
Risk factors for oesophageal adenocarcinoma
- Barrett's
- GORD
- Obesity
- Smoking
- High alcohol intake
- High fat diet
39
Complications of GORD
- Barrett's
- Stricture
- Bleeding
40
Most common site of external gastric mucosa
Meckel's diverticulum
41
Indication for surgical management of peptic ulcers
- Failure of medical treatment
- Complications
- Non-healed gastric ulcer
- Giant gastric ulcer (>3cm) that hasn't healed in 6-8 weeks
42
How can early dumping be managed
- Time and small meals
| - Subcut Somatostatin injections
43
Describe the course of the left gastric artery
1. Arises from coeliac axis
2. Runs along lesser curvature
3. Anastomoses with right gastric branch of hepatic artery
44
Role of Secretin
- Increases secretion of bicarbonate-rich fluid from pancreas and hepatic duct cells
- Reduces gastric acid secretion
- Inhibits antral contractions and increase pyloric sphincter tone
45
Treatment of Barett's (metaplasia and low-grade dysplasia)
- Laser/argon ablation causes squamous regeneration
- Anti-reflux surgery normalises cancer risk
- Long-term PPI
46
Atrophic gastritis
Caused by an autoimmune process attacking the parietal cells
47
Describe the effect of retrograde lymphatic spread in gastric cancer
Invades the hepatic nodes at the porta hepatis
48
Macroscopic appearance of linitis plastica (leather bottle stomach)
Marked fibrous reactions causing small, thickened, contracted stomach
49
Deficiencies resulting from gastrectomy
- Iron - as wrong ionic state for absorption
| - B12 - lack of intrinsic factor
50
Initial management steps of oesophageal rupture
1. Resus
2. NBM
3. Broad spectrum abx
3. Parenteral nutrition
4. PPI and analgesia
51
Which vessel is divided in the McKeown oesophagectomy
Azygous vein
52
Describe rolling hiatus hernia (Type 2)
- A.K.A. paraoesophageal
- GOJ remains in normal position below the diaphragm
- Stomach herniates into chest alongside oesophagus
- Entire stomach is covered in peritoneum
53
Origin and site of short gastric arteries
- Splenic artery
| - Within the gastrosplenic ligament
54
How is acid secretion reduced in duodenal ulcer surgery
Division of the vagus nerve
55
Complications of vagus nerve division
- Diarrhoea
- Gastric atony
- Gastric outlet obstruction
- Gallstones (due to GB denervation)
56
Clinical features of duodenal ulcers
- Epigastric pain on fasting
- Pain at night
- Relieved by food and antacids
- Penetrating posterior ulcers cause pain radiating to back
57
Complications of laparoscopic oesophagectomy
- Bleeding from azygous vein/intercostals/aorta
- Injury to tracheobroncial tree
- Injury to recurrent laryngeal nerve
58
Biochemical definition of GORD
Oesophageal pH of <4 for >4% of a 24-hour period
59
Angle of His
The oblique angle at which the oesophagus enters the stomach
60
Promotors of gastric emptying
Gastrin
61
Why is previous gastric surgery a cause of gastric cancer
Intestinal metaplasia at the anastomosis
62
Gland predominance in Fundus and body
Peptic and parietal
63
UGI re-bleed major stigmata
1. Pulsatile or oozing haemorrhage
2. Fresh clot on ulcer
3. Adherent clot on ulcer
4. Visible vessel in base of ulcer
64
Principles of gastric ulcer surgery
1. Removal of the ulcer
| 2. Removal of the gastrin-secreting part of the antrum
65
Role of Parietal (Oxyntic) cells
Secrete HCL and Intrinsic factor
66
Outline treatment of sliding hiatus hernia
- No surgery if asymptomatic
| - Antireflux procedure is persistent symptoms
67
What is the alkaline tide
- Production of HCO3 to protect the gastric mucosa
| - Influenced by prostaglandin E
68
Histological change seen in Barrett's
Transformation of the normal squamous lining into metaplastic columnar epithelium
69
In whom is LES pressure reduced
- Smokers
- Women on COCP
- People on atropine
- Pregnant women
70
Describe psuedo-achalasia
Carcinoma of the LES/cardia/extrinsic tumour (increased resistance to passing scope unlike true achalasia)
71
Describe Ivor-Lewis procedure
1. Laparotomy with mobilisation of stomach
2. Right thoracotomy for tumour resection
3. Mobilised stomach brought up to anastomose with oesophagus
72
Presentation of achalasia
Dysphagia to solids and liquids equally
73
Chagas disease associations
- Cardiomyopathy
- Megacolon
- Megaduodenum
- Megaureter
74
Role of Peptic (Chief) cells
Secrete pepsinogen
75
Site of drainage of Left gastro-omental vein
SMV
76
Metabolic picture of gastric outlet obstruction
Hypochloraemic hypokalaemic metabolic alkalosis
77
Laser used for controlling UGI haemorrhage
Nd:YAG laser
78
Site of drainage of right gastro-omental vein
Splenic vein which joins SMV
79
Anterior, posterior, and lateral relations of the cervical oesophagus
- Anterior = trachea, thyroid
- Posterior = lower cervical vertebrae, prevertebral fascia
- Left = left common carotid, left inferior thyroid artery, left subclavian, thoracic duct
- Right = right common carotid
(Recurrent laryngeal nerves lie on either side in the groove between trachea and oesophagus)
80
Adjuvant chemotherapy for GIST
Imatinib (Tyrosine Kinase Inhibitor)
81
Describe Zollinger-Ellison syndrome
Gastrin-secreting tumour (gastrinoma) of the pancreatic islet cells causing excessive acid secretion
82
Relative indications for emergency surgical ulcer treatment
- One re-bleed in hospital (2 if <60)
- Transfusion requirement:
> 4 units/24hr if >50
> 6 units/24hr if <50
83
Which MEN are gastrinomas related to
MEN 1
84
Embryological origin of foregut
Cranial region of endoderm
85
What comprises the foregut
- Oesophagus
- Stomach
- Duodenum (up to ampulla of vater)
- Liver
- Gallbladder
- Pancreas
- Spleen
86
Classification of Barrett's
- Short = <3cm
| - Long = >3cm
87
Physiology of parietal cell
- Proton pump spans apical surface of cell
- H+ from H/K ATPase system
- CL- from Cl/K co-transporter
88
Role of histamine in gastric acid secretion
1. Histamine release from mast cells
| 2. Stimulates parietal cels vial H2 receptors
89
Level of coeliac trunk
T12
90
Management of delayed presentation (>2 days) oesophageal perforation
Conservative as too friable to suture
91
Effect of stomach acid in the duodenum
- Delays gastric emptying
| - Increases Secretin release
92
Describe the course of the cervical oesophagus
Passes downwards and slightly to the left
93
Risk factors for oesophageal SCC
- High alcohol intake
- Tobacco
- Vitamin A + C deficiency
- Coeliac disease
- Strictures
- Achalasia
94
Anterior, posterior, and lateral relations of the thoracic oesophagus
- Anterior = left common carotid, trachea, left main bronchus, pericardium
- Posterior = thoracic vertebrae, thoracic duct, hemiazygous vein, descending aorta
- Left = left subclavian, aortic arch, left vagus and its recurrent laryngeal branch, thoracic duct, left pleura
- Right = right pleura, azygous vein
95
List conditions causing odynophagia
- Reflux
- Peptic ulcer
- Thrush
- Herpes
- Viral and bacterial pharyngitis
- Diffuse oesophageal spasm
96
Describe sliding hiatus hernia (Type 1)
Cephalid displacement of the GOJ and proximal stomach through the diaphragmatic hiatus into the posterior mediastinum
97
Dominant phase of gastric acid secretion
Gastric phase - responsible for 60%
98
Most common histological type of gastric cancer
Adenocarcinoma
99
Chemical inhibitors of Gastrin
- Somatostatin
- Secretin
- CCK
- GIP
100
Posterior relations of stomach
- Lesser sac
- Pancreas
- Left kidney
- Left adrenal
- Spleen
- Splenic artery
- Transverse mesocolon
101
Presentation of GISTs
- Haematemesis
- Melaena
- Palpable abdominal mass
102
Clinical features of diffuse oesophageal spasm
- Retrosternal pain
| - Radiates to jaw and intrascapular region
103
Anterior relations of stomach
- Diaphragm
- Greater omentum
- Anterior abdominal wall
- Left lobe of liver
- GB
104
Describe the lymphatic drainage of the oesophagus
- Upper 1/3rd = deep cervical
- Middle 1/3rd = mediastinal
- Lower 1/3rd = gastric
105
Definitive surgical treatment for duodenal ulcer
Vagotomy and pyloroplasty
106
Pathology of oesophageal carcinoma
1. Adenocarcinoma - 65% (occur in lower 1/3rd)
2. SCC - appear at any level
3. Oat cell carcinoma - rare and poor prognosis
107
Oesophageal epithelium type
Stratified squamous
108
Treatment of T1 Oesophageal disease
Endoscopic mucosal resection
109
What part of the stomach is removed in gastric ulcer surgery
Antrum - most recommend removal of the distal 1/3rd of the stomach
110
Site and cause of ulcer haemorrhage
- Posterior wall
| - Gastroduodenal artery
111
CXR features of hiatus hernia
Lateral film shows fluid level in posterior mediastinum
112
What denotes the change in mucosa from oesophageal to gastric
Z-line
113
When is total gastrectomy required in gastric cancer
Tumours within 5cm of the GOJ
114
Outline sympathetic innervation of the stomach
T6-T9 spinal segments which pass to coeliac plexus via greater splanchnic nerve
115
Describe the arterial supply of the oesophagus
- Upper 1/3rd = inferior thyroid artery
- Middle 1/3rd = aortic branches
- Lower 1/3rd = left gastric artery
116
How can late dumping be managed
- Small dry meals
| - Glucose sweets
117
Two types of gastric adenocarcinomas and associated prognosis
1. Intestinal type - poor
| 2. Diffuse type - better
118
Inhibitors of gastric emptying
- GIP
- CCK
- Enteroglucagon
- Secretin
119
Treatment of Barrett's (high-grade dysplasia)
- Histology should be confirmed by 2 pathologists
| - Oesophagectomy
120
Outline the 4 divisions of the stomach
1. Cardia - surrounds cardial orifice at T1 and posterior to 6th costal cartilage
2. Fundus - superior to cardia
3. Body - central portion
4. Pyloric part
121
What prevents the stomach lining being eroded by stomach acid
- Alkaline mucus
- Tight epithelial junctions
- Prostaglandin E stimulates alkaline tide
122
GORD biopsy position and histology
- 5cm above GOJ
| - Increased eosinophils and hypoplasia
123
What are the two types of Gastritis
1. Type A - associated with parietal cell antibodies
| 2. Type B - extends from pyloric region to the lesser curve and associated with gastric surgery
124
What type of bacteria is H. pylori
Gram negative bacillus specific for gastric mucosa
125
When does osteomalacia occur after partial gastrectomy
10-20 years
126
Outline treatment of rolling hiatus hernias
- All should be repaired
| - Hernia reduced, sac excised, fundoplication
127
Describe the course of the thoracic oesophagus
- Passes through superior and posterior mediastinum
- Reaches midline at T5
- Passes down, forward, and left to pierce diaphragm at T10
128
Role of gastric acid
- Convert pepsinogen to pepsin
- Tissue breakdown
- Forms soluble salts with calcium and iron
- Immune defence
129
Describe late dumping syndrome
Due to rapid swing in insulin production due to presence of glucose in small bowel - causes reflex hypoglycaemia
130
What is the endoscopic procedure for peptic ulcer diagnosis
- OGD
- At least 6 biopsies must be taken
- CLO test
131
Macroscopic appearance of malignant ulcer
Raised, everted edges
132
Describe the course of the right gastro-omental (epiploic) artery
1. Arises from gastroduodenal branch of hepatic artery
2. Supplies greater curvature
3. Anastomoses with left gastro-omental artery
133
GOLD standard investigation for hiatus hernia
Barium swallow
134
Site of drainage of right and left gastric veins
Hepatic portal vein
135
Why is gastrectomy a risk for TB
- Malnutrition
| - Decreased immunity
136
Management of benign pyloric strictures
- Rare
- Malignancy is a risk
- Resection and reconstruction is recommended
137
Surgical implication of prepyloric vein
Indicator of pylorus position (drains into right gastric vein)
138
Volume of gastric acid secretion per day
2-3L
139
Describe Chagas disease
Chronic infection with Trypansoma cruzi
140
Describe early dumping syndrome
- Occurs 30-45 mins after eating
- Due to rapid gastric emptying of hyperosmolar meal into small bowel
- Dizziness, weakness, palpitation
- Fluid moves into small bowel by osmosis
141
Outline the lymphatic drainage of the stomach
- Superior 2/3rd = gastric nodes
- Right 2/3rd = pyloric nodes
- Left 1/3rd = pancreaticoduodenal nodes
142
Describe McKeown Stage 3 oesophagectomy
1. Ivor-Lewis procedure plus a neck incision
| 2. Stomach is brought up to the cervical oesophagus
143
Treatment of GIST
Local excision without lymphadenectomy
144
Treatment of achalasia
1. Conservative
2. Balloon dilatation
3. Heller's cardiomyotomy
4. Botulinum toxin
145
Role of Gastrin
Stimulates:
- HCL, pepsinogen and IF release
- Gastric emptying
146
Role and site of stomach mucus cells
- Secrete mucus
| - Opening of the gastric glands
147
Management of small contained oesophageal perforation
1. Conservative
| 2. Repeat contrast study after 5 days
148
Management of large oesophageal perforation
1. Conservative for 12 hours
| 2. Surgical repair
149
Treatment of diffuse oesophageal spasm
Nifedipine
150
Macroscopic appearance of Colloid tumour
Massive gelatinous growth
151
Outline the follow-up of Barrett's
- No dysplastic cells = 2-yearly OGD
- Low-grade dysplasia = repeat (Quadran) biopsy after 8-12 weeks acid suppression
- High-grade dysplasia = esophagectomy if changes persist after acid suppression
152
Origin of right gastric artery
Hepatic artery
153
Mainstays of non-surgical management of ulcer perforation
1. NBM and NG
2. IVF and broad-spectrum abx
3. Continued assessment
154
Level of transpyloric plane
L1
155
Role of pepsin
Hydrolyses peptide bonds in proteins
156
Structure of the oesophagus
- Inner circular muscle
- Outer longitudinal muscle
- Submucosal layer with sparse mucous glands
157
Barrett's histological diagnosis
- Intestinal metaplasia
| - Presence of Goblet cells
158
Describe the intestinal phase of acid secretion
Presence of food in the duodenum stimulates gastrin release from G cells
159
Pathophysiology of achalasia
High LES pressure and failure of relaxation of the sphincter
160
Key vertebral levels associated with the oesophagus
- C6 = start
- T10 = pierces diaphragm
- T11 = end
161
Outline parasympathetic innervation of the stomach
- Anterior vagal trunk - hepatic branch and pyloric branch
| - Posterior vagal trunk - coeliac branch
162
Most common type of hiatus hernia
Sliding (Type 1)
163
What connects the liver to the stomach
Hepatogastric ligament (membranous portion of lesser omentum)
164
Absolute indications for emergency surgical ulcer treatment
- Continue bleeding at endoscopy
| - Lesions that invariably re-bleed
165
How is the gastric mucosa divided
- Columnar epithelium (secretes protective mucus layer)
| - Gastric glands (contain variety of secretory cells)
166
Role of Somatostatin (Ocreotide)
- Decreases acid and pepsinogen secretion
- Decreases gastrin secretion
- Decreases pancreatic enzyme secretion
- Decreases insulin and glucagon secretion
- Inhibits growth hormone production
- Stimulates gastric mucous production
167
Origin of the cystic artery
Right hepatic artery
168
Relation of the SMA to the uncinate process
Posterior to neck of pancreas but crosses anterior to uncinate process
169
Origin of the right gastro-epiploic artery
Gastroduodenal artery
170
Origin of the pancreas
Ventral and dorsal endodermal outgrowth of the duodenum
171
Origin of the spleen
Mesenchymal tissue
172
Borders of Hesselbachs triangle
Rectus, inguinal ligament and inferior epigastric vessels
173
Origin of pancreatic carcinoma
Ductular epithelium
174
Incision for Whipple's
Rooftop
175
How is splenic vein thrombosis managed following pancreatitis
Splenectomy
176
Management of pancreatic pseudocyst
Elective cystogastrostomy after 12 weeks as most regress
