General - gastric

Question 1

What is a peptic ulcer?

Answer 1

Break in the lining of the GI tract, extending through to the muscularis mucosae layer of the bowel wall
Endoscopic diagnosis
Most often located on the lesser curvature of the proximal stomach or the first part of the duodenum

Question 2

List risk factors for peptic ulcer disease

Answer 2

NSAIDs
H. pylori
Smoking
Corticosteroid use
Massive physiological stress

Question 3

Describe the pathophysiology of peptic ulcers

Answer 3

Normal gastrointestinal mucosa is protected by numerous defensive mechanisms – surface mucous secretion & HCO3- ion release
In PUD – imbalance between factors that protect the mucosa of the stomach and duodenum & factors that cause damage to it

Question 4

List clinical features of PUD

Answer 4

Epigastric/retrosternal pain
Nausea, bloating, post-prandial discomfort, early satiety
Presentation with complications – bleeding, perforation, gastric outlet obstruction

Question 5

Zollinger-ellison syndrome

Answer 5

Triad of:
1) Severe peptic ulcer disease
2) Gastric acid hypersecretion
3) Gastrinoma
Characteristic finding = fasting gastrin level of >1000 pg/ml

Question 6

PUD investigations

Answer 6

FBC
Non-invasive H. pylori testing – C13 urea breath test, serum antibodies to H. pylori and stool antigen test
OGD required in red flag symptoms, older patients or those with ongoing symptoms
Endoscopy – any peptic ulceration seen can be biopsied which will be sent for histology & for rapid urease test

Question 7

PUD conservative management

Answer 7

Any patient with suspected/confirmed PUD should be given lifestyle advice to reduce symptoms – smoking cessation, weight loss & reduction in alcohol consumption, avoidance of NSAIDs
PPI for 4-8 weeks to reduce acid production
Patients with a positive H. pylori should be started on triple therapy
Persistence of symptoms post-PPI +/- eradication therapy warrants further work-up – urgent OGD to exclude any malignancy

Question 8

PUD surgical management

Answer 8

Rare
Severe/relapsing disease – partial gastrectomy/selective vagotomy

Question 9

PUD complications

Answer 9

Perforation
Haemorrhage
Pyloric stenosis

Question 10

Gastric cancer

Answer 10

5th most common cancer globally, mostly due to patients presenting with advanced disease
Majority arise from the gastric mucosa as adenocarcinomas

Question 11

Gastric cancer risk factors

Answer 11

Male
H pylori infection
Increasing age
Smoking
Alcohol consumption

Question 12

Gastric cancer clinical features

Answer 12

Dyspepsia, dysphagia, early satiety, vomiting or melaena
Examination – epigastric mass may be felt in late stage disease, Troisier sign (palpable left supraclavicular node)
Metastatic disease – hepatomegaly, ascites, jaundice or acanthosis nigricans (hyperpigmentation of the skin creases)

Question 13

Gastric cancer investigations

Answer 13

Lab tests – urgent bloods: FBC, LFTs
Imaging – urgent upper GI endoscopy
Biopsies should be sent for:
- Histology: classification and grading of any neoplasia
- CLO test: presence of H. pylori
- HER2/neu protein expression: allow targeted monoclonal therapies if present
CT chest-abdomen-pelvis and a staging laparoscopy

Question 14

Gastric cancer curative treatment

Answer 14

Mainstay of curative treatment is surgery
- Proximal gastric cancers = total gastrectomy
- Distal gastric cancers = subtotal gastrectomy
Most commonly used method in reconstructing the alimentary anatomy is the Roux-en-Y reconstruction as it gives the best functional result
Patients with early tumours may be offered an endoscopic mucosal resection

Question 15

Gastrectomy complications

Answer 15

Death
Anastomotic leak
Re-operation
Dumping syndrome
Vitamin B12 deficiency

Question 16

Gastric cancers palliative management

Answer 16

Most patients will only be offered palliative care due to the extent of disease at time of presentation
- Chemotherapy
- Best supportive care
- Stenting
Palliative surgery can be used when stenting fails/is not available

Question 17

Gastric cancers complications

Answer 17

Gastric outlet obstruction
Iron-deficiency anaemia
Perforation
Malnutrition

Question 18

Hiatus hernia

Answer 18

Describes the protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus (typically the stomach)

Question 19

Hiatus hernia classification

Answer 19

Classified into two subtypes:
- Sliding hiatus hernia – GOJ, the abdominal part of the oesophagus and frequently the cardia of the stomach move or slide upwards through the diaphragmatic hiatus into the thorax
- Rolling/para-oesophageal hernia – upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ, which creates a bubble of stomach in the thorax (true hernia with a peritoneal sac)

Question 20

Hiatus hernia risk factors

Answer 20

Age
Increasing intrabdominal pressures
Increased size of diaphragmatic hiatus
Pregnancy, obesity & ascites

Question 21

Hiatus hernias clinical features

Answer 21

Vast majority are completely asymptomatic
GORD symptoms – burning epigastric pain, made worse by lying flat
Other symptoms – vomiting, weight loss, bleeding, anaemia, hiccups, palpitations, swallowing difficulties
In large hiatus hernia – bowel sounds may be auscultated within the chest

Question 22

Hiatus hernia investigations

Answer 22

Oesophagogastroduodenoscopy = gold standard investigation, showing upward displacement of the GOJ
Can also be diagnosed incidentally either on a CT or MRI

Question 23

Hiatus hernia conservative management

Answer 23

PPI
Weight loss, alteration of diet, sleeping with head of the bed raised
Smoking cessation, reduction in alcohol intake should be advised

Question 24

Hiatus hernia surgical management

Answer 24

Indicated when:
- Remaining symptomatic
- Increased risk of strangulation/volvulus
- Nutritional failure
Two aspects of surgery:
1) Cruroplasty – hernia is reduced from the thorax into the abdomen & the hiatus reapproximated to the appropriate size
2) Fundoplication – gastric fundus is wrapped around the lower oesophagus and stitched in place

Question 25

Hiatus hernia surgery complications

Answer 25

Recurrence of the hernia
Abdominal bloating
Dysphagia
Fundal necrosis

Question 26

Hiatus hernia complications

Answer 26

Prone to incarceration and strangulation
Gastric volvulus can occur – stomach twists on itself by 180 degrees, present with Borchardt’s triad:
1) Severe epigastric pain
2) Retching without vomiting
3) Inability to pass an NG tube