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Surgery Block > General - Stomach + Oesophagus > Flashcards

General - Stomach + Oesophagus Flashcards

1
Q

Define a hiatus hernia

A

Protrusion of an organ from the abdominal cavity into the thorax via the oesophageal hiatus

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2
Q

What are the two subtypes of hiatus herniae?

A

Sliding hiatus hernia (80%)

Rolling or para-oesophageal hernia (20%)

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3
Q

List some of the risk factors for developing a hiatus hernia

A

Age - loss of diaphragmatic tone, increased intra-abdominal pressure, increased size of hiatus
Pregnancy
Obesity
Ascites

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4
Q

Describe the typical presentations of a hiatus hernia

A
  • Completely asymptomatic
  • GORD symptoms
  • Vomiting + weight loss
  • Bleeding +/- anaemia
  • Hiccups or palpitations
  • Swallowing difficulties
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5
Q

Why may you get bleeding with or without anaemia in a hiatus hernia?

A

Secondary to oesophageal ulceration

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6
Q

What are the examination findings of a patient with a hiatus hernia?

A

Typically normal

If large then bowel sounds may be heard in the chest

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7
Q

What are the main DDx to exclude in a case of a hiatus hernia?

A
  • Cardiac chest pain
  • Gastric or pancreatic cancer
  • GORD
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8
Q

What is the gold standard investigation for a hiatus hernia?

A

OGD - will show displacement of the GOJ

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9
Q

What conservative management is indicated for a hiatus hernia?

A 
PPIs
Weight loss
Alteration of diet - low fat, earlier meals, smaller portions
Sleeping more uprights
Smoking cessation
Reduced alcohol intake
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10
Q

When is surgical management indicated for a hiatus hernia?

A
  • Patient remains symptomatic regardless of max medical therapy
  • Increased risk of strangulation/volvulus
  • Nutritional failure due to gastric outlet obstruction
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11
Q

What are the main aspects of hiatus hernia surgery

A

Cruroplasty (reduction of hernia and hiatus size)

Fundoplication (strengthens the LOS)

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12
Q

What are specific complications related to hiatus hernia surgery?

A
  • Hernia recurrence
  • Abdominal bloating (unable to belch)
  • Dysphagia
  • Fundal necrosis
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13
Q

What are the main complications of hiatus herniae?

A

Incarceration

Strangulation

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14
Q

What is the name given for the clinical presentation of gastric volvulus and what is it?

A

Borchardt’s triad:

  • Severe epigastric pain
  • Retching without vomiting
  • Inability to pass an NG tube
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15
Q

Define a peptic ulcer

A

A break in the lining of the GI tract, extending through the muscular mucosae

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16
Q

Where are peptic ulcers most commonly located?

A

Lesser curvature of the proximal stomach or first part of the duodenum

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17
Q

What are the common causes for peptic ulcer disease?

A
  • H pylori infection
  • NSAID overuse
  • Excess alcohol
  • Steroid overuse
  • Zollinger-Ellison syndrome
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18
Q

What is helicobacter pylori?

A

Gram negative spiral bacillus

Survives by producing an alkaline micro-environment which induces an inflammatory response in the mucosa

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19
Q

How does H pylori cause ulceration?

A
  • Cytokine and interleukin driven inflammatory response
  • Increasing gastric acid secretion (induces histamine release)
  • Degredation of surface glycoproteins and down regulating bicarb production (damages mucous secretion)
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20
Q

What mnemonic can be used for basis of referral for urgent endoscopy for malignancy?

A 
ALARMS
A - Anaemia
L - Lost weight
A - Anorexia
R - Recent rapid onset
M - Melaena
S - Swallowing difficulties
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21
Q

When do the NICE guidelines suggest referral for urgent OGD?

A
  • New onset dysphagia
  • Age >55yrs with weight loss and
    1. upper abdominal pain
    2. Reflux
    3. Dyspepsia
  • New onset dyspepsia not responding to PPIs
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22
Q

What is the classic clinical presentation of a gastric ulcer?

A
  • Epigastric pain, typically exacerbated by eating
  • Nausea and anorexia
  • Weight loss
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23
Q

What is the typical presentation of a duodenal ulcer?

A

Epigastric pain - worse around 2-5hrs post meal, but often alleviated by eating

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24
Q

What differentials should be ruled out before diagnosing a peptic ulcer?

A
  • Gastric malignancy
  • Pancreatitis
  • ACS
  • GORD
  • Gallstone disease
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25
Q

What is Zollinger-Ellison Syndrome?

A

Triad of

  1. Severe peptic ulcer disease
  2. Gastric acid hypersecretion
  3. Gastrinoma
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26
Q

What non-invasive H pylori testing is there?

A
  • Urea breath test
  • Serum antibodies to H pylori
  • Stool antigen test
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27
Q

What is needed to reduce risk of a false negative H pylori test?

A

Stop any current medical therapy 2 weeks prior to test

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28
Q

What is done with biopsies taken from an OGD of a peptic ulcer?

A

Histology and rapid urease CLO test

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29
Q

What is the triple therapy for H pylori positive peptic ulcers?

A
  • PPI
  • Amoxicillin
  • Clarithromycin or metronidazole
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30
Q

What is the initial medical treatment for peptic ulcers?

A

PPI for 8 weeks

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31
Q

What surgery can be done in peptic ulcer disease?

A

Partial gastrectomy

Selective vagotomy

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32
Q

By what mechanism are NSAIDs responsible for causing gastric ulceration?

A

Inhibition of prostaglandin secretion

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33
Q

What condition is most commonly associated with Zollinger-Ellison syndrome?

A

Multiple Endocrine Neoplasia

1/3 of cases are discovered as part of type 1 MEN

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34
Q

What is used in the diagnosis of Zollinger Ellison Syndrome?

A

Fasting gastrin levels

gastrin level >1000pg/ml

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35
Q

Why are gastric cancers the 2nd highest cause of cancer related deaths?

A

Patients often present with advanced disease

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36
Q

What are the different types of gastric cancers?

A
  • Adenocarcinomas (>90%)
  • CT malignancy
  • Lymphoid
  • Neuroendocrine
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37
Q

Where is gastric cancer more common?

A

Far Eastern countries eg. Japan and Korea

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38
Q

What are the major risk factors for development of gastric cancer?

A
  • Male
  • H pylori infection (^6x)
  • Increasing age
  • Smoking
  • Alcohol consumption

(+high salt diet, FHx, pernicious anaemia)

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39
Q

How does H pylori create an alkaline microenvironment?

A

Produces urease which breaks down urea into CO2 and ammonia. The ammonia neutralises the stomach acid

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40
Q

What are the common presenting symptoms of gastric cancer?

A
  • Dyspepsia (new onset or non responsive to PPI)
  • Dysphagia
  • Early satiety
  • Vomiting
  • Melena
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41
Q

What is used for the definitive diagnosis of gastric malignancy?

A

OGD + biopsy for:

  • Histology
  • CLO test
  • HER2/neu protein expression
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42
Q

Why is a CT scan not used for gastric malignancies?

A

It does not allow for direct visualisation or biopsy

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43
Q

What is used for staging of gastric cancers?

A

CT Chest-Abdo-Pelvis + staging laparoscopy (look for mets)

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44
Q

What is required to maintain adequate nutrition in a patient with gastric cancer?

A

Nutritional status assessment

+ Review with a dietician

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45
Q

What does peri-operative chemotherapy in gastric cancer consist of?

A

3 cycles of neoadjuvant therapy and 3 cycles of adjuvant

46
Q

What surgery is indicated for proximal gastric cancers?

A

Total gastrectomy

47
Q

What surgery is indicated for distal gastric cancers? What part does this refer to?

A

Antrum or pylorus

Subtotal gastrectomy

48
Q

What method is most commonly used for reconstructing the GI tract? Why?

A

Roux-en-Y reconstruction

Best functional result - less bile reflux

49
Q

What may be offered to patients with early T1a gastric tumours (confined to muscularis mucosa)?

A

Endoscopic Mucosal Resection

50
Q

What complications are there for gastrectomy?

A
  • Death (3-5%)
  • Anastomotic leak
  • Reoperation
  • Dumping syndrome
  • Vit B12 deficiency
51
Q

What is included in the palliative management for gastric cancer?

A
  • Chemotherapy
  • Best supportive care
  • Stenting (for outlet obstruction)
  • Palliative surgery
52
Q

What are the main complications of gastric cancers?

A
  • Gastric outlet obstruction
  • Iron deficiency anaemia
  • Perforation
  • Malnutrition
53
Q

Why is a PET scan not used for imaging of gastric cancers?

A

They do not take up the radioactive tracer well

54
Q

What is a Mallory-Weiss tear?

A

Superficial mucosal tear of the oesophageal wall - usually at the gastro-oesophageal junction

55
Q

What is Boerhaave’s syndrome?

A

Spontaneous full thickness rupture of the oesophageal wall

56
Q

What is Mackler’s triad?

A

For oesophageal rupture

  • Vomiting
  • Chest pain
  • Subcutaneous emphysema
57
Q

What are the most common causes for oesophageal rupture?

A
  • Iatrogenic

- Severe forceful vomiting

58
Q

What is the definitive investigation for oesophageal rupture? What is seen on this?

A

CT chest/abdo/pelvis with IV + oral contrast
–> air/fluid in the mediastinum or pleural cavity - leakage of oral contrast from oesophagus into mediastinum/chest is pathognomonic

59
Q

What are the principles of definitive management for an oesophageal rupture?

A
  • Control of the leak
  • Eradication of mediastinal/pleural contamination
  • Decompression of the oesophagus
  • Nutritional support
60
Q

What is the surgical management for an oesophageal rupture?

A
  • On table OGD –> find the site of perforation for site of incision
  • Immediate surgery (usually thoracotomy) –> control leak + wash out chest
    (- Feeding jejunostomy –> for nutrition)
61
Q

What is required prior to commencing oral intake in an oesophageal rupture? Why?

A

CT scan 10-14 days before –> leakage is common

62
Q

What non-operative management is there for oesophageal rupture?

A
  • Resuscitation + transfer to ICU/HDU
  • Abx and anti-fungal cover
  • NBM for 1-2 weeks
  • Endoscopic insertion of an NG tube
  • Large bore chest drain insertion
  • TPN or feeding jejunostomy
63
Q

What is the prognosis for oesophageal rupture?

A

High morbidity and mortality (50-80%)

64
Q

What is the usual history for a Mallory-Weiss tear?

A

Period of profuse vomiting –> short period of haematemesis

65
Q

How are Mallory-Weiss tears generally managed?

A

Conservatively - usually small and self limiting

66
Q

What are two major causes of oesophageal dysmotility?

A
  • Achalasia

- Diffuse oesophageal spasm

67
Q

What is achalasia characterised by?

A

Failure of relaxation of the lower oesophageal sphincter + progressive failure of contraction of the oesophageal smooth muscle

68
Q

What histological feature is characteristic for achalasia?

A

Progressive destruction of ganglion cells in the myenteric plexus

69
Q

How will patients with achalasia often present?

A
  • Progressive dysphagia
  • Vomiting
  • Chest discomfort
  • Regurgitation of food
  • Coughing
  • Chest pain
  • Weight loss
70
Q

What initial investigation is used for dysphagia? Why?

A

Urgent endoscopy

–> Exclude oesophageal cancer

71
Q

What is the gold standard investigation for oesophageal motility disorders?

A

Oesophageal manometry - pressure sensitive probe inserted into oesophagus to measure pressure of sphincter + surrounding muscle

72
Q

What are the key features of achalasia on manometry?

A
  • Absence of oesophageal peristalsis
  • Failure of relaxation of the LOS
  • High resting LOS tone
73
Q

What is characteristically seen on a barium swallow for achalasia?

A

‘Birds beak’ distally + proximal dilation

74
Q

What conservative management is there for achalasia?

A
  • Sleeping with multiple pillows
  • Eating slowly + chewing thoroughly
  • Plenty of fluids with food
  • CCB’s/nitrates (temporary relief)
  • Botox injections into LOS
75
Q

What are the main surgical treatments for achalasia?

A
  • Endoscopic balloon dilatation

- Laparascopic Heller myotomy

76
Q

What is diffuse oesophageal spasm?

A

Disease caused by multifocal high amplitude contractions of the oesophagus

77
Q

What causes diffuse oesophageal spasm?

A

Dysfunction of oesophageal inhibitory nerves

78
Q

What is seen on a barium swallow for diffuse oesophageal spasm?

A

Corkscrew appearance

79
Q

What is seen on manometry for diffuse oesophageal spasm?

A

Repetitive, simultaneous and ineffective contractions of the oesophagus
+/- LOS dysfunction

80
Q

What is the management for diffuse oesophageal spasm?

A
  • Nitrates or CCB –> relax oesophageal smooth muscle
  • Pneumatic dilatation (if hypotension of LOS)
  • Myotomy (if very severe)
81
Q

What autoimmune and CT disorders are associated with oesophageal dysmotility?

A
  • Systemic sclerosis
  • Polymyositis
  • Dermatomyositis
82
Q

What are the two main types of oesophageal cancer?

A
  • Squamous cell carcinoma

- Adenocarcinoma

83
Q

What is squamous cell carcinoma of the oesophagus strongly associated with?

A
  • Smoking
  • Excessive alcohol consumption
  • Chronic achalasia
  • Low vitamin A
  • Iron deficiency (rare)
84
Q

What are the risk factors of adenocarcinoma of the oesophagus?

A
  • Long standing GORD
  • Obesity
  • High dietary fat
85
Q

Which part of the oesophagus does squamous cell carcinoma tend to affect?

A

Middle + upper 2/3rds

86
Q

What does adenocarcinoma of the oesophagus develop from? Where does it affect?

A

Barrett’s oesophagus

Lower 1/3rd

87
Q

What are the red flag symptoms indicated by NICE for urgent endoscopy for suspected oesophageal malignancy?

A
  • Patients with dysphagia

- Patients >55yrs with weight loss + upper abdo pain, dyspepsia or reflux

88
Q

What symptoms may a patient with oesophageal cancer present with?

A
  • Dysphagia (progressive)
  • Significant weight loss
  • Odonyphagia
  • Hoarseness
89
Q

What is the investigation of choice for suspected oesophageal malignancy?

A

OGD –> biopsy + send for histology

90
Q

What staging investigations are done before treatment is commenced in oesophageal malignancy?

A
  • CT chest/abdo/pelvis
  • PET-CT scan
  • Endoscopic USS
  • Staging laparoscopy
91
Q

What is the curative treatment for squamous cell carcinomas of the oesophagus?

A
  • Upper –> definitive chemoradiotherapy

- Middle/lower –> definitive chemoradiotherapy or neoadjuvant CRT + then surgery

92
Q

What is the curative management for an adenocarcinoma of the oesophagus?

A

Neoadjuvant chemotherapy or chemoradiotherapy followed by oesophageal resection

93
Q

What are the main complications for oesophageal surgery?

A
  • Anastamotic leak
  • Re-operation
  • Pneumonia
  • Death
94
Q

What is involved in an oesophagectomy?

A

Removal of the tumour, top of the stomach and surrounding lymph nodes –> stomach made into a conduit to replace the oesophagus

95
Q

What palliative options may be given for a patient with oesophageal cancer?

A
  • Oesophageal stent
  • Radiotherapy + chemotherapy (reduce tumour size + bleeding - improves symptoms)
  • Photodynamic therapy
  • Nutritional support
  • RIG tube
96
Q

What is the five year survival for oesophageal cancer? Why?

A

5-10%

Late presentation

97
Q

What is the pathophysiology being GORD?

A

Frequent reflux of gastric contents into the oesophagus –> pain + mucosal damage

98
Q

What are the risk factors for GORD?

A
  • Age
  • Obesity
  • Male
  • Alcohol
  • Smoking
  • Caffeine
  • Fatty or spicy foods
99
Q

What are the clinical features of GORD?

A
  • Burning retrosternal chest pain
  • Pain worse after meals, lying down or bending over
  • Belching excessively
  • Odynophagia
  • Chronic cough
100
Q

What classification system is used to grade GORD? Briefly outline this

A 
Los Angeles Classification 
Grade A - breaks ≤ 5mm
Grade B - breaks >5mm
Grade C - breaks extending between the tops of ≥2 mucosal folds but <75% circumference
Grade D - circumferential breaks (≥75%)
101
Q

What are the main DDx to consider for GORD?

A
  • Malignancy
  • Peptic ulceration
  • Oesophageal motility disorders
  • Oesophagitis
  • Coronary artery disease
  • Biliary colic
102
Q

When is upper GI endoscopy used for GORD?

A
  • New onset in older patients

- Worsening despite PPI treatment

103
Q

What is the gold standard in diagnosis for GORD? When is it used?

A

24hr pH monitoring

Used if medical treatment fails and surgery is considered

104
Q

What are the indications for surgery in GORD?

A
  • Failure to respond/partial response to medical therapy
  • Patient preference to avoid life-long medication
  • Patients with complications of GORD (particularly respiratory complications)
105
Q

What surgical option is there for GORD? What does this involve?

A

Fundoplication - fundus wrapped around the GOJ

106
Q

What are the main complications of GORD?

A
  • Aspiration pneumonia
  • Barrett’s oesophagus
  • Oesophagitis
  • Oesophageal strictures
  • Oesophageal cancer
107
Q

Define Barrett’s oesophagus

A

Metaplasia of the oesophageal epithelial lining - normal stratified squamous epithelium is replaced by simple columnar epithelium

108
Q

What is seen on OGD for Barrett’s oesophagus?

A
  • Red + velvety oesophagus

- Preserved pale squamous islands

109
Q

What is the management for Barrett’s oesophagus?

A
  • High dose PPI
  • Stop NSAIDs
  • Lifestyle advice
  • Regular endoscopy (check for progression to adenocarcinoma)
110
Q

What surgical management is there for high grade dysplasia of Barrett’s oesophagus?

A
  • Endoscopic mucosal resection (EMR)

- Endoscopic submucosal dissection (ESD)

Surgery Block (12 decks)

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