General Surgery Flashcards
List 6 causes of dysphagia, solids > liquids
Zenker’s Diverticulum Oesophageal Stricture Oesophageal Cancer Oesophageal Web/Ring Plummer-Vinson Syndrome Oesophagitis
List 3 causes of dysphagia resulting from oesophageal motility problems
Achalasia
Diffuse Oesophageal Spasm
Scleroderma
1) Symptoms and presentation of Zenker’s Diverticulum
2) Pathology
3) Best Initial Diagnostic Test
4) Treatment and complications of surgery
1) dysphagia solids > liquids, food feels stuck in neck not chest or abdo, halitosis, regurgitation of food, normal physical exam, typically aged > 55. May present with aspiration pneumonia
2) False oesophageal Diverticulum, herniated through a weakness in the cricopharyngeal muscle
3) barium oesophagram, followed by OGD
4) Cricopharyngeal myotomy- reduced herniation by equalising pressure. Procedure specific complications include recurrent laryngeal nerve injury and oesophageal perforation.
1) presentation of oesophageal stricture
2) causes of oesophageal stricturing
3) best initial diagnostic test
4) treatment
1) dysphagia, solids > liquids, very slow progression, lack of weight loss, fatigue and other B sx, normal physical exam
2) GORD (80%), autoimmune, drug induced (bisphosphonates), acute caustic injury, malignancy
3) Barium oesophagram. If suspicious of malignancy follow with OGD and biopsy
4) endoscopic oesophageal dilation
1) presentation of oesophageal cancer
2) types of oesophageal cancer and anatomy and risk factors for each
3) best initial diagnostic test
4) most accurate test
5) treatment
1) Dysphagia, solids > liquids, progressive worsening of sx, weight loss, lymphadenopathy (Virchow’s node), upper GI bleeding, epigastric pain
2) adenocarcinoma = in lower 1/3, Hx of GORD or Barrett’s oesophagus. More common in Caucasians
Squamous cell carcinoma = upper 2/3rds, Hx of heavy smoking or alcohol use, more common in Afro-Caribbean’s
3) barium oesophagram
4) OGD and biopsy - cancer causes increased risk of perforation
5) if no mets or lymph node involvement then oesphagectomy will likely be curative. In advanced disease treatment is palliative with chemotherapy (5-fluorouracil) or dilation/stenting for symptomatic relief.
1) presentation of achalasia
2) pathology
3) best initial test
4) most accurate test
5) treatment
1) dysphagia liquids and solids, fullness in chest, regurgitation, weight loss
2) failure of lower oesophageal sphincter to properly relax resulting in an inability of food and liquids to enter the stomach.
3) barium oesophagram - birds beak distal dilation
4) oesophageal manometry
5) Heller Myotomy - cut through lower oesophageal sphincter followed by partial fundiplication to prevent ongoing problems with GORD. Non surgical - LOS Botox injections every 6 months
1) presentation of diffuse oesophageal spasm
2) pathology
3) best initial test
4) most accurate test
5) treatment
1) more common in white females, intermittent chest pain, often induced by hot, cold, or carbonated drinks. In a patient with a normal cardiac workup
2) uncoordinated oesophageal peristalsis
3) cardiac workup first! Then barium oesophagram - corkscrew appearance ( may be normal if patient not experiencing spasm at time of test)
4) oesophageal manometry
5) calcium channel blockers (diltiazem)
Pathology of GORD
Excessive relaxation of the lower oesophageal sphincter resulting in backflow of acidic stomach contents into the oesophagus.
Presentation of GORD
Burning substernal pain, hoarseness, cough, metallic taste, vomiting, sx related to eating, dysphagia
Patient may be obese or have history of hiatus hernia.
GI ALARM SYMPTOMS
Weight loss Age > 45 at onset of sx Odynophagia Anaemia Haem positive stool Dysphagia Long standing GORD
Best tests for GORD
1) if under 45
2) if over 45 or ALARM sx
Rule out cardiac cause first
1) clinical diagnosis, if unsure, 24hr manometry and pH monitoring
2) OGD and biopsy
Medical treatment of GORD
PPI Therapy (omeprazole, lansoprazole) \+/- H2 inhibitors (ranitidine) Lifestyle modification including weight loss, avoid food 3hrs before bed, elevate bed and sleep left lateral decubitus, avoid acidic foods and specific triggers e.g caffeine, fatty foods, chocolate
Surgical treatment for GORD
1) indications
2) procedure
3) complications
1) persistent sx despite maximum medical therapy, Barrett’s oesophagus found on OGD, paediatric patients
2) laparoscopic Nissen Fundoplication - fundus of stomach is wrapped 360 degrees around the lower oesophageal sphincter
3) perforation, dysphagia, post pyramidal discomfort, adhesions.
Three causes of oesophageal disruption
Mallory-Weiss tear
Boerhaave syndrome
Iatrogenic perforation
Pathology of Mallory-Weiss tear
Longitudinal partial-thickness laceration of the oesophagus secondary to vomiting or retching
