General Surgery - Stomach

Question 1

What are the RFs for stomach cancer?

Answer 1

• Male gender
• H. pylori infection*
• Increasing age
• Smoking
• Alcohol consumption.
• Other risk factors include salt in diet, positive family history, and pernicious anaemia

Question 2

What are the clinical features of stomach cancer?

Answer 2

• Dyspepsia (particularly if new onset or not responsive to simple PPI treatment)
• Dysphagia
• Early satiety,
• Vomiting
• Melena.
• Non-specific cancer symptoms: anorexia, weight loss, or anaemia) are markers of late stage disease.
• Late: epigastric mass, troisier sign is the presence of a palpable left supraclavicular node (Virchow node)
• Others: hepatomegaly, ascites, jaundice, or acanthosis nigricans

Question 3

What investigations are used for stomach cancer?

Answer 3

• Gold standard: Urgent upper GI endoscopy* (OGD)
• Biopsies: Histology, CLO testing, HER2/neu protein expression
• Endoscopic USS: Can help work out depth of invasion
• Staging:
  
  • CT Chest-Abdomen-Pelvis*
  • MRI
  • Staging laparoscopy

Question 4

How is stomach cancer treated?

Answer 4

• Conservative:
  
  • Pt should undergo nutritional status assessment and be reviewed by a dietician as necessary
  • Nutritional support, both pre- or post-treatment, via a NG (nasogastric) or RIG (radiologically-inserted gastrostomy) tube
• Peri-operative chemotherapy: 3 cycles of neoadjuvant and 3 cycles of adjuvant ; (eg epirubicin, cisplatin and fluorouracil)
  
  • ​Targeted therapies: trastuzamab - Her 2 +ve tumours
• Surgery
  
  • Proximal gastric cancers – total gastrectomy + roux en y reconstruction (gastric bypass)
  • Distal gastric cancers (antrum or pylorus) – subtotal gastrectomy
  • Endoscopic Mucosal Resection - pt with early T1a tumours (tumours confined to the muscular is mucosa)
• • Palliative: chemotherapy, best supportive care, or stenting

Question 5

What are some of the complications of a total gastrectomy?

Answer 5

• Death
• Anastomotic leak
• Re-operation
• Dumping syndrome
• Vitamin B12 deficiency (patients need 3-monthly vitamin B12 injections).

Question 6

What is a roux en y reconstruction and when is it used?

Answer 6

• Most commonly used method in reconstructing the alimentary anatomy.
• Post-gastrectomy, the distal oesophagus is end-to-end anastomosed directly to the small bowel, and the proximal small bowel is end-to-side anastomosed also to the small bowel
• Benefits: gives the best functional result, in particular with less bile reflux
• Uses: gastric cancer, gastric bypass

Question 7

Where are you most likely to get peptic ulcers?

Answer 7

located on the lesser curvature of the proximal stomach or the first part of the duodenum

Question 8

What are the causes of peptic ulcer disease?

Answer 8

• Helicobacter pylori (H. pylori)
• Non-Steroidal Anti-Inflammatory Drug* (NSAID) use

Question 9

How do you treat H Pylori?

Answer 9

7 day course bd of:

• PPI e.g. Omeprazole 20-40mg
• Amoxicillin 500mg
• Clarithromycin or metronidazole.

Question 10

What are the risk factors for peptic ulcer disease?

Answer 10

• H. pylori infection
• Prolonged NSAID use.
• Other risk factors: corticosteroid use (when used with NSAIDs), previous gastric bypass surgery, physiological stress (such as severe burns (Curling’s ulcer) or head trauma (Cushing’s ulcer)), or Zollinger-Ellison syndrome (rare

Question 11

What are the NICE guidelines suggest that a referral for urgent upper Oesophago-Gastro-Duodenoscopy (OGD)?

Answer 11

• New-onset dysphagia OR
• >55 years presenting + weight loss and either upper abdominal pain, reflux, or dyspepsia

Question 12

How are peptic ulcer disease investigated?

Answer 12

• Non-invasive H. pylori testing*:
  
  • Carbon-13 urea breath test
  • Serum antibodies to H. pylori
  • Stool antigen test
• OGD
  
  • Biopsy any peptic ulceration seen and sent for histology
  • Send for rapid urease test (the CLO test)
• NICE guidance recommends that all identified gastric ulcers are biopsied

Question 13

How is peptic ulcer disease managed?

Answer 13

• Conservative:
  
  • Lifestyle - smoking cessation, weight loss, and reduction in alcohol consumption. Avoidance / cessation of NSAIDs
  • H Pylori eradiacation (repeat OGD after 6-8 weeks)
  • PPI Use
• OGD to exclude malignancy
• Surgical in severe or relapsing disease
  • Partial gastrectomy
  • Selective vagotomy

Question 14

When are surgical options for peptic ulcer dsease indicated?

Answer 14

• Haemmorhage
• Perforation
• Pyloric Stenosis

Question 15

What elective surgical options are available for peptic ulcers?

Answer 15

1. Highly selective vagotomy
   
   • ​​If pt cannot tolerate medical treatment
   • Vagus nerve supplying lower oesophagus and stomach denervated
   • Nerve to pylorus left in tact
2. Gastrectomy - rarely required. E.g. zollinger ellison syndrome

Question 16

What emergency surgical options are available for peptic ulcers and their emergency complications?

Answer 16

• Haemorrhage: adrenaline injection, diathermy, laser coagulation, heat probe.
• Perforation: most pt undergo surgery.
  
  • Initial conservative approach is adopted: NBM, NG tube, IV abx and fluids - prevents surgery
  • Laparoscopic repair is good (better than open)
  • Post surgical H.pylori eradication
• Pyloric stenosis: late complication of duodenal ulcer due to scarring. Pt vomit large amounts of food.
  
  • Treatment: endoscopic balloon dilatation
  • Drainage +/- highly selective vagotomy - laparoscopically

Question 17

What are the requirements before conducting an OGD? Eg PPI and NBM

Answer 17

• Stop PPI 2 weeks before (pathology masking)
• NBM 4h before
• Dont drive the day of the procedure
• Continuous suction is needed to prevent aspiration
• Sedation: midazolam or profol

Question 18

What is a hiatus hernia?

Answer 18

• A protrusion of the stomach through the oesophageal hiatus such that it moved from the abdominal cavity in the thorax.
• This is typically the stomach herniating although rarely small bowel, colon, or mesentery can also herniate through*.
• Two types: sliding and rolling

Question 19

What are the two different types of the oesophageal hiatus?

Answer 19

• Sliding: GOJ slides up through the oesophageal hiatus such that the cardia enters the thoracic.
  
  • Less dangerous
• Rolling: True hernia within the peritoneal sac. Upward movement of the fundus such that then lies at the level of GOJ. Appears like a bubble.
  
  • Requires repair: more dangerous

Question 20

What are some of the risk factors for developing a hiatus hernia?

Answer 20

• Pregnancy, obesity, and ascites
• Age is the biggest

Question 21

What are some of the symptoms of hiatus hernia?

Answer 21

• GORD sx: Retrosternal burning epigastric pain, which is made worse by lying flat, dyspepsia etc.
• Vomiting
• Weight loss
• Bleeding and / or anaemia (secondary to oesophageal ulceration)
• Hiccups
• Palpitations: if the hiatus hernia is of sufficient size, it may cause irritation to either the diaphragm or the pericardial sac)
• Dysphagia

Question 22

How are hiatus hernias investigated?

Answer 22

• Gold standard: OGD
• CT/ MRI
• Barium swallow seldom used

Question 23

How are hiatus hernias managed?

When is surgery indicated?

Answer 23

• Conservative: stop smoking + alcohol, smaller meals, reduce fat intake, lose weight
• Medical: PPI to be taken morning before eating.
• Surgery:
  
  • Indications: symptomatic, voluvulus/ strangulation, nutritional failure due to gastric outlet obstruction
  • Methods:
    
    • Cruroplasty: The hernia is reduced from the thorax to the abdomen
    • Fundoplication: fundus of stomach is wrapped around the distal oesophagus reinforcing it and preventing the GOJ sliding

Question 24

What are some of the complications of hiatus hernias?

How does gastric volvulus present (clue: triad)?

Answer 24

• Obstruction, strangulation + incarceration
• Gastric volvulus: stomach twists on itself by 180 degrees causing obstruction + tissue necrosis - requires prompt surgical intervention
  
  • ​Presents as Borchardt’s triad:
    
    • Severe epigastric pain
    • Retching without vomiting
    • Inability to pass an NG tube