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Year 3 Surgery > General Surgery (Upper GI) > Flashcards

General Surgery (Upper GI) Flashcards

1
Q

Give 4 presenting features of GORD

A

Burning retrosternal chest pain
Excessive belching
Odynophagia
Chronic cough

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2
Q

Give 3 differentials for GORD

A

Malignancy
Peptic Ulcer
Oesophagitis

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3
Q

Describe the LA Classification of GORD (based on mucosal breaks in distal oesophagus)

A

A - breaks<5mm
B - breaks>5mm
C - breaks extending between the tops of two folds (but circumference<75%)
D- same as C but circumference>75%

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4
Q

Describe the Savary Miller Grading of GORD

A

1 - Single/Multiple erosions on a single fold
2 - Multiple erosions on multiple folds
3 - Multiple circumferential erosions
4 - Ulcer/Stenosis/Shortening
5 - Barrett’s Oesophagus

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5
Q

What is 24hr pH monitoring in GORD?

A

Used when medical treatment has failed and surgery is considered
Often used in combination with Manometry
Used to correlate oesophageal pH with symptoms

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6
Q

Give 3 indications for surgery in GORD

A

Failure to respond to medical therapy
Patient’s Preference (avoiding long term meds)
Complications of GORD

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7
Q

Describe the three surgical options for GORD

A

Fundoplication (Fundus wrapped around GOJ)
Stretta (Radiofrequency causing thickening of LOS)
Linx (String of magnetic beads inserted around LOS laproscopically)

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8
Q

State three post op complications of Fundoplication

A

Dysphagia
Bloating
Inability to vomit

Generally resolves after 6 weeks

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9
Q

Define Barrett’s Oesophagus

A

Metaplasia of lower oesophagus, transitioning from stratified squamous to simple columnar

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10
Q

How would Barrett’s Oesophagus appear on endoscopy?

A

Red and Velvety

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11
Q

How would you manage Barrett’s Oesophagus?

A

High dose PPi (BD)
Surveillance (monitoring for any dysplasia)
If high grade dysplasia - muscosal/submucosal resection

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12
Q

State four histological types of Oesophageal Cancer

A

Squamous Cell Carcinoma
Adenocarcinoma
Leimyosarcoma
Rhabdomyosarcoma

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13
Q

Describe 3 associations of SCC of Oesophagus, including where it normally occurs

A

Middle and Upper 1/3 of Oesophagus

Smoking, Excess Alcohol, Xeropthalmia

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14
Q

Describe 3 associations of Adenocarcinoma of Oesophagus, including where it normally occurs

A

Lower 1/3 of Oesophagus

GORD, Obesity, High Dietary Fat

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15
Q

Give four features of Oesophageal Cancer

A

Progressive Dysphagia (RED FLAG)
Weight Loss (RED FLAG)
Odynophagia
Hoarseness

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16
Q

Describe the inital investigation for suspected Oesophageal Cancer and then 3 further investiagtions

A

Initial - OGD and biopsy

CT Chest/Abdo/Pelvis
Endoscopic USS (Penetration into oesophageal wall)
Hoarseness? - Bronchoscopy

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17
Q

Describe 3 palliative managements of Oesophageal Cancer

A

Stent
Thickened Fluid
Photodynamic Therapy

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18
Q

What is Photodynamic Therapy?

A

Photosensitising agent that when exposed to a certain wavelength of light produces a certain oxygen that kills nearby cells

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19
Q

The curative management of Oesophageal Cancer is surgical resection (this is challenging in the upper 1/3). Describe the procedure in two brief steps

A

1) Removal of tumour, top of the stomach and surrounding lymph nodes
2) Remaining stomach is made into a conduit and brought up into chest to replace the oesophagus

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20
Q

Name three things to consider for patients about to undergo Oesophageal resection (Iver Lewis)

A

Major Surgery as both chest and abdo cavities need to be opened
One lung needs to be deflated intra-operatively for 2 hours
Lose resevoir capacity of stomach (requiring either jejunostomy or small frequent feeding)

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21
Q

What are the two types of Oesophageal Tears?

A

Full Thickness
Partial Thickness

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22
Q

Describe the pathophysiology of a Full Thickness Oesophageal Tear (i.e Oesophageal Perforation)

A

-Can be iatrogenic or after severe forceful vomiting
-Normally just above the diaphragm in the left posterolateral position
-Causes leakage of stomach contents into pleural cavity

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23
Q

How would a Full Thickness Oesophageal Tear present? (HINT: Mackler’s Triad)

A

Sudden onset retrosternal chest pain

Subcutaneous Emphysema

Severe vomiting

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24
Q

Give three possible investigations for a Full Thickness Oesophageal Tears

A

CXR (Pneumomediastinum)
CT (with oral contrast)
Endoscopy

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25
Q

Describe the general 4 step management plan for a Full Thickness Oesophageal Perforation

A

`1) Control the Leak
2) Eradicate contamination
3) Decompress the oesophagus
4) Nutritional support

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26
Q

How would you surgically control the leak of a Full Thickness Oesophageal Perforation (ie Step 1)?

A

Repair using flap from diaphragm

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27
Q

How would you surgically decompress the Oesophagus (ie Step 2)?

A

Insertion of trans-gastric drain (from oesophagus into fundus of the stomach)

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28
Q

What is a Partial Thickness Oesophageal Tear (AKA Mallory Weiss)?

A

Lacerations at oesophageal mucosa often after profuse vomiting (leading to brief episode of haematemesis)
Generally small and self limiting unless on anti-coags

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29
Q

Describe the anatomy of the Oesophagus in terms of muscle types

A

Upper 1/3 = Skeletal Muscle
Middle 1/3 = Skeletal and Smooth Muscle
Lower 1/3 = Smooth Muscle

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30
Q

State the purposes of the UOS and LOS respectively

A

UOS - Prevents air entering Oesophagus
LOS - Prevents reflux of contents into Oesophagus

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31
Q

Describe the Peristaltic Waves of the Oesophagus

A

Controlled by Oesophageal Myenteric Neurones
First Wave - Under control of swallowing centre
Second Wave - In response to distension

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32
Q

Define Achalasia

A

Failure of relaxation of LOS and progressive failure of Oesophageal Contraction (continued squeezing against obstruction)

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33
Q

Give four presenting features of Achalasia

A

Progressive dysphagia with solids AND liquids
Regurgitation
Coughing
Weight Loss

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34
Q

Achalasia often requires an endoscopy to rule out a malignant cause. What is the gold standard investigation for Achalasia?

A

Oesophageal Manometry (pressure sensitive probe inserted into Oesophagus, measuring pressure of sphincter and surrounding muscle)

Shows absence of oesophageal peristalsis, failure of relaxation of LOS, High Resting LOS tone

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35
Q

How would Achalasia appear on a Barium Swallow?

A

Proximal Dilation with Birds Beak appearance

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36
Q

Describe three conservative managements of Achalasia

A

Using many pillows
Eating slowly and chewing thoroughly
CCBs/Botox

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37
Q

Describe the two surgical managements of Achalasia

A

Endoscopic Balloon Dilation (stretches fibres of LOS, good response but risk of perforation)
Laproscopic Heller Myotomy (division of specific muscular fibres enabling LOS to relax)

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38
Q

What is Diffuse Oesophageal Spasm?

A

Multifocal high amplitude contractions of the oesophagus due to dysfunction of Oesophageal Inhibitory Nerves (can progress to Achalasia)

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39
Q

Give 3 clinical features of Diffuse Oesophageal Spasm

A

Severe dysphagia to solids and liquids
Central chest pain
Responsive to nitrates (therefoe may be difficult to distinguish from Angina)

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40
Q

What would the Manometry of Diffuse Oesophageal Spasm show?

A

Repetitive, simultaneous and ineffective contractions of the Oesophagus

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41
Q

Describe three possible managements of Diffuse Oesophageal Spasm

A

Nitrates and CCB
Pneumatic Dilation (if high LOS tone aswell)
Myotomy (if severe)

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42
Q

Other than Achalasia and Diffuse Oesophageal Spasm, give two causes of Oesophageal Dysmotility

A

Systemic Sclerosis
Polymyositis/Dermatomyositis

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43
Q

Describe the 2 types of Hiatus Hernia

A

Sliding - GOJ, Abdominal Oesophagus and Cardia slide up through diaphragmatic hernia into thorax
Rolling (AKA Paraoesophageal) - Upwards movement of Gastric Fundus to lie laterally to a normally positioned GOJ

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44
Q

Describe four clinical features of Hiatus Hernia

A

GORD symptoms
Hiccoughs (Diaphragmatic Irritation)
Palpitations (Pericardial Sac Irritation)
Swallowing Difficulties

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45
Q

What would the OGD of a Sliding Hernia feature?

A

Z line - Upwards displacement of GOJ

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46
Q

Hiatus Hernias are managed conservatively the same as GORD. Name three things that would qualify a patient for surgery

A

Symptomatic despite maximal medical therapy
High risk of Strangulation/Volvulus
Nutritional Failure

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47
Q

Describe two surgical options for Hiatus Hernia

A

Cruroplasty - Hernia reduced and hiatus reapproximated to right size
Fundoplication - Fundus wrapped around GOJ

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48
Q

How would a Gastric Volvulus present? (AKA Borchardts Triad)?

A

Severe Epigastric Pain
Wretching without vomiting
Inability to pass NG tube

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49
Q

Define Peptic Ulcer

A

A break in the lining of the GI tract extending through to the muscularis mucosa
Usually occurs in first part of Duodenum or Lesser Curvature of stomach

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50
Q

H.Pylori is often present in Peptic Ulcers (90% Duodenal and 70% Gastric), describe how the bacteria causes it

A

Produces an alkaline microenvironemnt via Urease
Degrades surface glycoproteins
Reduces bicarbonate layer

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51
Q

How do NSAIDs cause Peptic Ulcers?

A

Inhibits Prostaglandin Synthesis
Reduces secretion of glycoprotein/phospholipids/mucous

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52
Q

State the two types of Physiological Stress causing Peptic Ulcers

A

Head Trauma -Cushing’s Ulcer
Severe Burns - Curling’s Ulcer

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53
Q

Describe the triad of Zollinger Ellison

A

Gastrinoma
Hypersecretion of Gastric Acid
Severe Peptic Ulcer

54
Q

Describe four features of Peptic Ulcer Disease

A

Epigastric/Retrosternal Chest Pain
Nausea
Bloating
Early Satiety

55
Q

Describe three ways to test for H.Pylori

A

Carbon-13 Urea Breath Test
Serum Antibodies to H.Pylori
Stool Antigen Test

56
Q

What is the gold standard investigation for Peptic Ulcers?

A

OGD

57
Q

If the patient is H.Pylori positive, describe the management of Peptic Ulcer Disease

A

PPI
Oral Amoxicillin
Clarythromycin/Metronidazole

58
Q

What management would you use for a Perforated Peptic Ulcer?

A

Omental Patch
Broad Spectrum Antibiotics

59
Q

If Peptic Ulcer Disease is severe/relapsing, what surgical management could you use?

A

Partial Gastrectomy
Selective Vagotomy

60
Q

Give 5 Risk Factors of Gastric Cancer

A

Male Gender
H.Pylori
Smoking
High Salt Diet
Pernicious Anaemia

61
Q

Give 5 Clinical Features of Gastric Cancer

A

Dyspepsia (new onset or resistant to PPIs)
Dysphagia
Early Satiety
Malaena
Weight Loss

62
Q

Give 3 investigations used for suspected Gastric Cancer

A

Routine bloods
GI Endoscopy (and subsequent biopsy)
CT

63
Q

Describe the three features of curative management of Gastric Cancer

A

-Peri - Op Chemo (3 cycles before, 3 cycles after)
- Total Gastrectomy (for proximal cancers) or Subtotal Gastrectomy (for distal cancers)
- Reconstruction

64
Q

State three complications from the Gastrectomy procedure (total or subtotal)

A

Death
Anastamotic Leak
Vit B12 Deficiency

65
Q

Describe the reconstruction post Gastrectomy

A

Roux - en - Y
Small bowel connected to oesophagus and small bowel also reanastamosed to stomach (if poss)

66
Q

Define Direct Inguinal Hernia

A

Directly through Hesselbach’s triangle (often in older patients secondary to abdominal wall laxity)

67
Q

Define Indirect Inguinal Hernia

A

Bowel enters inguinal canal via deep inguinal ring, arising from incomplete closure of processus vaginalis

68
Q

Describe the presentation of a reducible Inguinal Hernia

A

Lump in the groin that disappears when lying flat or with minimal pressure
Lump is superomedial to pubic tubercle

69
Q

Describe the presentation of a strangulated Inguinal Hernia

A

Irreducible
Painful
Symptoms of Bowel Obstruction

Incarcerated = stuck
Strangulated = Ischaemic

70
Q

Give 3 differentials for an Inguinal Hernia

A

Femoral Hernia
Saphena Varix (Dilation of Saphenous Vein)
Inguinal Lymphadenopathy

71
Q

Describe the two surgical options.

A

Open Mesh Repair - Usually for Primary Inguinal Hernia
Laproscopic Approach - Used if female, bilateral or recurrent

72
Q

Give 3 complications of Inguinal Hernia Surgery

A

Bruising
Pain
Damage to Vas Deferens

73
Q

Describe the anatomy of the Femoral Hernia

A

Bowel travels through femoral ring into femoral canal (normally contains lymphatics, lymph nodes and loose CT)
Very narrow canal therefore high risk of strangulation
More common in Women due to wider pelvis

74
Q

Describe the clinical features of a Femoral Hernia

A

Small lump in groin
Lump is inferolateral to pubic tubercle

75
Q

Surgical repair of a Femoral Hernia aims to reduce the hernia and narrow the ring. Describe the two approaches

A

Low Approach - doesn’t interfere with any inguinal structures, smaller space for any bowel removal
High Approach - above inguinal ligament, easy access to compromised bowel

76
Q

Describe the presentation of an Epigastric Hernia

A

Upper midline through linea alba
Typically asymptomatic and disappears when lying down

77
Q

Describe the presentation of Divarification of Recti

A

A differential for Epigastric Hernia
Weakening and widening of Linea Alba without herniation

78
Q

Describe the presentation of a Paraumbilical Hernia

A

Through Linea Alba around umbilical region
Contains pre-peritoneal fat so rarely strangulates

79
Q

Describe the presentation of a Spigelian Hernia

A

Occurs at Semilunar line (Lateral border of Rectus) at around level of Arcuate line
Small mass with high risk of strangulation
Associated with Cryptorchidism

80
Q

Describe the pathophysiology of an Obturator Hernia

A

Bowel travels through Obturator Foramen into canal
Common in those who have had rapid weight loss

81
Q

How would an Obturator Hernia present?

A

Mass in upper medial thigh (at high risk of strangulation)
Compression of Obturator Nerve (Howship Romberg Sign - Hip and Knee Pain exacerbated by extension, medial rotation and abduction)

82
Q

Describe a Littres Hernia

A

Herniation of Meckel’s Diverticulum into Inguinal Canal

83
Q

Describe a Lumbar Hernia

A

Rare posterior hernia
May occur post renal surgery

84
Q

Describe a Richter’s Hernia

A

Partial herniation at any site, only involves anti-mesenteric border

85
Q

Define Dysentery

A

Loose stools with blood and mucous

86
Q

Define Traveller’s Diarrhoea

A

More than 3 loose stools commencing within 24hrs of foreign travel

87
Q

Related to Gastroenteritis, name two notifiable diseases

A

Food Poisoning
Bloody Diarrhoea

88
Q

Describe the transmission of Campylobacter

A

Food poisoning from affected chicken/eggs/milk

89
Q

Give 3 complications of Campylobacter infection

A

Reactive Arthritis
Haemolytic Uraemic Syndrome
Guillaine Barre

90
Q

Describe the transmission of E.Coli

A

Contaminated food
Person to person
Infected Animals

91
Q

Describe the transmission of Shigella

A

Contaminated dairy products and water

92
Q

Bacterial Toxins cause acute onset diarrhoea/vomiting lasting less than 24hrs. Name 3

A

Bacillus Cereus (from reheated rice)
Clostrodium Perfringes (from reheating meat, vomiting rare)
Staph Aureus

93
Q

If you suspect a parasitic cause of Gastroenteritis, what investigation should you do?

A

Stool Culture for Ova/Cysts/Parasites

94
Q

Name a complication of Entomoeba Histolytica

A

Liver Abscesses

95
Q

Acute Giardia infection presents with a classical Gastroenteritis picture, how does Chronic Giardia infection present?

A

Steatorrhoea
Weight Loss
Malabsorption
Lactose Intolerance

96
Q

Describe the presentation of Schistosomiasis

A

Fever
Malaise
Abdo Pain
Bloody Diarrhoea
Hepatosplenomegaly

Swimmers rash and Katayama syndrome

97
Q

How would you manage Schistosomiasis?

A

Praziquentel

98
Q

Describe the two exotoxins of C.Diff

A

A - Enterotoxin
B - Cytotoxin

99
Q

Give 3 non infective causes of Gastroenteritis

A

Radiation Colitis
IBD
Chronic Ischaemic Colitis (blue swollen mucosa)

100
Q

What is the most common vascular abnormality of the GI tract?

A

Angiodysplasia

101
Q

What is Angiodysplasia?

A

Formation of AV malformations between previously healthy blood vessels, normally in the caecum and ascending clon

102
Q

Describe the pathophysiology of Acquired Angiodysplasia

A

Chronic and intermittent contraction of the colon causes dilated submucosal veins and reduced drainage

Small AV connections begin

103
Q

Describe the two main presenting symptoms of Acquried Angiodysplasia

A

Rectal Bleeding
Anaemia

104
Q

Describe two investigations required for Angiodysplasia

A

Endoscopy
Mesenteric Angiography (radio-opaque dye inserted followed by CT/MRI)

105
Q

How would you manage a haemodynamically stable patient with Angiodysplasia?

A

Bed Rest
IV Fluid
Tranexamic Acid

106
Q

Describe two non surgical managements of unstable Angiodysplasia

A

Endoscopy - electrical current or band ligation
Mesenteric Angiography - Catheterisation and embolisation

107
Q

Describe the surgical management of Angiodysplasia

A

Resection and Anastamosis

108
Q

What is a Neuroendocrine Tumour?

A

Any cells that recieve input from neurotransmitters and subsequently release hormones into the bloodstream

109
Q

Give 2 risk factors for Neuroendocrine Tumours

A

MEN1
Von Hippel Lindau

110
Q

How do Neuroendocrine Tumours present?

A

Vague Abdominal Pain
Nausea
Abdominal DIstension
(can be hypersecreting but generally non functioning)

111
Q

What is Carcinoid Syndrome?

A

Follows Metastasis of a carcinoid tumour
Metastasised cells over secrete serotonin/prostaglandins/gastrin

112
Q

Name 3 lab investigations you could do for Neuroendocrine Tumours

A

Routine Bloods
Chromogranin A
5-HIAA (main metabolite of serotonin)

113
Q

If you had a Metastatic Neurendocrine Disease with an unknown primary, what investigation would you do?

A

Whole Body Somatostatin Receptor Scintigraphy

114
Q

What is a Carcinoid Crisis?

A

Overwhelming release of hormones resulting in severe hypotension

115
Q

Surgery is the definitive management for Carcinoid Tumours. How would you manage a Gastric Tumour?

A

Grade 1-2 = Endoscopic Resection
Grade 3 = Partial/Total Gastrectomy

116
Q

Surgery is the definitive management for Carcinoid Tumours. How would you manage a Small Intestinal Tumour?

A

Resection and Lymph Node Clearance

117
Q

Surgery is the definitive management for Carcinoid Tumours. How would you manage a Appendiceal Tumour?

A

Appendectomy and Right Hemicolectomy if large

118
Q

Surgery is the definitive management for Carcinoid Tumours. How would you manage a Colonic Tumour?

A

Partial Colectomy and Regional LN Clearance

119
Q

Surgery is the definitive management for Carcinoid Tumours. How would you manage a Rectal Tumour?

A

Resection

120
Q

What is a Krukenberg Tumour?

A

Gastric mass as a result of a ovarian tumour

121
Q

What is an USS FAST scan?

A

Used in urgent care to look for haemoperitoneum and pericardial effusion

122
Q

How should adhesions be managed?

A

Often self resolve

Conservative treatment for one day, then give gastrograffin and do AXR
If gastrograffin moved - will likely self resolve

123
Q

What is the therapeutic effect of gastrograffin

A

Osmotic effect as well as dye

124
Q

What is a Peptic Ulcer ?

A

A break in the lining of the GI tract extending through muscularis mucosa

125
Q

Where are Peptic Ulcers commonly found?

A

Proximal stomach and Duodenum

126
Q

Describe two common causes of Ulcers

A

NSAIDS
H.Pylori (increases gastric acid via histamine, degrades bicarbonate production)

127
Q

Describe the presentation of peptic ulcers vs duodenal ulcers

A

Peptic - soon after eating, worsened by eating, vomiting common
Duodenal - 2-4h post food, improved by eating, vomiting uncommon

128
Q

How is Peptic Ulcer disease investigated?

A

Young Patients - H.Pylori testing
Old patients or red flag- OGD and biopsy

129
Q

How can Peptic Ulcer disease be managed medically?

A

If H.Pylori - triple therapy

Otherwise lifestyle advice, smoking cessation , 8-12 week trial of PPI and then review

130
Q

How can Peptic Ulcers be managed surgically ?

A

Rare and only if refractory

Selective vagotomy or partial gastrectomy

131
Q

A complication of Peptic Ulcers is perforation, how should this be managed?

A

Omental Patch

132
Q

A complication of Peptic Ulcers is haemorrhage, how should this be managed?

A

Usually due to posterior wall erosion into gastroduodenal

Adrenaline Injections in combination with cautery and high dose IV PPI

Year 3 Surgery (11 decks)

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