General Surgery (Upper GI) Flashcards
Give 4 presenting features of GORD
Burning retrosternal chest pain
Excessive belching
Odynophagia
Chronic cough
Give 3 differentials for GORD
Malignancy
Peptic Ulcer
Oesophagitis
Describe the LA Classification of GORD (based on mucosal breaks in distal oesophagus)
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%
Describe the Savary Miller Grading of GORD
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
What is 24hr pH monitoring in GORD?
Used when medical treatment has failed and surgery is considered
Often used in combination with Manometry
Used to correlate oesophageal pH with symptoms
Give 3 indications for surgery in GORD
Failure to respond to medical therapy
Patient’s Preference (avoiding long term meds)
Complications of GORD
Describe the three surgical options for GORD
Fundoplication (Fundus wrapped around GOJ)
Stretta (Radiofrequency causing thickening of LOS)
Linx (String of magnetic beads inserted around LOS laproscopically)
State three post op complications of Fundoplication
Dysphagia
Bloating
Inability to vomit
Generally resolves after 6 weeks
Define Barrett’s Oesophagus
Metaplasia of lower oesophagus, transitioning from stratified squamous to simple columnar
How would Barrett’s Oesophagus appear on endoscopy?
Red and Velvety
How would you manage Barrett’s Oesophagus?
High dose PPi (BD)
Surveillance (monitoring for any dysplasia)
If high grade dysplasia - muscosal/submucosal resection
State four histological types of Oesophageal Cancer
Squamous Cell Carcinoma
Adenocarcinoma
Leimyosarcoma
Rhabdomyosarcoma
Describe 4 associations of SCC of Oesophagus, including where it normally occurs
Middle and Upper 1/3 of Oesophagus
Smoking, Excess Alcohol, Xeropthalmia, Achalasia
Describe 3 associations of Adenocarcinoma of Oesophagus, including where it normally occurs
Lower 1/3 of Oesophagus
GORD, Obesity, High Dietary Fat
Give four features of Oesophageal Cancer
Progressive Dysphagia (RED FLAG)
Weight Loss (RED FLAG)
Odynophagia
Hoarseness
Describe the inital investigation for suspected Oesophageal Cancer and then 3 further investiagtions
Initial - OGD and biopsy
CT Chest/Abdo/Pelvis Endoscopic USS (Penetration into oesophageal wall) Hoarseness? - Bronchoscopy
Describe 3 palliative managements of Oesophageal Cancer
Stent
Thickened Fluid
Photodynamic Therapy
What is Photodynamic Therapy?
Photosensitising agent that when exposed to a certain wavelength of light produces a certain oxygen that kills nearby cells
The curative management of Oesophageal Cancer is surgical resection (this is challenging in the upper 1/3). Describe the procedure in two brief steps
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
Name three things to consider for patients about to undergo Oesophageal resection
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)
What are the two types of Oesophageal Tears?
Full Thickness
Partial Thickness
Describe the pathophysiology of a Full Thickness Oesophageal Tear (i.e Oesophageal Perforation)
- 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
How would a Full Thickness Oesophageal Tear present? (HINT: Mackler’s Triad)
Sudden onset retrosternal chest pain
Subcutaneous Emphysema
Severe vomiting
Give three possible investigations for a Full Thickness Oesophageal Tears
CXR (Pneumomediastinum)
CT (with oral contrast)
Endoscopy
Describe the general 4 step management plan for a Full Thickness Oesophageal Perforation
`1) Control the Leak
2) Eradicate contamination
3) Decompress the oesophagus
4) Nutritional support
How would you surgically control the leak of a Full Thickness Oesophageal Perforation (ie Step 1)?
Repair using flap from diaphragm
How would you surgically decompress the Oesophagus (ie Step 2)?
Insertion of trans-gastric drain (from oesophagus into fundus of the stomach)
What is a Partial Thickness Oesophageal Tear (AKA Mallory Weiss)?
Lacerations at oesophageal mucosa often after profuse vomiting (leading to brief episode of haematemesis)
Generally small and self limiting unless on anti-coags
Describe the anatomy of the Oesophagus in terms of muscle types
Upper 1/3 = Skeletal Muscle
Middle 1/3 = Skeletal and Smooth Muscle
Lower 1/3 = Smooth Muscle
State the purposes of the UOS and LOS respectively
UOS - Prevents air entering Oesophagus
LOS - Prevents reflux of contents into Oesophagus
Describe the Peristaltic Waves of the Oesophagus
Controlled by Oesophageal Myenteric Neurones
First Wave - Under control of swallowing centre
Second Wave - In response to distension
Define Achalasia
Failure of relaxation of LOS and progressive failure of Oesophageal Contraction (continued squeezing against obstruction)
Give four presenting features of Achalasia
Progressive dysphagia with solids AND liquids
Regurgitation
Coughing
Weight Loss
Achalasia often requires an endoscopy to rule out a malignant cause. What is the gold standard investigation for Achalasia?
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
How would Achalasia appear on a Barium Swallow?
Proximal Dilation with Birds Beak appearance
Describe three conservative managements of Achalasia
Using many pillows
Eating slowly and chewing thoroughly
CCBs/Botox
Describe the two surgical managements of Achalasia
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)
What is Diffuse Oesophageal Spasm?
Multifocal high amplitude contractions of the oesophagus due to dysfunction of Oesophageal Inhibitory Nerves (can progress to Achalasia)
Give 3 clinical features of Diffuse Oesophageal Spasm
Severe dysphagia to solids and liquids
Central chest pain
Responsive to nitrates (therefoe may be difficult to distinguish from Angina)
What would the Manometry of Diffuse Oesophageal Spasm show?
Repetitive, simultaneous and ineffective contractions of the Oesophagus
Describe three possible managements of Diffuse Oesophageal Spasm
Nitrates and CCB
Pneumatic Dilation (if high LOS tone aswell)
Myotomy (if severe)
Other than Achalasia and Diffuse Oesophageal Spasm, give two causes of Oesophageal Dysmotility
Systemic Sclerosis
Polymyositis/Dermatomyositis
Describe the 2 types of Hiatus Hernia
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
Describe four clinical features of Hiatus Hernia
GORD symptoms
Hiccoughs (Diaphragmatic Irritation)
Palpitations (Pericardial Sac Irritation)
Swallowing Difficulties
What would the OGD of a Sliding Hernia feature?
Z line - Upwards displacement of GOJ
Hiatus Hernias are managed conservatively the same as GORD. Name three things that would qualify a patient for surgery
Symptomatic despite maximal medical therapy
High risk of Strangulation/Volvulus
Nutritional Failure
Describe two surgical options for Hiatus Hernia
Cruroplasty - Hernia reduced and hiatus reapproximated to right size
Fundoplication - Fundus wrapped around GOJ
How would a Gastric Volvulus present? (AKA Borchardts Triad)?
Severe Epigastric Pain
Wretching without vomiting
Inability to pass NG tube
Define Peptic Ulcer
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
H.Pylori is often present in Peptic Ulcers (90% Duodenal and 70% Gastric), describe how the bacteria causes it
Produces an alkaline microenvironemnt via Urease
Degrades surface glycoproteins
Reduces bicarbonate layer
How do NSAIDs cause Peptic Ulcers?
Inhibits Prostaglandin Synthesis
Reduces secretion of glycoprotein/phospholipids/mucous
State the two types of Physiological Stress causing Peptic Ulcers
Head Trauma -Cushing’s Ulcer
Severe Burns - Curling’s Ulcer
Describe the triad of Zollinger Ellison
Gastrinoma
Hypersecretion of Gastric Acid
Severe Peptic Ulcer
Describe four features of Peptic Ulcer Disease
Epigastric/Retrosternal Chest Pain
Nausea
Bloating
Early Satiety
Describe three ways to test for H.Pylori
Carbon-13 Urea Breath Test
Serum Antibodies to H.Pylori
Stool Antigen Test
What is the gold standard investigation for Peptic Ulcers?
OGD
If the patient is H.Pylori positive, describe the management of Peptic Ulcer Disease
PPI
Oral Amoxicillin
Clarythromycin/Metronidazole
What management would you use for a Perforated Peptic Ulcer?
Omental Patch
Broad Spectrum Antibiotics
If Peptic Ulcer Disease is severe/relapsing, what surgical management could you use?
Partial Gastrectomy
Selective Vagotomy
Give 5 Risk Factors of Gastric Cancer
Male Gender H.Pylori Smoking High Salt Diet Pernicious Anaemia
Give 5 Clinical Features of Gastric Cancer
Dyspepsia (new onset or resistant to PPIs) Dysphagia Early Satiety Malaena Weight Loss
Give 3 investigations used for suspected Gastric Cancer
Routine bloods
GI Endoscopy (and subsequent biopsy)
CT
Describe the three features of curative management of Gastric Cancer
- Peri - Op Chemo (3 cycles before, 3 cycles after)
- Total Gastrectomy (for proximal cancers) or Subtotal Gastrectomy (for distal cancers)
- Reconstruction
State three complications from the Gastrectomy procedure (total or subtotal)
Death
Anastamotic Leak
Vit B12 Deficiency
Describe the reconstruction post Gastrectomy
Roux - en - Y
Small bowel connected to oesophagus and small bowel also reanastamosed to stomach (if poss)
Define Direct Inguinal Hernia
Directly through Hesselbach’s triangle (often in older patients secondary to abdominal wall laxity)
Define Indirect Inguinal Hernia
Bowel enters inguinal canal via deep inguinal ring, arising from incomplete closure of processus vaginalis
Describe the presentation of a reducible Inguinal Hernia
Lump in the groin that disappears when lying flat or with minimal pressure
Lump is superomedial to pubic tubercle
Describe the presentation of a strangulated Inguinal Hernia
Irreducible
Painful
Symptoms of Bowel Obstruction
Give 3 differentials for an Inguinal Hernia
Femoral Hernia
Saphena Varix (Dilation of Saphenous Vein)
Inguinal Lymphadenopathy
Surgical repair is only recommended if the patient is symptomatic or if the Inguinal Hernia is strangulated. Describe the two surgical options.
Open Mesh Repair - Usually for Primary Inguinal Hernia
Laproscopic Approach - Used if female, bilateral or recurrent
Give 3 complications of Inguinal Hernia Surgery
Bruising
Pain
Damage to Vas Deferens
Describe the anatomy of the Femoral Hernia
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
Describe the clinical features of a Femoral Hernia
Small lump in groin
Lump is inferolateral to pubic tubercle
Surgical repair of a Femoral Hernia aims to reduce the hernia and narrow the ring. Describe the two approaches
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
Describe the presentation of an Epigastric Hernia
Upper midline through linea alba
Typically asymptomatic and disappears when lying down
Describe the presentation of Divarification of Recti
A differential for Epigastric Hernia
Weakening and widening of Linea Alba without herniation
Describe the presentation of a Paraumbilical Hernia
Through Linea Alba around umbilical region
Contains pre-peritoneal fat so rarely strangulates
Describe the presentation of a Spigelian Hernia
Occurs at Semilunar line (Lateral border of Rectus) at around level of Arcuate line
Small mass with high risk of strangulation
Associated with Cryptorchidism
Describe the pathophysiology of an Obturator Hernia
Bowel travels through Obturator Foramen into canal
Common in those who have had rapid weight loss
How would an Obturator Hernia present?
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)
Describe a Littres Hernia
Herniation of Meckel’s Diverticulum into Inguinal Canal
Describe a Lumbar Hernia
Rare posterior hernia
May occur post renal surgery
Describe a Richter’s Hernia
Partial herniation at any site, only involves anti-mesenteric border
Define Dysentery
Loose stools with blood and mucous
Define Traveller’s Diarrhoea
More than 3 loose stools commencing within 24hrs of foreign travel
Related to Gastroenteritis, name two notifiable diseases
Food Poisoning
Bloody Diarrhoea
Describe the transmission of Campylobacter
Food poisoning from affected chicken/eggs/milk
Give 3 complications of Campylobacter infection
Reactive Arthritis
Haemolytic Uraemic Syndrome
Guillaine Barre
Describe the transmission of E.Coli
Contaminated food
Person to person
Infected Animals
Describe the transmission of Shigella
Contaminated dairy products and water
Bacterial Toxins cause acute onset diarrhoea/vomiting lasting less than 24hrs. Name 3
Bacillus Cereus (from reheated rice) Clostrodium Perfringes (from reheating meat, vomiting rare) Vibrio Cholera (from contaminated water, rice water diarrhoea)
If you suspect a parasitic cause of Gastroenteritis, what investigation should you do?
Stool Culture for Ova/Cysts/Parasites
Name a complication of Entomoeba Histolytica
Liver Abscesses
Acute Giardia infection presents with a classical Gastroenteritis picture, how does Chronic Giardia infection present?
Steatorrhoea
Weight Loss
Malabsorption
Lactose Intolerance
Describe the presentation of Schistosomiasis
Fever Malaise Abdo Pain Bloody Diarrhoea Hepatosplenomegaly
How would you manage Schistosomiasis?
Praziquentel
Describe the two exotoxins of C.Diff
A - Enterotoxin
B - Cytotoxin
Give 3 non infective causes of Gastroenteritis
Radiation Colitis
IBD
Chronic Ischaemic Colitis (blue swollen mucosa)
What is the most common vascular abnormality of the GI tract?
Angiodysplasia
What is Angiodysplasia?
Formation of AV malformations between previously healthy blood vessels, normally in the caecum and ascending clon
Describe the pathophysiology of Acquired Angiodysplasia
Chronic and intermittent contraction of the colon causes dilated submucosal veins and reduced drainage
Small AV connections begin
Describe the two main presenting symptoms of Acquried Angiodysplasia
Rectal Bleeding
Anaemia
Describe two investigations required for Angiodysplasia
Endoscopy Mesenteric Angiography (radio-opaque dye inserted followed by CT/MRI)
How would you manage a haemodynamically stable patient with Angiodysplasia?
Bed Rest
IV Fluid
Tranexamic Acid
Describe two non surgical managements of unstable Angiodysplasia
Endoscopy - electrical current or band ligation
Mesenteric Angiography - Catheterisation and embolisation
Describe the surgical management of Angiodysplasia
Resection and Anastamosis
What is a Neuroendocrine Tumour?
Any cells that recieve input from neurotransmitters and subsequently release hormones into the bloodstream
Give 2 risk factors for Neuroendocrine Tumours
MEN1
Von Hippel Lindau
How do Neuroendocrine Tumours present?
Vague Abdominal Pain Nausea Abdominal DIstension (can be hypersecreting but generally non functioning)
What is Carcinoid Syndrome?
Follows Metastasis of a carcinoid tumour
Metastasised cells over secrete serotonin/prostaglandins/gastrin
Name 3 lab investigations you could do for Neuroendocrine Tumours
Routine Bloods
Chromogranin A
5-HIAA (main metabolite of serotonin)
If you had a Metastatic Neurendocrine Disease with an unknown primary, what investigation would you do?
Whole Body Somatostatin Receptor Scintigraphy
What is a Carcinoid Crisis?
Overwhelming release of hormones resulting in severe hypotension
Surgery is the definitive management for Carcinoid Tumours. How would you manage a Gastric Tumour?
Grade 1-2 = Endoscopic Resection
Grade 3 = Partial/Total Gastrectomy
Surgery is the definitive management for Carcinoid Tumours. How would you manage a Small Intestinal Tumour?
Resection and Lymph Node Clearance
Surgery is the definitive management for Carcinoid Tumours. How would you manage a Appendiceal Tumour?
Appendectomy and Right Hemicolectomy if large
Surgery is the definitive management for Carcinoid Tumours. How would you manage a Colonic Tumour?
Partial Colectomy and Regional LN Clearance
Surgery is the definitive management for Carcinoid Tumours. How would you manage a Rectal Tumour?
Resection
What is a Krukenberg Tumour?
Ovarian mass as a result of a gastric tumour
