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