GI Session 5 Flashcards
What are the causes of GORD?
LOS problems
Delayed gastric emptying –> raised intra-gastric pressure –> increased workload on LOS
Hiatus hernia
Obesity
What are the S/S of GORD?
Heartburn Cough +/- wheeze Sore throat Dysphagia Odynophagia
What are the consequences of GORD?
Oesophagitis
Fibrous strictures –> regurgitation
Barrett’s oesophagus
What Tx can be used for GORD?
Lifestyle modifications: smaller more frequent meals, wait 3 hrs after eating to sleep Antacids H2 antagonists PPIs Surgery
What surgical technique can be used to Tx externae cases of GORD?
Wrap fundus around oesophagus
Give an example of a PPI which is slightly more effective than H2 antagonists.
Omeprazole
How are H2 antagonists available to pts?
Low does over the counter
What is acute gastritis?
Localised/general transient mucosal inflammatory process
What causes acute gastritis?
Heavy NSAID use
Excessive alcohol intake
Chemotherapy
Bile reflux in reverse peristalsis of duodenum
How does chemotherapy lead to acute gastritis?
Targets rapidly regenerating cells so acts on defence cells in stomach
What are the S/S of acute gastritis?
Usually asymptomatic
Pain
N+V
Bleeding
When can acute gastritis be fatal?
If generalised gastritis leads to extensive bleeding
What is visible on histology in acute gastritis?
Inflammatory cell invasion
What are the consequences of acute gastritis?
Stomach ulcer
Polyps
Neoplasm
What is the Tx for acute gastritis?
Antacids
H2 antagonists
PPIs
Change away from NSAID painkiller
Give two examples of H2 antagonists used to Tx acute gastritis.
Cimetidine
Ranitidine
What is chronic gastritis?
Localised/generalised persistent mucosal inflammatory process
What are the causes of chronic gastritis?
H.pylori infection Autoimmun production of antibodies to gastric parietal cells Chronic alcohol abuse NSAIDs Bile reflux
What S/S are seen in chronic gastritis due to H.pylori?
Asymptomatic
Similar to acute gastritis
Sometimes due to complications
What are the S/S of chronic gastritis due to autoimmune disease?
S/S of aneamia, classically glossitis
Anorexia
Neurological problems e.g. abnormal gait, numbness, tingling
What are the consequences of chronic gastritis due to H.pylori?
Peptic ulcers
Adenocarcinoma
MALT lymphoma
What are consequences of autoimmune chronic gastritis?
Pernicious anaemia +/- neurological disturbance
What causes neurological disturbance in autoimmune chronic gastritis?
Lack of B12 from deficiency in intrinsic factor
What is the Tx for chronic gastritis?
Abx if H.pylori (PPI+clarithromycin+amoxicillin)
PPIs
H2 antagonists
Antacids
What is dyspepsia?
Umbrella term for upper GI symptoms
What is peptic ulcer disease?
Defect in gastric/duodenal mucosa which extends through muscularis mucosa
Where are peptic ulcers most commonly found?
First part of duodenum
Lesser curvature of stomach
Body of stomach
What are the causes of peptic ulcer disease?
Stomach acid not being removed by adequate mucosal bloodflow
H.pylori
NSAIDs
Massive physiological stress (massive burns/trauma)
What effect does smoking have on peptic ulcer disease?
Contributes to relapse but does not initiate disease
What are the S/S of peptic ulcer disease?
Asymptomatic Epigastric pain with burning/gnawing after meals Bleeding Anaemia Early satiety Weight loss
What are the consequences of peptic ulcer disease?
Posterior erosion into gastroduodenal artery –> massive haematemisis
Melaena
Perforation –> peritonitis +/- sepsis
Gastric outlet obstruction
What Tx can be used for peptic ulcer disease?
Abx, PPIs, H2 antagonists, antacids
What is functional dyspepsia?
Symptoms of peptic ulcer without physical evidence of organic disease
Why is functional dyspepsia a diagnosis of exclusion?
Blood tests -ve for anaemia
Endoscopy -ve
What Tx are used for functional dyspepsia?
PPIs
What aids the survival of H.pylori in the stomach?
Production of urease to create alkaline surroundings
Flagellum for motility in gastric mucosa
Flagellum for adherence to gastric epithelium
How does H.pylori damage the host?
Release cytokines –> direct epithelial injury
Production of toxic ammonia
Possible degradation of mucus layer
Promotion of inflammatory response –> self-injury
What is the result of H.pylori colonisation in the body of the stomach?
Atrophic effect –> gastric ulcer –> intestinal metaplasia
What is the effect of H.pylori colonisation in the antrum?
Increase gastrin
Increase parietal cell acid production
When are H.pylori found in the duodenum?
Only after metaplasia to gastric epithelium
What is the result of H.pylori colonisation of the duodenum?
Ulcer formation
What is Zollinger-Ellison syndrome?
Non-beta islet cell gastrin secreting tumour of the pancreas such may also be in duodenum/abdomen/lymph nodes/ectopic
What is the pathogenesis of Zollinger-Ellison syndrome?
Proliferation of parietal cells –> increased acid production –> severe stomach and small bowel ulceration
What are the S/S of Zollinger-Ellison syndrome?
Abdominal pain
Diarrhoea
Malabsorption
What syndrome can Z-E form part of?
Autosomal dominant familial Multiple Endocrine Neoplasia Type 1 (MEN1)
What Tx can be used for Z-E syndrome?
PPI and H2 antagonists before surgery/chemotherapy
Octneotide (mimics somatostatin)
Describe the epidemiology of stomach cancer.
3rd most common cancer in the world
~7000 new cases per year in the UK
High rates in Chile, Japan and South America
Why does stomach cancer usually present late?
Has to be quite large before it becomes symptomatic
What are the risk factors for developing stomach cancer?
Male
H.pylori
High salt intake
Smoking
What are the S/S of stomach cancer?
Dysphasia Loss of appetite Malaena Weightloss N+V Virchow's nodes
What are Virchow’s nodes?
Palpable node in L supra clavicular fossa MCL
What types of stomach cancer are seen?
Majority adenocarcinomas - intestinal/diffuse
Small numbersof lymphomas, carcinomas, stromal tumours
How is stomach cancer diagnosed?
Bloods for tumour markers
Upper GI endoscopy +/- biopsy
CT scan
What is the Tx for stomach cancer?
Endoscopic mucosal resection in very early detection
Surgery/chemo/radiotherapy
How can diagnosis of GI pathology be made?
Upper GI endoscopy Urease breath test (measure exhaled radiolabelled carbon) Erect CXR (space under diaphragm = perforation) Blood test (anaemia)
What is the function of the hepatic artery proper?
Supplies liver with arterial blood from coeliac trunk
How is lymph drained from the liver?
Hepatic lymph nodes along vessels and ducts in the lesser omentum –> coeliac nodes
What are the ligaments of the liver?
Falciform
L+R coronary
L+R triangular
What is the function of the falciform ligament?
Attach anterior lover surface to anterior abdominal wall
What does the free edge of the falciform ligament contain?
Ligamentum teres
What is the ligamentum teres?
Remnant of the umbilical vein
What is the function of the L+R coronary ligaments of the liver?
Attach superior surface to diaphragm
What is the function of the L+R triangular ligaments of the liver?
Attach superior liver to diaphragm
What innervates Glisson’s capsule?
Branches of lower intercostal nerves
Does distension of Glisson’s capsule cause well localised or diffuse pain?
Sharp, well-localised
What is the function of the hepatic portal vein?
Supply deoxygenated blood with nutrients from the small intestine to the liver parenchyma for gut-related functions
What two ligaments that attach to the liver are found in the lesser omentum?
Hepatoduodenal
Hepatogastric
On postero-inferior views of the liver is the caudate or quadrate lobe more superior?
Caudate
Where is the caudate lobe of the liver located?
Between IVC and ligamentum venosum fossa
What is the function of the porta hepatis?
Transmit all vessels, nerves, ducts in and out of the liver
What are the four lobes of the liver?
L, caudate, quadrate, R
What separates the L lobe from the caudate and quadrate lobes?
Umbilical (L sagittal) fissure
What forms the R portal fissure?
Position of R hepatic vein
What separates the R lobe form the caudate and quadrate loves of the liver?
R sagittal fissure
Where is the quadrate lobe of the liver located?
Between gallbladder and ligamentum teres fossa
What is found between the R+L coronary ligaments, L triangular ligament and IVC?
Bare area
Which 3 hepatic veins drain into the IVC?
Right, intermediate and left
What helps to hold the liver in place?
3 hepatic veins draining into IVC in groove of liver
What is in the portal triad?
Portal vein
Hepatic artery
Bile passages
How is the liver parenchyma innervated?
Hepatic plexus
Sympathetic coeliac plexus
Parasympathetic vagus nerve fibres
What are the three hepatic recesses?
L+R subphrenic spaces
Sub hepatic space
Morrison’s pouch
Where are the L+R subphrenic spaces?
Between diaphragm and lover either side of falciform ligament
Where os the subhepatic space?
Between inferior surface of liver and transverse colon
Where is Morrion’s pouch?
Between visceral surface and R kidney
Why does fluid collect in Morrison’s pouch when bedridden?
Deepest part of peritoneal cavity when supine
What is the result of infected fluid collection in the hepatic recesses?
Abscess
Where is Hartmann’s pouch?
Neck of gallbladder
What is Hartmann’s pouch?
Mucosal fold which is a common site of gallstone lodging
What perforates the gallbladder when it is in the fossa in the liver?
Cystic veins
What does the duodenum secrete to stimulate bile secretion?
CCK
Give a brief structure of the biliary tree.
R+L hepatic ducts–> common hepatic duct + cystic duct –> common bile duct + pancreatic duct –> hepatopancreatic Ampulla of Vater controlled by Sphincter of Oddi
What gives arterial supply to the gallbladder?
Common hepatic –> hepatic artery –> cystic artery
What gives venous drainage to the gallbladder?
Cystic vein –> portal vein
What gives neural supply to the gallbladder?
Coeliac plexus (sympathetic and sensory fibres) Vagus nerve (parasympathetic)
What is the action of vagus nerve stimulation of the gallbladder?
Contraction and secretion of bile into cystic duct
How is lymph drained from the gallbladder?
Cystic node in gallbladder neck –> hepatic lymph node –> coeliac node
Describe the branches of the hepatic portal vein.
SMV+splenic vein –> hepatic portal vein –> R+L branches –> secondary branches to medial and lateral divisions –> tertiary branches to supply 7 out of 8 hepatic segments
Are gallstones more common in males or females?
Females
Where is the head of the pancreas located?
Curve of duodenum
Where is the neck of the pancreas positioned?
Overlies SMA+V with anterior surface adjacent to Pylorus of stomach
Where is the body of the pancreas located?
Left of SMVA+V in omental bursa
Does the posterior surface of the pancreatic body have peritoneum?
No
Where is the pancreatic tail positioned?
Anterior to L kidney between layers of splenorenal ligament
