Oesophagogastric

Question 1

Grading of oesophageal strictures

Answer 1

Marchand classification
1: Incomplete, short, fibrotic
2: Incomplete, short, elastic
3: Circumferential, <1cm, fibrotic
4: Circumferential, >1cm, superficial fibrosis, non-progressive, dilates easily
5: Circumferential, >1cm, deep fibrosis, tubular, progressive, difficult to dilate

Question 2

Grade of endoscopic severity of caustic injury

Answer 2

Zargar classification
0: Normal
1: Mucosal oedema and hyperaemia
2 - ulcers
2a: Superficial ulcers, bleeding, exudates
2b: Deep focal or circumferential ulcers
3 - necrosis
3a: Focal necrosis with multiple and deep ulcerations and small scattered areas of necrosis
3b: Extensive necrosis

Question 3

Classification of gastric cancer

Answer 3

Lauren classification
- Intestinal type (defined mass, usually distal, better prognosis)
- Diffuse type (linitus plastica, diffuse, signet ring, less differentiated, poorer prognosis)

Question 4

Gastric cancer pathophysiology

Answer 4

Correa hypothesis
- Stepwise progression from normal mucosa to chronic gastritis to artophic gastritis to intestinal metaplasia due to exspruse to risk factors - H pylori, smoking, inflammation, ROS
- Progression from metaplasia to dysplasia to carcinoma due to mutations in genes - CDH1, p53, MLH1, KRAS.

Question 5

Mechanism of action of bariatric surgery

Answer 5

Restrictive
- decreased capacity of stomach
Malabsorptive
- Absorptive aspects of proximal small bowel bypassed, leading to decreased nutrient absortion
Metabolic
- Increased satiety (increased gut peptides GLP!, GLP2, PYY), - decreased hunger, altered preferences due to altered vagal and hypothlamic signalling
- Bile acid levels increase causing intestinal hyperrtophy, gut hormone secretion, lipid and glucose metabolism and increased energy expenditure
- decreased levels of pro-inflammatory adipokines

Question 6

Gastric cancer staging

Answer 6

TNM8
T1a: Invasion of mucosa
T1b: Invasion of submucosa
T2: Invasion of muscularis
T3: Invasion into serosa but no peritoneal breach or spread into adjacent organs
T4: Invasion into adjacent organs
N1: 1-3 nodes
N2: 4-6 nodes
N3: 7 or more nodes

Question 7

Oesophageal cancer staging

Answer 7

TNM8. Tumours with epicentres within 2cm of cardia classed as oesophageal
T1a - invades mucosa or muscularis mucosa
T1b - invades submucosa
T2 - Invades muscularis propria
T3 - Invades adventitia but not into other organs
T4a - invades azygous vein, pleura, pericardium, peritoneum,
T4b - Invades aorta, trachea/ vertebral bodies
N1 - 1-2 nodes
N2 - 3-6 nodes
N3 - 7+ nodes

Question 8

types of gastric ulcers

Answer 8

Johnson criteria
- Type 1: Lesser curve. Non acid related 60%
- Type 2: 2x ulcers involving duodenum and body of stomach. Acid related. 15%
- Type 3: Prepyloric. Acid related. 20%
- Type 4: GOJ/ proximal lesser curve <5%. Non acid related
- Type 5: Anywhere on stomach. due to meds

Question 9

Forest criteria

Answer 9

1a: Active spurting. 55% rebleed, 10% mortality
1b: Active ooze. 55% rebleed, 10% mortality
2a: Non-bleeding vessel. 40% rebleed. 11% mortality
2b: Adherant clot. 20% rebleed. 7% mortality
2c: Flat pigmented spot. 10% rebleed. 3% mortality
3: clean ulcer base. 5% rebleed. 2% mortality

Question 10

Rockall Criteria

Answer 10

Criteria that quantifies risk of rebleeding and mortality i people with bleeding . Based on age, degree of shock, comorbidities and endoscopic findings/ cause of bleeding

• Low score: 0% risk of mortality, 5% rebleeding risk
• Moderate score: 10% mortality risk, 15% rebleeding
• High score: 30% mortality, 30% rebleeding

Question 11

Imatinib (Gleevac)

Answer 11

Tyrosine kinase inhibitor, which affects the rapidly dividing tumour cells, causing arrest of proliferation and apoptosis.
- Used in neoadjuvant setting to shrink large GIST to facilitate organ-preserving surgery
- Used in adjuvant treatment for 3 years in those with high risk GIST and in some cases intermediate risk GIST
- USed in unresectable/ metastatic GISt to control disease (can result in > 50% having survival > 5 years).

Question 12

LN stations (stomach cancer)

Answer 12

1 - right crus
2 - left crus
3 - lesser curve
4 -greater curve
5 - suprpyloric
6 - infrpyloric
7 - left gastric
8 - common heptic
9 - coeliac
10 - splenic hilum
11 - splenic artery
12 - porta

Question 13

Grading of oesophagitis

Answer 13

A - One or more mucosal breaks < 5mm length
B - Mucosal break > 5mm, but not continuous between folds
C - Mucosal breaks continuous between folds, but not circimferential
D - Mucosal breaks involveing at least 3/4 of circumference

Question 14

Borchardt’s triad

Answer 14

Inability to vomit
Epigastric/ lower thoracic pain
Inability to pass NG