Oesophogastric

Question 1

What are the indications for EMR or ESD in early gastric cancer?

Answer 1

T1a
< 2cm
No ulceration
Well differentiated
No LVI

Question 2

What are the indications for bariatric surgery?

Answer 2

1) All patients with a BMI > 35
2) Patients with a BMI of 30-35 with metabolic disease not responsive to non surgical treatment
3) Asian population BMI > 27.5

Question 3

What is the pathophysiology of obesity?

Answer 3

This is the result of an energy imbalance with intake and expenditure which is the result of abnormal haemostasis:

1) Abnormal set point of hypothalamus
- maintain excessive weight

2) Leptin resistance
- leptin regulates long term satiety with release from adipose tissue -> a-MSH from hypothalamus -> hypothalamic melanocrtin 4 receptor -> inhibit food intake. (obese patients are leptin resistant)

3) Abnormal signalling from GIT
Grehlin (produced by the gastric fundus. hunger hormone with higher levels in obesity)
GLP-1 and peptide YY (satiety hormones produced distal SB in response to food in the lumen and slow gastric empyting)

The above is affected by a number for factors

1) Lifestyle - calorie intake and reduced physical activity

2) genetic - familial predisposition, rare single gene mutations and genetic syndromes (Prader Willi)

3) medical - hypothyroidism and cushings as well as medications benzodiazepines, steroids, antipsychotics TCAs

4) psychosocial - stress, marriage, smoking cessation, giving up sport, and life stage (pregnancy and menopause)

Question 4

List obesity related medical comorbidities

Answer 4

CVD
- HTN, MI, venous stasis, DVT, pulmonary HTN, right sided heart failure

Pulmonary
- OSA, hypoventilation syndrome, Asthma

Metabolic
- T2DM, hyperlipidaemia, hypercholesterolaemia, NASH, NAFLD

Gastrointestinal
- GORD and cholelithiasis

MSK
- OA, degenerative joint disease, lumbar disc disease, ventral hernias

GU
- Stress urinary incontinence, ESRD

Gynae
- menstrual irregularities

Psychological
- depression, anxiety, low self esteem, stroke

Social
- hx of physical and sexual abuse, discrimination for employment and social discrimination

Question 5

What are the virulence factors for H Pylori?

Answer 5

Gram negative rod

LUVFACE G

Lipase enzyme
Urease - converts urea to ammonium and thus neutralises the stomach (allows for protective barrier around the bacteria)
VacA - damages cells
Flagella - allows for mobility in viscous fluid
Adhesions - attachment to specific gastric epithelial cell receptors
CagA - produce antigenic substances such as inflammatory cytokines (IL1, 6, 8 and TNF alpha) -> neutrophil and monocyte recruitment -> further cytokine release -> oxidative free radicals
Enzymes - phospholipase and mucinase disrupts the integrity of the mucous layer, converting lecithin to lysolecithin (toxic to cells)

Gastrin - increased release due to reduced pH from Hpylori -> stimulation of G cells with gastrin secreted -> D cells damaged -> reduced somatostatin production -> less G cell inhibition -> increased gastrin

Question 6

What is the zargar grading system for caustic injury for burns?

Answer 6

A grading system to identify the grade of injury on endoscopy that guides further management

Grade 1 - superficial with mucosal oedema and hyperaemia
Grade 2 - transmucosal +/- muscularis
2a - superficial ulcers , bleeding, exudates
2b - deep focal or circumferential
Grade 3 - full thickness or adjacent organ involvement
3a - full thickness focal necorsis with multiple and deep ulcers
3b - extensive necrosis

Question 7

What are the criteria for ESD or EMR for early gastric cancer?

Answer 7

T1a
No LVI
No ulceration
< 2cm
Well differentiated