Stomach🥳

Question 1

HH definition

Answer 1

HERNIA - protrusion of a whole or part of an organ through the wall of the cavity that contains it into an abnormal position
HH - protrusion of an organ from the abdo cavity into the thorax through the oesophageal hiatus. typically stomach.

Question 2

HH types? pic on TMS

Answer 2

• sliding (?%) - gastro oesophageal junction(GOJ), abdo part of oesophagus and cardia of stomach move through diaphragmatic hiatus into thorax
• rolling (?%) - upward movement of gastric fungus occurs to lie alongside a normally position GOJ creating a bubble of stomach in the thorax

Question 3

HH risk factors?

Answer 3

- age why?
inc intra abdominal pressure eg
- pregnancy
- obesity 
- ascites

Question 4

HH clinical features?

Answer 4

• majority asymptomatic
• may experience GORD symptoms - worse in what position?
  other signs & symptoms inc:
• vomiting & weight loss (rare but serious - why?)
• bleeding/anaemia (2° to what?)
• hiccups or palpitations (why?)
• swallowing difficulties (why?)

Question 5

HH on examination?

Answer 5

• typically normal

- those w v large HHs - bowel sounds may be auscultated within the chest

Question 6

HH differential diagnoses?

Answer 6

• cardiac chest pain
• gastric & pancreatic cancer (particularly if there is evidence of what? x3)
• GORD

Question 7

HH investigations?

Answer 7

• OGD is gold standard. shows upward displacement of of the GOJ
• incidental diagnosis on CT or MRI
• less common - contrast swallow

Question 8

HH conservative managment?

Answer 8

• PPIs to reduce acid secretion & aid in symptom control. (when should they be taken? why?)
• lifestyle modification (eg ??)
• smoking cessation & reduced alcohol intake (what do both nicotine & alc do to LOS function?)

Question 9

HH when is surgical management indicated?

Answer 9

• pt is remaining symptomatic, despite mac medical therapy
• inc risk of strangulation/volvulus (rolling/mixed type HH) (obstruction suspected? what should happen prior to surgery???)
• nutritional failure (why does this happen?)

Question 10

HH surgical management options?

Answer 10

• cruroplasty - what is this?

- fundoplication - what is this?

Question 11

HH surgical management complications?

Answer 11

despite good success rate (?%) comps include:

• recurrence of hernia
• abdo bloating (why?)
• dysphagia (why?)
• fundal necrosis (if blood supply from what artery has been disrupted?) surgical emergency!! - requires major gastric resection

Question 12

HH complications?

Answer 12

• prone to incarceration & strangulation (what type is more prone?)
• gastric volvulus - stomach twists on itself by 180° so gastric passage is obstructed leading to tissue necrosis. presents w Borchardt’s triad (what is this?)

Question 13

PUD peptic ulcer definition?

Answer 13

a break in the lining of the GI tract extending through the muscularis mucosae of the bowel wall. an endoscopic diagnosis.
- where are they most commonly located?

Question 14

PUD aetiology?

Answer 14

• Gi mucosas normal defense mechanisms? x2
• PUD occurs when there is an imbalance between factors that protect the mucosa of the stomach & duodenum & factors that cause damage to it

Question 15

PUD risk factors?

Answer 15

• H pylori - how does it inc risk?
• NSAID use? - how does it inc risk?
• corticosteroid use (in conjuction w what?)
• prev gastric bypass surgery
• physiological stress (eg??? x2)
• zollinger-ellison syndrome

Question 16

PUD clinical features?

Answer 16

• 70% PUs asymptomatic
• symptomatic pts present w epigastric or retrosternal pain (when after eating are gastric vs duodenal ulcers exacerbated?), nausea, bloating, post prandial discomfort or early satiety
• less commonly pts may present w complications of PUD eg bleeding, perf or gastric outlet obstruction

Question 17

PUD when does NICE suggest an urgent OGD?

Answer 17

if pts present w either:

• new onset dysphagia
• aged > 55 yrs w weight loss & either upper abdo pain, reflux or dyspepsia
• new onset dyspepsia not responding to PPIs

Question 18

PUD differential diagnoses?

Answer 18

anything that causes dyspepsia, chest pain or epigastric pain eg ???

Question 19

PUD investigations?

Answer 19

• FBC to assess potential anaemia
• most pts (espescially younger) - non invasive h pylori testing via C13 breath test, serum antibodies to H pylori or stool antigen test
• older pts, pts w red flags or pts w ongoing symptoms despite empirical treatment - OGD. @ endoscopy any PUs seen can be biopsied & sent for biopsy (if sus for malignancy) & for rapid urease test (what is this?)

Question 20

PUD conservative management?

Answer 20

• lifestyle advice to reduce symptoms eg ??
• suspected or confirmed PUs? PPI for 4-8 wks to reduce acid production. then they should be reassessed for resolution of symptoms
• H pylori +ve? triple therapy (what is this?)
• none of this works? urgent OGD

Question 21

PUD surgical management?

Answer 21

rare except for emergencies eg perf or in the managemnt of ZE syndrome. however, in severe or relapsing disease either partial gastrectomy or selective vagotomy may be considered

Question 22

PUD complications?

Answer 22

perf, haemorrhage, pyloric stenosis (rare)