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Year 4 > Surgery - Upper GI > Flashcards

Surgery - Upper GI Flashcards

1
Q

What is the definition of GORD?

A

reflux of gastric contents with pH <4 into the oesophagus

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2
Q

What factors can cause GORD?

A

H. pylori
hiatus hernia
smoking and alcohol
obesity

mixture of:

  • gastric acid hypersecretion
  • reduced oesophageal clearance
  • LOS incompetence
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3
Q

What are the signs and symptoms of GORD?

A 
ALARMS
anaemia
loss of weight
anorexia
recent onset
malaenia/haematemesis
swallowing difficulties
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4
Q

What are the investigations for GORD (age dependent?)

A

<55 = H. pylori testing (must have stopped using PPI for 1 month before)

> 55 or ALARM symptoms = upper scope and biopsies, 24hr pH monitoring, manometry, barium swallow

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5
Q

What classical signs are seen on a barium swallow in a patient with achalasia?

A

Bird Beak deformity

Cork screw deformity

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6
Q

What is the treatment of GORD?

A

Lifestyle

  • weight loss
  • small regular meals
  • avoid caffeine, smoking, alcohol
  • sleep propped up and don’t eat <3hrs before sleep

Medication

  • antacids
  • alginates
  • PPI
  • H2 receptor antagonist

Surgery

  • cruroplasty
  • fundoplication
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7
Q

What drugs should be avoided in GORD as they affect intestinal motility?

A

Calcium channel blockers
Anticholinergics
Nitrates (GTN, isosorbide mononitrate)

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8
Q

What drugs should be avoided in GORD as they damage the mucosa?

A

NSAIDs
bisphosphonates
K+ salts

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9
Q

What complications can arise from GORD?

A

oesophagitis
strictures
barrett’s oesophagus
malignancy

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10
Q

What is the definition of a hernia?

A

protrusion of the whole/part of an organ through the wall of the cavity that contains it, into an abnormal position

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11
Q

What are the two types of hiatus hernia?

A

20% = para-oesophageal (rolling) = OG junction remains in abdomen, but bulge of the stomach herniates into the chest alongside the oesophagus, has risk of strangulation -> ischaemia -> necrosis

80% = sliding hernia where OG junction and a portion of stomach come up into the chest due to reduced LOS pressure, there is a risk of acid reflux as the OG junction becomes less competent

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12
Q

How are hiatus hernias investigated?

A

OGD - gold standard for showing displacement of Z line

May be found incidentally on CT/MRI

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13
Q

What is the Z line?

A

the squamous-columnar junction where there is a transition from squamous to gastric mucosa

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14
Q

How are hiatus hernias managed?

A

Conservative
- weight loss, PPI, less smoking and alcohol

Surgery = if symptomatic/strangulated/gastric outlet compromise

  • cruroplasty
  • fundoplication (nissens or watsons)
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15
Q

Describe the difference between the two types of fundoplication:

A 
Nissens = posterior, 360 degree wrap
Watson's = anterior, not complete circle wrap
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16
Q

What are some complications of fundoplication?

A

Hernia recurrence
Bloating (unable to belch)
Dysphagia
Fundal necrosis

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17
Q

What is gastritis (acute and chronic) and its causes?

A

= inflammation of the stomach lining

Acute = caused by alcohol, NSAIDs, trauma
Chronic =
-Autoimmune (autoantibodies against parietal cells = less IF and HCl to convert pepsinogen into pepsin)
-Bacterial = caused by H.pylori, releases urease enzyme converting urea -> NH3 which surrounds the D cells in a cloud meaning they cannot sense the true stomach pH = they make no somatostatin and G cells are not inhibited = XS acid production
-Chemical e.g. alcohol, NSAIDs, bile reflux, oral iron

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18
Q

What are the S/Sx of gastritis?

A 
epigastric pain
dyspepsia (indigestion)
anorexia
N&V
haematemesis
malaena
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19
Q

What are the differentials for gastritis?

A

peptic ulcer, hernia, gastric cancer

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20
Q

How is gastritis investigated?

A
  • FBC (B12 levels, IF levels, parietal antibodies, Hb, WCC, blood cultures)
  • Endoscopy +/- biopsy
  • H. pylori testing
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21
Q

How do you test for H.pylori infection?

A

NON-INVASIVE:

  • blood (serology)
  • breath (C-urea breath test)
  • faeces (antigen testing)

INVASIVE

  • histology (from biopsy)
  • CLO test (rapid urease test, performed at time of gastroscopy using biopsy sample)
  • microbiological culture
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22
Q

How is GORD treated?

A
  • PPI/H2 antagonists
  • antibiotics to eradicate H.pylori
  • surgery (gastrectomy if metaplasia/cancer)
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23
Q

How is H.pylori treated?

A

Triple therapy for 7 days

1) PPI
2) antibiotic (clarithromycin)
3) antibiotic (amoxicillin)

(use metronidazole for (3) if pen allergic)

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24
Q

Name some complications of gastritis

A

anaemia
vit B12 deficient
peptic ulcer disease
gastric cancer

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25
Q

What is duodenitis and its causes?

A

Inflammation of the duodenum

H. pylori, XS stomach acid secretion, smoking, NSAIDs…

26
Q

What is Zollinger-Ellison syndrome?

A

Gastrin secreting tumour
Usually a gastrinoma
Increases gastric acid and mucosal damage/ulceration

27
Q

What is peptic ulcer disease

A

Break in the mucosal lining of the stomach/duodenum >5mm diameter and with depth to the submucosa
Can be gastric or duodenal

28
Q

What is the pathophysiology behind peptic ulcers?

A 
Imbalance between factors promoting:
Damage
- NSAIDs
-h.pylori
- gastric acid
- pepsin
Protection
- prostaglandins
-mucous
-bicarbonate
-reduced mucosal blood flow
29
Q

What are the signs and symptoms of gastric/peptic ulcers?

A
  • epigastric pain
  • Nausea
  • anaemia
  • anorexia
  • weight loss

Duodenal = relieved by eating, pain worse when hungry
-> duodenal ulcer may cause R shoulder/back pain (referred)
Gastric = pain worse when eating and after meals

30
Q

What are some epigastric pain differentials?

A 
GORD
pancreatitis
gastritis
MI
IBS
coeliac disease
pericarditis
oesophagitis
ulcers
31
Q

How are peptic ulcers investigated?

A

Bloods - FBC, urea, WCC, CRP, gastrin levels
Blood cultures
H.pylori testing

<55 = start eradication therapy 
>55 = endoscopy and biopsies (to exclude malignancy)
32
Q

Which type of peptic ulcer is more common?

A

duodenal ulcers 4x more common than gastric ulcers

33
Q

How are peptic ulcers treated?

A

Conservative (weight loss, diet, smoking, avoid NSAIDs)
Medical (H.pylori eradication, antacids/alginates, PPI/H2 receptor antagonists)
Surgical (gastrectomy or vagotomy)

34
Q

What is dumping syndrome?

A

When undigested gastric contents pass too quickly into the SI
= N&V, sweating, flushing, distended abdomen

35
Q

What is blind loop syndrome?

A

when normal SI bacteria proliferate causing deranged digestion and absorption = abnormal bowel function (malabsorption and diarrhoea)

36
Q

What are the causes of chronic pancreatitis:

A 
AGITS!
alcohol
genetics
(auto)immune
Infection (viral or bacterial)
Tumour
Structural (stricture/congenital abnormality)
37
Q

What are the signs/symptoms of chronic pancreatitis?

A 
epigastric pain radiating to the back
relieved by sitting forwards
worse when eating
steatorrhoea
weight loss (due to malabsorption)
diabetes (reduced endocrine function)
epigastric mass (e.g. pseudocyst) on examination
38
Q

What investigations are carried out for chronic pancreatitis?

A

Bloods - high WCC, low/normal amylase, faecal elastase (low), U&E, CRP, LFT, BM (high)

Imaging - abdominal USS, CT abdo/pelvis, MRCP, ERCP

39
Q

How is chronic pancreatitis managed?

A 
Diet - less fat
Medical - analgesia, enzyme and vit replacement
Surgery
-> pancreatectomy
-> endoscopic sphincterotomy/drainage
-> Whipple's resection
40
Q

What is a Whipple’s resection?

A 
Pancreaticoduodenectomy
Remove:
- HOP
- GB
- bile duct
- part of duodenum

Then rejoin the pancreas, bile duct, stomach into the intestine

41
Q

Whats the most common type of pancreatic cancer?

A

PDA = pancreatic ductal adenocarcinoma

42
Q

What are pancreatic cancer risk factors?

A 
smoking
FHx
obesity
DM
chronic pancreatitis
43
Q

What is Courvoisier’s law?

A

jaundice + enlarged palpable GB is likely to be malignancy rather than GS

44
Q

Name some causes of obstructive jaundice

A

gallstones
HOP cancer
benign GB stricture

45
Q

What investigations are carried out if pancreatic adenocarcinoma is suspected?

A

FBC (anaemia, thrombocytopenia)
LFTS (high BR, ALK, obstructive picture?)
Tumour markers = Ca19

46
Q

How is pancreatic cancer treated?

A

surgery +/- adjuvant chemo
palliative e.g. chemo/biliary stenting
medical e.g. pancreatic enzyme replacement

47
Q

Describe the two pain types of oesophageal carcinoma

A 
Adenocarcinoma (lower 1/3, associated with GORD and Barretts)
Squamous carcinoma (occurs any location/higher, associated with alcohol, smoking and poor diet)
48
Q

What are the S/Sx of oesophageal cancer

A 
odynophagia
lymphadenopathy
weight loss
fever 
sweating
neck swelling
?Horners syndrome (miosis, ptosis and anhidrosis)
haemoptysis
cough
dysphonia
49
Q

How is oesophageal cancer investigated?

A

OGD
Barium swallow
USS/CT/PET

50
Q

What is Barrett’s oesophagus?

A

Metaplastic response to chronic mucosal injury
Metaplasia = conversion of one adult cell type into another
Metaplasia of epithelium from non-keratinised stratified squamous -> columnar, glandular intestinal type (presence of intestinal goblet cells)

51
Q

What is the most common type of gastric cancer?

A

adenocarcinoma

52
Q

What are the two surgical treatment methods of gastric resection?

A

Roux-en-Y = remove entire stomach and stitch the start of the duodenum shut, then rejoin the oesophagus ad the duodenum to the jejunum

Bilroth II = remove PART of the stomach and a gastro-jejunostomy is carried out

53
Q

Describe the musculature of the oesophagus

A

Top -> bottom

Striated -> mixed -> smooth

54
Q

What is dysphasia and its causes?

A

Term for swallowing difficulties
causes can be:
A) Inflammatory - GORD, oesophagitis, candida, ulcers
B) Neuromuscular LOCAL = achalasia, diffuse oesophageal spasm, nutcracker oesophagus
B) Neuromuscular SYSTEMIC = stroke, MND, systemic sclerosis
C) Mechanical INTRINSIC = food, foreign body, stricture, plummer vinson syndrome (oesophageal webs)
D) Mechanical EXTRINSIC = hernia, goitre, lung cancer, lymphadenopathy

55
Q

How is dysphagia investigated?

A 
History - solids/liquids, time scale...
Bloods - anaemia/nutritional status?
OGD
Barium swallow
Manometry
56
Q

How is dysphagia managed?

A 
Medical = PPI, NGT, antibiotics
Surgical = endoscopic
57
Q

What is achalasia and how does it present?

A

Failure of LOS to relax when swallowing

Presents with dysphagia, weight loss, regurgitation and abdo pain

58
Q

What are complications of achalasia?

A

Aspiration

Oesophageal carcinoma

59
Q

How is achalasia investigated?

A 
OGD (to rule out differentials, not usually diagnostic)
Barium swallow (birds beak deformity)
Manometry
60
Q

How is achalasia managed?

A

Conservative (liquid diet/ensure drinks)
Medical = tube feeding
Surgical = endoscopic (botox injection/balloon dilatation), or laparoscopic (myotomy or fundoplication)

Year 4 (28 decks)

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