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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
What is duodenitis and its causes?
Inflammation of the duodenum H. pylori, XS stomach acid secretion, smoking, NSAIDs...
26
What is Zollinger-Ellison syndrome?
Gastrin secreting tumour Usually a gastrinoma Increases gastric acid and mucosal damage/ulceration
27
What is peptic ulcer disease
Break in the mucosal lining of the stomach/duodenum >5mm diameter and with depth to the submucosa Can be gastric or duodenal
28
What is the pathophysiology behind peptic ulcers?
``` Imbalance between factors promoting: Damage - NSAIDs -h.pylori - gastric acid - pepsin Protection - prostaglandins -mucous -bicarbonate -reduced mucosal blood flow ```
29
What are the signs and symptoms of gastric/peptic ulcers?
- 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
What are some epigastric pain differentials?
``` GORD pancreatitis gastritis MI IBS coeliac disease pericarditis oesophagitis ulcers ```
31
How are peptic ulcers investigated?
Bloods - FBC, urea, WCC, CRP, gastrin levels Blood cultures H.pylori testing ``` <55 = start eradication therapy >55 = endoscopy and biopsies (to exclude malignancy) ```
32
Which type of peptic ulcer is more common?
duodenal ulcers 4x more common than gastric ulcers
33
How are peptic ulcers treated?
Conservative (weight loss, diet, smoking, avoid NSAIDs) Medical (H.pylori eradication, antacids/alginates, PPI/H2 receptor antagonists) Surgical (gastrectomy or vagotomy)
34
What is dumping syndrome?
When undigested gastric contents pass too quickly into the SI = N&V, sweating, flushing, distended abdomen
35
What is blind loop syndrome?
when normal SI bacteria proliferate causing deranged digestion and absorption = abnormal bowel function (malabsorption and diarrhoea)
36
What are the causes of chronic pancreatitis:
``` AGITS! alcohol genetics (auto)immune Infection (viral or bacterial) Tumour Structural (stricture/congenital abnormality) ```
37
What are the signs/symptoms of chronic pancreatitis?
``` 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
What investigations are carried out for chronic pancreatitis?
Bloods - high WCC, low/normal amylase, faecal elastase (low), U&E, CRP, LFT, BM (high) Imaging - abdominal USS, CT abdo/pelvis, MRCP, ERCP
39
How is chronic pancreatitis managed?
``` Diet - less fat Medical - analgesia, enzyme and vit replacement Surgery -> pancreatectomy -> endoscopic sphincterotomy/drainage -> Whipple's resection ```
40
What is a Whipple's resection?
``` Pancreaticoduodenectomy Remove: - HOP - GB - bile duct - part of duodenum ``` Then rejoin the pancreas, bile duct, stomach into the intestine
41
Whats the most common type of pancreatic cancer?
PDA = pancreatic ductal adenocarcinoma
42
What are pancreatic cancer risk factors?
``` smoking FHx obesity DM chronic pancreatitis ```
43
What is Courvoisier's law?
jaundice + enlarged palpable GB is likely to be malignancy rather than GS
44
Name some causes of obstructive jaundice
gallstones HOP cancer benign GB stricture
45
What investigations are carried out if pancreatic adenocarcinoma is suspected?
FBC (anaemia, thrombocytopenia) LFTS (high BR, ALK, obstructive picture?) Tumour markers = Ca19
46
How is pancreatic cancer treated?
surgery +/- adjuvant chemo palliative e.g. chemo/biliary stenting medical e.g. pancreatic enzyme replacement
47
Describe the two pain types of oesophageal carcinoma
``` Adenocarcinoma (lower 1/3, associated with GORD and Barretts) Squamous carcinoma (occurs any location/higher, associated with alcohol, smoking and poor diet) ```
48
What are the S/Sx of oesophageal cancer
``` odynophagia lymphadenopathy weight loss fever sweating neck swelling ?Horners syndrome (miosis, ptosis and anhidrosis) haemoptysis cough dysphonia ```
49
How is oesophageal cancer investigated?
OGD Barium swallow USS/CT/PET
50
What is Barrett's oesophagus?
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
What is the most common type of gastric cancer?
adenocarcinoma
52
What are the two surgical treatment methods of gastric resection?
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
Describe the musculature of the oesophagus
Top -> bottom | Striated -> mixed -> smooth
54
What is dysphasia and its causes?
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
How is dysphagia investigated?
``` History - solids/liquids, time scale... Bloods - anaemia/nutritional status? OGD Barium swallow Manometry ```
56
How is dysphagia managed?
``` Medical = PPI, NGT, antibiotics Surgical = endoscopic ```
57
What is achalasia and how does it present?
Failure of LOS to relax when swallowing | Presents with dysphagia, weight loss, regurgitation and abdo pain
58
What are complications of achalasia?
Aspiration | Oesophageal carcinoma
59
How is achalasia investigated?
``` OGD (to rule out differentials, not usually diagnostic) Barium swallow (birds beak deformity) Manometry ```
60
How is achalasia managed?
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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