Surgery - Upper GI Flashcards
What is the definition of GORD?
reflux of gastric contents with pH <4 into the oesophagus
What factors can cause GORD?
H. pylori
hiatus hernia
smoking and alcohol
obesity
mixture of:
- gastric acid hypersecretion
- reduced oesophageal clearance
- LOS incompetence
What are the signs and symptoms of GORD?
ALARMS anaemia loss of weight anorexia recent onset malaenia/haematemesis swallowing difficulties
What are the investigations for GORD (age dependent?)
<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
What classical signs are seen on a barium swallow in a patient with achalasia?
Bird Beak deformity
Cork screw deformity
What is the treatment of GORD?
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
What drugs should be avoided in GORD as they affect intestinal motility?
Calcium channel blockers
Anticholinergics
Nitrates (GTN, isosorbide mononitrate)
What drugs should be avoided in GORD as they damage the mucosa?
NSAIDs
bisphosphonates
K+ salts
What complications can arise from GORD?
oesophagitis
strictures
barrett’s oesophagus
malignancy
What is the definition of a hernia?
protrusion of the whole/part of an organ through the wall of the cavity that contains it, into an abnormal position
What are the two types of hiatus hernia?
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
How are hiatus hernias investigated?
OGD - gold standard for showing displacement of Z line
May be found incidentally on CT/MRI
What is the Z line?
the squamous-columnar junction where there is a transition from squamous to gastric mucosa
How are hiatus hernias managed?
Conservative
- weight loss, PPI, less smoking and alcohol
Surgery = if symptomatic/strangulated/gastric outlet compromise
- cruroplasty
- fundoplication (nissens or watsons)
Describe the difference between the two types of fundoplication:
Nissens = posterior, 360 degree wrap Watson's = anterior, not complete circle wrap
What are some complications of fundoplication?
Hernia recurrence
Bloating (unable to belch)
Dysphagia
Fundal necrosis
What is gastritis (acute and chronic) and its causes?
= 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
What are the S/Sx of gastritis?
epigastric pain dyspepsia (indigestion) anorexia N&V haematemesis malaena
What are the differentials for gastritis?
peptic ulcer, hernia, gastric cancer
How is gastritis investigated?
- FBC (B12 levels, IF levels, parietal antibodies, Hb, WCC, blood cultures)
- Endoscopy +/- biopsy
- H. pylori testing
How do you test for H.pylori infection?
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
How is GORD treated?
- PPI/H2 antagonists
- antibiotics to eradicate H.pylori
- surgery (gastrectomy if metaplasia/cancer)
How is H.pylori treated?
Triple therapy for 7 days
1) PPI
2) antibiotic (clarithromycin)
3) antibiotic (amoxicillin)
(use metronidazole for (3) if pen allergic)
Name some complications of gastritis
anaemia
vit B12 deficient
peptic ulcer disease
gastric cancer
What is duodenitis and its causes?
Inflammation of the duodenum
H. pylori, XS stomach acid secretion, smoking, NSAIDs…
What is Zollinger-Ellison syndrome?
Gastrin secreting tumour
Usually a gastrinoma
Increases gastric acid and mucosal damage/ulceration
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
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
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
What are some epigastric pain differentials?
GORD pancreatitis gastritis MI IBS coeliac disease pericarditis oesophagitis ulcers
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)
Which type of peptic ulcer is more common?
duodenal ulcers 4x more common than gastric ulcers
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)
What is dumping syndrome?
When undigested gastric contents pass too quickly into the SI
= N&V, sweating, flushing, distended abdomen
What is blind loop syndrome?
when normal SI bacteria proliferate causing deranged digestion and absorption = abnormal bowel function (malabsorption and diarrhoea)
What are the causes of chronic pancreatitis:
AGITS! alcohol genetics (auto)immune Infection (viral or bacterial) Tumour Structural (stricture/congenital abnormality)
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
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
How is chronic pancreatitis managed?
Diet - less fat Medical - analgesia, enzyme and vit replacement Surgery -> pancreatectomy -> endoscopic sphincterotomy/drainage -> Whipple's resection
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
Whats the most common type of pancreatic cancer?
PDA = pancreatic ductal adenocarcinoma
What are pancreatic cancer risk factors?
smoking FHx obesity DM chronic pancreatitis
What is Courvoisier’s law?
jaundice + enlarged palpable GB is likely to be malignancy rather than GS
Name some causes of obstructive jaundice
gallstones
HOP cancer
benign GB stricture
What investigations are carried out if pancreatic adenocarcinoma is suspected?
FBC (anaemia, thrombocytopenia)
LFTS (high BR, ALK, obstructive picture?)
Tumour markers = Ca19
How is pancreatic cancer treated?
surgery +/- adjuvant chemo
palliative e.g. chemo/biliary stenting
medical e.g. pancreatic enzyme replacement
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)
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
How is oesophageal cancer investigated?
OGD
Barium swallow
USS/CT/PET
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)
What is the most common type of gastric cancer?
adenocarcinoma
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
Describe the musculature of the oesophagus
Top -> bottom
Striated -> mixed -> smooth
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
How is dysphagia investigated?
History - solids/liquids, time scale... Bloods - anaemia/nutritional status? OGD Barium swallow Manometry
How is dysphagia managed?
Medical = PPI, NGT, antibiotics Surgical = endoscopic
What is achalasia and how does it present?
Failure of LOS to relax when swallowing
Presents with dysphagia, weight loss, regurgitation and abdo pain
What are complications of achalasia?
Aspiration
Oesophageal carcinoma
How is achalasia investigated?
OGD (to rule out differentials, not usually diagnostic) Barium swallow (birds beak deformity) Manometry
How is achalasia managed?
Conservative (liquid diet/ensure drinks)
Medical = tube feeding
Surgical = endoscopic (botox injection/balloon dilatation), or laparoscopic (myotomy or fundoplication)
