UGI

Question 1

Frequency of PUD perforations by location

Answer 1

Duodenal 60%
Antral/pyloric 20%
Gastric body 20%

Question 2

Pathophysiology PUD perforation

Answer 2

imbalance between protective and hostile factors:
- H. Pylori (DU)
- XS NSAIDs (GU)
- smoking
- drinking

• Protective mucosal barrier is broken
• acidic exposure of the mucosa –> tissue destruction.
• Spillage of gastroduodenal contents
  → severe chemical peritonitis → bacterial infection
  → SIRS
  → multiorgan failure
  → death

Question 3

Mx perforated PUD

Answer 3

Initial management
- Resuscitation
- Broad-spectrum IV ABx
- IV PPI
- NGT decompression

Surgery
- Laparotomy, peritoneal lavage and closure of defect with patch

Location: D1 -> pre-pyloric region -> lesser curve

• if not found -> divide lesser omentum through pars flaccida and examine lesser curve -> examine posterior stomach and GOJ -> run small bowel and large bowel

DU
- No Biopsy
4 D’s – Define, Debridement, drainage and divert
- Graham omental patch/serosal patch

If large DU:
- Partial gastrectomy with B2 recon (to remove gastrin producing cells of antrum and divert acid away) + closure of the duodenal stump +/- T tube (to create controlled fistula), widely drain

Other options: -> nissen procedure, pyloric exclusion
Drain

GU
- Biopsy – risk of malignancy (4% overall, 30% for ulcers >3cm)
- Omental patch or serosal patch

• If obviously malignant -> consider gastrectomy
• Large perforations
  Excision of ulcer and primary closure
• Partial gastrectomy (antrectomy) + B2 reconstruction +/- truncal vagotomy (not highly selective vagotomy)

H pylori eradication
Commence empirically → present in 90% of perforation

Question 4

Role of staging laparoscopy in gastric cancer

Answer 4

Indication:
>T1 lesion on EUS, medically fit and no disseminated disease

Goal:
1. Exclude peritoneal disease

2. Assess serosal involvement and invasion of adjacent organs (don’t enter lesser sac unless suspicious on imaging)
3. Peritoneal cytology (1L LUQ/RUQ/greater omentum)
4. Confirm resectability

20% change Mx

20-30% >T1 have peritoneal Mets at diagnostic lap

Question 5

Cirrhosis/Portal hypertension: risk of surgery pathophysiology

Answer 5

protein synthesis dysfunction
- poor wound healing

PHTN
- Increased bleeding risk
- Splenic sequestration (thrombocytopenia)
- abnormal 2ndry haemostasis (increased bleeding and clotting)
- abnormal drug metabolism
- deceased renal function

electrolyte imbalance (Na)

Anaemia

Hypoalbuminaemia

Question 6

Japanese endoscopic society classification early gastric cancer subtypes

Answer 6

On macroscopic appearance

Type 1: protruberant (sessile, smooth nodule <3cm)

Type 2: superficial
2A - slightly elevated
2B - flat
2C - depressed

Type 3: ulcerating

Question 7

Advanced gastric cancer - Bormann classification

Answer 7

On macroscopic appearance

Type 1: fungating

Type 2: excavated

Type 3: ulcerative

Type 4: infiltrative (linitus plastica)

Question 8

What determines prognosis for gastric cancer?

Answer 8

T-stage/depth

Lymphovascular invasion and LN Mets

Location in stomach (distal better)

Degree of histological differentiation