Upper gastrointestinal surgery Flashcards
Which of the following procedures is not performed for obesity?
Sleeve gastrectomy Gastric band Intra gastric balloon Mckeown procedure Small bowel bypass
Mckeown procedure
A McKeown procedure is a total oesophagectomy.
A 70 year old lady presents with an upper gastrointestinal haemorrhage. This surprises the surgical team as she has been taking a proton pump inhibitor at high dose since a recent admission with epigastric pain. At endoscopy, the duodenum is found to contain multiple ulcers. What is the most likely explanation?
Infection with helicobacter pylori Gastrinoma Duodenal lymphoma Adenocarcinoma of the duodenum Alcoholism
Gastrinoma
Gastrinomas are typically the source of gastrin in Zollinger Ellison syndrome.
Which of the following criteria is not an indication for bariatric surgery to be performed in the UK National Institute of Clinical Excellence Guidelines?
Patients must be non smoking for at least one year
Patients must have tried conservative management for at least 6 months
Commitment to long-term follow up
Surgery to be performed in a specialist unit
BMI > 35 kg/m2 and hypertensive
Patients must be non smoking for at least one year
Being a non smoker is not included in the criteria, however poor respiratory function due to smoking may affect fitness for surgery.
A 45 year old man has been troubled with dysphagia for many years. He is known to have achalasia and has had numerous dilatations. Over the past 6 weeks his dysphagia has worsened. At endoscopy, a friable mass is noted in the proximal oesophagus. What is the most likely diagnosis?
Adenocarcinoma Squamous cell carcinoma Leiomyoma Barretts oesophagus Sarcoma
Squamous cell carcinoma
The risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia. The condition often presents late and has a poor prognosis.
A 52 year old man with long standing Barretts oesophagus is diagnosed with high grade dysplasia on recent endoscopy. The lesions are multifocal and mainly distally sited. What is the best course of action?
Endoscopic surveillance at 3 monthly intervals Photodynamic therapy Nissens fundoplication Oesophagectomy External beam radiotherapy
Oesophagectomy
Some may argue for local therapy. However, in young patients who are otherwise fit, multifocal disease such as this should probably be resected.
A 35 year old man is admitted with an episode of collapse and passage of malaena. He has been suffering from post prandial abdominal pain for 5 weeks and this is most marked several hours after eating. What is the most likely cause?
Anterior duodenal ulcer Posterior duodenal ulcer Oesophageal varices Dieulafoy lesion Carcinoma of the stomach
Posterior duodenal ulcer
Patients with duodenal ulcers will usually have a history of epigastric pain that occurs several hours after eating. The pain is often improved by eating food. They are most frequently located in the first part of the duodenum. Anteriorly sited ulcers may perforate and result in peritonitis, posteriorly sited ulcers may erode the gastroduodenal artery and present with haematemesis and/ or malaena.
A 34-year-old HIV positive man is referred to the surgical out patient department with jaundice and abnormal liver function tests. Liver function tests are as follows:
Albumin 34 g/l
ALP 540 iu/l
Bilirubin 67 µmol/l
ALT 45 iu/l
What is the most likely diagnosis?
Hepatic abscess Fungal obstruction of the bile duct Duodenal adenoma Primary biliary cirrhosis Sclerosing cholangitis
Sclerosing cholangitis
The LFTs clearly show a cholestatic picture. Given the background of HIV the most likely cause is sclerosing cholangitis.
HIV: biliary and pancreatic disease
The most common cause of biliary disease in patients with HIV is sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia
Pancreatitis in the context of HIV infection may be secondary to anti-retroviral treatment (especially didanosine) or by opportunistic infections e.g. CMV
Which of the following strategies is not employed in the management of acutely bleeding oesophageal varices?
Endoscopic sclerotherapy Intravenous vasopressin Intravenous beta blockers Endoscopic rubber band ligation of varices Insertion of Sengstaken Blakemore tube
Intravenous beta blockers
Intravenous beta blockers are not typically used to manage an acute event, their value lies in prophylaxis by lowering portal venous pressure.
During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?
Vagus nerve Azygos vein Right inferior lobar bronchus Phrenic nerve Pericardiophrenic artery
Azygos vein
The azygos vein is routinely divided during an oesophagectomy to allow mobilisation. It arches anteriorly to insert into the SVC on the right hand side.
A 55 year old man with dyspepsia undergoes an upper GI endoscopy. An irregular erythematous area is seen to protrude proximally from the gastro-oesophageal junction. Apart from specialised intestinal metaplasia, which of the following cell types should also be present for a diagnosis of Barretts oesophagus to be made?
Goblet cell Neutrophil Lymphocytes Epithelial cells Macrophages
Goblet cell
Goblet cells need to be present for a diagnosis of Barrett’s oesophagus to be made.
A 40 year old man is reviewed in the clinic 6 months after a redo fundoplication operation for gastro-oesophageal reflux disease. He complains of abdominal distension and bloating. Endoscopy shows a patent gastro-oesophageal junction and upper GI contrast studies show delayed gastric emptying. What is the most likely explanation for this?
Excessive release of cholecystokinin Excessive release of gastrin Damage to the vagus nerve Damage to the short gastric vessels Excessive release of insulin
Damage to the vagus nerve
Redo fundoplication surgery carries with it a risk of damaging the vagus nerves. If both are damaged, there will be delay to gastric emptying. Its important to exclude issues at the gastro-oesophageal junction ( as these are more common, usually due to overtight wrap) these are excluded here with the OGD showing that it was normal.
Which of the following variables is not included in the Rockall score?
Congestive cardiac failure Liver failure Systolic blood pressure < 100mmHg Aspirin usage Age
Aspirin usage
Patients should have their Rockall score calculated following endoscopy for upper GI haemorrhage
Mnemonic for Rockall score ABCDE A: Age B: Blood pressure drop (Shock) C: Co-morbidity D: Diagnosis E: Evidence of bleeding
A 56 year old lady presents with a 6 month history of dysphagia to solids. She has a long history of retrosternal chest pain that is worse on lying flat and bending forwards. She undergoes an upper GI endoscopy where a smooth stricture is identified. What is the most likely diagnosis?
Globus Adenocarcinoma Leiomyoma Benign stricture Squamous cell carcinoma
Benign stricture
A six month history of dysphagia is a relatively long history and makes malignancy less likely. The lesion should be biopsied for histological confirmation. Long standing oesophagitis may be complicated by the development of strictures, Barretts oesophagus or both.
A 65 year old male attends surgical out patients with epigastric discomfort. He has recently been diagnosed with diabetes by the GP and is a heavy smoker. An OGD is normal. What is the most likely diagnosis?
Pancreatic adenocarcinoma Pancreatic squamous cell carcinoma Pancreatic insulinoma Pancreatic glucagonoma Pancreatic gastrinoma
Pancreatic adenocarcinoma
The dominant differential diagnosis should be of pancreatic adenocarcinoma in this setting. Glucagonomas are very rare and may be associated with a bullous rash.
A 76 year old man presents with a 5 week history of progressive dysphagia. An upper GI endoscopy is performed and the surgeon notices changes that are compatible with Barretts oesophagus. The oesophagus is filled with food debris that cannot be cleared and the endoscope encounters a resistance that cannot be passed. What is the most likely underlying diagnosis?
Adenocarcinoma Squamous cell carcinoma Achalasia cardia Nutcracker oesophagus Benign peptic stricture
Adenocarcinoma
A short history of dysphagia together with food debris and Barretts changes makes adenocarcinoma the most likely diagnosis.
A 53 year old man presents with dyspepsia. At upper GI endoscopy he has a punched out ulcer on the lesser curve of the stomach. It measures approximately 2cm in diameter and is seen to penetrate muscle with fibrosis present at the base. What is the most likely diagnosis?
Curlings ulcer Cushings ulcer Chronic ulcer Adenocarcinoma Gastric lymphoma
Chronic ulcer
Fibrosis is usually a sign of chronic ulcer. It should be biopsied carefully, a proton pump inhibitor started and re endoscopy should occur at 6 weeks.
A 67 year old lady presents with jaundice and abdominal pain. Her investigations show a dilated common bile duct, a carcinoma of the pancreatic head compressing the pancreatic duct. Her liver contains bi-lobar metastasis. What is the most appropriate course of action?
Undertake synchronous resection of liver metastases and pancreatoduodenectomy
Resection of liver metastases, chemotherapy and then resection of the primary lesion
Insertion of endoscopic biliary stent and consideration of palliative chemotherapy
Palliation alone
Insertion of PTC drain and palliation
Resection of liver metastases, chemotherapy and then resection of the primary lesion
The presence of metastatic disease in the context of pancreatic cancer renders this incurable and resection of metastatic disease is not appropriate.
A 45 year old man undergoes an upper gastrointestinal endoscopy for a benign oesophageal stricture. This is dilated and he suffers an iatrogenic perforation at the site. His imaging shows a small contained leak and a small amount of surgical emphysema. What is the most appropriate nutritional option?
Nil by mouth and intravenous fluids alone Intravenous fluids and sips orally Total parenteral nutrition Nasogastric feeding PEG tube feeding
Total parenteral nutrition
Iatrogenic perforations of the oesophagus may be managed non operatively. This usually involves a nil by mouth regime, tube thoracostomy may be needed. Total parenteral nutrition is the safest option. Insertion of NG feeding tubes and PEG tubes may complicate the process or allow feed to enter the perforation site.
A 22 year old man presents with a 5 month history of episodic retrosternal chest pain together with episodes of dysphagia to liquids. An upper GI endoscopy is performed and no mucosal abnormality is seen. What is the most likely diagnosis?
Motility disorder Leiomyosarcoma Gastro intestinal stromal tumour Squamous cell carcinoma Benign peptic stricture
Motility disorder
Dysphagia that is episodic and varies between solids and liquids is more likely to represent a motility disorder.
A 70 year old lady has a cerebrovascular accident and has been recovering in hospital for the past 3 weeks. She has been deemed to have an unsafe swallow. What is the best option for long term feeding?
Endoscopically inserted PEG feeding tube
Long term fine bore nasogastric feeding tube
Surgically inserted feeding jejunostomy tube
TPN via a central vein
TPN via a peripheral cannula
Endoscopically inserted PEG feeding tube
At 3 weeks, it is unlikely that feeding orally is going to resume and therefore a definitive long term feeding solution is needed. A PEG is favored over a feeding jejunostomy in such circumstances.
A 42 year old woman with known multiple gastric ulcers attends the surgical out patient unit. She has not improved despite 2 months of proton pump inhibitor treatment. She is found to have a gastrinoma. Where are these most often located?
Duodenum Pancreatic head Pancreatic tail Jejunum Gastric antrum
Duodenum
Most commonly found in the duodenum (in up to 50% patients), then the pancreas (approximately 20%). Other ectopic areas include stomach, spleen, gallbladder and ovary
Greater than 4/5 of gastrinomas are found within the triangle bounded by:
Cystic and common bile duct (Top)
2nd and 3rd part of the duodenum (Bottom)
Neck and body of pancreas (Medial)
Pancreatic gastrinomas are normally solitary and display malignant behaviour.
Zollinger Ellison syndrome is composed of the triad of:
1. Non beta islet cell tumours of the pancreas
2. Hypergastrinaemia
3. Severe ulcer disease
Clinical features related to peptic ulcer disease. Diagnosis is based on 3 criteria:
- Fasting hypergastrinaemia
- Increased basal acid output
- Secretin stimulation test positive
Management
Resection if localised disease
