Upper gastrointestinal tract Flashcards
204 What are the main types of bariatric operations that are performed for obesity? How do they work?
Restrictive procedures:
a) Adjustable gastric banding = tight adjustable prosthetic band placed around cardia/fundus of the stomach to compartmentalise upper stomach and create early satiety
- Benefits: lowest mortality, shorter hospital stay
- Long-term complications: reflux, oesophageal dysmotility, band slippage, band erosion
b) Sleeve gastrectomy = partial gastrectomy of the greater curvature of the stomach to create a smaller, tube-shaped stomach
- Benefits: technically easier, safer, 60% weight loss at 2 years
- Complications: leakage, stenosis of sleeve, dilation of sleeve, reflux
Malabsorptive procedure:
c) Biliopancreatic diversion (BPD) with duodenal switch = sleeve gastrectomy with pylorus preservation + Roux limb with short common channel
- Benefits: reduced action of bile (fat absorption) and pancreatic enzymes (amylase, lipase), restriction from sleeve
- Complications: significant risk of long-term malabsorption (therefore only used in severe obesity where BMI >50)
Duodenal switch is favoured (compared to BPD alone) because:
1) Allows more forward flow of biliopancreatic limb
2) Avoids complications of stasis
3) Associated with a lower incidence of stomal ulceration and diarrhoea
Combination procedure:
d) Roux-en-Y gastric bypass = stomach divided, small intestine divided 30-50cm distal to ligament of Treitz, small gastric pouch anastomosed to jejunum to form a Roux limb (intake restriction), gastric remnant and proximal biliopancreatic limb anastomosed to Roux limb 75-150cm distal to gastrojejunostomy (bypass of distal stomach and duodenum → malabsorption)
- Benefits: greater weight loss, greater resolution of glucose abnormalities
- Complications: more immediate surgical complications, long-term nutritional deficiency (B12, folate, iron, calcium, vitamin D)
205 You are asked to organise the staging investigations to help decide the treatment plan for a 65 yoa man who has been found to have an oesophageal cancer (adenocarcinoma) when he had an UGI endoscopy performed to investigate dysphagia. Biopsies taken at that investigation have confirmed that what looked like a cancer, is a cancer. What tests are needed? What are they aimed at deciding?
Further investigations are required to stage the cancer, providing information about prognosis and to guide treatment
Local staging: endoluminal ultrasound (assess depth of invasion and regional lymph nodes)
Regional staging: chest and abdomen CT (local invasion, regional lymphadenopaty, liver disease), laparoscopy (for junctional tumours)
Disseminated disease: PET
206 You are asked to organise the pre operative assessment to help decide whether a 65 yoa man is fit for surgery for a locally confined oesophageal cancer (adenocarcinoma). He presented with dysphagia. His cancer has been proven, and staging complete. The best chance of cure is surgery. What issues are most important in this patient’s pre op work up?
While oesophagectomy is the only curative treatment for oesophageal cancer, it is associated with an operative mortality of up to 5%
Factors that need to be considered include:
1) Post-operative quality of life
- 12-24 months recovery from surgery
- Problems eating, breathlessness, diarrhoea, reflux, fatigue, odynophagia can persist even 3 years after
2) Age
- Increased age is associated with greater morbidity following oesophagectomy (relative contraindication)
3) Pulmonary function
- Intensive pre-operative respiratory rehabilitation reduces post-op pulmonary complications
4) Smoking status
5) Co-morbid illness (increased risk of post-op complications)
6) Cardiovascular fitness (ECG, echo, stress test)
7) Nutritional status
207 You are a GP. A previously fit 65 yoa woman consults you and gives a history of 3 months of progressive dysphagia, initially she struggled to swallow large food boluses, eg bread or meat, now she can only swallow fluids. She is losing weight. What would you like to do to manage this lady?
New onset dysphagia = oesophageal cancer until proven otherwise
1) History
2) Examination
3) Investigations
- Oesophageal endoscopy + biopsy of any lesion (definitive/therapeutic)
- CT neck/PET - staging of any potential cancer
4) Referral to ENT surgeon
5) Treatment
- Usually palliative
- Potentially curative: chemotherapy + radical resection
208 You are a GP. An otherwise fit 30 year old man consults you. He has persistent gastrooesophageal reflux disease, he is well maintained on 40mg omeprazole per day, but gets bad symptoms very quickly if he stops taking the treatment. He is not keen on a lifetime of medication. He wants to know if there are any other treatments, and what the risks are of them
1) Optimise existing treatment
- Dosing, timing, compliance, switch PPI
2) Lifestyle modification
- Weight loss
- Moderate exercise
- Avoidance of exacerbating foods
- Smoking cessation (tobacco decreases lower oesophageal sphincter pressure, decreases salivation)
- Slightly elevate head during sleep
3) Medical alternatives
- Histamine-2 receptor antagonists = reduce acid secretion
4) Surgical options
- Nissen fundoplication (360-degree wrap) = mobilise fundus, preserve vagus nerve, pass fundus behind oesophagus left to right and secure
- Partial wrap (170-270-degree, anterior or posterior) = intended to reduce post-op bloating and dysphagia
Indications for surgery
- Associated complications of GORD (e.g. Barrett’s metaplasia, stricturing)
- Failed optimal medical management (incl. intolerance or non-compliance)
- Medication-dependent patients unwilling to continue lifelong
Complications of surgical treatment:
- Initial = post-op ileus
- Early = dysphagia (up to 6 weeks), bloating (difficulty belching), pneumothorax (5-8%)
- Late = failure of wrap (5-10%), pain when vomiting
- Mortality <1%
209 This patient with dyspepsia is having a Gastroscopy. What does this show in the duodenum? How might this be complicated? What is the common cause of this? How is this condition treated?
Duodenal ulcer or duodenal malignancy arising from ulceration
Complications: bleeding, perforation, fistulation, gastric outlet obstruction
Common causes: H. Pylori, NSAIDs
Treatment: H. Pylori triple therapy, stop NSAIDs, long-term PPI
210 Achalasia.
Q1: What is the name of this investigation?
Q2: What does this test show?
Q3: What investigation should come next?
Q1. Barium swallow
Q2. Bird-beaking, indicative of excessive lower oesophageal sphincter tone and oesophageal narrowing
Q3. Oesophageal mannometry (showing increased resting pressure, incomplete relaxation)
211 This is a laparoscopic view of the upper abdomen.
Q1. What organs can you see?
Q2. What is the normal laparoscopic insuflation pressure and why?
Q1. Liver, stomach, spleen, gallbladder
Q2. 8-12 mm Hg
- Allow for adequate surgical exposure without causing pneumoperitoneum or vascular collapse
- Prevents displacement of diaphragm which may place pressure on IVC
212 This is the endoscopic photo of a patient with a small sliding Hiatus Hernia. The photo is taken from just above the Gastro-oesophageal junction.
Q1: What does this show.
Q2: What is the severity of the reflux in this case?
Q3: How should this be treated?
Q4: If this is a patient who has failed to respond to medical therapy, what is the next ooption.
Q1. Barrett’s oesophagus - metaplasia characterised by by the replacement of the normal stratified squamous epithelium lining of the esophagus by simple columnar epithelium with goblet cells
Q2. Los Angeles classification
Grade A to D
A: 1+mucosal breaks that are less than 5mm
B: A + but > 5mm but without continuity
C:
D: Greater than 75% of circumference involved
Q3. Treatment
- Most patients can be treated conservatively (weight loss, smoking cessation, alcohol reduction)
- Alginate (liquid or chewable tablets taken after meals)
- Prokinetic agents (metoclopramide, domperidone)
- PPI (omeprazole)
Q4. Fundoplication (Nissen, partial wrap)
213 This is the endoscopic picture of a 65 year old male with a history of chronic dyspepsia. The bottom 2 photos show an area of slough in the first part of the duodenum posteriorly.
Q1. What are the likely causes of this?
Q2. What complications can occur with this pathology?
Q3. What is the treatment?
Two major aetiologies of peptic ulcer disease = H. Pylori infection, excess long-term NSAID use
Rarer causes: gastric ischaemia, Zollinger-Ellison syndrome (excess acid secretion due to neuroendocrine tumour), medications, infections, Crohn’s
Potential complications: upper GI bleeding, perforation, fistulation into surrounding organ, gastric outlet obstruction (scarring of pyloric channel, malignant growth)
Treatment:
1) H. Pylori eradication - triple therapy = PPI + clarithromycin + amoxycillin/metronidazole
2) Withdrawal of offending or contributing factors (i.e. NSAIDs)
3) Anti-secretory therapy (i.e. PPI) if not already commenced
4) Endoscopy - assessment/treatment of bleeding, malignant change
5) Maintenance therapy (long-term PPI) in high-risk groups
214 A 52 year old man presents to his GP with 2 months of difficulty swallowing.
Q1. What questions are important to ask?
Q2. What is the most important diagnosis to exclude and
Q3. How should he be investigated?
Dysphagia = subjective sensation of difficulty or abnormality of swallowing
HISTORY - OROPHARYNGEAL VS. OESOPHAGEAL
• Oropharyngeal = difficulty initiating swallowing
- Numerous iatrogenic, infectious, metabolic, myopathic, neurological, and structural causes
• Oesophageal dysphasia = “food getting stuck”
Questions to ask:
Oropharyngeal = initiating swallowing, cough/choke/regurgitation through nose after swallowing Oesophageal = food gets stuck after a few seconds, liquids only = motility, solids → liquids = obstruction
- How long? Progression, stable, or intermittent? (rapidly progressing raises concerns of malignancy)
- Other symptoms? (e.g. ↓appetite, N/V, weight loss, regurgitation, heartburn, haematemesis, pain during swallowing, chest pain)
- Other medical conditions?
- Past surgery on larynx, oesophagus, stomach, or spine?
- Past radiation therapy?
- Current medications?
Important diagnosis to exclude = oesophageal carcinoma
- Difficulty with solids → liquids; may have chest pain, weight loss, anaemia, anorexia, odynophagia (pain)
DDx:
i) Intraluminal
- Food impaction (complete obstruction, usually after meat consumption)
ii) Intrinsic
- Oesophageal stricture (complication of reflux, associated with older age, male, longer duration of reflux symptoms
- Oesophagitis (eosinophilic, lymphocytic, or infectious)
- Oesophageal webs (thin mucosal folds) and rings (usually muscosal, found at gastroesophageal junction)
- Radiation injury (risk of developing oesophageal strictures or oesophagitis)
iii) Extrinsic
- Cardiovascular abnormalities compressing the oesophagus (double aortic arch, right aortic arch, etc.)
iv) Motility disorders
- Achalasia (loss of peristalsis in distal oesophagus and failure of lower oesophageal sphincter relaxation with swallowing)
- Spastic Motility Disorders
- Hypocontractile Motility Disorders
- Scleroderma
- Sjögren’s Syndrome
DIAGNOSIS
1) Upper endoscopy ± biopsy
2) Barium swallow
3) Oesophageal manometry (motility testing)
215 This series of photographs shows a Gastric Tumour that is very close to the gastro-oesopgaheal junction at endoscopy.
Q1. What types of gastic tumours do you know?
Q2. How would you investigate this patient if the biopsy of this lesion proved to be an adenocarcinoma?
Q3. What treatment would be required for a lesion in this location?
Gastric tumours:
1) Gastric adenocarcinoma
2) Gastrointestinal stromal tumour (GIST)
3) Gastric lymphoma
4) Carcinoid tumours
Investigations (for staging)
- *Endoscopic ultrasound** - assessment of tumour depth and local lymph nodes
- *Abdo, pelvic, thoracic CT** - mets
- *Diagnostic laparoscopy** - determine whether a disease is resectable
Treatment
- *Endoscopic resection** (only if very early)
- *Radical gastrectomy and lymphadenectomy** (operative standard)
216 This photo taken at Gastroscopy shows the area of the lower oesophagus just above the gastro-oesophageal junction.
Q1. What can you see?
Q2. What is the most likely cause of this process?
Q3. How would this be treated?
Q1. Barrett’s oesophagus, achalasia, hiatus hernia, varices
Q2. chronic GORD/LOS spasm/trauma or iatrogenic/portal hypertension
Q3. Reflux treatment/disruption of muscle fibres/PPI GORD if asymptomatic, otherwise repair/octreotide, ligation or scleropathy, b-blockers
