Upper GI Flashcards
Post Gastectomy complications
Rapid emptying of food from stomach into the duodenum: diarrhoea, abdominal pain, hypoglycaemia
Complications: Vitamin B12 and iron malabsorption, osteoporosis
Treatment: High protein, low carbohydrate diet. Replace B12/Fe/Ca
Dieulafoy lesion
These small arterial lesions are a rare cause of bleeding and are characterised by a single large tortuous arteriole in the sub mucosa.
Feeding in CVA with unsafe swallow
PEG
Will be jejenostomy if oesophagectomy
Tx of 50yo with Barretts oesophagus is diagnosed with high grade dysplasia on recent endoscopy. The lesions are multifocal and mainly distally sited
Oesophgectomy
Tx of Barrets with dysplasia in elderly with localised lesion
Endoscopic mucosal resection
Low grade dysplasia in conjunction with Barretts oesphagus should be monitored with regular (6 monthly) upper GI endoscopy and quadrantic biopsies. If the disease remains static at 2 years then the screening frequency may be decreased.
Ivor Lewis procedure
Combined laparotomy and right thoracotomy
Laparotomy To mobilize the stomach
The greater omentum is incised away from its attachment to the right gastroepiploic vessels
The left gastric vessels are then ligated,
Right Thoracotomy Oesophageal resection and oesophagogastric anastomosis
Through 5th intercostal space
Indication
Lower and middle third oesophageal tumours
Acute vs chronic ulcer on endoscopy
Acute- small and no fibrosis
Chronic- large and fibroses
Proximal Oesophageal SCC mx
managed with radical chemoradiotherapy
Mx of oesophageal cancer if distant disease
Palliate with metallic stent
Cholestatic picture with HIV dx
HIV is sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia
Iatrogenic perforations of the oesophagus management
TPN
This usually involves a nil by mouth regime, tube thoracostomy may be needed. Total parenteral nutrition is the safest option.
Mx of UGI bleeds
Admission to hospital careful monitoring, cross match blood, check FBC, LFTs, U+E and Clotting (as a minimum)
Patients with on-going bleeding and haemodynamic instability are likely to require O negative blood pending cross matched blood
Patients with suspected varices should receive terlipressin prior to endoscopy
Ideally all should undergo Upper GI endoscopy within 24 hours of admission.
Varices should be banded or subjected to sclerotherapy.
If this is not possible owing to active bleeding then a Sengstaken- Blakemore tube (or Minnesota tube) should be inserted. This should be done with care; gastric balloon should be inflated first and oesophageal balloon second.
Remember the balloon will need deflating after 12 hours (ideally sooner) to prevent necrosis. Portal pressure should be lowered by combination of medical therapy +/- TIPSS.
Patients with erosive oesophagitis / gastritis should receive a proton pump inhibitor.
Mallory Weiss tears will typically resolve spontaneously
Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment.
All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate.
Cellular origin of pancreatic tumours
Ductal epithelium
Gastrinoma most common locatin
Duodenum
Most commonly found in the duodenum (in up to 50% patients), then the pancreas (approximately 20%)
Within triangle
-junction of common and cystic BD, junction of 2nd/3rd part od duodenum, junction of body and neck of pancreas
Epigastric discomfort and episodes of migratory thrombophlebitis. On examination he is mildly jaundiced
Adenocarcinoma of the pancreas
Trousseau’s sign: migratory superficial thrombophlebitis
What is usually divided during an Ivor Lewis Oesophagectomy
Azygous vein
Mx of bleeding duodenal ulcer on endoscopy
Inject adrenaline
+/- clips
Following these interventions patients should receive a proton pump inhibitor infusion. Those who re-bleed, may require surgery.
Types of bariatric surgery
Gastric banding: band applied to upper stomach which can be inflated or deflated with normal saline. This affects satiety. Over a 5 year period complications requiring further surgery occur in up to 15% cases.
Roux-en-Y gastric bypass: a gastric pouch is formed and connected to the jejunum. Patients achieve greater and more longterm weight loss than gastric banding.
Sleeve gastrectomy: body and fundus resected to leave a small section of stomach
Biliopancreatic diversion +/- duodenal switch: bypass the small bowel. Greatest weight loss but a very complex procedure associated with malnutrition and diarrhoea.
Vertical banded gastroplasty (stomach stapling): rarely performed due to longterm failure rate.
Gastric balloon- highest failure rate- really only suitable as a bridge to a more definitive surgical solution.
Where is zinc absorbed
Duodenum and jujenum
Metastatic pancreatic cancer with jaundice tx
Endoscopic stent and palliative chemo
If no obstruction- palliative chemo
Low grade dysplastic Barrets mx
Monitored with regular (6 monthly) upper GI endoscopy and quadrantic biopsies.
If the disease remains static at 2 years then the screening frequency may be decreased.
Achalasia and mass in proximal oesophagus
Squamous CC
Achalasia is a RF
Rockall score
ABCDE
A: Age
B: Blood pressure drop (Shock)
C: Co-morbidity - i.e score 2 for Major organ disease e.g. IHD, CCF, 3 for Renal or liver failure, metastatic cancer
D: Diagnosis - 0 MW, 2 for gastric cancer
E: Evidence of bleeding
5w history of dysphagia, Barrett and food on endoscopy
Adenocarcinoma
A 38 year old woman undergoes a gastric bypass procedure. Post operatively she attends the clinic and complains that following a meal she develops dizziness and develops crampy abdominal pain. What is the most likely underlying explanation?
Dumping syndrome, which can be divided into early and late, may occur following gastric surgery. It occurs as a result of a hyperosmolar load rapidly entering the proximal jejunum. Osmosis drags water into the lumen, this results in lumen distension (pain) and then diarrhoea. Excessive insulin release also occurs and results in hypoglycaemic symptoms.
Dysphagia that is episodic and varies between solids and liquids
More likely motility disorder
Bleeding ulcer- originally managed through adrenaline injection in endoscopy- suddenly tachy and hypo- mx?
Laparotomy and under running of ulcer
Criteria for bariatric surgery
BMI >/= 40 kg/m2 or between 35-40 kg/m2 and other significant disease
Trialled conservative measures for 6 months.
Will receive intensive specialist management
They are generally fit for anaesthesia and surgery
They commit to the need for long-term follow-up
Difficult OGD with noted surgical emphysema after
Pharyngeal pouch
Which bariatric surgery associated with delayed gastric emptying and which has the best function
Anterior gastrojejunostomy- worst
Roux en Y- best
Young adult with recurrent ulcerations- diagnosis and blood results
MEN1- zollinger Ellison
Gastrin
Where mineral/vitamin absorption occurs
Iron- duodenum
Folate- jejunum
B12- terminal ileum
Anterior vs posterior duodenal ulcer presentation
Anteriorly sited ulcers may perforate and result in peritonitis
Posteriorly sited ulcers may erode the gastroduodenal artery and present with haematemesis and/ or malaena.
Diagnosis of barrels on histology
Metaplasia to columnar cells with goblets
Mx of insulinoma of head of panc
Enucleation of lesion
Complication of re fundoplication
Damage to vagus nerve
If both are damaged, there will be delay to gastric emptying.
Which bariatric surgery has the highest failure rates
Gastric balloon
Most common location of gastronome
Duodenum
Then pancreas
Management of upper oesophageal cancer
Radio and chemo
Post oesophagectomy, chest pain, bubbling in chest drain
Air leak from lung
Another sign for achalasia on Barium swallow
Rats tail
