Upper GI Flashcards
What are the presenting features of GORD?
Retrosternal burning chest/epigastric pain that is worse when lying down, after meals, bending over or straining.
- Excessive belching
- Odynophagia
- Chronic/Nocturnal cough
What are some red flag features you should check for that could indicate a GI malignancy when a person presents with GORD symptoms?
Dysphagia
Weight loss
Early sateity
Malaise
Loss of appetite
What investigations are done to confirm a diangosis of GORD?
Usually a Hx and resolution with PPI is enough
May do endoscopy if suspect malignancy (dysphagia or >55 with alarm symptoms) or complications
- Gold standard: 24h pH monitoring combined with oesophageal manometry to exclude oesophageal dysmotility. Used when medical treatment fails and surgery is being considered
What are the main post op complications of fundoplication?
Dysphagia (if too tight)
Bloating
Inability to vomit/belch (Gas-Bloat syndrome)
New onset diarrhoea
Most s/e settle after 6 weeks
What are some of the complications of GORD?
Aspiration pneumonia
Barrett’s oesophagus (Fundoplication does not lower risk of this developing into cancer)
Oesophagitis
Oesophageal strictures
Oesophageal cancer
What are the histological types of oesophageal cancer and what is their typical location?
SCC- middle and upper thirds. RF smoking and alcohol
adenocarcinoma - lower third RF barrets
palliative tx for oesophageal cancer
oesophageal stent
radio/chemo
thickened fluid and nutritional supplements
What are the main complications of an oesophagectomy used to treat oesophageal cancer?
- Pneumonia (most common)
- Anastomotic leak!!! (any deterioration in oesophagectomy patient is leak until proven otherwise)
- Death
- Post operative nutrition issues (lose reservoir capacity of stomach so need feeding jejunostomy or small frequent meals)
Why is an oesophageal perforation a surgical emergency that needs rapid recognition and management?
Perforation leads to leakage of stomach contents into the mediastinum and pleural cavity triggering a severe inflammatory response which rapidly becomes overwhelming causing physiological collapse and multi-organ failure and death
What is the surgical management of a full thickness oesophageal tear?
- On-table endoscopy to locate site and decide incision site
- Thoracotomy
- Control leak by repairing with diaphragm
- Wash out chest
- Decompress with Transgastric drain or endoscopically placed NG tube
- Feeding jejunostomy as need CT at 10-14 days to show no leakage before oral intake
What is the anatomy of the oesophagus in terms of the muscles?
25cm
Upper third + UOS: skeletal
Middle third: transition zone of skeletal and smooth
Lower third + LOS: smooth
Describe the peristalsis of the oesophagus.
Controlled by myenteric neurones
- Primary wave: under control of swallowing centre
- Secondary wave: activated in response to distension
What is achalasia and what is the pathophysiology of this?
Failure of relaxation of the LOS and progressive failure of contraction of the oesophageal smooth muscle
Food bolus gets stuck as cannot pass into stomach and proximal oesophagus damaged as constantly pushing against obstruction
Histologically there is progressive destruction of the ganglion cells in the myenteric plexus
How is achalasia managed conservatively?
Non-Pharmacological
Sleep with many pillows to stop regurg
Eat slowly
Chew food thoroughly
Take lots of fluids with food
Pharmacological
CCBs/Nitrates for temporary relief
Botox into LOS by endoscopy every few months
What is diffuse oesophageal spasm and what is the pathophysiology of this?
Multi-focal high amplitude contractions of the oesophagus
- Dysfunction of oesophageal inhibitory nerves
What is a hiatal hernia and how are they classified
Protrusion of an organ from the abdominal cavity into the thorax through the oesophageal hiatus. Often the stomach but can be small bowel, mesentry, colon
Sliding (80%): GOJ, abdominal part of oesophagus and cardia of stomach slide up through diaphraghmatic hiatus to thorax
Rolling/Paraoesophageal (20%): fundus of stomach comes up to the GOJ forming a bubble of stomach in thorax. True hernia as has peritoneal sac. Eventually whole stomach can go up there
Mixed: rare
Most hiatal hernias are managed conservatively like GORD. What is the conservative management for a hiatal hernia?
1st line: PPI in the morning before food
Lifestyle modification: weight loss, low fat meals, earlier meals, smaller portions, sleeping with lots of pillows
Smoking cessation and Alcohol reduction as these inhibit LOS function
When is surgical management for a hiatal hernia indicated?
- Remaining symptomatic despire conservative measures
- Risk of strangulation/volvulus e.g mixed, rolling, other abdominal viscera
- Nutritional failure (due to gastric outflow obstruction)
Decompress stomach with NG tube before surgical intervention if obstruction, volvulus or strangulation
What are the two surgical options for hiatal hernia repair?
Cruroplasty – hernia reduced back into the abdomen and the hiatus reapproximated to the appropriate size. Large defects usually require mesh to strengthen the repair.
Fundoplication - wrap fundus around the LOS to strengthen it to prevent reflux and to hold GOJ in place
What is a peptic ulcer and where are they commonly found?
Break in the lining of the GI tract extending through to the muscle layer (muscularis mucosae)
Most commonly on lesser curvature of the proximal stomach or the first part of the duodenum (present earlier in life)
How is peptic ulcer disease managed?
- Lifestyle advice: avoid NSAIDs, smoking cessation, alcohol reduction, weight loss
- PPI for 4-8 weeks then reassess to see if resolved
- Triple therapy if H.Pylori positive
- OGD: if eradication/PPI therapy does not work to rule out malignancy. Following this can consider other causes like Zollinger-Elison or treatment failure
What is the triple therapy for H Pylori eradication?
PPI
Amoxicillin
Clarithromycin or Metronidazole
When would you surgically manage peptic ulcer disease?
- Perforation: broad spectrum abx and omental patch to repair. Take biopsy to check for malignancy
- Haemorraghe: endoscopic adrenaline injection, diathermy or heat probe and then underrun or oversew ulcer
- Pyloric Stenosis: late complication due to scarring. Endoscopic balloon dilation then max acid supression. If unsuccessful use a drainage procedure with a highly selective vagotomoty
- Zollinger-Ellison Syndrome management
- Severe or relapsing disease: partial gastrectomy or highly selective vagotomy (supply to LOS and stomach, nerve of Latarget to pylorus left in tact so stomach emptying fine)
What is Dumping syndrome and how is it managed?
Complication of gastric bypass/gastrectomy where a patient feels very faint, tachycardic and sweaty after eating due to food of high osmotic potential being dumped in the jejunum causing hypovolaemia
Improves with time but managed by small frequent meals, avoidance of simple carbohydrates, and separation of eating and drinking
