Upper GI Flashcards
barretts esophagus
endoscopically visible columnar epithelium within the esophagus regardless of length , with interstitial metaplasia and histological examination
- IRREVERSIBLE
percentage of Barrets esophagus that goes to cancer
1%
causes of difficulty / painful swallowing
ANATOMICAL
- FB, malignancy, web, pharyngeal pouch, strictures, schedlasia
- EXTRENSIC lesions: LAD, retrosternal loiter, bronchial CA, left atrial enlargement due to MS
FUNCTIONAL NEURO - post CVD, MND, globus hystericus ESOPHAGEAL dysmotility - diffuse esophageal spasm - scleroderma
Plummer vinson syndrome
non b islet cell tumour secreting gastrin ass. w/ acid hyper secretion and severe PUD
ph study score
DeMESSTER score - composite that measures of reflux episodes and length of occasions that the PH is <4
CXR of achalasia
air fluid level in the mediastinal shadow with dilated esophagus
achalasia
characteristic increase pressure in LE and failure to relax due to a damage of ganglion in Auerbach’s plexus resulting in poor parastasis throughout the esophagus
investigation achalasia
- endoscopy
- barium swallow - bird beak
- manometry - absence parastasis
complicationachalasia
nocturnal aspiration
bronchiectasis
lung abscess
carcinoma - 3% - SCC
treatment achalasia
- ballon dilatation
- Heller’s cardiomyotomy
- injection of botulinum toxin - injection into LOS
diffuse esophageal spasm
retrosternal pain radiating to the jaw and inter capsular region and you get NUTCRACKER ESOPAHgus with high amplitude peristalsis
treatment diffuse esophageal spasm
nifdepine and reassurance
chagas disease
similar to achalechia due to trypanosome cruzi . also ass. w/ megacolon, CM, megaduodenum, megaureter
manometry findings in scleroderma
HYPOTENSIVE
what is the number one test for hiatus hernia
Barium swallow
GERD Definitionn
reflux of gastric contents into the esophagus, esophageal ph <4 for 4% over a 24 hour period on ph Monitoring
Cause of GERd
- esophageal clearance - relies on gravity, saliva flow, normal motility, fixation to efficient peristalsis
- LES competence
- OCP, smoking, pregnancy lose LOS tone - Gastric clearance
- gastic outlet obstruction can reflux
- obseity and pregnancy- causes low clearance b/c increase pressure in abdomen
What surgery for GERD
nissen fundoplication - wraps the funds of the stomach around the intra=abdominal esophagus to augment high pressure zones
INDICATIONS:
- persistent symptoms despite max medical treatment
- large reflux with aspiration pneumonia
- Complication of reflux - stricture and severe ulcerations
test for H.pylori
urease testing (from Bx on endoscopy)
Urea breath testing
stool antigen test
serology
failure of PU to heal with meds
- NSAID sbuse
- non compliant
- chrons
- gastric secreting tumour
- malignancy
treatment of haemorrhage in pUD
- injection of adrenaline, thermo-coagulation , clipping, hawmostasis, nano powered spray
if these fail
- surgery - overseeing of the artery
treatment of perf PUD
ulcer overseen and secured with a plug of omentum
Gastric outlet obstruction how?
pylorus / pre pylori are areas of chronic ulcerations , healing with fibrosis leads to stricture formation and pyloric stenosis
Gastric outlet obstruction clinical
projectile vomitting unrelated to eating, episodic
SUCCUSSION SPLASH on abdo exam
HYPOCLOREMIC ALKALSIS
DILATED STOMACH
Gastric outlet obstruction Tx
aggressive resuscitation gastric drainage gastro-enterostomy truncal vagotomy prloroplasty rare: - partial gastrectomy
treatment adenocarcinoma in the esophagus
SRUGERY
CTX
treatment of SCC of esophagus
surgery
RTX
causes adenocarcinoma of esophagus
GERD Baretts obesity high fat intake cigarettes high alcohol intake
causes SCCof esophagus
high alcohol intake tobacco use nitrosamines vita and C coeliac idsase strictures and webs achalasia PUD
staging of esophagus investigation
local: endoluminal Ultrasound
regional: CT scanning and laparoscopy (to asses peritoneal disease)
Disseminated: PET scanning may be use to exclude occult disseminated disease in patients otherwise consider potentially curative tx
surgical treatment for esophageal cancer
Ivor Leis procedure (abdomen - throat opened)
McKwoen three phase esophagectomy (ado-thorax- neck)
Transmittal resection (abdo- neck opened)
CTX treatment for esophageal cancer
- adeno
- patient is fit
- curative
- mets
RTX treatment for esophageal cancer
- SCC
- strictures
- fistulas
palliative treatment for esophageal cancer
- incubation
- stent - SEMS - self expanding metal stenting
- laser treatment
- good for intrinsic tutors
- carries risk of perforation
R.F for gastric adenocarcinoma
- diet rich in Nitrosamines (smoked fresh fish, pickled fruit)
- chronic Atrophic gastritis
- blood group A
- chronic gastric ulceration related to H. pylori
NAAH
symptoms of gastric adenocarcinoma
- DYSPEPSIA (indigestion)
- N V WL Anorexia
Anemia - Fe deficiency
EARLY SAIETY
signs gastric adenocarcinoma
- WL
palpable epigastric mass
Supraclavicular nodes - VIRCHOWS and Troisers sign
Dx gastric adenocarcinoma
- gastroscopy and Bx Staging investigation - CT TAP - endoluminal US - laparoscopy
treatment gastric adenocarcinoma - GOLD STANDARD
- SURGERY
- resection - GOLD STANDARD
Treatment gastric adenocarcinoma
surgery - number 1
if advanced disease - not surgical candidates
total or partial gastrectomy
chemotherapy
palliation (with limited radiation therapy (palliative gastrojejunostomy to control symptoms
dumping syndrome
late complication post gastrectomy
- general weakness, faint and sweating
Early: rapid transit of hyperosmolar solutions
late: hypoglycaemia due to increase insulin secretion
epidemiology gastric adenocarcinoma
Men > 50
acute complication of gastrectomy
ACUTE PANCREATITIS others: - haemorrhage anastomotic leak duodenal stump disribution respiratory compromised
how long before OGD do you have to go without food and water
6 hours fasting
2 hours water
what medication do you have to stop prior to OGD
PPI for 2 weeks before OGD
tell patient to warn doctor if they are on warfarin aspirin or plavix
prehaptic causes of Jaundice
H.A
Congenital hyperbilirubinemia
transfusion reactions
Drug toxicity
intraheptatic causes of Jaundice
UCB:
- CN (absence UGT uridine glucoronyl transferase)
- Gilbert syndrome ( defect in the bilirubin canicular transport
CB - viral hepatits alcoholic liver disease toxic drug jaundice mets
post hepatic obstructive jaundice cause
Intramural - cholidocolithaisis
Mural - biliary stricture , PBC
Extrinsic - pancreatitis , pancreas carcinoma
enlarged LN , Mirizzi syndrome
-
Mirizzi syndrome
external biliary compression from stone impacted in the neck of the gallbladder
medications that cause Jaundice
Chlorpromazine
Spider Navei pathological
> 3 in the Superior Vena Cava distribution
Ascites in abdomen
Hypoproteninaemia
intra abdo malignancy - pancreas , stomach, ovary, colon
Caput medusae
Portal hypertension ass. w/ CLD
large tender smooth live
Hepatitis
Large irregular liver
mets
Courvoisor’s Law
non tender palpable gallbladder in the presence of jaundice is UNLIKELY to be gallstones and duet malignant obstruction of the gland
LFT of hemolysis
RISED UCB
NORMAL Alk P, GGT, transaminase, lactate dehydrogenase
LFT in hepatocellular
RAISED AST and ALT
less raised GGT, lactate dehydrogenase
NORMAL alk phospate
RASIED UCB
OBSTRUCtive LFT
VERY RAISED ALK P, GGT
Transaminase normal
lactate dehydrogenase - Normal
UCB - normal
what autoantibodies do you test in liver disease
anti-microsomal (PBC)
anti-nuclear
anti-smooth muscle
US findings in gallstones
dilated cystic duct
thickened gallbladder wall
gallstone
General treatment of Liver disease
correct dehydration
monitor urine output
clotting factors (vit K if PT is prolonged)
Diet - enternal feeding, dietician
ERCP: sphincterotomy, stent insertion , percutaneous transhepatic cholangiogram , surgical drainage
hemolytic jaundice treatment
steroids for autoimmune cases
splenectomy
hepatic failure
transplantation
head of pancreas tumour tx
whipples prancreATICOduodeneCTOMY
definition acute pancreatitis
is an inflammatory process of the pancreas , resulting in release of inflammatory cytokines and pancreatic enzyme (lipase, trypsin) initiated by pancreatic injury
acute pseudocyst
collection of pancreatic juice surrounded by a wall of fibrous tissue that occurs 6-8 weeks after acute pancreatitis
pancreatic abscess
circumscibred intra-abdominal collection of pus arising close primximity to the pancreas but containing LITTLE TO NO pancreatic necrosis which arises as a consequence of acute pancreatitis
medications that can cause acute pancreatitis
Metronidazole tetracycline
azathioprine mercaptopurine
H2 blockers
metabolic causes of acute pancreatitis
hyperglycaemia
jhypercalcaemia
hypertriglyceridemia
acute pseudocyst treatment
percutansou ultrasound guided drainage
clinical pancreatitis necrosis
SWINING PYREXIA
late complication of acute pancreatitis
DM
Malabsorption (due to loss of secretion of pancreatic digestive enzymes
within first 2 weeks complication of acute pancreatitis
multiple organ failure
- cardiovascular collapse from fluid shifts
- pulmonary failure
- pneumonia
- ARD
- renal failure from hypotension.
Pancreatic necrosis and peri-pancreatic necrosis
after 2 weeks complication of acute pancreatitis
pancreatic psudeocyst
pancreatic abscess
chronic pancreatitis
characterized by recurrent or persistent abdominal pain and pancreatitis , often ass. with either exocrine or endocrine pancreatic insufficiency
chronic inflammation in chronic pancreatitis cases
- glandular atrophy
- ductal ectasia
- micro calcification
- intraductal stone formation
- ## cystic changes secondary to duct formation
Causes chronic pancreatitis
1/ recurrent episodes of acute pancreatitis usually alcohol induced
2/ secondly to pancreatic duct obstruction
- pancreatic head tumours and cyst
- pancreatic duct stricture
- congenital pancreatic abnormality
- cystic fibrosis
3/ autoimmune - PBC, PSC
clinical chronic pancreatitis
Recurrent abdo pain
STEATORRHEA
- WL and anorexia
-INSULin dependant DM
how do you differentiate chronic pancreatitis from tumour
endoscopic US combined with aspiration cytology / biopsies
how do you test exocrine function in chronic pancreatitis
fecal elastase
Treatment of chronic pancreatitis
Treat cause - stop alcohol, cholecystectomy , treat A.I disease
Diet change CREON PPI INSULIN - if DM ANALGESIA CONSIDER if not responding - extracorporeal shock wave lithotripsy - celiac nerve block - denervation surgery SRUGERY - only if not responding to medical treatment with obstructed pancreatic duct - Whipples - partial or distal pancreatectomy pancreaticojejunostomy
R.F for pancreatic cancer
smoking
alcoholism
Dm
chronic pancreatitis
type of pancreatic cancer
ductal adenocarcinoma
Cystic neoplasm (7%)
3% islet cell tumours
tumour marker for pancreatic Ca
CA 19-9
images for pancreatic Ca
US abdomen - to investigate obstructive jaundice - gallstone
CT - to see pancreatic mass, local invasion, mets
endoscopic US - detecting SMALL CA and peripancreatic node involvement
US or CT guided FNA cytology
ERCP
PET
LAPrascopy - for staging (outule peritoneal disease)
most common endocrine pancreatic tumour
INSULINOMA - whipple’s triad
Symptoms due to hypoglycemia especially after fasting or heavy exercise
A low plasma glucose with symptoms
Relief of symptoms when the glucose is raised to normal
endocrine pancreatic tumour investigation
abdominal CT scanning and selective pancreatic arteriography
