Upper GI Flashcards
What is the Classification of ERCP perforation and management
Stapler Classification 1. Free bowel wall perforation - laparotomy (if recognised during endoscopy can be managed endoscopically) 2. Retroperitoneal duodenal perforation secondary to periampullary injury (most common) 3. Pancreatic/bile duct injury 4. Retroperitoneal air only (can be normal after sphincterotomy)
What are the indications for surgical management in Stapler 2-4 ERCP perforations and what oprtions are available
Major Contrast leak
Persistent biliary obstruction
Cholangitis
No improvement with non-operative management
- Repair primarily, drainage of abscess, choledochojejunostomy or whipples
List worrisome and high risk features of Pancreatic IPMN
High risk - MPD >9mm
Solid enhancing nodule >5mm
obstructive jaundice
Worrisome features-
MPD 5-9mm non-enhancing murla nodule/thickened enhancing wall size >3cm abrupt cutoff of pancreatic duct lymphadenopathy
Resect if high risk or if MPD 5-9mm plus worrisome features (BD or MPD IPMN)
What is borderline resectable and unresectable for pancreatic head cancer
Borderline <180 degree encasement of SMA >180 degree encasement of SMV Contact of common hepatic artery but not the coeliac or proper hepatic A Unresectable Metastatic disease/organ involvement Occludded SMV/portal vein - un-reconstrunctionable >180 encasement of SMA Involvement of aorta/IVC Involvement of coeliac axis Contact with first jejunal branch of SMV
What is the demeester score and what is the main mechanism of reflex
Score significant reflux in oesophageal reflux. Score> 14.2 is consistent with reflux score components - % total/upright/supine time ph<4, number of symptomatic reflux episodes, number of reflux episodes >5mins, longest reflux episode Main cause of reflux is due to transient relaxation of lower oesophageal sphincter
What are the 5 goals of anti-reflux surgery
maintain tissue planes don’t damage the vagus identify try OGJ for wrap placement have sufficient length of intra-abdominal oesophagus (3cm at least) re-establish angle of His
what are indications for urgent gastroscopy removal of foreign body (within 2-6 hours vs within 24h)
- complete obstruction - battery - sharp objects
What is grading of oesophageal varies
- Short straight varices 2. Enlarged tortuous varices Less than 1/3 circumference 3. More that 1/3
Grading of oesophagitis
LA grade A. minimal erosions less than 5 mm B. erosions more than 5mm non contnious C. continuous erosions between folds 4. Continuous erosions more than 75% of circumference involved
What is the size cutoff for treatment of hydatid cysts
PAIR for more than 5cm Otherwise albendzole Surgery for complex cysts = with evidence of biliary fistula, or rupture, or greater than 10cm or compression of vital structures
what is the forrest classification of upper GI blleds
Appearance of ulcer which risk stratifies bleeding risk without intervention. Recommended to do two types of intervention on an ulcer - e.g. haemoclip, injection, coagulation. brackets show risk of rebleed with medical therapy alone. 1. a - active arterial haemorrhage (90%) b -oozing blood (10-20%) 2. a. non bleeding oozing vessell (50%) b. adherent clot (25-30%) c. flat pigmented spot (7-10%) 3 - clean ulcer base (3-5%)
What are the 3 types of gastric NET and treatment implications
Type 1 Secondary to atrophic gastritis and prolonged hypergastrinemia Type 2 Secondary to high gastrin from gastronoma Type 3 Sporadic (20%) - aggressive Type 1 and 2 indolent- endoscopic resection
What is the differential diagnosis for a sub epithelial gastric tumour
GIST
Leiomyoma
Leiomyosarcoma
Nerve sheath tumour schwannoma
Desmond
Myofibroblastic tumour
Stain GIST - DOG 1, CD117, CD 34
S100 for schwannoma
What are the most common Mets to the spleen
Breast, lung, malenoma, ovarian, stomach, prostate
What are the clinical radiological And blood signs for portal htn
And what is hepatic venous pressure gradient which will be clinically significant
Clinical - splenomegaly, ascites, varies
Radiological - spleen larger than 13cm and portal vein diameter greater than 13mm
Bloods - platelet <150
HVPG
Risk for varice bleeding and ascites at more than 12.
10 or more is high risk for decompensation with surgery.
5 or more defines portal hypertension
What are the components of the Rockall score
This is a score to risk stratify patients with upper GI bleed into low and high risk for further bleeding or death -
age - shock - Major comorbidities -Diagnosis (mallory weis vs non malignant vs cancer) -Recent bleed
Johnson classification of ulcers and surgical management
type 1 - in lesser curvature near junction of fundus and antrum = acid hyposecretion - treat with distal gastrectomy (treat disease + check for occult malignancy)
type 2 - synchronous duodenal and pyloric +/-scarring. - acid hypersecretion - antrectomy + vagotomy
type 3 - prepyloric - increased acid secretion - treat same as tyoe 1 and 2 - may present with GOO.
type 4 - close to GOJ high on lesser curve acid hyposecretion. difficult to resect - may need roux en y
type 5 - throughout stomach - associated with NSAID use
What is borchardt’s triad
For gastric volvulus in 70% of patients Pain Vomiting Unable to pass NGT
What are the indications for cholecystectomy for asymptomatic gallstones
Size greater than 3cm Anomalous BPD Adenoma Porcelain gallbladder
Bismuth classification of perihilar lesions
1 - below confluence 2 - at confluence 3 - extending into right (a) or left (b) duct 4 - both right and left ducts involved
Strasburg bile duct injury
A; leak from cystic duct stump/ “duct of lushka” B; clipped off right posterior sectoral duct C; leak from right posterior sectoral duct D; side hole in CBD E1 - CBD transected >2cm from confluence 2- <2cm 3- at confluence 4 - Right and left ducts separated 5 - combination of injury to common hepatic duct and right posterior sectoral
How are choledocholcysts classified
todani classification 1 - dilatation of CBD (50-85%) - Need to resect and hepaticojejunostomy 2 - saccular dilation of CBD- true diverticulum (2%)- can transect the sac 3 - Intraduodenal dilatation of the CBD (1-5%)- can be managed endoscopically. 4 (15-35%) - mainly type b a - both intra and extra hepatic cysts b - multiple extrahepatic cysts 5 - rare- one or more intrahepatic cysts (caroli disease) - if on single side can do hepatectomy, but may need transplant
what is the differential of a solid pancreatic lesion
Adenocarcinoma NET Lymphoma focal pancreatitis autoimmune pancreatitis (IgG4) metastases (rare - RCC, malenoma) Suspect autoimmune in young patients, alcoholism, other autoimmune disease, diffuse ductal changes or multifocal biliary strictures
what is the ‘double duct sign’
both pancreatic and biliary duct dilatation - signifies likely ampullary lesion
what is the overall 5 years survival of R0 N0 pancreatic cancer
30%
Grading of pancreatic leak/fistula
>3x upper limit of normal amylase in drain on or after day 3
A - Spike in drain amylase, resolves without intervention
B - Persistent drainage >3 weeks, or changes management, or perc/endoscopic management, or angio for bleeding, or signs of infection
C - B + infection with organ failure, or reoperation or Death related to fistula
B and C are clinically relevant leaks
Complications of pancreatitis
<4 weeks - acute necrotic collection, peripancreatic fluid collection
>4weeks - walled of necrosis, pseudocyst
Suspect infection if sudden deterioration - will require percutaneous drainage - try to avoid operative intervention within 4 weeks. Need antibiotic that can penetrate the necrosum - fluoroquinolone, ceftazadime, ertapenem
Vascular complications - venous thrombosis. pseudoaneurysm (suspect pseudoaneuryms if sudden drop in Hb, increase in pseudocyst or GI bleeding)
What are the goals of surgery for pancreatic necrosis and what are management options
clear/debride necrotic/infected tissue
preserve functional pancreatic tissue
control duct disruption/fistula
- 1/3 successful - perc drainage (note pancreatic fistula will form), retroperitoneal video assisted debridement
- endoscopic frainage through stomach 69% effective
- open/laparoscopic debridement if others fail (can do transgastric with WON)
what are the diagnostic criteria for IgG4 disease
HiSORT
Histology - plasma cells with IgG4
S - serology - IgG4 level high
O - other organ involvement (cholangitis, retroperitoneal fibrosis, mediastinal fibrosis, sjogren syndrome, IBD)
RT- response to glucocorticoid therapy
what are the forms of hereditary pancreatitis
PRSS! - serine protease 1 gene mutation - autosomal dominant. Gene encoding for cationic trypsinogen - easier activation of trypsinogen
SPINK1 - trypsin inhibitor. Found in pancreatic acinar cells. Autosomal recessive. Loss of function leads to decreased protection from inappropriate acitvation
CFTR gene
Causes of chronic pancreatitis
TIGAR - O
Toxins (alcohol, cigarette smoke, triglycerides - form FFA from Lipase)
Idiopathic
Genetic
Autoimmune
Recurrent acute pancreatitis
Obstructive
What are the indications for referral for liver transplant in chronic liver failure
2 of 5
- Complications of portal HTN - ascites, variceal bleeding
- Encephalopathy
- intractable pruritis
- Severe impairment of quality of life
- Impaired synthetic function - low albumin and deranged coagulation
MELD score 15 or more (exceptions - HCC, metabolic liver disease, acute liver failure,)
what are the indications for cholecystectomy in asymptomatic cholelithaisis
Gallstone >3cm
porcelain gallbladder
gallbladder polyps/adenoma
abberent pancreticobiliary duct junction
If haemolytic disorder and having abdominal surgery for another reason (e.g. splenectomy for spherocytosis)
Gallbladder cancer tnm staging
T1a - invasion of lamina propria
1b- invasion of muscular layer
2- a perimuscular connective tissue invasion on peritoneal side - serosa ok
b - invasion on liver side - liver not involved
3 - invason through serosa or into liver or adjacent organ
4 - invasion of major vasculature or x2 organs
gallbladder cancer treatment
1a - cholecystectomy alone ok
1b and above - extended cholecysectomy (or formal central liver resection of segment IVb and V)
remove all lymph nodes around porta hepatis and hepaticoduodenal ligament
Rememeber staging laparoscopy - if has not had a laparoscopy recently.
Unresectable disease - extensive involvement of the porta hepatis, involvement of ceoliac/sma/cava, distant mets, liver mets, malignant ascites,
Note that direct invasion of colon/stomach/duodenum/liver is not a contraindication for treatment
siewart -stein classificatio
1-5cm above GOJ
1-2 cm around GOJ
2-5cm distal
What are the indications for anti-reflux surgery
medically refractory reflux
noncompliance to meds
severe oesophagitis
barrett’s oesophigitis
benign stricutre
high volume reflux
grading of oesophageal caustic injury and significance
Grade 1-3
1 - superficial mucousal oedema
2- a - superficial ulceration
b - deep or circumferential ulceration
3-a patches of necrosis
b - extensive necrosis
1 and 2a will heal with no issues - no muscularis involvment
2b and 3a will likely stricture
3b usually need operation (70% mortality)
2b/3 will need NG feeding - perforation risk for 7 days
CROSS protocol
+ “definitive chemordatiation”
Craboplatin + placitaxel + RTx
Deifinitive is an extra 20Gy of radiation + additional cycles of chemo
siewert-stein
1- >1-5cm
2- 1-2cm
3 - >2-5cm
complications of peptic ulcer disease
bleeding
perforation
gastric outlet obstruciton
penetrating/fistula disease
GIST immunohistochemistry
CD 117 - c-kit
CD34
DOG -1 (positive regardless of c-kit and PDGFRA
prognostic factors in GIST (best categories)
Size (<2cm),
Site (stomach)
mitotic rate (<5)
what is the pathophys for pernicious anaemia
H+/K+ ATPase pump destroyed in parietal cells by immune cells.
Increased gastrin, risk of NET (Type 1) and cancer
steps for band removal and how do band erosions present
expsore the band
mobilise and define the buckle
stay on the band
cut the buckle and remove
DECOMPRESS PROXIMAL STOMACH (cut the eschar)
ERosion prsents - loss of satiety, port injection, epigastric pain,
complications of gastric sleeve
leak (1%)
stenosis
volvulus
bleeding
portal venous thrombosis
obstruction at incisura
dilatation and weight regain
chronic reflux/hiatus hernia
indications for imatinib
neoadjuvant - borderline/unresectable tumour/large
Adjuvant - >5/50HPF mitoses, >5cm tumour (risk of recurrence)
Metastases
Recurrent
Remember C-kit/PDGFRA
ADVERSE effects of obesity
Metainflammation - release of inflammatory mediators from adipocytes - leads to dysfunction of peripheral tissue leading to metabolic disease, insulin resistance, predisposition to malignancy. TNF-a, IL-6, Il-1B
Free fatty acids - proinflammatory. Disordered lipolysis; free fatty acids deposit in liver - fatty liver + muscle - insulin resistance
Adipokines - hormones - leptinm adiponectin,
what are indications for imatinib for GIST tumour
need to be c-kit/PDGFRA mutation positve
size>10cm
mitotic rate>10
size >5 + mitotic rate>5
incomplete resection/perforated tumour
neoadjuvant treatment for unresectable tumour to downstage it
mechanisms of reflux
transient lower oesophageal relaxations
weak lower oesophageal sphincter
anatomical - hiatus hernia
Classification of caustic injury to oesophagus
Acid - coagulative necrosis
Alkali - Liquefactive necrosis
Zargar’s classification
1 - Erythema, mucosal oedema
2a - superficial ulceration, small areas
b - deep ulceration/continuous circumferential
3- a Focal areas of necrosis + ulcerations
b - extensive necrosis (+other organs involved)
1 and 2a minimal stricture rate with very good prognosis
2b and 3a high rate of stricture 70%
3b - mortality 65% and need resection
Causes of splenomegaly
Congestive - portal hypertension/cirrhosis, splenic vein thrombosis
malignancy - metastases (malenoma, breast, stomach, ovarian, lung), lymphoma, leukiemia, thrombocythemia
Infections - Tb, salmonella, abscess, EBV/CMV, malaria, hydatid cyst
Inflammatory - SLE, Sarcoid, RA
haematological - sickle cell aneamia, hereditary spherocytosis, thalassemia
Traumatic cyst,
