Upper GI Disorders

Question 1

How

Answer 1

1 year history of upper abdominal pain
Always worse when hungover
A&E with worsening abdo pain for 3 hours 
1 vomit 
Slightly raised WBC

Question 2

What are causes of upper abdo pain? (surgical)

Answer 2

PUD/GORD
Pancreatitis 
Biliary pathology 
Abdominal wall 
Vascular
Small bowel
Large bowel

Question 3

What are causes of upper abdo pain? (non-surgical)

Answer 3

Cardica
Gastroenterological
MSK
Diabete 
Derm

Question 4

What is the first investigation after bloods for abdo pain?

Answer 4

CXR and AXR

Look for air under the diaphragm - perforation

Question 5

How does the patient represent?

Answer 5

Been taking double dose ibuprofen a
Worsening epigastric pain
Vomiting
Sinus tachycardia

Question 6

What does the patient have?

Answer 6

Perforated viscus

Question 7

What is the sign of perforated vicus on CXR?

Answer 7

Rigler’s sign
Free intraperitoneal air
Free subdiaphragmatic air

Question 8

What is the most-likely perforated organ?

Answer 8

Duodenum

Question 9

What is the primary management for perforation?

Answer 9

NGT
NBM
IV fluids
ABx

Question 10

What is the aim of surgical treatment of perforation?

Answer 10

1. Identification of aetiology
2. Eradication of peritoneal source of contamination
3. Peritoneal lavage and drainage

Question 11

What is the range of treatment for peritonitis?

Answer 11

Conservative treatment (Taylor’s approach) - not free drainage of gasrtic contents, perforation has sealed itself off

Racial surgery (vagotomy, gasterctomy)

Question 12

Where are perforations found?

Answer 12

Anterior/superior surface of the first part of the duodenum

Rarely pre=pyloric antrum

Less frequently stomach

Rarely posterior surface

Question 13

What is the safest surgery for perforation?

Answer 13

Laparoscopic omental patch

Stitch one side of the defect, take a bit of omentum to cover the hole

Question 14

What happened to the patient post-op?

Answer 14

SOB
O2 drops to 87% on 2L nasal specs
Temp - 38.5
100 bpm

Question 15

What is the most likely cause of his deterioration?

Answer 15

Pneumonia

Question 16

How does pneumonia develop?

Answer 16

Pain relief inadequate
Do not take deep breaths 
Air does not fill lung
Lungs fill with fluid 
Infection

Question 17

How does the second patient present?

Answer 17

Intermittent abdo pain for 1 yr
Now severe with vomiting
Pyrexial
WCC up
LFTs slightly abnormal
Amylase 2150 
100bpm

Question 18

What is the most likely diagnosis for the patient?

Answer 18

Gallstone pancreatitis

Question 19

What are the 4 principles of management of gallstone pancreatitis?

Answer 19

Fluid resuscitation
Analgesia
Pancreatic rest (nutritional support if prolonged recovery)
Determine underlying cause

Question 20

What is a HIDA scan?

Answer 20

Nuclear medicine

labels bile

Question 21

What is the next investigation after bloods for gallstone pancreatitis?

Answer 21

USS abdo

Question 22

What would your next investigation be?

Answer 22

MRCP

LFTs are still deranged

Question 23

What would the third investigation be?

Answer 23

ERCP

After establishing she has stones in common bile duct

Question 24

What happens of Day 7 of inpatient admission?

Answer 24

In pain

Tachycardia

Question 25

What investigation would you do?

Answer 25

CT abdo/pelvis

A week later now - complications form pancreatitis now present

Question 26

What is cholecystitis?

Answer 26

Inflamed galbladder

Question 27

When do you do acute laparoscopic cholecystectomy?

Answer 27

Within 48 hours

Question 28

What do you do if is noticed later than 48 hours?

Answer 28

Treat conservatively

Then book in for day case surgery

Question 29

What two structures need to be identifies and divided during a laparoscopic cholecystectomy?

Answer 29

Cystic duct and cystic artery

Question 30

What can be seen in surgery?

Answer 30

Biliary anomalies

Vascular anomalies