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Surgery > Upper GI/Hepatobiliary > Flashcards

Upper GI/Hepatobiliary Flashcards

1
Q

Causes of acute pancreatitis?

A

Idiopathic
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia/Hypercalcaemia
ERCP
Drugs (furosemide, thiazides, azathioprine, NSAIDs, mesalazine, sodium valproate)

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2
Q

Drugs which can cause acute pancreatitis?

A

steroids
NSAIDs
furosemide
thiazides
azathioprine
mesalazine
sodium valproate

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3
Q

Presentation of acute pancreatitis?

A

severe epigastric pain
radiation through to back
pain may be eased on leaning forward
nausea and vomiting
systemically unwell
dehydration

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4
Q

Investigations for acute pancreatitis?

A

FBC (WCC)
U&E (urea)
LFT (transaminases + amylase)
Calcium
ABG
amylase + lipase (3 times upper limit of normal)
CRP
US (gallstones)
CT abdo (complications)

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5
Q

Amylase vs Lipase in acute pancreatitis?

A

lipase more sensitive and specific and is raised for longer period of time
however amylase widely used in practice (cheaper)

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6
Q

What is the Glasgow score used for?

A

to assess and stratify the severity of the pancreatitis
>3 = severe pancreatitis

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7
Q

What score is used to assess the severity of pancreatitis?

A

Glasgow Score

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8
Q

Components of Glasgow score?

A

PaO2
Age
Neutrophils
Calcium
Renal (Urea)
Enzymes (LDH, AST/ALT)
Albumin
Sugar (Glucose)

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9
Q

Management of Acute Pancreatitis?

A

Assess Glasgow Score (moderate and severe pancreatitis to HDU or ICU)
ABCDE
Fluid resuscitation
Analgesia (opiates)
Anti-emetics
Treat underlying cause if possible (gallstones etc)
Antibiotics if specific infection
Treat complications

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10
Q

Local complications of acute pancreatitis?

A

necrosis of pancreas
infection in necrotic area
abscess formation
peripancreatic fluid collections
pseudocysts (4wks after)
chronic pancreatitis

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11
Q

Systemic complications of acute pancreatitis?

A

Disseminated intravascular coagulation
SIRS
ARDS
Hypocalcaemia
Hyperglycaemia
Hypovolaemia (third spacing)
Retroperitoneal Haemorrhage (Grey Turner’s sign, Cullen’s sign)

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12
Q

Presentation of pancreatic cancer?

A

painless obstructive jaundice
yellow skin
scleral icterus
pale stools
dark urine
pruritus
non-specific upper abdo or back pain
weight loss
palpable mass
change in bowel habit
nausea or vomiting
new-onset or sudden worsening on T2DM

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13
Q

When to refer for suspected pancreatic ca?

A

over 40 with jaundice - 2 week wait
over 60 with weight loss + symptom - direct CT abdo

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14
Q

What does Courvoisier’s law state?

A

palpable gallbladder with jaundice is unlikely to be caused by gallstones

(cholangiocarcinoma or pancreatic ca)

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15
Q

What does Trousseau’s sign of malignancy state?

A

that migratory thrombophlebitisI is a sign of malignancy, particularly pancreatic adenocarcinoma

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16
Q

Investigations for pancreatic cancer?

A

CT abdo
CT TAP for staging
CA 19-9 tumour marker
ERCP/MRCP
Biopsy

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17
Q

Management of pancreatic cancer?

A

often late presentation -> curative sx not possible
Sx options
stents to relieve obstruction
palliative chemo
palliative radiotherapy
end of life care with symptom controlS

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18
Q

Sx options for pancreatic cancer?

A

Total pancreatectomy
Distal pancreatectomy
Pylorus-preserving pancreaticoduodenectomy (Modified Whipple’s)
Whipple’s procedure

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19
Q

What is Whipple’s procedure?

A

pancreaticoduodenectomy

removal of:
head of pancreas
pylorus of stomach
1st and 2nd parts of duodenum
gallbladder
common bile duct
relevant lymph nodes

anastomose stomach, tail of pancreas and hepatic duct to the jejunum

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20
Q

RFs for gallstones?

A

6 Fs:
female
fat
fair
forty
fertile
FHx

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21
Q

Presentation of gallstones?

A

asymptomatic if gallstones in gallbladder
biliary colic:
severe, colicky, epigastric pain or RUQ pain
triggered by meals
lasting between 30 mins and 8 hrs
may be associated with N&V

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22
Q

Complications of gallstones?

A

acute cholecystitis
ascending cholangitis
obstructive jaundice
pancreatitis
gallstone ileus
gallbladder empyema
perforation
gangrene

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23
Q

What is biliary colic?

A

gallstones temporarily obstructing the drainage of the gallbladder
resolves when stones fall back into the gallbladder

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24
Q

Investigations for biliary colic?

A

obstructive picture on LFTs
US
MRCP
ERCP (also treatment)

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25
Q

Complications of ERCP?

A

pancreatitis
excessive bleeding
cholangitis

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26
Q

Mx of gallstones?

A

asymptomatic -> no treatment required
symptoms or complications -> cholecystectomy

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27
Q

Complications of cholecystectomy?

A

bleeding, infection, pain, scars
damage to bile duct
stones left in bile duct
damage to bowel, blood vessels, other organs
anaesthetic risks
VTE
post-cholecystectomy syndrome

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28
Q

What is post-cholecystectomy syndrome?

A

group of non-specific symptoms that can occur after a cholecystectomy

diarrhoea
indigestion
epigastric or RUQ pain
nausea
intolerance of fatty foods
flatulence

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29
Q

What is acute cholecystitis?

A

inflammation of the gallbladder
calculous (95%)
acalculous (long periods of fasting leading to build up of pressure i.e., ICU)

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30
Q

Presentation of acute cholecystitis?

A

RUQ pain
radiating to right shoulder
fever
nausea and vomiting
tachycardia, tachypnoea
RUQ tenderness
Murphy’s sign positive
raised inflammatory markers

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31
Q

What is Murphy’s sign?

A

place a hand on RUQ
ask patient to take deep breath in
during inspiration the gallbladder will move down, come in contact with your hand and cause cessation of inspiration due to tenderness

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32
Q

Investigations for acute cholecystitis?

A

LFTs
raised inflammatory markers
abdo US
MRCP

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33
Q

Mx of acute cholecystitis?

A

nil by mouth
IV fluids
antibiotics
NG tube if required
ERCP to remove stones
cholecystectomy (acutely or delayed)

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34
Q

Complications of acute cholecystitis?

A

sepsis
gallbladder empyema
gangrenous gallbladder
perforation

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35
Q

Mx of gallbladder empyema?

A

IV antibiotics
cholecystectomy
cholecystostomy

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36
Q

What is ascending cholangitis?

A

infection and inflammation of the bile ducts
surgical emergency
high mortality rate due to rapid progression to sepsis

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37
Q

Causes of ascending cholangitis?

A

obstruction (gallstones)
post-ERCP

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38
Q

Most common organisms in ascending cholangitis?

A

E coli
Klebsiella
Enterococcus

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39
Q

What is Charcot’s triad?

A

fever
jaundice
RUQ pain

(+hypotension and confusion = Reynold’s pentad)

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40
Q

Mx of ascending cholangitis?

A

nil by mouth
IV fluids
blood cultures
IV Abx (met + ceft)
potential HDU or ICU

ERCP for stone removal, balloon dilatation, biliary stenting
Percutaneous transhepatic cholangiogram can be used where ERCP not suitable or failed

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41
Q

Investigations for ascending cholangitis?

A

raised inflammatory markers
LFTs
blood cultures
US
CT
MRCP
ERCP

42
Q

RFs for cholangiocarcinoma?

A

PSC
liver flukes (parasitic)

43
Q

What is cholangiocarcinoma?

A

cancer originating from the bile ducts
majority are adenocarcinomas

44
Q

Most common site for cholangiocarcinoma?

A

perihilar region
(where the right and left hepatic duct have joined to become the common bile duct after leaving the liver)

45
Q

Presentation of cholangiocarcinoma?

A

painless jaundice
pale stools
dark urine
general pruritus
unexplained weight loss
RUQ pain
palpable gallbladder
hepatomegaly

46
Q

Investigations for cholangiocarcinoma?

A

CT/MRI + biopsy
staging CT TAP
CA 19-9
MRCP
ERCP

47
Q

Mx of cholangiocarcinoma?

A

MDT
curative surgery may be possible in early cases
adjuvant chemorads

palliative:
stents to relieve obstruction
sx to improve symptoms
palliative chemorads
end of life care

48
Q

Types of gallstones?

A

cholesterol (10%)
bile salts (10%)
mixed (80%)

49
Q

US findings in gallstone disease?

A

presence of gallstones
GB wall thickening
bile duct dilatation

50
Q

What is GORD?

A

excessive reflux of gastric contents into the oesophagus
resulting in symptoms and/or mucosal injury

51
Q

RFs for GORD?

A

FHx
obesity
alcohol use
smoking
pregnancy

52
Q

Features of GORD?

A

heartburn
acid reflux
worse at night and after large meals
dysphagia (if ulceration or stricture)
globus
pulmonary aspiration

53
Q

Investigations for GORD?

A

clinical diagnosis
oesophageal manometry
OGD must be performed to rule out cancer if new cases >45, dysphagia or weight loss

54
Q

Mx of GORD?

A

lifestyle modification
medical -> PPI, Gaviscon
surgical -> Nissen’s fundoplication

55
Q

Indications for surgery in GORD?

A

persistent symptoms despite maximal medical therapy
risk of aspiration pneumonia
strictures
severe ulceration
Barrett’s oesophagus
young patient with uncontrolled symptoms

56
Q

Complications of GORD?

A

oesophagitis and ulceration
peptic stricture
Barrett’s oesophagus
oesophageal adenocarcinoma

57
Q

What is Barrett’s oesophagus?

A

metaplasia of stratified squamous epithelium of the distal oesophagus to columnar epithelium
+/- dysplasia

58
Q

RFs for Barrett’s oesophagus?

A

consequence of prolonged severe GORD
obesity

59
Q

Risk associated with Barrett’s oesophagus?

A

1% per year develop into adenocarcinoma

60
Q

Mx of Barrett’s oesophagus?

A

conservative -> lifestyle modifications

medical -> PPI, Gaviscon, eradication of H pylori

surgical -> OGD surveillance, endoscopic ablation, endoscopic mucosal resection, oesophagectomy

61
Q

What is a hiatus hernia?

A

prolapse of the gastro-oesophageal junction of part of the stomach into the thoracic cavity through the oesophageal diaphragmatic hernia

62
Q

Types of hiatus hernias?

A

Type I - sliding
Type II - para-oesophageal or rolling
Type III - combined
Type IV - complex

63
Q

Investigations for hiatus hernia?

A

CXR
Barium swallow - best
OGD
CT

64
Q

Mx of hiatus hernia?

A

conservative/medical management

surgical:
indicated if persistent symptoms despite maximal medical therapy
Nissen’s fundoplication

65
Q

Complications of hiatus hernia?

A

oesophageal:
inflammation
ulceration
bleeding

iron deficiency anaemia
gastric volvulus
gastric ischaemia and infarction

66
Q

What is peptic ulcer disease?

A

breakdown of the mucosal layer of the stomach or duodenum typically secondary to excessive acid production of damaged barrier mechanisms

67
Q

RFs for peptic ulcer disease?

A

H pylori
NSAIDs or aspirin
smoking
alcohol
stress
steroids
gastrinoma (Zollinger-Ellison syndrome)

68
Q

Features of peptic ulcer disease?

A

dyspepsia
nausea
epigastric pain
heartburn
anaemia
duodenal -> relieved by food, cyclical pain
gastric -> worsened by food, less cyclical

69
Q

Investigations for peptic ulcer disease?

A

H pylori:
urease test
urea breath test
stool antigen test

OGD
biopsy to rule out malignancy

70
Q

Mx of peptic ulcer disease?

A

H pylori -> triple therapy
antacids
PPIs

71
Q

Complications of peptic ulcer disease?

A

bleeding
perforation
sepsis
gastric outlet obstruction

72
Q

Mx of peptic ulcer complications?

A

Bleeding:
ABC
IV fluids, transfusion, PPI infusion, tranexamic acid
OGD

Perforation:
ABC
IV fluids, broad spectrum ABx
surgical -> Graham patch repair -> closure of ulcer followed by omental patch and fixation

73
Q

What is upper GI bleeding?

A

bleeding above the ligament of Treitz
oesophagus
stomach
duodenum

74
Q

Mx of upper GI bleed?

A

ABD
bloods, group and crossmatch
NPO, IV fluids, transfusion

correct clotting abnormalities
IV PPI, IV tranexamic acid
if variceal -> terlipressin, Sengstaken-Blakemore tube

urgent OGD:
sclerotherapy
variceal banding
adrenaline injection
coagulation

75
Q

What is the Rockall Score used for?

A

to estimate the risk of rebleeding or death in upper GI bleed

performed after OGD

76
Q

What is the Glasgow-Blatchford score used for?

A

to assess the severity of an upper GI bleed prior to OGD to assess if patient suitable for outpatient management

77
Q

What is dysphagia?

A

difficulty swallowing

78
Q

What is odynophagia?

A

painful swallowing

79
Q

Causes of dysphagia?

A

congenital:
oesophageal atresia

luminal:
foreign body

oesophageal wall:
oesophageal web
Plummer-Vinson
carcinoma
stricture
achalasia
GORD
oesophagitis
scleroderma

extramural:
pouch
compression

neurological:
stroke
MG
MND

80
Q

Oesophageal motility disorders?

A

primary:
achalasia
diffuse oesophageal spasm

secondary:
scleroderma
Chagas
DM
amyloid
MG

81
Q

What is achalasia?

A

loss of oesophageal peristalsis, incr. lower oesophageal sphincter tone and failure to relax

82
Q

Features of achalasia?

A

progressive dysphagia to both liquids and solids
risk of SCC

83
Q

Investigations for achalasia?

A

upper GI endoscopy
Barium swallow (‘bird-beak’)
manometry

84
Q

Complications of achalasia?

A

nocturnal aspiration
bronchiectasis
lung abscess
SCC

85
Q

Mx of achalasia?

A

balloon dilatation
injection of Botox
Heller’s cardiomyotomy

86
Q

Types of oesophageal cancer?

A

SCC
adenocarcinoma

87
Q

Features of oesophageal adenocarcinoma?

A

most common in Western world
lower third of oesophagus
reflux

88
Q

Features of oesophageal SCC?

A

most common globally
upper and middle parts of oesophagus
carcinogens

89
Q

RFs for oesophageal adenocarcinoma?

A

Barrett’s
GORD
obesity
high fat intake
smoking
alcohol

90
Q

RFs for oesophageal SCC?

A

high alcohol intake
smoking
nitrosamines
Vit A, C deficiency
coeliac
strictures and webs
achalasia
peptic ulcer disease

91
Q

Presentation of oesophageal cancer?

A

dysphagia
weight loss
haematemesis
screening
mets
local invasions (hoarseness, Horner’s, SVC obstruction)

92
Q

Investigations for oesophageal cancer?

A

OGD biopsies
CT TAP/PET

93
Q

Mx of oesophageal cancer?

A

MDT
endoscopic ablation and resection in high-grade dysplasia

oesophagectomy + neoadjuvant chemorads (SCC better response to rads)

94
Q

Surgical options for oesophagectomy?

A

Ivor-Lewis (2-stage oesophagectomy) -> performed for distal tumours

McKeown Procedure (3 stage for proximal tumours)

transhiatal resection

95
Q

Types of gastric cancer?

A

adenocarcinoma
adenocarcinoma of GOJ
GISTs
neuroendocrine tumours (carcinoid)
lymphoma (H pylori)

96
Q

RFs for gastric adenocarcinoma?

A

chronic ulceration related to H pylori
nitrosamines
EBV
FHx
Blood type A

97
Q

Investigations for gastric adenocarcinoma?

A

gastroscopy and biopsy
CT TAP/PET

98
Q

Mx of gastric adenocarcinoma?

A

gastrectomy (partial or total)

neoadjuvant chemotherapy

palliative gastrojejunostomy

99
Q

Complications of partial/total gastrectomy?

A

Early:
haemorrhage
acute pancreatitis
anastomotic leak
duodenal stump disruption
respiratory compromise

Late:
dumping syndrome
bile reflux
vomiting
diarrhoea
recurrent stomal ulceration
metabolic abnormalities (iron def, B12 def)

100
Q

Complications of OGD?

A

perforation
bleeding
damage to teeth
sedation risks
aspiration
numbness, risk of scalds
sore throat

Surgery (10 decks)

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