Upper GI Surger Flashcards
oesophageal margins
C6 to T10
stratify causes of dysphagia x3 and give examples of causes
inflammatory - infection (tonsillitis, pharyngitis), oesophagitis, GORD, oral candidiasis, aphthous ulcers
neuro local - achalasia, spasm, nutcracker oesophagus, MND palsies
neuro systemic - systemic sclerosis, mya gravis
mechanical obstruction
can be luminal
mural - oesophageal pouch,
extramural - lung ca, goitre, hiatus hernia, aorta
investigating dysphagia
OGD
barium swallow
manometry
achalalsia classic history
dysphagia to fluids then solids regurg at night weight loss caused by degen in myenteric plexus often unknown cause
can get oesophageal SCCs
achalasia inv findings
§ Ba swallow: dilated tapering oesophagus
- Bird’s beak!
§ Manometry: failure of relaxation + ↓ peristalsis
§ CXR: widened mediastinum, double RH border
§ OGD: exclude malignancy
treating achalasia
botox
endoscopic balloon dilatation
Heller’s cardiomyotomy
pharyngeal pouch presentation and treatment
Pres: Regurgitation, halitosis, gurgling sounds
• Rx: excision, endoscopic stapling
diffuse oesophageal spasm
corkscrew oesophagus on barium swallow
intermittent severe chest pain and dysphagia
oesophageal rupture
usually iatrogenic
Features
• Odonophagia
• Mediastinitis: tachypnoea, dyspnoea, fever, shock
• Surgical emphysema
Mx
• Iatrogenic: PPI, NGT, Abx
• Other: resus, PPI, Abx, antifungals, debridement +
formation of oesophago-cutaneous fistula ¯c T-tube
Plummer Vinson Syndrome
Severe IDA → hyperkeratinisation of upper 3rd of
oesophagus → web formation
risk factors oesophageal cancer
achalasia
GORD
Plummer Vinson
smoking
oesophageal cancers by risk factor
GORD - adenocarcinoma
smoking - SCC
presentation oesophageal cancer
progressive dysphagia, starts with fluids and progresses to less and less FLAWS symptoms hoarseness retrosternal chest pain cough
diagnosing oesophageal cancer
FBC - anaemia
LFT - liver mets
OGD + biopsy
CT staging
lap
treatment oesophageal cancers
MDT approach
poor prognosis
neoadjuvant Ctherapy
oesophagectomy
palliative - stenting, radioT
risk factors GORD
Hiatus hernia • Smoking • EtOH • Obesity • Pregnancy • Drugs: anti-AChM, nitrates, CCB, TCAs
complications of GORD
Barrett’s
ulceration
stricture
cancers
DDx GORD
consider oesophagitis - infection
IBD
caustic substances
cancers
when to give an OGD with GORD
OGD if: § >55yrs § Persistent symptoms despite Rx § Anaemia § Loss of wt. § Anorexia § Recent onset progressive symptoms § Melaena § Swallowing difficulty § OGD allows grading by Los Angeles Classification
GORD management
stop smoking, coffee, alcohol raise head of bed alter diet, no spice PPIs Gaviscon small reg meals, never eat before bed avoid NSAIDs, calantags, antimuscarinics
Nissen fundoplication (refractory to medical treatment, pH confirmed)
hiatus hernia investigations
CXR: gas bubble and fluid level in chest • Ba swallow: diagnostic • OGD: assess for oesophagitis • 24h pH + manometry: exclude dysmotility or achalasia
types of hiatus hernia
sliding, rolling, mixed
sliding most common, GORD assoc, medical management
rolling -some stomach in chest and can strangulate
treating hiatus hernia
• Lose wt.
• Rx reflux
• Surgery if intractable symptoms despite medical Rx.
§ Should repair rolling hernia (even if asympto)
as it may strangulate
gastric vs duodenal ulcer
DU - Before meals and at night - Relieved by eating § GU - Worse on eating (→ ↓ wt.) - Relieved by anatacids
duodenal are commoner
complications of GI ulcers
bleeding
perforation
gastric outflow obstruction
malignancy
investigating peptic ulcers
FBC - microcytic anaemia, raised urea if GI bleed
OGD after 2 weeks no PPI
breath test H pylori
ulcer biopsy
gastrin levels if suspect Zoll El syndrome suspected
peptic ulcer disease treatment
avoid risk factors
lanzoprazole
eradication therapy
surgery:
vagotomy - cut vagal nerve supply to reduce acid secretion, widening of outlet needed too
antrectomy and anastom
complications of peptic ulcer surgery (antrectomy, vagotomy)
Ca: ↑ risk of gastric Ca • Reflux or bilious vomiting (improves ¯c time) • Abdominal fullness • Stricture • Stump leakage
metabolic complications of antrectomy / vagotomy
Dumping syndrome
§ Abdo distension, flushing, n/v, fainting,
sweating
§ Early: osmotic hypovolaemia
§ Late: reactive hypoglycaemia
• Blind loop syndrome → malabsorption, diarrhoea
§ Overgrowth of bacteria in duodenal stump
• Vitamin deficiency
§ ↓ parietal cells → B12 deficiency
§ Bypassing proximal SB → Fe + folate
deficiency
§ Osteoporosis
• Wt. loss: malabsorption of ↓ calories intake
upper GI bleeding management pathway
RESUS
• Head down
• 100% O2, protect airway
• 2 x 14G cannulae + IV crystalloid infusion up to 1L.
• Bloods: FBC, U+E (↑ urea), LFTs, clotting, x-match 6u,
ABG, glucose
BLOOD if shocked (O neg and send G+S)
maintenance and correct blood abnormalities (thiamine if alcohol)
terlipressin and abx if variceal
URGENT OGD
OGD variceal treatment
2 of: banding, sclerotherapy, adrenaline, coagulation
• Balloon tamponade ¯c Sengstaken-Blakemore tube
§ Only used if exsanguinating haemorrhage or failure
of endoscopic therapy
• TIPSS if bleeding can’t be stopped endoscopically
OGD if vessel or ulcer bleeding
- Adrenaline injection
- Thermal / laser coagulation
- Fibrin glue
- Endoclips
indications for surgery with upper GI bleed
Re-bleeding • Bleeding despite transfusing 6u • Uncontrollable bleeding at endoscopy • Initial Rockall score ≥3, or final >6. • Open stomach, find bleeder and underrun vessel
normal history with upper GI bleed
• Previous bleeds • Dyspepsia, known ulcers • Liver disease or oesophageal varices • Dysphagia, wt. loss • Drugs and EtOH • Co-morbidities blood thinning meds
on examination acute GI bleed
Signs of CLD • PR: melaena • Shock? § Cool, clammy, CRT>2s § ↓BP (<100) or postural hypotension (>20 drop) § ↓ urine output (<30ml/h) § Tachy
differentials upper GI bleed
- peptic ulcer: 40% (
- Acute erosions / gastritis:20%
- Mallory-Weiss tear: 10%
- Varices: 5%
- Oesophagitis: 5%
- Ca stomach / oesophagus:<3%
causes of portal HTN
• Pre-hepatic: portal vein thrombosis
• Hepatic: cirrhosis (80% in UK), schisto (commonest
worldwide), sarcoidosis.
• Post-hepatic: Budd-Chiari, RHF, constrict pericarditis
what is the TIPSS procedure?
IR creates artificial channel between hepatic vein and
portal vein → ↓ portal pressure.
• Colapinto needle creates tract through liver
parenchyma which is expand using a balloon and
maintained by placement of a stent.
• Used prophylactically or acutely if endoscopic therapy
fails to control variceal bleeding.
perforated peptic ulcer presentation
• Sudden onset severe pain, beginning in the
epigastrium and then becoming generalised.
• Vomiting
• Peritonitis
consider Pancreatitis
• Acute cholecystitis
• AAA
• MI
peptic ulcer perf investigations
bloods G+S, clotting, coag
urine dip
erect CXR (stand for 15 mins) - air under diaphragm
Rigler’s sign - air either side of gut wall
managing peptic ulcer perf
NBM fluid resus abx analgesia antiemetic
can consider conservative if no peritonism (1/2 will self-seal)
surgery- duodenal = washout and omental repair, gastric - excise and repair
screen ulcer for cancers
treat afterwards for H pylori
causes of gastric outlet obstruction
cancers or
late peptic ulcer causing strictures
presentation gastric outlet obstruction
• Hx of bloating, early satiety and nausea
• Outlet obstruction § Copious projectile, non-bilious vomiting a few hrs after meals. § Contains stale food. § Epigastric distension f
investigation findings in gastric outlet obstruction
ABG: Hypochloraemic hypokalaemic met alkalosis
• AXR
§ Dilated gastric air bubble, air fluid level
§ Collapsed distal bowel
• OGD
• Contrast meal
treating gastric oulet obstruction
• Correct metabolic abnormality: 0.9% NS + KCl • Benign § Endoscopic balloon dilatation § Pyloroplasty or gastroenterostomy • Malignant § Stenting § Resection
classic pyloric stenosis presentation
6-8wks
• Projectile vomiting minutes after feeding
• RUQ mass: olive
• Visible peristalsis
pyloric stenosis inv and management
Dx
• Test feed: palpate mass + see peristalsis
• Hypochloraemic hypokalaemic metabolic alkalosis
• US
Mx
• Resuscitate and correct metabolic abnormality
• NGT
• Ramstedt pyloromyotomy: divide muscularis propria
classification of gastric cancers
Borrmann
4 types • Polypoid / fungating • Excavating • Ulcerating and raised • Linitis plastica: leather-bottle like thickening ¯c flat rugae
risk factors gastric cancre
diet smoking ulcers metaplasia FH
symptoms and signs of gastric cancers
Usually present late • Wt. loss + anorexia • Dyspepsia: epigastric or retrosternal pain/discomfort • Dysphagia • vomiting and nausea
Anaemia • Epigastric mass • Jaundice • Ascites • Hepatomegaly • Virchow’s node (= Troisier’s sign) • Acanthosis nigricans
complications of gastric cancers
perf
bleed
obstruction
investigating gastric cancer
Bloods § FBC: anaemia § LFTs and clotting • Imaging § CXR: mets § USS: liver mets § Gastroscopy + biopsy § Ba meal • Staging § Endoluminal US § CT/MRI § Diagnostic laparoscopy
gastric cancer treatment
if very lucky can do gastrectomy and cure
palliative care
stenting
GI stromal tumour
Arise from intestinal cells of Cajal § Located in muscularis propria § Pacemaker cells • OGD: well-demarcated spherical mass ¯c central punctum
mass effects
bleeding
carcinoid tumours
enterchromaffin cell origin
secrete hormones
flushing diarrhoea mainly
paroxysms as hormones released in random bursts
gastric lymphoma
most common extranodal site
often gastric MALToma due to H pylori
eradication can cure
Zollinger Ellison syndrome
tumour secretes gastrin
refractory peptic ulcers
diagnose gastrin levels
MRI/CT
somatostatin receptor scintigraphy (also used for finding carcinoid)
PPI and resect
indications bariatric surgery
• All the criteria must be met
§ BMI ≥40 or ≥35 ¯c significant co-morbidities that
could improve ¯c ↓ wt.
§ Failure of non-surgical Mx to achieve and
maintain clinically beneficial wt. loss for 6mo.
§ Fit for surgery and anaesthesia
§ Integrated program providing guidance on diet,
physical activity, psychosocial concerns and
lifelong medical monitoring
§ Well-informed and motivated pt.
• If BMI >50, surgery is 1st-line Rx
