Upper GI Surger

Question 1

oesophageal margins

Answer 1

C6 to T10

Question 2

stratify causes of dysphagia x3 and give examples of causes

Answer 2

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

Question 3

investigating dysphagia

Answer 3

OGD
barium swallow
manometry

Question 4

achalalsia classic history

Answer 4

dysphagia to fluids then solids 
regurg at night
weight loss
caused by degen in myenteric plexus
often unknown cause

can get oesophageal SCCs

Question 5

achalasia inv findings

Answer 5

§ Ba swallow: dilated tapering oesophagus
- Bird’s beak!
§ Manometry: failure of relaxation + ↓ peristalsis
§ CXR: widened mediastinum, double RH border
§ OGD: exclude malignancy

Question 6

treating achalasia

Answer 6

botox
endoscopic balloon dilatation
Heller’s cardiomyotomy

Question 7

pharyngeal pouch presentation and treatment

Answer 7

Pres: Regurgitation, halitosis, gurgling sounds

• Rx: excision, endoscopic stapling

Question 8

diffuse oesophageal spasm

Answer 8

corkscrew oesophagus on barium swallow

intermittent severe chest pain and dysphagia

Question 9

oesophageal rupture

Answer 9

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

Question 10

Plummer Vinson Syndrome

Answer 10

Severe IDA → hyperkeratinisation of upper 3rd of

oesophagus → web formation

Question 11

risk factors oesophageal cancer

Answer 11

achalasia
GORD
Plummer Vinson
smoking

Question 12

oesophageal cancers by risk factor

Answer 12

GORD - adenocarcinoma

smoking - SCC

Question 13

presentation oesophageal cancer

Answer 13

progressive dysphagia, starts with fluids and progresses to less and less
FLAWS symptoms 
hoarseness
retrosternal chest pain
cough

Question 14

diagnosing oesophageal cancer

Answer 14

FBC - anaemia
LFT - liver mets

OGD + biopsy

CT staging
lap

Question 15

treatment oesophageal cancers

Answer 15

MDT approach
poor prognosis
neoadjuvant Ctherapy
oesophagectomy

palliative - stenting, radioT

Question 16

risk factors GORD

Answer 16

Hiatus hernia
• Smoking
• EtOH
• Obesity
• Pregnancy
• Drugs: anti-AChM, nitrates, CCB, TCAs

Question 17

complications of GORD

Answer 17

Barrett’s
ulceration
stricture
cancers

Question 18

DDx GORD

Answer 18

consider oesophagitis - infection
IBD
caustic substances
cancers

Question 19

when to give an OGD with GORD

Answer 19

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

Question 20

GORD management

Answer 20

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)

Question 21

hiatus hernia investigations

Answer 21

CXR: gas bubble and fluid level in chest
• Ba swallow: diagnostic
• OGD: assess for oesophagitis
• 24h pH + manometry: exclude dysmotility or
achalasia

Question 22

types of hiatus hernia

Answer 22

sliding, rolling, mixed

sliding most common, GORD assoc, medical management

rolling -some stomach in chest and can strangulate

Question 23

treating hiatus hernia

Answer 23

• Lose wt.
• Rx reflux
• Surgery if intractable symptoms despite medical Rx.
§ Should repair rolling hernia (even if asympto)
as it may strangulate

Question 24

gastric vs duodenal ulcer

Answer 24

DU
- Before meals and at night
- Relieved by eating
§ GU
- Worse on eating (→ ↓ wt.)
- Relieved by anatacids

duodenal are commoner

Question 25

complications of GI ulcers

Answer 25

bleeding
perforation
gastric outflow obstruction
malignancy

Question 26

investigating peptic ulcers

Answer 26

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

Question 27

peptic ulcer disease treatment

Answer 27

avoid risk factors
lanzoprazole
eradication therapy

surgery:
vagotomy - cut vagal nerve supply to reduce acid secretion, widening of outlet needed too
antrectomy and anastom

Question 28

complications of peptic ulcer surgery (antrectomy, vagotomy)

Answer 28

Ca: ↑ risk of gastric Ca
• Reflux or bilious vomiting (improves ¯c time)
• Abdominal fullness
• Stricture
• Stump leakage

Question 29

metabolic complications of antrectomy / vagotomy

Answer 29

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

Question 30

upper GI bleeding management pathway

Answer 30

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

Question 31

OGD variceal treatment

Answer 31

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

Question 32

OGD if vessel or ulcer bleeding

Answer 32

• Adrenaline injection
• Thermal / laser coagulation
• Fibrin glue
• Endoclips

Question 33

indications for surgery with upper GI bleed

Answer 33

Re-bleeding
• Bleeding despite transfusing 6u
• Uncontrollable bleeding at endoscopy
• Initial Rockall score ≥3, or final >6.
• Open stomach, find bleeder and underrun vessel

Question 34

normal history with upper GI bleed

Answer 34

• Previous bleeds
• Dyspepsia, known ulcers
• Liver disease or oesophageal varices
• Dysphagia, wt. loss
• Drugs and EtOH
• Co-morbidities
blood thinning meds

Question 35

on examination acute GI bleed

Answer 35

Signs of CLD
• PR: melaena
• Shock?
§ Cool, clammy, CRT>2s
§ ↓BP (<100) or postural hypotension (>20 drop)
§ ↓ urine output (<30ml/h)
§ Tachy

Question 36

differentials upper GI bleed

Answer 36

• peptic ulcer: 40% (
• Acute erosions / gastritis:20%
• Mallory-Weiss tear: 10%
• Varices: 5%
• Oesophagitis: 5%
• Ca stomach / oesophagus:<3%

Question 37

causes of portal HTN

Answer 37

• Pre-hepatic: portal vein thrombosis
• Hepatic: cirrhosis (80% in UK), schisto (commonest
worldwide), sarcoidosis.
• Post-hepatic: Budd-Chiari, RHF, constrict pericarditis

Question 38

what is the TIPSS procedure?

Answer 38

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.

Question 39

perforated peptic ulcer presentation

Answer 39

• Sudden onset severe pain, beginning in the
epigastrium and then becoming generalised.
• Vomiting
• Peritonitis

consider Pancreatitis
• Acute cholecystitis
• AAA
• MI

Question 40

peptic ulcer perf investigations

Answer 40

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

Question 41

managing peptic ulcer perf

Answer 41

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

Question 42

causes of gastric outlet obstruction

Answer 42

cancers or

late peptic ulcer causing strictures

Question 43

presentation gastric outlet obstruction

Answer 43

• 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

Question 44

investigation findings in gastric outlet obstruction

Answer 44

ABG: Hypochloraemic hypokalaemic met alkalosis
• AXR
§ Dilated gastric air bubble, air fluid level
§ Collapsed distal bowel
• OGD
• Contrast meal

Question 45

treating gastric oulet obstruction

Answer 45

• Correct metabolic abnormality: 0.9% NS + KCl
• Benign
§ Endoscopic balloon dilatation
§ Pyloroplasty or gastroenterostomy
• Malignant
§ Stenting
§ Resection

Question 46

classic pyloric stenosis presentation

Answer 46

6-8wks
• Projectile vomiting minutes after feeding
• RUQ mass: olive
• Visible peristalsis

Question 47

pyloric stenosis inv and management

Answer 47

Dx
• Test feed: palpate mass + see peristalsis
• Hypochloraemic hypokalaemic metabolic alkalosis
• US
Mx
• Resuscitate and correct metabolic abnormality
• NGT
• Ramstedt pyloromyotomy: divide muscularis propria

Question 48

classification of gastric cancers

Answer 48

Borrmann

4 types
• Polypoid / fungating
• Excavating
• Ulcerating and raised
• Linitis plastica: leather-bottle like thickening ¯c flat
rugae

Question 49

risk factors gastric cancre

Answer 49

diet
smoking
ulcers 
metaplasia 
FH

Question 50

symptoms and signs of gastric cancers

Answer 50

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

Question 51

complications of gastric cancers

Answer 51

perf
bleed
obstruction

Question 52

investigating gastric cancer

Answer 52

Bloods
§ FBC: anaemia
§ LFTs and clotting
• Imaging
§ CXR: mets
§ USS: liver mets
§ Gastroscopy + biopsy
§ Ba meal
• Staging
§ Endoluminal US
§ CT/MRI
§ Diagnostic laparoscopy

Question 53

gastric cancer treatment

Answer 53

if very lucky can do gastrectomy and cure

palliative care
stenting

Question 54

GI stromal tumour

Answer 54

Arise from intestinal cells of Cajal
§ Located in muscularis propria
§ Pacemaker cells
• OGD: well-demarcated spherical mass ¯c central
punctum

mass effects
bleeding

Question 55

carcinoid tumours

Answer 55

enterchromaffin cell origin
secrete hormones

flushing diarrhoea mainly
paroxysms as hormones released in random bursts

Question 56

gastric lymphoma

Answer 56

most common extranodal site

often gastric MALToma due to H pylori
eradication can cure

Question 57

Zollinger Ellison syndrome

Answer 57

tumour secretes gastrin

refractory peptic ulcers

diagnose gastrin levels
MRI/CT
somatostatin receptor scintigraphy (also used for finding carcinoid)

PPI and resect

Question 58

indications bariatric surgery

Answer 58

• 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