Upper GI surgery Flashcards
What is the presentation of gallstones?
*RUQ/epigastric pain
*Postprandial pain - typically one hour after eating
*RUQ tenderness
What investigations should you carry out in suspected gallstones?
*Abdominal USS
*LFTS: in uncomplicated should be normal, if in bile duct then rise in ALP and bilirubin
*FBC: normal if uncomplicated
*Check lipase or amylase if epigastric pain
What is the management of gallstones?
*Symptomatic: NSAID (diclofenac), consider anti-emetic (hyoscine), elective laparoscopic cholecystectomy
*Asymptomatic: observation, consider a lap chole if >3cm or at high risk of complications
What are the complications of gallstones?
*Gallstone ileus: stone erodes the wall creating a cholecystoenteric fistula leading to obstruction of the bowel
*Acute cholecystitis
*Acute cholangitis
*Acute biliary pancreatitis
What is the presentation of chronic pancreatitis?
*Epigastric pain, radiates to the back, worse 30 mins post prandially
*Steatorrhoea (Increased fat in stool)|
*Weight loss/malnutrition (due to fear of pain or malabsorption or diabetes)
*Diabetes mellitus/glucose intolerance
*Nausea and vomiting
What investigations should be carried out in suspected chronic pancreatitis?
*CT/MRI: pancreatic calcification, enlargement, ductal dilation
*Endoscopic ultrasonography if diagnosis is not confirmed after CT/MRI
What is the management of chronic pancreatitis?
*Alcohol and smoking cessation
* Analgesia
*Replacement pancreatic enzymes
*Treat diabetes and complications
What are the complications of chronic pancreatitis?
*Pancreatic exocrine insufficiency
*Diabetes mellitus
*Pancreatic calcifications/duct obstruction/pseudocysts
*Low trauma fracture due to decreased bone mineral density, malnutrition, inflammation
What is the most common pancreatic carcinoma?
Primary pancreatic ductal adenocarcinoma, most occur in the head of the pancreas
What is the presentation of pancreatic adenocarcinoma?
*Painless obstructive jaundice
*Upper abdominal pain/discomfort, back pain
*Weight loss and anorexia
*New onset diabetes or worsening of type 2 diabetes
*Nausea, vomiting, change of bowel habit
What investigations should be carried out in suspected pancreatic carcinoma?
*CT
*Abdominal USS
*LFTs, FBC
*Cancer antigen 19-9 biomarker (CA19-9)
*MRCP to assess biliary obstruction, ERCP to relieve it and obtain a biopsy
*Biopsy
What is the management of pancreatic adenocarcinoma?
*Surgery: total or distal pancreatectomy; whipples
*Pancreatic enzyme replacement
*If there are cholangitis symtpoms: biliary stenting
*Chemotherapy/radiotherapy
*Analgesia
What is whipples procedure?
Removal of the head of the pancreas, pylorus of the stomach, duodenum, bile duct, relevant lymph nodes and the gallbladder
What is the difference between whipple’s and modified whipple’s procedure?
Modified does not remove the pylorus of the stomach
What is a hiatus hernia?
Protrusion of intra-abdominal contnets in to the thoracic cavity through an enlarged oesophageal hiatus of the diaphragm
What are the 4 types of hiatus hernia?
1: Sliding
2: Rolling
3: combination
4: large opening with additional organs entering into the thorax
What is a sliding hiatus hernia?
Gastro-oesophageal junction protrudes thorugh the oesophageal hiatus, followed by the body of the stomach
What is a rolling hiatus hernia?
The fundus/body of the stomach enters in to the thorax and the gastro-oesophageal junction remains below the diaphragm
What are the risk factors for a hiatus hernia?
*Obesity
*Previous GORD
*Elevated intra abdominal pressure
*Increasing age
*Pregnancy
What is the presentation of a hiatus hernia?
*Bowel sounds in the abdomen
*Heartburn: type 1 will have gord and the rest may
*Regurgitation, especially when lying flat
*Bloating
*burping and halitosis
What investigations should be carried out in suspected hiatus hernia?
*Chest Xray
*Barium oesophagus
*Endoscopy
*CT or MRI
What is the conservative management of a hiatus hernia?
*PPI for GORD symptoms
*Lifestyle changes: avoid nicotine, chocolate, peppermint, caffeine, fatty foods
*Avoid nitrates, CCB and beta blockers
What is the surgical repair of a hiatus hernia?
Laparoscopic fundoplication
What are the complications of a hiatus hernia?
*Gastric volvulus
*Obstruction
*Oesophagitis -> GI bleeding
*Barrett’s oesophagus
What are the surgical complications of hiatus hernia repair?
*Bloating - usually resolves itself
*Recurrent hernia
*Dysphagia
*Post operative haemorrhage
What are the two main types of oesophageal carcinoma and which is the most common?
Adenocarcinoma and squamous cell, adenocarcinoma is more common in the developed world
What is the presentation of oesophageal caricnoma?
*Dysphagia
*Odynophagia
*Weight loss
What are the risk factors for oesophageal adenocarcinoma?
*Male
*Age
*Smoking
*GORD
*Barretts
*Hiatus hernia
What are the risk factors for oesophageal squamous cell carcinoma?
*Male
*Age
*Smoking
*Excessive alcohol
*Family history
* High temperature food and beverages
What investigations should be carried out in suspected oesophageal carcinoma?
*Oesophagogastroduodenoscopy with biopsy
*CT ches/abdomen
*FDG-PET scan
*Metabolic profile
What is the treatment of oesophageal carcinoma?
*Surgery: oesophagectomy
*Chemotherapy
*Trastuzumab if HER2 positive metastatic disease
What is the most common type of gastric carcinoma?
Adenocarcinoma
What are the risk factors of gastric adenocarcinoma?
*Pernicious anaemia
*H.pylori
*Male
*Smoker
What are the investigations for suspected gastric carcinoma?
*Upper GI endoscopy with biopsy: ulcer/mass/mucosal changes
*FBC
*UEs, LFTs
*CT chest/abdo/pelvis to look for metastases
What is the presentation of GORD?
*Heartburn
*Retrosternal/epigastric pain
*Bloating
*Nocturnal cough
*Hoarse voice
What is the management of GORD?
*Lifestyle advice: avoid caffeine and alcohol, lose weight, quit smoking, smaller and lighter meals, stay upright after meals
*Gaviscon/rennies, PPI (omeprazole or rantidine)
*Surgery: laparoscopic fundoplicaiton
What is the eradication therapy for H.pylori?
Triple therapy with PPI and 2 antibiotics (amoxicillin and clarithromycin) for 7 days
What are the complications of GORD?
*Barrett’s oesophagus
*Oesophagitis
*Anaemia
*ulcers
*Oesophageal carcinoma
*Benign strictures
What are the causes of gastritis?
-Helicobacter pylori inflection
-NSAIDs
-Alcohol
-Stress secondary to mucosal ischaemia
-Autoimmune
What are the symptoms of gastritis?
-Nausea and vomiting
-Severe emesis
-Acute abdominal pain - epigastric area
- Fever
Which type of ulcer is worse on eating?
Gastric
What is the severity scoring system for pancreatitis?
Glasgow scale of pancreatitis severity
Explain the glasgow scale of pancreatitis severity
- PaO2<7.9kPa
- Age>55
- Neutrophils WCC>15
- Calcium <2
- Renal function: urea >16mmol/L
- Enzymes LDH >600
- Albumin <32g/L
- Sugar: blood glucose >10
What can be used as a marker of the pancreas’ exocrine function?
Faecal elastase
What is the most common cause of cholangitis?
E.coli
What tumour marker is used for cholangiocarcinoma?
Ca19-9
