Upper GI Surgery Flashcards
What are the factors that prevent GORD
- Intra-abdominal segment of oesophagus which is under influence of the positive intra-abdominal pressure (most important factor)
- Pinch cock action of the crura of diaphragm
- Phreno-oesophageal ligament
- Angle of His between oesophagus and fundus of stomach
Oesophageal motility is important in ensuring clearance of GOR to prevent damage to mucosa lining of lower oesophagus
Features of Achalasia on xray
Esophageal dilatation
Failure of Lowe esophageal sphincter to relax
Clinical features of paraoesophageal hernias
Early satiety
Epigastric discomfort
Dysphagia
Chest pain
Occasional cardiac and respiratory complains
Clinical features of paraoesophageal hernias
Early satiety
Epigastric discomfort
Dysphagia
Chest pain
Occasional cardiac and respiratory complains
Complications of GORD
Oesophagitis
Circumferential ulceration complicated by stenosis and bleeding
Strictures
Barrett’s oesophagitis (metaplastic columnar epithelium replaces squamous epithelium)
Adenocarinoma
Causes of oosophageal perforation
Instrumental
Endoscopy
Sclerotherapy
Dilatation
Intubation with stents
Non instrumental
Post emetic : PPP: Mallory weis tear, Submucosal haematoma, free rupture)
foreign body
penetrating injuries
anatomical risk
Management of oesophageal perforation
Supportive:
IV fluids
Broad spectrum antibiotics
Maintain airway
Drainage and debridement of contaminated space
Oesophageal stents in selected patients
Cervical perforation: nil per mouth and supportive
Thoracic oesophagus for local perforation: fine bore feeding tube into stomach or proximal jejunum
Thoracic oesophagus for transmural perforation: urgent thoracotomy and explore mediastinum, repair urgently
Causes dysphagia
Benign:
GORD
Ingestion of caustic agents
Motility disorders eg spasms
Drug induced
Post Nissen Fundoplication
Eosinophilic oesophagitis
Oesophageal webs
Malignant
Squamous carcinoma
Adenocarcinoma
Metastasis
Risk factors of oesophageal cancer
Squamous cell carcinoma
Sex: male
Age: 60-70 (adeno in younger people)
Smoking (mostly for squamous cc)
Alcohol
Achalasia
Oesophageal diverticula
HPV infection
Diet
Adenocarcinoma
Smoking
GORD
Barret oesophagitis
Obesity (GORD related )
Symptoms of oesophageal cancer
Local tumour symptoms
Dysphagia
Odynophagia
Cough and regurg
Upper GI bleeding
LOW
Invasion of surrounding structures
Hoarseness from recurrent laryngeal nerve (irresectable)
Respiratory fistula
Hiccups from phrenic nerves invasion
Pain from local spread
Distal disease/Metastasis
Mets of liver, lungs, and CNS
Hypercalcemia (paraneoplastic syndrome)
How do diagnose oesophageal ca
Physical exam: normal unless mets to lymph nodes or liver (hepatomegaly)
Imaging
Endoscopy
Contrast swallow
CT (mets to lungs, liver, pelvis)
PET scan
Endoscopic US (local depth T, node involvement N, and M - non regional nodes)
How do diagnose oesophageal ca
Physical exam: normal unless mets to lymph nodes or liver (hepatomegaly)
Imaging
Endoscopy
Contrast swallow
CT (mets to lungs, liver, pelvis)
PET scan
Endoscopic US (local depth T, node involvement N, and M - non regional nodes)
Management of oesophageal cancer
Oesophageactomy
Radiotherapy (as neoadjuvant with chemo )
Stunting (in those who can’t undergo surgery)
Palliative chemo (Cisplatin, 5Fluorouracil and anthracyclines)
Others: laser therapy for temporal relief of dysphagi
Risk factors of PUD
H.pilori
NSAID use
Smoking
Severe physiological stress
Genetic
Hypersecretofy states
Sx of malignancy in a or with PUD
Bleeding or anaemia
Early satiety
LOW
Progressive Dysphagia
Recurrrent vomiting
Fx hx of gastric ca
