Upper GI surgery Flashcards by Desmini Desmanramesh

what are the conditions of Upper GI surgery ?

Gastroesophageal Reflux Disease (GORD)
* Barret Oesophagus
* Oesophageal Cancer
* Gastric Cancer
* Gallstone Disease
* Symptomatic cholelithiasis
* Acute cholecystitis
* Choledocholithiasis
* Acute cholangitis

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Definition of GORD?

It is a Chronic condition characterized by r**eflux of gastric contents **
(particularly acid, bile, and pepsin)
back into the oesophagus

prevelance increase with age and most commonly in women overall

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What is the pathophysiology of GORD?

Mechanical disorder of the LES allowing
reflux of gastric contents
* Poor oesophageal motility decreases clearance
of acidic material.
* A dysfunctional LES allows reflux of large
amounts of gastric juice.
* Delayed gastric emptying can increase gastric
volume & pressure coupled with a defective
valve mechanism GOR

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What is the Risk factors of Gord?

Obesity, alcohol consumption, smoking, certain
foods & pregnancy

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What are the clinical presentation of Gord ?

Heartburn
Retrosternal burning sensation
Can occur after eating or when
lying supine or bending over.

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what are the other symptoms of GORD?

Bloating,
nausea & vomiting
Atypical symptoms include difficulty in swallowing, hoarseness, sore throat & cough

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What is the investigation of GORD?

Endoscopy
* Can help confirm the
diagnosis of reflux
* Can identify complications
like esophagitis, strictures,
Barrett oesophagus)
* Can help in evaluating the
anatomy (eg, hiatal hernia,
masses, strictures).

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What are the red flags of GORD ?

** Dysphagia
* Hoarse voice
* Recurring or persistent cough
* Upper or lower GI tract bleeding
* Weight loss
* Lymphadenopathy
* Epigastric or supraclavicular
mass
* Requires urgent referral and
investigation**

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What is the management for GORD?

Lifestyle modifications
* Medications
* Proton-pump inhibitors
* H2-receptor antagonist therapy if
inadequate response to PPI

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What is the surgery for GORD?

Laparoscopic fundoplication
* Gastric fundus is sutured around the
LES to reinforce & lessen any acid
reflux

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What is Barret Oesophagus ?

When healthy oesophgeal
epithelium is replaced with
metaplastic columnar cells due to prolonged exposure of
to the acid reflux from GORD.

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What is the risk in barret oesophagus?

Risk of progression from barret oesophagus to adenocarcinoma

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What is the pathophysiology of Barret Oesophagus?

barret oesophagus eventually lead to pre cancerous changes (low grade dysplasia & high grade dysplasia) and that lead to cancer

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What is the clinical presentation of Barret oesophagus?

Pts often present with a chronic history of gastroesophageal reflux
and complain of heartburn
acid regurgitation occasionally, dysphagia

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What investigation would you carry out for Barret Oesophagus?

Oesophagogastroduodenoscopy (OGDS) is the procedure of choice for the diagnosis of Barrett oesophagus.

DIagnosis require biopsy confirmation of specialized intestinal metaplasia in
the oesophagus

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What is the management for Barret oesophagus?

Close monitoring- yearly surveillance endoscopy
Pharmacologic- prescribe medications to control/stop acid reflux
Radiofrequency ablation- destroys the involved area of the
oesophagus
Mucosal resection through an endoscope

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What surgery do you carry out for barret oesophagu?

tightens the junction between the GE junction to prevent
acid reflux

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What is Oesophageal cancer?

Cancerous cells are present in the oesophagus

What is the pathophysiology of oesophageal cancer?

Majority of malignancies are
adenocarcinomas (60-70%)
Previously were squamous cell
carcinomas (still predominant in
parts of Asia)
Cancer cells may fungate into the
lumen of the or often infiltrate
diffusely along & around the
wall go through & invade
adjoining mediastinal structures

What is the etiology of the oesophageal cancer?

Squamous cell CA- smoking,
alcohol consumption, long
standing achalasia, lye strictures
Starts as epithelial dysplasia,
which progresses in sequence to
carcinoma in situ, and finally to
invasive carcinoma
Adenocarcinoma- Barret’s
esophagus, gastroesophageal
reflux

What is the clinical presentation of Oesophageal carcinoma?

Dysphagia develops insidiously and is the classic symptom (initial to solids
then even to liquids); considered as a late feature

What are the other symptoms of oesophageal cancer?

Loss of appetite
weight loss & fatigue
* Abdominal pain, chest or back
* Locally advanced tumours may involve the
laryngeal nerve hoarseness or with
tracheoesophageal fistula

What do you find in physical examination of the oesophageal cancer?

Enlarged cervical & supraclavicular

What is the investigation of Oesophageal cancer?

Barium swallow-assess outline
oesophageal lumen
* Endoscopy- provides direct
visualization inside the lumen
* Biopsy provides a histologic
diagnosis
* Once confirmed staging is
done to guide therapy and
predict prognosis.

List the stages of oesophageal cancer?

Primary Tumour (T) invades Regional LNs (N) Metastases (M)

What is the first staging in oesophageal cancer?

Primary Tumour (T) invades T1 lamina propria/submucosa T2 muscularis propria T3 adventitia T4 adjacent structures

What is the second stage in oesophageal cancer?

Regional LNs (N) N1 1/2 nearby nodes N2 3-6 nearby nodes N3 >7 nearby nodes

What is the last stage in oesophageal cancer?

Metastases (M) M1 distant spread

What is the management of Oesophagela cancer?

Treatment is based on patient’s status & stage of the carcinoma

What is the primary treatment of oesophageal carcinoma?

Primary treatment is by removing the malignancy through surgery * Selection of curative vs. palliative operation is based on the following: * Location of the tumor * Patient’s age and health * Extent of the disease * Preoperative staging

What is the curative management of the oesophagal cancer?

* Surgery * Chemo/radiotherapy Two-thirds of patients are already incurable at the time of diagnosi

What is the palliative management of oesophageal cancer?

* Chemotherapy * Radiotherapy * Placement of stents

What is Gastric cancer?

Presence of malignant cells in the lining of the stomach * Marked variations in the incidence worldwide: * UK- approximately 15 per 100,000 per year * USA- 10 per 100,000 per year * Japan- 70 per 100,000 per year * 4,200 stomach cancer deaths in the UK every year (about 12 every day) (2017-2019). * Prognosis tends to be poor, with cure rates little better than 5–10%, although better results are obtained in Japan, where the disease is common

What is the RF of gastric cancer?

**Dietary habits** * Pickled, salted, or smoked food (fresh fruits and vegetables are protective) **Helicobacter pylori** * Strongest established risk factor worldwide ** * Epstein-Barr Virus** * About 10% of gastric adenoCA carry the EBV virus *** Genetic Factors ** * Most common genetic abnormalities in sporadic gastric cancer affect the p53 and COX-2 genes. * **Premalignant conditions of the stomach **

What is the clinical condition of Gastric cancer?

Vague abdominal pain, unexplained weight loss, early satiety, dysphagia, iron deficiency anaemia, cachexia * PE findings are often nonspecific or absent * Patients present in a delayed fashion due to vague and nonspecific symptoms * If patient does have significant findings have advanced, incurable disease. * palpable epigastric mass * palpable left supraclavicular LNs (Virchow’s node) * periumbilical lymphadenopathy (Sister Mary Joseph node

What is the red flags for gastric cancer?

Important in the diagnosis of cancer is that these “benign” symptoms fail to resolve after 6 weeks of antacid therapy or the presence of dyspepsia in combination with so called “ALARM” symptoms * Anaemia (iron deficiency) * Loss of weight * Anorexia * Recent onset of progressive symptoms * Melena/hematemesis * Dysphagia * Dyspepsia and age >55 years

What is the investigation of gastric cancer?

Endoscopy plus biopsy to confirm diagnosis * allows direct visualization of the gastric mucosa * localization of the tumour for operative planning * ability to biopsy suspicious lesions *adenocarcinoma most common

What are the staging investigation for gastric cancer?

CT scan (chest, abdomen, pelvis) * PET scan * Endoscopic ultrasound

What are the management of gastric cancer?

depends on how advanced the cancer is

What is the surgical intervention of gastric cancer?

gastrectomy and others include chemotherapy and radiotherapy

What are the Gallstone disease?

* Symptomatic cholelithiasis * Acute cholecystitis * Choledocholithiasis * Acute cholangitis

What is the definition of choleothesis?

stones in the gallbladder

What are the symptoms of cholelithiasis ?

condition where gallstones cause symptoms, most commonly biliary colic.