Upper GI surgery Flashcards
Recognised predisposing factors to oesophageal cancer
Cigarette smoking High alcohol intake Barrett's Oesophagus Ingestion of corrosive liquids Achalasia Hot herbal tea infusates
Definition of Barrett’s oesophagus/barrett’s metaplasia
When the squamocolumnar junction is displaced proximal tot he gastro-oesophageal junction and the squamous lining of the lower oesophagus is replaced by metaplastic columnar epithelium secondary to chronic gastric acid reflux
Epidemiology of Barrett’s oesophagus
5% of patients with weekly heartburn will have Barrett’s oesophagus
Annual risk of progression to oesophageal carcinoma - 0.5%
Diagnosis of Barrett’s oesophagus
Diffuse and patchy nature of specialised intestinal epithelium
- Reddish, velvet-like texture of columnar epithelium
- pale glossy appearance of squamous epithelium
Management of Barrett’s oesophagus
Biopsy:
- long term relief of GORD
- Monitor for advanced mucosal injury, dysplasia or carcinoima
Without dysplasia:
- PPI therapy
- endoscopic surveillance yearly (if low-grade dysplasia)
High-grade dysplasia:
- surgery is standard treatment
Red flag symptoms of oesophageal adenocarcinoma
Dysphagia Odynophagia Upper GI bleeding (haematemesis) Chest pain Weight loss Malnutrition
Diagnosis of oesophageal carcinoma
Upper endoscopy with biopsy
- PPI to suppress acid production for 6-8 weeks prior to biopsy so that dysplasia features are not covered by acid oesophagitis
Definition of Mallory-Weiss tear
Longitudinal mucosal laceration in the region of the gastroesophgeal junction (not transmural)
Cause of Mallory-Weiss tear
Due to acute increase in intra-abdominal pressure being transmitted to the oesophagus usually secondary to repeated vomiting
Acute management of Mallory Weiss tear
If haemodynamically unstable:
- Fluid resuscitation
- transfusion as appropriate
Nasogastric decompression
Antiemetics
Endoscopic therapy (electrocoagulation, sclerotherapy, Injection of adrenaline, endoscopic haemoclips)
Laparotomy with gastrotomy and oversewing of the tear if uncontrolled bleeding
Definition of Boerhaave syndrome
Spontaneous transmural rupture of the oesophagus under raised intraluminal pressure
Clinical features of Boerhaave syndrome
Classic presentation = Mackler triad
- vomiting
- lower thoracic pain
- subcutaneous emphysema
Repeated episodes of vomiting/retching, typically DOES NOT cause haematemesis
Swallowing may be painful, and may cause coughing
SOB
Hamman crunch
Crackling sound on auscultation of the chest coinciding with each heart beat - due to air in mediastinum
management of Boerhaave syndrome
Conservative:
- if contained perforation
- continuous nasogastric suction
- Broad-spectrum IV antibiotics
- parenteral nutrition
- endoscopic drainage of abscesses and effusions
Surgical management:
- if free perforation and no contraindications
- oesophageal resection, stenting (in malignant stenotic lesion setting) or primary closure
Definition of oesophageal varices
Dilated submucosal veins occurring in patients with underlying portal hypertension and can result in severe upper GI haemorrhage
