Upper GI Surgery Flashcards

1
Q

Oesophageal anatomy

A

25cm long muscular tube (40cm from GOJ → lips)
Starts at level of cricoid cartilage (C6)
In the neck lies in the visceral column

Runs in posterior mediastinum and passes through right
crus of diaphragm @ T10.

Continues for 2-3cm before entering the cardia

3 locations of narrowing
 Level of cricoid
 Posterior to left main bronchus and aortic arch
 LOS

Divided into 3rds: reflects change in musculature from
striated → mixed → smooth.

Lined by non-keratinising squamous epithelium.

Z-line: transition from squamous → gastric columnar

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Achalasia

A

Degeneration of myenteric plexus (Auerbach’s)
↓ peristalsis
LOS fails to relax

Cause
primary/idiopathic (commonest)
2ndary - Chagas disease (T. cruzil)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Achalasia Presentation + Comps

A
Presentation
 Dysphagia: liquids then solids
 Regurgitation (esp. @ night)
 Substernal cramps
 Wt. loss

Comps: Chronic → oesophageal SCC in 3-5%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Achalasia Ix + Rx

A

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

Rx:
 Med: CCBs, nitrates
 Int: botox injection, endoscopic balloon dilatation
 Surg: Heller’s cardiomyotomy (open or lap)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Pharyngeal Pouch (Zenker’s Diverticulum)

A

Outpouching betw/ crico- + thyro-pharyngeal
parts of inf. pharyngeal constrictor.
 Area of weakness = Killian’s dehiscence

Defect usually occurs posteriorly but swelling usually
bulges to left side of neck.

Food debris → pouch expansion → oesophageal
compression → dysphagia.

Pres: Regurgitation, halitosis, gurgling sounds

Rx: excision, endoscopic stapling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Diffuse Oesophageal Spasm

A

 Intermittent severe chest pain ± dysphagia

 Ba swallow shows corkscrew oesophagus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Nutcracker Oesophagus

A

 Intermittent dysphagia ± chest pain

 ↑ contraction pressure c¯ normal peristalsis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Plummer Vinson Syndrome

A

Severe IDA → hyperkeratinisation of upper 3rd of
oesophagus → web formation

 Pre-malignant: 20% risk of SCC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Oesophageal Rupture

A

Iatrogenic (85-90%): endoscopy, biopsy, dilatation
Violent emesis: Boerhaave’s syndrome
Carcinoma
Caustic ingestion
Trauma: surgical emphysema ± pneumothorax

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Nissen Fundoplication

A

Prevent reflux and repair diaphragm
Usually laparoscopic approach

Mobilise gastric fundus and wrap around lower
oesophagus
 Close any diaphragmatic hiatus

Complications
 Gas-bloat syn.: inability to belch / vomit
 Dysphagia if wrap too tight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Hiatus hernia

A

Sliding (80%)- gastro-oespophageal junction slides up into chest (GORD)

15% g-o junction remains in abdomen, bulge of stomach rolls into chest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Peptid Ulcer Disease Surgery

A

Vagotomy
- Truncal
 ↓ acid secretion directly and via ↓ gastrin
 Prevents pyloric sphincter relaxation
  must be combined c¯ pyloroplasty (widening of
pylorus) or gastroenterostomy
- Selective
 Vagus nerve only denervated where it supplies
lower oesophagus and stomach
 Nerves of Laterjet (supply pylorus) left intact

Antrectomy c¯ Vagotomy
 Distal half of stomach removed.
 Anastomosis:
 Billroth 1: directly to duodenum
 Billroth 2 /Polya: to small bowel loop c¯ duodenal
stump oversewn

Subtotal Gastrectomy c¯ Roux-en-Y
 Occasionally performed for Zollinger-Ellison

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

PUD Surgery Metabolic Complications

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Upper GI bleed

A
 PUD: 40% (DU commonly)
 Acute erosions / gastritis:20%
 Mallory-Weiss tear: 10%
 Varices: 5%
 Oesophagitis: 5%
 Ca stomach / oesophagus:<3%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Rockall Score (Upper GI bleed)

A

Prediction of re-bleeding and mortality
40% of re-bleeders die

Initial score pre-endoscopy
 Age
 Shock: BP, pulse
 Comorbidities

Final score post-endoscopy
- Final Dx + evidence of recent haemorrhage
 Active bleeding
 Visible vessel
 Adherent clot

Initial score ≥3 or final >6 are indications for surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Variceal bleed

A
Initially IV terlipressin *splanchnic vasopressor)
Prophylactic Abx (ciprofloxacin 1g/24h)

(resus, fluid resus + maintenance)

Urgent Endoscopy

17
Q

Variceal bleeding Urgent Endoscopy

A

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

18
Q

TIPPS Transjugular intrahepatic porto-systemic shunt

A

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.

19
Q

Urgent Endoscopy (haemostasis of vessel or ulcer)

A

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

20
Q

Peptic Ulcer Perforation

A

Presents
Sudden onset severe pain, beginning in epigastrium
Vom
Peritonitis

Perforated duodenal ulcer is commonest
 1st part of the duodenum: highest acid conc
 Ant. perforation → air under diaphragm
 Post. perforation can erode into GDA → bleed
 ¾ of duodenum retroperitoneal  no air under diaphragm if perforated.
Perforated GU
Perforated gastric Ca

21
Q

Peptid Ulcer Perforation Ix

A

Bloods
 FBC, U+E, amylase, CRP, G+S, clotting
 ABG: ? mesenteric ischaemia

Urine dipstick

Imaging
Erect CXR
 Must be erect for ~15min first
 Air under the diaphragm seen in 70%
 False +ve in Chailaditi’s sign

AXR
 Rigler’s: air on both sides of bowel wall

22
Q

Peptic Ulcer Perforation Mx

A
Resuscitation
 NBM
 Aggressive fluid resuscitation
 Urinary Catheter ± CVP line
 Analgesia: morphine 5-10mg/2h max
 ± cyclizine
 Abx: cef and met
 NGT

Conservative
 May be considered if pt. isn’t peritonitic
 Careful monitoring, fluids + Abx
 Omentum may seal perforation spontaneously
preventing operation in ~50%

Surgical: Laparotomy
 DU: abdominal washout + omental patch repair
 GU: excise ulcer and repair defect
 Partial / gastrectomy may rarely be required
 Send specimen for histo: exclude Ca

Test and Treat
 90% of perforated PU assoc. c¯ H. pylori

23
Q

Gastric Outlet Obstruction

causes + presentation

A

Causes
Late complication of PUD → fibrotic stricturing
Gastric Ca

Presentation
Hx of bloating, early satiety and nausea
Outlet obstruction
 Copious projectile, non-bilious vomiting a few hrs
after meals.
 Contains stale food.
 Epigastric distension + succussion splash

24
Q

Gastric Outlet Obstruction

Ix + Rx

A

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

Rx
Correct metabolic abnormality: 0.9% NS + KCl

Benign
 Endoscopic balloon dilatation
 Pyloroplasty or gastroenterostomy

Malignant
 Stenting
 Resection

25
Q

Hypertophic Pyloric Stenosis

A

Presents 6-8 weeks

  • projectile vomiting minutes after feeding
  • RUQ mass (olive)
  • Visible Peristalsis

Dx

  • Test feed - palpate mass + see peristalsis
  • hypochloraemic hypokalaemic metabolic alkalosis
  • USS

Mx

  • Resuscitate and correct metabolic abnormality
  • NGT
  • Ramstedt pyloromyotomy - divide muscularis propria
26
Q

signet ring cell

A

diffuse gastric cancer

27
Q

Gastric Cancer Spread

A

w/i stomach: linitis plastica

Direct invasion: pancreas

Lymphatic: Virchow’s node

Blood: liver and lung

Transcoelomic
 Ovaries: Krukenberg tumour (Signet ring morph)
 Sister Mary Joseph nodule: umbilical mets

28
Q

Gastric Cancer Mx

A
Medical Palliation
 Analgesia: e.g. fentanyl patch
 PPI
 Secretion control
 Chemo: epirubicin, 5FU, cisplatin
 Palliative care team package

Surgical Palliation
 Pyloric stenting
 Bypass procedures

Curative Surgery
- EGC may be resected endoscopically
- Partial or total gastrectomy c¯ roux-en-Y to prevent bile
reflux.
 Spleen and part of pancreas may be removed

29
Q

Gastric Lymphoma

A

MALToma

chronic h pylori

most common extranodal tumour

30
Q

Carcinoid tumours

A

gastric carcinoids arise from enterochromaffin cells

31
Q

Gsatrointestinal stromal tumour

A

50+% in stomach

Arise from intestinal cells of Cajal (in muscularis propria, pacemaker cells)

OGD - well demarcated spherical mass with central punctum

Presentation
 Mass effects: abdo pain, obstruction
 Ulceration: → bleeding
Poor Prognosticators
 ↑ size ↑ mitotic index
 Extra-gastric location

Mx

Medical
 Unresectable, recurrent or metastatic disease
 Imatinib: kit selective tyrosine kinase inhibitor

Surgical
 Resection

32
Q

Zollinger Ellison

A

Gastrin secreting

Abdominal pain and dyspepsia
Chronic diarrhoea / Steatorrhoea
Refractory PUD

Ix
 ↑ gastrin c¯ ↑↑ HCl (pH<2)
 MRI/CT
 Somatostatin receptor scintigraphy

Rx
 High dose PPI
 Surgery
 Tumour resection
 May do subtotal gastrectomy c¯ Roux en Y
33
Q

Bariatric Surgery Indications

A

ALL of the following:
 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.

BMI >50, surgery is 1st line Rx

34
Q

Laparoscopic Gastric Banding

A

 Inflatable silicone band around proximal stomach →
small pre-stomach pouch.
 Limits food intake
 Slows digestion

At 1yr 46% mean excess wt. loss

35
Q

Roux-en Y Gastric Bypass

A

Oesophagojejunostomy allows bypass of stomach, duodenum and proximal jejunum.

Alters secretion of hormones influencing glucose regulation and perception of hunger / satiety.

Greater wt. loss and lower reoperation rates.

Complications
 Dumping syndrome
 Wound infection
 Hernias
 Malabsorption
 Diarrhoea
 Mortality 0.5%