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Surgery > Upper GI Surgery > Flashcards

Upper GI Surgery Flashcards

1
Q

where are the 3 locations of narrowing of the oesophagus?

A
  1. level of cricoid cartilage (C6)
  2. posterior to left main bronchus and aortic arch (T4)
  3. lower oesophageal sphincter (T11)
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2
Q

what is the z line in the oesophagus?

A

transition from squamous to gastric columnar epithelium

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3
Q

Ix for dysphagia

A

Upper GI endoscopy

Barium Swallow

Manometry (assess LOS fn)

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4
Q

projectile vomiting

child hungry after vomiting

failure to gain weight

dehydration/ constipation

Dx?

A

Pyloric stenosis

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5
Q

diagnosis of pyloric stenosis?

A

test feed- visible peristalsis

Abdo USS to visualize the hypertrophied pyloric sphincter

abdo xray - may reveal dilated stomach w minimum gas in bowel.

barium meal - reveals the pyloric obstruction w characteristic shouldering of the pyloric antrum

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6
Q

what is the metabolic abnormality with pyloric stenosis?

A

hypochloraemic hypokalaemic met alkalosis

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7
Q

what is Ramstedt’s pyloromyotomy?

A

for pyloric stenosis

  • a longitudinal incision is made through the hypertrophied muscle of the pylorus down to mucosa and the cut edges are separated.

commonly done laparoscopically.

infant is given glucose water 3h after op and followed by 3hrly milk feeds.

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8
Q

what medications predispose a pt to peptic ulceration and perforation?

A

steroids

NSAIDs (aspirin, indometacin, ibuprofen etc)

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9
Q

examination findings of a pt with perforated peptic ulcer

A

patient in severe pain

cold and sweating w rapid, shallow respirations

abdomen rigid and silent

pneumoperitoneum -> may lead to diminished liver dullness

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10
Q

presentation of peptic ulcer perforation on examination

in a delayed (>12h onset) presentation

A

if delayed (>12h) presentation

features of generalized peritonitis with paralytic ileus

distended abdomen

vomiting

pt extremely toxic and in oligaemic shock

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11
Q

Ix to order for suspected perforated peptic ulcer

A

CXR: erect.

  • free gas below the diaphragm

CT abdo

  • to detect free intraperitoneal gas and can exclude common differentials e.g. pancreatitis
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12
Q

DDx of perforated peptic ulcer

A

perforated appendicitis

acute cholecystitis

acute pancreatitis

myocardial infarction

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13
Q

tx of perforated peptic ulcer

A

NG tube: to empty stomach and decrease further leakage

Pain relief: opiates

IV fluid resus

ABx to contend w peritoneal infection

IV H2 blocker or PPI

Immediate operative repair of the perforation

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14
Q

what does surgery of perforated peptic ulcer involve?

A

suturing of omental plug to seal the perforation

+

lavage of the peritoneal cavity

+

biopsy of *gastric ulcer to exclude malignancy

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15
Q

Postoperative tx for perforated Peptic ulcer

A

H pylori eradication

omeprazole, amoxicillin, clari

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16
Q

profuse vomiting, non-bilious

may contain food particles

weight loss, constipation, weakness due to electrolyte disturbance

A

pyloric stenosis

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17
Q

Examination findings of pyloric stenosis

A

visible peristalsis seen, from L-R of upper abdomen

grossly dilated, hypertrophied stomach, full of stale food and fluid, can be palpated

gastric splash (succussion splash) can be elicited by shaking pt’s abdomen several hrs after a meal

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18
Q

Ix of pyloric stenosis

A

Gastroscopy - following decompression of stomach w NG tube

CT scan

ABG and electrolytes-> hypochloraemic, hypokalaemic alkalosis and uraemia

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19
Q

metabolic disturbances of pyloric stenosis

A

dehydrated, Hct raised

serum Cl, Na, K low

plasma bicarb and urea raised

alkalosis

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20
Q

DDx of pyloric stenosis

A

ca of pylorus

Other causes of pyloric obstruction are unusual

in the adult:

  • scarring associated with a benign gastric ulcer near the pylorus;
  • carcinoma of the head of the pancreas infiltrating the duodenum and pylorus;
  • chronic pancreatitis;
  • invasion of the pylorus by malignant nodes.
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21
Q

differentiating between benign ulcer-> pyloric stenosis vs carcinoma of the pylorus

A
  • Length of history: a history of several years of characteristic peptic ulcer pain is in favour of benign ulcer. Cancer usually has a history of only months and indeed may be painless.
  • Gross dilatation of the stomach favours a benign lesion, as it may take several years for this to develop.
  • The presence of a mass at the pylorus indicates malignant disease, although, rarely, a palpable inflammatory mass in association with a large duodenal ulcer can be detected.
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22
Q

tx of pyloric stenosis

A

preop:

IV saline + K to correct dehydration/ electrolyte depletion

daily gastric lavage to remove debris from stomach

Vitamin C

surgical correction:

usually an antrectomy w a Roux-en-Y gastroenterostomy

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23
Q

oesophageal causes of GI haemorrhage

A
  • reflux oesophagitis (associated with hiatus
    hernia) ;
  • oesophageal varices (associated with portal

hypertension)

  • peptic ulcer;
  • tumours (benign and malignant).
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24
Q

stomach causes of GI haemorrhage

A

gastric ulcer

acute erosions (assoc w aspirin, other NSAIDs, corticosteroids)

gastritis

Mallory-Weiss tear

vascular malformation (e.g. Dieulafoy lesion)

tumours (benign and malignant)

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25
Q

Duodenal Causes of GI haemorrhage

A

duodenitis

duodenal ulcer

erosion of the duodenum by a pancreatic tumour

aortoduodenal fistula, in patients with previous aortic graft

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26
Q

small intestine causes of GI haemorrhage

A

tumours

meckel’s diverticulum

angiodysplasia

aortoenteric fistula

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27
Q

large bowel causes of GI haemorrhage

A

Tumours (benign and malignant, commonly adenoCas)

diverticulitis

Angiodysplasia

colitis (UC, Ischaemic colitis and infective colitis)

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28
Q

General causes of bleeding?

A

anticoagulant therapy

haemophilia

leukaemia

thrombocytopenia

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29
Q

Ix with GI bleeding

A

Hb - useful as baseline

Serum Urea - raised following upper GI bleed (can distinguish between upper and lower GI bleed)

Coagulation screen and Pl count

LFTs

Cross Match, Group and Save

Upper GI fibreoptic endoscopy - will identify the exact site of bleeding in upper GI haemorrhage

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30
Q

Tx of Upper GI Bleed

A

A to E approach-> stabilize the patient

pain relief

if shock present: fluid resus/ blood transfusion

central venous catheter to measure central venous pressure and assist in fluid replacement

urinary catheter to monitor UO

treat underlying cause

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31
Q

tx of actively bleeding peptic ulcers

A

treated endoscopically by injection of adrenaline into and around the vessels in the ulcer bed.

dual modality tx superior to injection alone: e.g. + coagulation w a heater probe or placement of a clip directly onto the bleeding vessel

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32
Q

GI stromal tumours

mutation in what gene?

A

c-kit gene coding for c-kit protein (CD117) on the cell

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33
Q

Tx of GIST (GI stromal tumour)

A

surgical excision

chemotx - with c-kit tyrosine kinase inhibitor (imatinib mesilate)

-> can be given to shrin tumour pre-surgery or given post-op to treat metastases or when complete resection was not possible

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34
Q

Risk factors for Stomach Ca

(Predisposing conditions)

A

pernicious anaemia and atrophic gastritis

previous gastric resection

chronic peptic ulcer

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35
Q

Risk factors of stomach ca

envt factors

A

H pylori infection

Low SES

Smoking

Nationality: Japan(?)

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36
Q

genetic risk factor for stomach cancer?

A

HNPCC

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37
Q

lymph drainage of carcinoma from cardiac end of stomach?

A

mediastinal nodes

supraclavicular nodes of Virchow

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38
Q

lymph drainage from carcinoma of the pylorus?

A

subpyloric and hepatic nodes

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39
Q

type of obstruction when blood supply of the involved segment of intestine is cut off

A

strangulating obstruction

e.g. with strangulated hernia, volvulus, intussusception

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40
Q

symptoms of intestinal obstruction

A

colicky abdo pain

distension

absolute constipation

vomiting

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41
Q

Examination of suspected intestinal obstruction should include?

A

hernias

scars

  • suggests previous operation and adhesions/ band as a cause
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42
Q

features of strangulating obstruction

vs simple obstruction

A

change in character of pain from colicky to continuous

tachycardia

pyrexia

peritonism

bowel sounds absent/ reduced

raised WCC

raised CRP

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43
Q

causes of intestinal obstruction

(in the lumen)

A

faecal impaction

gallstone ileus

food bolus

parasites

intussusception

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44
Q

causes of intestinal obstruction

(in the wall)

A

congenital atresia

Crohn’s disease

tumours

diverticulitis

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45
Q

causes of intestinal obstruction

(outside the wall)

A

volvulus

strangulated hernia

obstruction due to adhesions or bands

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46
Q

differentiation between small and large bowel obstruction on Abdo Xray?

A

central vs peripheral position of distented/dilated loops

striations that pass completely across width of loop (small bowel) vs haustra of the taenia coli which do not extend across the whole width (large bowel)

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47
Q

Mx in acute intestinal obstruction

A

NG tube for gastric aspiration & to decompress bowel

IV fluids + K if K is low

ABx if intestinal strangulation is likely

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48
Q

signs of non-viability in affected bowel of intestinal obstruction

A
  1. loss of peristalsis
  2. loss of normal sheen
  3. colour (greenish or black bowel is non-viable; purple bowel may still recover)
  4. loss of arterial pulsation in the supplying mesentery
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49
Q

closed loop obstruction

where is it most commonly seen?

A

left sided colonic obstruction

in the presence of a competent ileocaecal valve.

-> the caecum, the most distensible part of the large bowel, blows up like a balloon and perforation of the caecum, with faecal peritonitis, may occur

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50
Q

adhesions from previous surgeries usually lead to what kind of bowel obstruction?

A

small bowel

(about 75%)

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51
Q

what are the three main arteries supplying the gut

A

coeliac

super mesenteric

inferior mesenteric

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52
Q

acute colicky abdo pain, rectal bleeding and shock

in an elderly patient who has AF

A

mesenteric vascular occlusion

e.g. embolus, mesenteric arterial/ venous thrombosis, non-occlusive infarction of the intestine

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53
Q

neonatal intestinal obstruction ddx?

A

intestinal atresia

volvulus neonatorum

meconium ileus

necrotizing enterocolitis

hirschsprung’s disease

anorectal atresia

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54
Q

Meconium ileus treatment?

A

instillation of Gastrografin per rectum under X ray control

-> radio opaque and hyperosmolar and contains an emulsifying agent, which facilitates evacuation of the meconium

2nd line: surgery- enterotomy and removal of the inspissated meconium by lavage

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55
Q

tx of necrotizing enterocolitis

A

resus

NG tube for gastric aspiration

IV fluids

TPN and broad spectrum abx

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56
Q

Hirschsprungs Disease

what pathology?

A

absence of ganglion cells in the submucosal plexus of Auerbach and intermyenteric plexus of Meissner

in the rectum, and sometimes extends into the lower colon.

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57
Q

tx of Hirschsprung’s

A

surgery

aganglionic segment is resected and an abdominoperineal pull-through anastomosis between normal colon and the anal canal.

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58
Q

commonest area of intussusception

A

ileocolic

  • through the ileocaecal valve
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59
Q

meckel’s diverticulum is the remnant of which duct of the embryo?

A

vitellointestinal duct

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60
Q

Crohn’s disease

  • which parts of the bowel is affected
A

anywhere from mouth to anus

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61
Q

Crohns Disease Risk factors

A

genetic - NOD2

environmental - smoking

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62
Q

Macroscopic appearance of affected Crohns’ segment

A

cobblestone appearance of mucous appearance

  • bowel is bright red and swollen, mucosal ulceration and intervening oedema leads to cobblestone appearance

intestine wall is thickened

skip lesions

fistulae

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63
Q

common symptoms of crohns disease

A

abdo pain

diarrhoea

palpable mass in the RIF

if acute-> may present like appendicitis

intestinal obstruction due to stenotic segments from inflammatory exacerbations-> fibrosis

fistula formation

malabsorption with steatorrhoea and multiple vitamin deficiencies

perianal disease (fissures to fistulae)

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64
Q

what are helful indices of disease activity in Crohns disease?

A

CRP

acute phase proteins

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65
Q

complications of Crohns Disease

A

skin: pyoderma gangrenosum, erythema nodosum

anterior uveitis

sacroiliitis

primary sclerosing cholangitis

Renal/ Biliary Calculi

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66
Q

medical mx of crohn’s disease

A

elemental diet / nutritional support

acute episodes treated with steroids and immunosuppressants such as azathioprine

infliximab (anti-TNFa) monoclonal antibody to TNF-a

Sulfasalazine/ mesalazine

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67
Q

when is surgery indicated for crohns disease?

A

surgery indicated for severe/ recurrent obstructive symptoms, and for fistulae into bladder/ skin

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68
Q

what do carcinoid tumours secrete

A

5-HT (serotonin)

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69
Q

symptoms of carcinoid syndrome

A

flushing with attacks of cyanosis,

often precipitated by stress or ingestion of food/ alcohol

diarrhoea

bronchospasm

abdo pain

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70
Q

Ix of Carcinoid Syndrome

A

5-HIAA urinary concentration (will be raised)

Chromogranin A serum concentration raised

CT liver to seek metastases

Radiolabelled octreotide scintigraphy: for screening for tumour. the octreotide binds to somatostatin receptors often expressed on the tumour

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71
Q

what medication can be used to control symptoms in carcinoid syndrome?

A

octreotide, a somatostatin analogue that inhibits 5-HT release

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72
Q

diagnostic sequence of acute appendicitis?

A

colicky central abdo pain

followed by vomiting

followed by movement of the pain to the RIF

+ anorexia/ constipation usually

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73
Q

symptoms with perforation of the appendix?

A

temporary remission/ cessation of the pain as tension in the distended organ is relieved

followed by

more severe and more generalized pain w profuse vomiting as general peritonitis develops

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74
Q

ix of suspected appendicitis

A

WCC: mild raised neutrophils

CT abdo

US RIF may be diagnostic

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75
Q

when is immediate appendicectomy not indicated?

A

patient moribund w advanced peritonitis -> 1st aggressive resus w fluids, abx, analgesia

attack already resolved -> can be done electively

appendix mass has formed without evidence of general peritonitis -> immediate sx may be difficult and dangerous w a risk of damage to adjacent bowel loops

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76
Q

medical tx of acute appendicitis?

apart from appendicectomy

A

antibiotic prophylaxis

  • metronidazole and gentamicin

drain inserted after appendicectomy

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77
Q

what are the muscle types in each 1/3 of the oesophagus?

A

top 1/3: striated

middle: mixed

bottom 1/3: smooth muscle

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78
Q

how long is the oesophagus?

A

25 cm long muscular tube

(40 cm from lips to GOJ)

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79
Q

where does the oesophagus start?

A

at the level of the cricoid cartilage C6

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80
Q

what is achalasia?

A

LOS fails to relax during swallowing

due to degeneration of myenteric plexus (Auerbach’s)

-> decreased peristalsis

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81
Q

cause of achalasia?

A

most commonly idiopathic

coule be secondary to Chagas disease (trypanosoma cruzii)

82
Q

dysphagia of liquids AND solids (intermittent)

regurgitation esp at night

substernal cramps/ pressure

relieved by drinking through pain with cold water

weight loss

dx?

A

achalasia

83
Q

features of achalasia?

A

dysphagia of liquids AND solids (intermittent)

regurgitation esp at night

substernal cramps/ pressure

relieved by drinking through pain with cold water

weight loss

84
Q

complications of achalasia?

A

oesophageal SCC in 3-5%

85
Q

Gold standard Ix of Achalasia?

A

Oesophageal Manometry

abnormal Lower Oesophageal sphincter pressure during swallow

86
Q

Ix of achalasia?

A

Manometry: showing abnormal LOS pressure during swallow

Barium swallow: Birds beak sign (dilated tapering oesophagus)

OGD: exclude malignancy

CXR: widened mediastinum, double RH border

87
Q

what sign points to achalasia on barium swallow?

A

Birds Beak sign

88
Q

Mx of achalasia?

A

conservative:

nothing if asymptomatic

medical:

CCB, nitrates (decrease LES pressure)

interventional:

botox injection to LES, endoscopic balloon dilatation

surgical:

heller’s cardiomyotomy

89
Q

what is the surgical tx of achalasia?

A

Heller’s cardiomyotomy

(muscles of LES are cut)

90
Q

what is a pharyngeal pouch?

A

outpouching at the top of the oesophagus

between crico and thyropharyngeal components of the inf pharyngeal constrictor

at the area of weakness - Killian’s dehiscence

defect usually occurs posteriorly but swelling usually bulges to L side of neck

91
Q

what is the area of weakness where a pharyngeal pouch usually develops from?

A

Killian’s dehiscence

92
Q

feeling of a lump in your throat, difficulty swallowing (dysphagia), bringing up food after a meal and bad breath.

dx?

A

pharyngeal pouch

93
Q

pharyngeal pouch presentation?

A

dysphagia

regurgitation

halitosis

feeling of lump in throat

gurgling sounds

94
Q

tx of pharyngeal pouch

A

excision

endoscopic stapling

95
Q

Barium swallow showing corkscrew oesophagus?

A

diffuse oesophageal spasm

96
Q

what is diffuse oesophageal spasm?

A

condition characterized by uncoordinated contractions of the oesophagus

difficulty swallowing (dysphagia) +/- intermittent severe chest pain

97
Q

Ix of diffuse oesophageal spasm?

A

barium swallow - shows corkscrew oesophagus

98
Q

what is nutcracker oesophagus?

or hypertensive peristalsis

A

normal peristalsis but w raised contraction pressure

causes chest pain + dysphagia to liquids and solids (intermittent)

oesophageal manometry used to diagnose when pressures > 180mmHg (like a mechanical nutcracker)

99
Q

what is Plummer-Vinson syndrome?

A

IDA, dysphagia, oesophageal webs, glossitis, cheilosis

pre-malignant: 20% risk of SCC of oesophagus/ pharynx

Treatment with iron supplementation and mechanical widening of the esophagus generally provides an excellent outcome

100
Q

IDA, dysphagia, oesophageal webs, glossitis, cheilosis

Dx?

A

Plummer vinson syndrome

101
Q

causes of oesophageal rupture?

A

Iatrogenic (85-90%): endoscopy, biopsy, dilatation

Violent emesis: Boerhaave’s syndrome

Carcinoma

caustic injestion

trauma: surgical emphysema +/- pneumothorax

102
Q

features of oesophageal rupture

A

odynophagia (painful swallowing)

mediastinitis: tachypnoea, dyspnoea, fever, shock

surgical emphysema (aka subcut emphysema- air in subcut tissues)

103
Q

Mx of oesophageal rupture

A

resus

PPI, NGT, Abx

104
Q

Causes of Squamous Cell Carcinoma of the oesophagus?

A
  1. Toxins: Smoking/ Alcohol
  2. Diet: processed/ red meats
  3. Obesity, achalasia, Plummer-Vinson syndrome
105
Q

causes of adenocarcinoma of the oesophagus?

A

GORD-> Barrett’s -> dysplasia -> Ca

106
Q

what is the most common type of oesophageal ca in UK?

A

65% adenoca

35% SCC (commonest worldwide)

107
Q

what regions of the oesophagus are more assoc w adenoca/ and which with SCC?

A

AdenoCa: lower 3rd

SCC: upper and middle 3rds

108
Q

features of Oesophageal Ca?

A
  1. progressive dysphagia and odynophagia:

solids then liquids

  1. Upper GI signs: voice hoarseness (ca invading recurrent laryngeal n), cough +/- aspiration pneumonia, retrosternal chest pain
  2. Red flags: weight loss, anaemia, haematemesis/ melaena, lymphadenopathy
109
Q

Ix of oesophageal ca?

A

Bloods:

FBC (IDA), LFTs (mets), bone profile (mets)

Imaging:

OGD endoscopy + biopsy

Ba swallow: not often used, apple core stricture

Staging: TNM

e.g. CT

110
Q

gold standard ix for oesophageal ca?

A

OGD endoscopy + biopsy

111
Q

curative Mx of oesophageal Ca? (25%)

A

MDT: surgeon, gastroenterologist, specialist nurse, onco, palliative care

surgical:

oesophagectomy

medical:

neoadjuvant chemo to downsize tumour before surgery e.g. cisplatin + 5FU

112
Q

what are the 3 surgical approaches to oesophagectomy?

A

Ivor-Lewis (2 incisions)

McKeown (3 incisions)

Trans-hiatal

MIT

113
Q

what is the Ivor-Lewis oesophagectomy?

A

esophageal tumor removed through abdominal incision + right thoracotomy

the esophagogastric anastomosis is located in the upper chest.

114
Q

What is the Mckeown oesophagectomy?

A

like the ivor-lewis, but used for cancers that are higher up in the oesophagus

laparotomy + right thoracotomy + L neck incision

115
Q

abdominal incision + right thoracotomy

esophagogastric anastomosis located in the upper chest.

A

Ivor-Lewis oesophagectomy

116
Q

midline abdominal incision + right thoracotomy + left neck incision?

A

McKeown’s oesophagectomy

117
Q

what is transhiatal oesophagectomy?

A

upper midline incision + oblique incision in neck along lower L border of Sternocleidomastoid

patient’s diseased esophagus and proximal (top part) stomach is removed.

118
Q

midline abdominal incision + neck incision ?

A

transhiatal oesophagectomy

119
Q

Palliative Mx of Oesophageal Ca? (75%)

A
  1. palliative care: macmillan nurses
  2. Analgesia, palliative chemo
  3. intervention: Stenting, Palliative radiotx
120
Q

what is GORD?

A

LOS dysfunction -> reflux of gastric contents -> oesophagitis

121
Q

Risk factors of GORD?

A
  1. anatomical disruption of the gastro-oesophageal junction
    - hiatus hernia
  2. Hypotensive LES/ transient LES relaxations
    e. g. coffee, alcohol, smoking, obesity, chocolate
  3. Delayed oesophageal acid clearance
    - dysmotility, cigarette smoking (decreased saliva -> decreased neutralisation -> increased acid), severe oesophagitis
  4. Iatrogenic: hellers myotomy, drugs e.g. nitrates, CCB
122
Q

Features of GORD?

A

Retrosternal burning

  • related to meals, worse lying down, relieved by antacids

Regurgitation/ acid brash

Dysphagia, odynophagia, cough, hoarse voice, asthma

*all symptoms are worse at night

123
Q

complications of GORD?

A
  1. oesophagitis
  2. Barrett’s oesophagus (metaplasia)
  3. Oesophageal AdenoCa
  4. strictures causing dysphagia
124
Q

Ix of GORD?

A
  1. Conservative /mx trial -> diagnosis if responds
  2. Imaging: OGD endoscopy +/- biopsy if:

>55 yo, persistent systems, anaemia, weight loss, anorexia, recent onset progressive symptoms, melaena, swallowing difficulty

  1. Special ix: 24 hr pH testing +/- manometry
125
Q

what findings indicated GORD on 24 hr pH testing?

A

pH <4 for > 4h

126
Q

Conservative Mx of GORD?

A

Diet: avoid spicy foods, coffee, alcohol, smaller meals, avoid drinking/ eating close to bedtime

Weight loss

Sleep on side/ bed elevated

Stop drugs that may be causing it e.g. NSAIDs, nitrates, CCB, anti-AChM

127
Q

Medical Mx of GORD?

A

Antacids e.g. gaviscon

Full-dose PPI for 1-2 months

e.g. Omeprazole 20mg OD / Lansoprazole 30mg

if no response -> double dose PPI BD

if no response -> add H2RA

e.g. Ranitidine 300mg nocte

128
Q

surgical mx of GORD?

A

Nissen’s fundoplication

  • usually laparoscopic
  • wrap gastric fundus around lower oesophagus
  • close any diaphragmatic hiatus
129
Q

indications for nissen’s fundoplication - surigcal mx of GORD?

A

all 3:

severe symptoms

refractory to medical tx

confirmed reflux on pH monitoring

130
Q

Complications of Nissen’s fundoplication?

A

dysphagia if wrap too tight

gas bloat syndrome: inability to belch/ vomit

131
Q

what are the different types of hiatus hernias?

A

Type I: Sliding (80%)

  • GOJ in chest -> GORD common

Type II: rolling

  • stomach herniated (paraoesophageal) but GOJ in normal position

can -> strangulation

III: mix of I and II

IV:

other organs in addition to the stomach (colon, small intestine, spleen) also herniated into chest

132
Q

Ix of hiatus hernia?

A

CXR: gas bubble and fluid level in chest

Ba Swallow: diagnostic

OGD: assess for oesophagitis

24 pH + manometry: exclude dysmotility or achalasia

133
Q

what is the diagnostic ix of hiatus hernia?

A

barium swallow

134
Q

Mx of Hiatus hernia?

A

Lose weight

treat reflux

surgery if intractable symptoms despite medical mx

-> should repair rolling hernia even if asymptomatic as it may strangulate

135
Q

what is an ulcer?

A

a break in the epithelium

136
Q

epigastric pain

relieved by eating, worse at nights/ before meals

A

duodenal ulcer

137
Q

epigastric pain

worse on eating -> weight loss

relieved by antacids

A

gastric ulcer

138
Q

what type of ulcer is most common with peptic ulcer disease?

A

duodenal 4x more common than gastric

139
Q

Risk factors of Peptic Ulcer disease?

A
  1. Infection: H Pylori
  2. Toxins: Smoking, Alcohol
  3. Drugs: NSAIDs, steroids
  4. Stress: Cushings ulcers, Curling’s ulcers

Zollinger- Ellison

140
Q

where are gastric ulcers usually found?

A

lesser curvature of gastric antrum

141
Q

where are duodenal ulcers usually found?

A

1st part of duodenum

142
Q

Complications of Peptic Ulcer Disease?

A

Haemorrhage:

  • IDA
  • haematemesis, melaena

perforation: peritonitis

Gastric outflow obstruction:

vomiting, colic, distension

malignancy:

gastric ulcers-> increased risk of gastric ca

143
Q

Features of peptic ulcer disease

A
  1. epigastric pain
  2. fullness/ bloating/ belching
  3. n/v
144
Q

Ix of peptic ulcer disease?

if >55 +/- RFs +/- no response to Tx

A

OGD +/- biopsy

145
Q

Ix of Peptic Ulcer disease?

< 55 and No alarm symptoms

A

h Pylori breath test

Stool Antigen test

?gastrin levels if zollinger ellison suspected

146
Q

mx of peptic ulcer disease?

A
  1. stop smoking, decrease alcohol, avoid spicy foods/ drugs e.g. NSAIDS, steroids
  2. Medical tx:

Triple therapy - Omeprazole + Clarithro + Metro

Antacids e.g. gaviscon

Acid suppression- PPIs (lansoprazole) or H2RA: ranitidine

  1. Surgical mx
147
Q

what is the medical tx of peptic ulcer disease?

A

Triple therapy - Omeprazole + Clarithro + Metro

Antacids e.g. gaviscon

Acid suppression- PPIs (lansoprazole) or H2RA: ranitidine

148
Q

what increases acid production in the stomach?

A

acid secretion is stimulated by gastrin (from antral G cells) and vagus nerve

149
Q

surgical mx of Peptic ulcer disease?

A

Vagotomy

+/- pyloroplasty

+/- antrectomy

Subtotal Gastrectomy w Roux-en-Y:

occasionally performed for Zollinger-Ellison

150
Q

types of vagotomy?

A

Selective vagotomy

or

Truncal vagotomy

151
Q

difference between truncal and selective vagotomy?

A

Selective vagotomy:

  • vagus nerve only denervated where it supplies lower oesophagus and stomach
  • Nerves of Laterjet (supplying pylorus) left intact

Truncal vagotomy:

  • decreases acid secretion directly and via decreasing gastrin
  • prevents pyloric sphincter relaxation (Nerves of Laterjet affected)
  • must be combined w pyloroplasty (widening of the pylorus) or gastroenterostomy
152
Q

what is Antrectomy with Vagotomy?

A

Truncal vagotomy

+

Distal half of stomach (antrum) removed

-> gastrin producing cells removed

+

Billroth I anastamosis: directly to duodenum

Billroth II: to small bowel loop w duodenum oversewn

153
Q

Metabolic complications of surgery for PUD?

A

Weight loss: malabsorption

Vitamin deficiency: less parietal cells -> B12 deficiency, bypassing proximal small bowel -> Fe + Folate deficiency

Blind loop syndrome:

overgrowth of bacteria in duodenal stump -> malabsorption, darrhoea

Dumping syndrome:

abdominal discomfort, and sometimes abnormally rapid bowel evacuation after meal

-> osmotic hypovolaemia, reactive hypoglycaemia

154
Q

Physical complications of Peptic ulcer disease surgery?

A

Ca: increase risk gastric ca

stump leakage

stricture

abdominal fullness

reflux or bilious vomiting (improves w time)

155
Q

risk factors for Upper GI bleed?

A

previous bleeds

known ulcers

oesophageal varices

malignancy

156
Q

Signs O/E with upper GI bleed?

A

Melaena

Shock

Signs of Chronic liver disease

157
Q

causes of upper GI bleeding?

A

most commonly peptic ulcer disease (DU): 40%

acute erosions/ gastritis: 20%

Mallory-Weiss tear: 10%

Varices: 5%

Oesophagitis: 5%

Ca stomach/ oesophagus: <3%

158
Q

Scoring systems for Upper GI bleed?

A

Rockall score

Glasgow-Blatchford bleeding score

159
Q

what is the Glasgow-Blatchford score?

A

screening tool to assess the likelihood that a patient with an acute upper GI bleeding will need to have medical intervention such as a blood transfusion or endoscopic intervention.

looks at:
Hb levels

Urea Levels

systolic blood pressure

tachycardia, melaena, syncope, heart failure, liver failure

160
Q

What is the Rockall score?

A

risk stratification of patients with upper GI bleed

prediction of re-bleeding and mortality

ABCDE

Age

Blood pressure fall (Shock)

Co-morbidity (e.g. heart, liver, renal failure)

Diagnosis

Evidence of bleeding: active bleeding, visible vessel, adherent clot

D/E is seen on OGD.

score >6 indication for surgery, >8 high risk of mortality

161
Q

what are oesophageal varices?

A

portal HTN -> dilated veins at sites of porto-systemic anastomosis:

L gastric and inferior oesophageal veins

30-50% risk of bleeding

overall mortality 25%

162
Q

causes of portal HTN

A

pre-hepatic: portal vein thrombosis

hepatic: cirrhosis (most common in UK), schistosomiasis (commonest worldwide)

Post-hepatic: Budd-Chiari, Right HF, constrictive pericarditis

163
Q

prevention of Upper GI bleed?

A

primary prevention: BB, repeat endoscopic banding

Secondary: BB, repeat banding, TIPSS (transjugular intrahepatic porto-systemic shunt)

164
Q

What is TIPSS?

trans-jugular intrahepatic porto-systemic shunt

A

artificial channel between inflow portal vein and outflow hepatic vein to decrease portal pressure

used prophylactically or acutely if endoscopic therapy fails to control variceal bleeding

165
Q

Mx of acute upper GI bleed?

A

A to E approach

Fluid resuscitation, protect airway, Bloods (Clotting, FBC, U+E, Group and save, x-match)

O- blood until cross matched

Urgent OGD

166
Q

mx of variceal bleed?

A

IV terlipressin

prophylactic abx e.g. ciprofloxacin

oesophageal varices: 1st line band ligation

gastric: endoscopic injection of N-butyl-2-cyanoacrylate

167
Q

1st line endoscopic mx of oesophageal varices?

A

endoscopic banding

2nd line: TIPSS

other: balloon-tamponade w Sengstaken-Blakemore tube

(only used if exsanguinating haemorrhage/ failure of endoscopic therapy)

168
Q

Mx of non-variceal upper GI bleeding?

A

urgent endoscopy:

  • a mechanical method (for example, clips) with or without adrenaline
  • thermal coagulation with adrenaline
  • fibrin or thrombin with adrenaline

+ PPIs

169
Q

Indications of surgery for upper GI bleed?

A

re-bleeding

bleeding despite 6 u transfusion

uncontrollable bleeding at endoscopy

initial Rockall score 3 or more, or final >6

open stomach, find bleeder and underrun vessel

170
Q

Mx after endoscopic tx of upper GI bleed?

A

Omeprazole (decreases re bleeding)

H Pylori testing and eradication

stop offending drugs e.g. NSAIDs, steroids

171
Q

sudden onset severe pain, beginning in epigastrium then generalised

vomiting

peritonitis

hx of pain after food/ relieved by eating

A

perforated peptic ulcer

most commonly duodenal ulcer

172
Q

perforation of peptic ulcer can create which signs?

A

ant perforation: air under diaphragm

posterior perf: can erode into gastroduodenal artery -> bleed

173
Q

Ix of suspected perforated peptic ulcer?

A

Bloods

Urine dip

Imaging:

Erect CXR - air under diaphragm

AXR: riglers sign

174
Q

Mx of perforated peptic ulcer

A

resuscitation:

fluid resus, NBM, analgesia, abx (cef and met), NGT

conservative: may be considered if pt not peritonitic

careful monitoring, fluids, abx

omentum may seal perforation spontaneously preventing operation in 50%

Surgical: laparotomy

repair

  • send specimen for histology to exclude ca
175
Q

Mx of perforated peptic ulcer after surgery

A

H Pylori eradication - triple therapy

176
Q

causes of gastric outlet obstruction?

A

gastric ca

late complication of peptic ulcer disease -> fibrotic stricturing

177
Q

hx of bloating, early satiety and nausea

copious projectile, non-bilious vomiting a few hours after meals

contains stale food

epigastric distension + succussion splash

Dx?

A

Gastric outlet obstruction

178
Q

Ix of gastric outlet obstruction?

A

ABG: hypochloraemic hypokalaemic metabolic alkalosis

AXR:

dilated gastric air bubble

collapsed distal bowel

OGD

Contrast meal

179
Q

tx of gastric outflow obstruction?

A

correct metabolic abnormality: 0.9% Normal saline + KCl

Benign: endoscopic balloon dilatation, pyloroplasty or gastroenterostomy

Malignant: stenting, resection

180
Q

projectile vomiting minutes after feeding

RUQ mass

visible peristalsis

6-8wk old infant

Dx?

A

Pyloric stenosis

181
Q

Diagnosis of Pyloric stenosis?

A

test feed: palpate mass + see peristalsis

HypoCl HypoK met alkalosis

US to confirm pylorus hypertrophy

182
Q

Mx of pyloric stenosis?

A

Resus, correct metabolic abnormality

NG tube - prevent aspiration

ramstedt pyloromyotomy

183
Q

complications of gastric cancer?

A

perforation

upper GI bleed

gastric outlet obstruction

184
Q

ix of gastric cancer?

A

Bloods

FBC: anaemia

LFTs and clotting (mets)

Imaging:

CXR: mets

USS: liver mets

gastroscopy + biopsy

Ba meal

Staging:

CT/MRI

diagnostic laparoscopy

185
Q

Mx of gastric cancer?

A

Palliative care:

analgesia, Chemo, PPI, pyloric stenting

Curative surgery:

resection of tumour

partial or total gastrectomy w roux-en-y to prevent bile reflux

186
Q

Risk factors of gastric cancer?

A

atrophic gastritis

h pylori

diet: high in nitrates (carcinogenic nitrosamines)

smoking

187
Q

pathology of gastric ca?

A

mainly adenocarcinomas

usually located on gastric antrum

H Pylori -> MALToma

188
Q

what is zollinger-ellison syndrome?

A

gastrin-secreting tumour (gastrinoma) most commonly in small intestine/ pancreas

↑ Gastrin → ↑HCL→ PUD + chronic diarrhoea

(diarrhoea due to inactivation of pancreatic enzymes)

25% assoc w MEN1

189
Q

refractory Peptic ulcer disease

chronic diarrhoea/ steatorrhoea

abdominal pain and dyspepsia

dx?

A

zollinger-ellison syndrome

190
Q

Ix of zollinger-ellison syndrome

A

Gastrin levels: high

pH<2 in stomach

MRI/CT scan

Somatostatin receptor scintigraphy- used to find carcinoid, pancreatic neuroendocrine tumors

191
Q

Mx of Zollinger-Ellison Syndrome?

A

High dose PPI (omeprazole)

Surgery:

tumour resection

may do subtotal gastrectomy w Roux-en-Y

192
Q

what is gastrointestinal stromal tumour? (GIST)

A

commonest mesenchymal tumour of the GIT

>50% occus in the stomach

arise in the smooth muscle pacemaker interstitial cell of Cajal

193
Q

mx of Gastrointestinal stromal tumours?

A

medical:

for unresectable, recurrent or metastatic disease

imatinib: KIT selective tyrosine kinase inhibitor

Surgical resection

194
Q

what is a carcinoid tumour?

A

neuroendocrine tumour of enterochromaffin cell origin

may secrete multiple hormones e.g. serotonin

195
Q

risk factors for gastric carcinoids?

A

atrophic gastritis -> low acid production -> increased gastrin production -> ECL hyperplasia -> carcinoid tumour

Gastrinomas may also -> carcinoid

196
Q

Most common cause of Gastric lymphoma (MALToma)?

A

chronic H pylori

197
Q

Benefits of bariatric surgery?

A

sustained weight loss

symptom improvement:

sleep apnoea

mobility

HTN

DM

198
Q

Indications of bariatric surgery?

A

All:

  • BMI ≥40 or ≥35 w significant co-morbidities
  • failure of medical mx to achieve and maintain clinically beneficial weight loss for 6 months
  • fit for surgery and anaesthesia
  • integrated program providing guidance on diet, physical acitivity, psychosocial concerns, and lifelong medical monitoring
  • well-informed and motivated pt

if BMI>50, surgery is 1st line mx

199
Q

what is laparoscopic gastric banding?

A

inflatable silicone band around proximal stomach -> small pre-stomach pouch

limits food intake, slows digestion

at 1 yr: 46% mean excess weight loss

200
Q

what is roux-en-y gastric bypass surgery?

A

oesophagojejunostomy allows bypass of stomach, duodenum and proximal jejunum

alters secretion of hormones influencing glucose regulation and perception of hunger/ satiety

greater weight loss and lower reoperation rates

Surgery (17 decks)

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