Upper GI Surgery Flashcards
where are the 3 locations of narrowing of the oesophagus?
- level of cricoid cartilage (C6)
- posterior to left main bronchus and aortic arch (T4)
- lower oesophageal sphincter (T11)
what is the z line in the oesophagus?
transition from squamous to gastric columnar epithelium
Ix for dysphagia
Upper GI endoscopy
Barium Swallow
Manometry (assess LOS fn)
projectile vomiting
child hungry after vomiting
failure to gain weight
dehydration/ constipation
Dx?
Pyloric stenosis
diagnosis of pyloric stenosis?
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
what is the metabolic abnormality with pyloric stenosis?
hypochloraemic hypokalaemic met alkalosis
what is Ramstedt’s pyloromyotomy?
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.
what medications predispose a pt to peptic ulceration and perforation?
steroids
NSAIDs (aspirin, indometacin, ibuprofen etc)
examination findings of a pt with perforated peptic ulcer
patient in severe pain
cold and sweating w rapid, shallow respirations
abdomen rigid and silent
pneumoperitoneum -> may lead to diminished liver dullness
presentation of peptic ulcer perforation on examination
in a delayed (>12h onset) presentation
if delayed (>12h) presentation
features of generalized peritonitis with paralytic ileus
distended abdomen
vomiting
pt extremely toxic and in oligaemic shock
Ix to order for suspected perforated peptic ulcer
CXR: erect.
- free gas below the diaphragm
CT abdo
- to detect free intraperitoneal gas and can exclude common differentials e.g. pancreatitis
DDx of perforated peptic ulcer
perforated appendicitis
acute cholecystitis
acute pancreatitis
myocardial infarction
tx of perforated peptic ulcer
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
what does surgery of perforated peptic ulcer involve?
suturing of omental plug to seal the perforation
+
lavage of the peritoneal cavity
+
biopsy of *gastric ulcer to exclude malignancy
Postoperative tx for perforated Peptic ulcer
H pylori eradication
omeprazole, amoxicillin, clari
profuse vomiting, non-bilious
may contain food particles
weight loss, constipation, weakness due to electrolyte disturbance
pyloric stenosis
Examination findings of pyloric stenosis
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
Ix of pyloric stenosis
Gastroscopy - following decompression of stomach w NG tube
CT scan
ABG and electrolytes-> hypochloraemic, hypokalaemic alkalosis and uraemia
metabolic disturbances of pyloric stenosis
dehydrated, Hct raised
serum Cl, Na, K low
plasma bicarb and urea raised
alkalosis
DDx of pyloric stenosis
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.
differentiating between benign ulcer-> pyloric stenosis vs carcinoma of the pylorus
- 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.
tx of pyloric stenosis
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
oesophageal causes of GI haemorrhage
- reflux oesophagitis (associated with hiatus
hernia) ; - oesophageal varices (associated with portal
hypertension)
- peptic ulcer;
- tumours (benign and malignant).
stomach causes of GI haemorrhage
gastric ulcer
acute erosions (assoc w aspirin, other NSAIDs, corticosteroids)
gastritis
Mallory-Weiss tear
vascular malformation (e.g. Dieulafoy lesion)
tumours (benign and malignant)
Duodenal Causes of GI haemorrhage
duodenitis
duodenal ulcer
erosion of the duodenum by a pancreatic tumour
aortoduodenal fistula, in patients with previous aortic graft
small intestine causes of GI haemorrhage
tumours
meckel’s diverticulum
angiodysplasia
aortoenteric fistula
large bowel causes of GI haemorrhage
Tumours (benign and malignant, commonly adenoCas)
diverticulitis
Angiodysplasia
colitis (UC, Ischaemic colitis and infective colitis)
General causes of bleeding?
anticoagulant therapy
haemophilia
leukaemia
thrombocytopenia
Ix with GI bleeding
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
Tx of Upper GI Bleed
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
tx of actively bleeding peptic ulcers
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
GI stromal tumours
mutation in what gene?
c-kit gene coding for c-kit protein (CD117) on the cell
Tx of GIST (GI stromal tumour)
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
Risk factors for Stomach Ca
(Predisposing conditions)
pernicious anaemia and atrophic gastritis
previous gastric resection
chronic peptic ulcer
Risk factors of stomach ca
envt factors
H pylori infection
Low SES
Smoking
Nationality: Japan(?)
genetic risk factor for stomach cancer?
HNPCC
lymph drainage of carcinoma from cardiac end of stomach?
mediastinal nodes
supraclavicular nodes of Virchow
lymph drainage from carcinoma of the pylorus?
subpyloric and hepatic nodes
type of obstruction when blood supply of the involved segment of intestine is cut off
strangulating obstruction
e.g. with strangulated hernia, volvulus, intussusception
symptoms of intestinal obstruction
colicky abdo pain
distension
absolute constipation
vomiting
Examination of suspected intestinal obstruction should include?
hernias
scars
- suggests previous operation and adhesions/ band as a cause
features of strangulating obstruction
vs simple obstruction
change in character of pain from colicky to continuous
tachycardia
pyrexia
peritonism
bowel sounds absent/ reduced
raised WCC
raised CRP
causes of intestinal obstruction
(in the lumen)
faecal impaction
gallstone ileus
food bolus
parasites
intussusception
causes of intestinal obstruction
(in the wall)
congenital atresia
Crohn’s disease
tumours
diverticulitis
causes of intestinal obstruction
(outside the wall)
volvulus
strangulated hernia
obstruction due to adhesions or bands
differentiation between small and large bowel obstruction on Abdo Xray?
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)
Mx in acute intestinal obstruction
NG tube for gastric aspiration & to decompress bowel
IV fluids + K if K is low
ABx if intestinal strangulation is likely
signs of non-viability in affected bowel of intestinal obstruction
- loss of peristalsis
- loss of normal sheen
- colour (greenish or black bowel is non-viable; purple bowel may still recover)
- loss of arterial pulsation in the supplying mesentery
closed loop obstruction
where is it most commonly seen?
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
adhesions from previous surgeries usually lead to what kind of bowel obstruction?
small bowel
(about 75%)
what are the three main arteries supplying the gut
coeliac
super mesenteric
inferior mesenteric
acute colicky abdo pain, rectal bleeding and shock
in an elderly patient who has AF
mesenteric vascular occlusion
e.g. embolus, mesenteric arterial/ venous thrombosis, non-occlusive infarction of the intestine
neonatal intestinal obstruction ddx?
intestinal atresia
volvulus neonatorum
meconium ileus
necrotizing enterocolitis
hirschsprung’s disease
anorectal atresia
Meconium ileus treatment?
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
tx of necrotizing enterocolitis
resus
NG tube for gastric aspiration
IV fluids
TPN and broad spectrum abx
Hirschsprungs Disease
what pathology?
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.
tx of Hirschsprung’s
surgery
aganglionic segment is resected and an abdominoperineal pull-through anastomosis between normal colon and the anal canal.
commonest area of intussusception
ileocolic
- through the ileocaecal valve
meckel’s diverticulum is the remnant of which duct of the embryo?
vitellointestinal duct
Crohn’s disease
- which parts of the bowel is affected
anywhere from mouth to anus
Crohns Disease Risk factors
genetic - NOD2
environmental - smoking
Macroscopic appearance of affected Crohns’ segment
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
common symptoms of crohns disease
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)
what are helful indices of disease activity in Crohns disease?
CRP
acute phase proteins
complications of Crohns Disease
skin: pyoderma gangrenosum, erythema nodosum
anterior uveitis
sacroiliitis
primary sclerosing cholangitis
Renal/ Biliary Calculi
medical mx of crohn’s disease
elemental diet / nutritional support
acute episodes treated with steroids and immunosuppressants such as azathioprine
infliximab (anti-TNFa) monoclonal antibody to TNF-a
Sulfasalazine/ mesalazine
when is surgery indicated for crohns disease?
surgery indicated for severe/ recurrent obstructive symptoms, and for fistulae into bladder/ skin
what do carcinoid tumours secrete
5-HT (serotonin)
symptoms of carcinoid syndrome
flushing with attacks of cyanosis,
often precipitated by stress or ingestion of food/ alcohol
diarrhoea
bronchospasm
abdo pain
Ix of Carcinoid Syndrome
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
what medication can be used to control symptoms in carcinoid syndrome?
octreotide, a somatostatin analogue that inhibits 5-HT release
diagnostic sequence of acute appendicitis?
colicky central abdo pain
followed by vomiting
followed by movement of the pain to the RIF
+ anorexia/ constipation usually
symptoms with perforation of the appendix?
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
ix of suspected appendicitis
WCC: mild raised neutrophils
CT abdo
US RIF may be diagnostic
when is immediate appendicectomy not indicated?
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
medical tx of acute appendicitis?
apart from appendicectomy
antibiotic prophylaxis
- metronidazole and gentamicin
drain inserted after appendicectomy
what are the muscle types in each 1/3 of the oesophagus?
top 1/3: striated
middle: mixed
bottom 1/3: smooth muscle
how long is the oesophagus?
25 cm long muscular tube
(40 cm from lips to GOJ)
where does the oesophagus start?
at the level of the cricoid cartilage C6
what is achalasia?
LOS fails to relax during swallowing
due to degeneration of myenteric plexus (Auerbach’s)
-> decreased peristalsis
cause of achalasia?
most commonly idiopathic
coule be secondary to Chagas disease (trypanosoma cruzii)
dysphagia of liquids AND solids (intermittent)
regurgitation esp at night
substernal cramps/ pressure
relieved by drinking through pain with cold water
weight loss
dx?
achalasia
features of achalasia?
dysphagia of liquids AND solids (intermittent)
regurgitation esp at night
substernal cramps/ pressure
relieved by drinking through pain with cold water
weight loss
complications of achalasia?
oesophageal SCC in 3-5%
Gold standard Ix of Achalasia?
Oesophageal Manometry
abnormal Lower Oesophageal sphincter pressure during swallow
Ix of achalasia?
Manometry: showing abnormal LOS pressure during swallow
Barium swallow: Birds beak sign (dilated tapering oesophagus)
OGD: exclude malignancy
CXR: widened mediastinum, double RH border
what sign points to achalasia on barium swallow?
Birds Beak sign
Mx of achalasia?
conservative:
nothing if asymptomatic
medical:
CCB, nitrates (decrease LES pressure)
interventional:
botox injection to LES, endoscopic balloon dilatation
surgical:
heller’s cardiomyotomy
what is the surgical tx of achalasia?
Heller’s cardiomyotomy
(muscles of LES are cut)
what is a pharyngeal pouch?
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
what is the area of weakness where a pharyngeal pouch usually develops from?
Killian’s dehiscence
feeling of a lump in your throat, difficulty swallowing (dysphagia), bringing up food after a meal and bad breath.
dx?
pharyngeal pouch
pharyngeal pouch presentation?
dysphagia
regurgitation
halitosis
feeling of lump in throat
gurgling sounds
tx of pharyngeal pouch
excision
endoscopic stapling
Barium swallow showing corkscrew oesophagus?
diffuse oesophageal spasm
what is diffuse oesophageal spasm?
condition characterized by uncoordinated contractions of the oesophagus
difficulty swallowing (dysphagia) +/- intermittent severe chest pain
Ix of diffuse oesophageal spasm?
barium swallow - shows corkscrew oesophagus
what is nutcracker oesophagus?
or hypertensive peristalsis
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)
what is Plummer-Vinson syndrome?
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
IDA, dysphagia, oesophageal webs, glossitis, cheilosis
Dx?
Plummer vinson syndrome
causes of oesophageal rupture?
Iatrogenic (85-90%): endoscopy, biopsy, dilatation
Violent emesis: Boerhaave’s syndrome
Carcinoma
caustic injestion
trauma: surgical emphysema +/- pneumothorax
features of oesophageal rupture
odynophagia (painful swallowing)
mediastinitis: tachypnoea, dyspnoea, fever, shock
surgical emphysema (aka subcut emphysema- air in subcut tissues)
Mx of oesophageal rupture
resus
PPI, NGT, Abx
Causes of Squamous Cell Carcinoma of the oesophagus?
- Toxins: Smoking/ Alcohol
- Diet: processed/ red meats
- Obesity, achalasia, Plummer-Vinson syndrome
causes of adenocarcinoma of the oesophagus?
GORD-> Barrett’s -> dysplasia -> Ca
what is the most common type of oesophageal ca in UK?
65% adenoca
35% SCC (commonest worldwide)
what regions of the oesophagus are more assoc w adenoca/ and which with SCC?
AdenoCa: lower 3rd
SCC: upper and middle 3rds
features of Oesophageal Ca?
- progressive dysphagia and odynophagia:
solids then liquids
- Upper GI signs: voice hoarseness (ca invading recurrent laryngeal n), cough +/- aspiration pneumonia, retrosternal chest pain
- Red flags: weight loss, anaemia, haematemesis/ melaena, lymphadenopathy
Ix of oesophageal ca?
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
gold standard ix for oesophageal ca?
OGD endoscopy + biopsy
curative Mx of oesophageal Ca? (25%)
MDT: surgeon, gastroenterologist, specialist nurse, onco, palliative care
surgical:
oesophagectomy
medical:
neoadjuvant chemo to downsize tumour before surgery e.g. cisplatin + 5FU
what are the 3 surgical approaches to oesophagectomy?
Ivor-Lewis (2 incisions)
McKeown (3 incisions)
Trans-hiatal
MIT
what is the Ivor-Lewis oesophagectomy?
esophageal tumor removed through abdominal incision + right thoracotomy
the esophagogastric anastomosis is located in the upper chest.
What is the Mckeown oesophagectomy?
like the ivor-lewis, but used for cancers that are higher up in the oesophagus
laparotomy + right thoracotomy + L neck incision
abdominal incision + right thoracotomy
esophagogastric anastomosis located in the upper chest.
Ivor-Lewis oesophagectomy
midline abdominal incision + right thoracotomy + left neck incision?
McKeown’s oesophagectomy
what is transhiatal oesophagectomy?
upper midline incision + oblique incision in neck along lower L border of Sternocleidomastoid
patient’s diseased esophagus and proximal (top part) stomach is removed.
midline abdominal incision + neck incision ?
transhiatal oesophagectomy
Palliative Mx of Oesophageal Ca? (75%)
- palliative care: macmillan nurses
- Analgesia, palliative chemo
- intervention: Stenting, Palliative radiotx
what is GORD?
LOS dysfunction -> reflux of gastric contents -> oesophagitis
Risk factors of GORD?
- anatomical disruption of the gastro-oesophageal junction
- hiatus hernia - Hypotensive LES/ transient LES relaxations
e. g. coffee, alcohol, smoking, obesity, chocolate - Delayed oesophageal acid clearance
- dysmotility, cigarette smoking (decreased saliva -> decreased neutralisation -> increased acid), severe oesophagitis - Iatrogenic: hellers myotomy, drugs e.g. nitrates, CCB
Features of GORD?
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
complications of GORD?
- oesophagitis
- Barrett’s oesophagus (metaplasia)
- Oesophageal AdenoCa
- strictures causing dysphagia
Ix of GORD?
- Conservative /mx trial -> diagnosis if responds
- Imaging: OGD endoscopy +/- biopsy if:
>55 yo, persistent systems, anaemia, weight loss, anorexia, recent onset progressive symptoms, melaena, swallowing difficulty
- Special ix: 24 hr pH testing +/- manometry
what findings indicated GORD on 24 hr pH testing?
pH <4 for > 4h
Conservative Mx of GORD?
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
Medical Mx of GORD?
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
surgical mx of GORD?
Nissen’s fundoplication
- usually laparoscopic
- wrap gastric fundus around lower oesophagus
- close any diaphragmatic hiatus
indications for nissen’s fundoplication - surigcal mx of GORD?
all 3:
severe symptoms
refractory to medical tx
confirmed reflux on pH monitoring
Complications of Nissen’s fundoplication?
dysphagia if wrap too tight
gas bloat syndrome: inability to belch/ vomit
what are the different types of hiatus hernias?
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
Ix of hiatus hernia?
CXR: gas bubble and fluid level in chest
Ba Swallow: diagnostic
OGD: assess for oesophagitis
24 pH + manometry: exclude dysmotility or achalasia
what is the diagnostic ix of hiatus hernia?
barium swallow
Mx of Hiatus hernia?
Lose weight
treat reflux
surgery if intractable symptoms despite medical mx
-> should repair rolling hernia even if asymptomatic as it may strangulate
what is an ulcer?
a break in the epithelium
epigastric pain
relieved by eating, worse at nights/ before meals
duodenal ulcer
epigastric pain
worse on eating -> weight loss
relieved by antacids
gastric ulcer
what type of ulcer is most common with peptic ulcer disease?
duodenal 4x more common than gastric
Risk factors of Peptic Ulcer disease?
- Infection: H Pylori
- Toxins: Smoking, Alcohol
- Drugs: NSAIDs, steroids
- Stress: Cushings ulcers, Curling’s ulcers
Zollinger- Ellison
where are gastric ulcers usually found?
lesser curvature of gastric antrum
where are duodenal ulcers usually found?
1st part of duodenum
Complications of Peptic Ulcer Disease?
Haemorrhage:
- IDA
- haematemesis, melaena
perforation: peritonitis
Gastric outflow obstruction:
vomiting, colic, distension
malignancy:
gastric ulcers-> increased risk of gastric ca
Features of peptic ulcer disease
- epigastric pain
- fullness/ bloating/ belching
- n/v
Ix of peptic ulcer disease?
if >55 +/- RFs +/- no response to Tx
OGD +/- biopsy
Ix of Peptic Ulcer disease?
< 55 and No alarm symptoms
h Pylori breath test
Stool Antigen test
?gastrin levels if zollinger ellison suspected
mx of peptic ulcer disease?
- stop smoking, decrease alcohol, avoid spicy foods/ drugs e.g. NSAIDS, steroids
- Medical tx:
Triple therapy - Omeprazole + Clarithro + Metro
Antacids e.g. gaviscon
Acid suppression- PPIs (lansoprazole) or H2RA: ranitidine
- Surgical mx
what is the medical tx of peptic ulcer disease?
Triple therapy - Omeprazole + Clarithro + Metro
Antacids e.g. gaviscon
Acid suppression- PPIs (lansoprazole) or H2RA: ranitidine
what increases acid production in the stomach?
acid secretion is stimulated by gastrin (from antral G cells) and vagus nerve
surgical mx of Peptic ulcer disease?
Vagotomy
+/- pyloroplasty
+/- antrectomy
Subtotal Gastrectomy w Roux-en-Y:
occasionally performed for Zollinger-Ellison
types of vagotomy?
Selective vagotomy
or
Truncal vagotomy
difference between truncal and selective vagotomy?
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
what is Antrectomy with Vagotomy?
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
Metabolic complications of surgery for PUD?
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
Physical complications of Peptic ulcer disease surgery?
Ca: increase risk gastric ca
stump leakage
stricture
abdominal fullness
reflux or bilious vomiting (improves w time)
risk factors for Upper GI bleed?
previous bleeds
known ulcers
oesophageal varices
malignancy
Signs O/E with upper GI bleed?
Melaena
Shock
Signs of Chronic liver disease
causes of upper GI bleeding?
most commonly peptic ulcer disease (DU): 40%
acute erosions/ gastritis: 20%
Mallory-Weiss tear: 10%
Varices: 5%
Oesophagitis: 5%
Ca stomach/ oesophagus: <3%
Scoring systems for Upper GI bleed?
Rockall score
Glasgow-Blatchford bleeding score
what is the Glasgow-Blatchford score?
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
What is the Rockall score?
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
what are oesophageal varices?
portal HTN -> dilated veins at sites of porto-systemic anastomosis:
L gastric and inferior oesophageal veins
30-50% risk of bleeding
overall mortality 25%
causes of portal HTN
pre-hepatic: portal vein thrombosis
hepatic: cirrhosis (most common in UK), schistosomiasis (commonest worldwide)
Post-hepatic: Budd-Chiari, Right HF, constrictive pericarditis
prevention of Upper GI bleed?
primary prevention: BB, repeat endoscopic banding
Secondary: BB, repeat banding, TIPSS (transjugular intrahepatic porto-systemic shunt)
What is TIPSS?
trans-jugular intrahepatic porto-systemic shunt
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
Mx of acute upper GI bleed?
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
mx of variceal bleed?
IV terlipressin
prophylactic abx e.g. ciprofloxacin
oesophageal varices: 1st line band ligation
gastric: endoscopic injection of N-butyl-2-cyanoacrylate
1st line endoscopic mx of oesophageal varices?
endoscopic banding
2nd line: TIPSS
other: balloon-tamponade w Sengstaken-Blakemore tube
(only used if exsanguinating haemorrhage/ failure of endoscopic therapy)
Mx of non-variceal upper GI bleeding?
urgent endoscopy:
- a mechanical method (for example, clips) with or without adrenaline
- thermal coagulation with adrenaline
- fibrin or thrombin with adrenaline
+ PPIs
Indications of surgery for upper GI bleed?
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
Mx after endoscopic tx of upper GI bleed?
Omeprazole (decreases re bleeding)
H Pylori testing and eradication
stop offending drugs e.g. NSAIDs, steroids
sudden onset severe pain, beginning in epigastrium then generalised
vomiting
peritonitis
hx of pain after food/ relieved by eating
perforated peptic ulcer
most commonly duodenal ulcer
perforation of peptic ulcer can create which signs?
ant perforation: air under diaphragm
posterior perf: can erode into gastroduodenal artery -> bleed
Ix of suspected perforated peptic ulcer?
Bloods
Urine dip
Imaging:
Erect CXR - air under diaphragm
AXR: riglers sign
Mx of perforated peptic ulcer
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
Mx of perforated peptic ulcer after surgery
H Pylori eradication - triple therapy
causes of gastric outlet obstruction?
gastric ca
late complication of peptic ulcer disease -> fibrotic stricturing
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?
Gastric outlet obstruction
Ix of gastric outlet obstruction?
ABG: hypochloraemic hypokalaemic metabolic alkalosis
AXR:
dilated gastric air bubble
collapsed distal bowel
OGD
Contrast meal
tx of gastric outflow obstruction?
correct metabolic abnormality: 0.9% Normal saline + KCl
Benign: endoscopic balloon dilatation, pyloroplasty or gastroenterostomy
Malignant: stenting, resection
projectile vomiting minutes after feeding
RUQ mass
visible peristalsis
6-8wk old infant
Dx?
Pyloric stenosis
Diagnosis of Pyloric stenosis?
test feed: palpate mass + see peristalsis
HypoCl HypoK met alkalosis
US to confirm pylorus hypertrophy
Mx of pyloric stenosis?
Resus, correct metabolic abnormality
NG tube - prevent aspiration
ramstedt pyloromyotomy
complications of gastric cancer?
perforation
upper GI bleed
gastric outlet obstruction
ix of gastric cancer?
Bloods
FBC: anaemia
LFTs and clotting (mets)
Imaging:
CXR: mets
USS: liver mets
gastroscopy + biopsy
Ba meal
Staging:
CT/MRI
diagnostic laparoscopy
Mx of gastric cancer?
Palliative care:
analgesia, Chemo, PPI, pyloric stenting
Curative surgery:
resection of tumour
partial or total gastrectomy w roux-en-y to prevent bile reflux
Risk factors of gastric cancer?
atrophic gastritis
h pylori
diet: high in nitrates (carcinogenic nitrosamines)
smoking
pathology of gastric ca?
mainly adenocarcinomas
usually located on gastric antrum
H Pylori -> MALToma
what is zollinger-ellison syndrome?
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
refractory Peptic ulcer disease
chronic diarrhoea/ steatorrhoea
abdominal pain and dyspepsia
dx?
zollinger-ellison syndrome
Ix of zollinger-ellison syndrome
Gastrin levels: high
pH<2 in stomach
MRI/CT scan
Somatostatin receptor scintigraphy- used to find carcinoid, pancreatic neuroendocrine tumors
Mx of Zollinger-Ellison Syndrome?
High dose PPI (omeprazole)
Surgery:
tumour resection
may do subtotal gastrectomy w Roux-en-Y
what is gastrointestinal stromal tumour? (GIST)
commonest mesenchymal tumour of the GIT
>50% occus in the stomach
arise in the smooth muscle pacemaker interstitial cell of Cajal
mx of Gastrointestinal stromal tumours?
medical:
for unresectable, recurrent or metastatic disease
imatinib: KIT selective tyrosine kinase inhibitor
Surgical resection
what is a carcinoid tumour?
neuroendocrine tumour of enterochromaffin cell origin
may secrete multiple hormones e.g. serotonin
risk factors for gastric carcinoids?
atrophic gastritis -> low acid production -> increased gastrin production -> ECL hyperplasia -> carcinoid tumour
Gastrinomas may also -> carcinoid
Most common cause of Gastric lymphoma (MALToma)?
chronic H pylori
Benefits of bariatric surgery?
sustained weight loss
symptom improvement:
sleep apnoea
mobility
HTN
DM
Indications of bariatric surgery?
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
what is laparoscopic gastric banding?
inflatable silicone band around proximal stomach -> small pre-stomach pouch
limits food intake, slows digestion
at 1 yr: 46% mean excess weight loss
what is roux-en-y gastric bypass surgery?
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
