Upper GI Surgery

Question 1

where are the three areas of constriction of the oesophagus?

Answer 1

level of cricoid
posterior to left main bronchus and aortic arch
LOS

Question 2

what is the oesophagus lined with?

Answer 2

non keratinising squamous epithelium

Question 3

state some inflammatory causes of dysphagia?

Answer 3

tonsilitis 
oesophagitis 
GORD 
oral candidiasis 
aphthous ulcers

Question 4

state some neurological/motility causes of dysphagia?

Answer 4

achalasia 
diffuse oesophageal spasm 
nutcracker oseophagus 
bulbar/pseudobulbar palsy 
systemic sclerosis 
MG

Question 5

state some obstructive causes of dysphagia?

Answer 5

foreign body 
benign stricture - web (plummer vision), oesophagitis, trauma) 
malignant stricture 
pharyngeal pouch 
retrosternal goitre 
rolling hiatus hernia 
lung cancer 
mediastinal LNs 
thoracic AA

Question 6

What surgery can be done for achalasia ?

Answer 6

Heller’s cardiomyotomy

Question 7

what is the area of weakness in the inferior pharyngeal constrictor that causes pharyngeal pouch?

Answer 7

Killian dehiscence

Question 8

what is the presentation of pharyngeal pouch?

Answer 8

Regurgitation, halitosis, gurgling sounds

Question 9

what does diffuse oesophageal spasm look like on barium swallow ?

Answer 9

corkscrew oesophagus

Question 10

what is the presentation of nutcracker oesophagus ?

Answer 10

Intermittent dysphagia ± chest pain

􏰀 ↑ contraction pressure ̄c normal peristalsis

Question 11

is plummer vision syndrome pre malignant?

Answer 11

yes

20% risk of SCC

Question 12

what causes plummer vision syndrome ?

Answer 12

iron deficiency anaemia

Question 13

what oesophageal feature is seen in plummer vision syndrome?

Answer 13

pharyngeal web from hyperkeratinisation of upper 3rd of oesophagus

Question 14

what are two syndromes caused by violent emesis ?

Answer 14

Boerhaave’s syndrome

Mallory Weiss syndrome

Question 15

what is the difference between Boerhaave’s syndrome and Mallory Weiss syndrome ?

Answer 15

Boerhaave syndrome is a transmural perforation of the esophagus to be distinguished from Mallory-Weiss syndrome, a nontransmural esophageal tear also associated with vomiting.

Question 16

what is the features of oesophageal rupture ?

Answer 16

Odonophagia
􏰀 Mediastinitis: tachypnoea, dyspnoea, fever, shock
􏰀 Surgical emphysema

Question 17

what is the treatment of oesophageal rupture?

Answer 17

PPI, NGT, Abx

Question 18

what is the commonest cause of oesophageal rupture?

Answer 18

iatrogenic - endoscopy, biopsy, dilation

Question 19

state a secondary cause of achalasia ?

Answer 19

Chages disease

- caused by T cruzii parasite

Question 20

what medication can increase risk of GORD?

Answer 20

anti-AChM, nitrates, CCB, TCAs

Question 21

what surgical procedure can increase risk of GORD?

Answer 21

hellers myotomy

Question 22

what are the epithelial changes seen in barretts oesophagus?

Answer 22

Metaplasia → dysplasia → adenocarcinoma

Question 23

what are extra oesophageal features of GORD?

Answer 23

Nocturnal asthma
􏰀 Chronic cough
􏰀 Laryngitis, sinusits

Question 24

what are DD for GORD?

Answer 24

oesophagitis
peptic ulcer disease
oesophageal cancer

Question 25

what PPI should be used for GORD and for how long ?

Answer 25

Lansoprazole 30mg OD | 1-2months

Question 26

what is Ranitidine and whats it used for?

Answer 26

H2RA | - used for GORD

Question 27

what three criteria has to be met for nissen fundoplication for GORDD?

Answer 27

Severe symptoms 􏰁 Refractory to medical therapy 􏰁 Confirmed reflux (pH monitoring)

Question 28

state some complications of fundoplication?

Answer 28

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

Question 29

what is a sliding hiatus hernia associated with

Answer 29

GORD

Question 30

is a sliding or paraoesophagheal hiatus hernia more common?

Answer 30

sliding (80%)

Question 31

what hiatus hernia requires surgery and why?

Answer 31

paraoesophageal because it may cause strangulation and ischaemia

Question 32

what makes duodenal ulcers worse and better?

Answer 32

worse before meals and at night | better by eating

Question 33

what makes gastric ulcers worse and better?

Answer 33

worse on eating (which can result in weight loss) | relieved by antacids

Question 34

state some risk factors for peptic ulcer disease ?

Answer 34

``` H pylori NSAIDs, Steroids Smoking EtOH Stress ```

Question 35

what causes cushings ulcer?

Answer 35

gastric ulcer associated with elevated intracranial pressure.

Question 36

what causes curling ulcers ?

Answer 36

complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis

Question 37

what do peptic ulcers look like?

Answer 37

punched out ulcers

Question 38

are duodenal ulcers or gastric ulcers more common?

Answer 38

duodenal ulcers are more common

Question 39

what tests can be done for peptic ulcers ?

Answer 39

FBC, urea C13 urea breath test CLO / urease test for H. pylori Gastrin levels if Zollinger-Ellison suspected

Question 40

what is gastric acid stimulated by?

Answer 40

gastrin, histamine and ACh from vagus nerve increases acid production

Question 41

state some features of dumping syndrome ?

Answer 41

Abdo distension, flushing, n/v, fainting, sweating 􏰁 Early: osmotic hypovolaemia 􏰁 Late: reactive hypoglycaemia

Question 42

decreased activity of parietal cells will result in what deficiency ?

Answer 42

B 12

Question 43

what is blind loop syndrome ?

Answer 43

associated with bacterial overgrowth in limb of intestine excluded from flow after a subtotal gastrectomy which causes malabsorption and diarrhoea

Question 44

what is Mg trisilicate used for?

Answer 44

antacid

Question 45

what is the management of upper GI bleeds ?

Answer 45

Beta blockers endoscopic banding TIPSS (Transjugular Intrahepatic PortoSystemic Shunt)

Question 46

what is a DD of a perforated peptic ulcer?

Answer 46

pancreatitis acute cholecystitis AAA MI

Question 47

what is Chailaditi’s sign?

Answer 47

when loop of large intestine (usually transverse colon) in between the diaphragm and the liver

Question 48

what should be seen on a CXR with a ulcer perforation ?

Answer 48

Air under the diaphragm seen in 70%

Question 49

state the presentation of gastric outlet obstruction?

Answer 49

Copious projectile, non-bilious vomiting a few hrs after meals. 􏰁 Contains stale food. 􏰁 Epigastric distension + succussion splash

Question 50

what does a AXR show for gastric outlet obstruction?

Answer 50

Dilated gastric air bubble, air fluid level | 􏰁Collapsed distal bowel

Question 51

what surgical interventions can be done for gastric outlet obstruction?

Answer 51

Endoscopic balloon dilatation 􏰁Pyloroplasty Stenting

Question 52

what gender is most affected by hypertrophic pyloric stenosis ?

Answer 52

males

Question 53

what is the presentation of hypertrophic pyloric stenosis ?

Answer 53

Projectile vomiting minutes after feeding 􏰀 RUQ mass: olive 􏰀 Visible peristalsis

Question 54

what are the 5 criteria for bariatric surgery?

Answer 54

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.