Upper GI Surgery Flashcards
where are the three areas of constriction of the oesophagus?
level of cricoid
posterior to left main bronchus and aortic arch
LOS
what is the oesophagus lined with?
non keratinising squamous epithelium
state some inflammatory causes of dysphagia?
tonsilitis oesophagitis GORD oral candidiasis aphthous ulcers
state some neurological/motility causes of dysphagia?
achalasia diffuse oesophageal spasm nutcracker oseophagus bulbar/pseudobulbar palsy systemic sclerosis MG
state some obstructive causes of dysphagia?
foreign body benign stricture - web (plummer vision), oesophagitis, trauma) malignant stricture pharyngeal pouch retrosternal goitre rolling hiatus hernia lung cancer mediastinal LNs thoracic AA
What surgery can be done for achalasia ?
Heller’s cardiomyotomy
what is the area of weakness in the inferior pharyngeal constrictor that causes pharyngeal pouch?
Killian dehiscence
what is the presentation of pharyngeal pouch?
Regurgitation, halitosis, gurgling sounds
what does diffuse oesophageal spasm look like on barium swallow ?
corkscrew oesophagus
what is the presentation of nutcracker oesophagus ?
Intermittent dysphagia ± chest pain
↑ contraction pressure ̄c normal peristalsis
is plummer vision syndrome pre malignant?
yes
20% risk of SCC
what causes plummer vision syndrome ?
iron deficiency anaemia
what oesophageal feature is seen in plummer vision syndrome?
pharyngeal web from hyperkeratinisation of upper 3rd of oesophagus
what are two syndromes caused by violent emesis ?
Boerhaave’s syndrome
Mallory Weiss syndrome
what is the difference between Boerhaave’s syndrome and Mallory Weiss syndrome ?
Boerhaave syndrome is a transmural perforation of the esophagus to be distinguished from Mallory-Weiss syndrome, a nontransmural esophageal tear also associated with vomiting.
what is the features of oesophageal rupture ?
Odonophagia
Mediastinitis: tachypnoea, dyspnoea, fever, shock
Surgical emphysema
what is the treatment of oesophageal rupture?
PPI, NGT, Abx
what is the commonest cause of oesophageal rupture?
iatrogenic - endoscopy, biopsy, dilation
state a secondary cause of achalasia ?
Chages disease
- caused by T cruzii parasite
what medication can increase risk of GORD?
anti-AChM, nitrates, CCB, TCAs
what surgical procedure can increase risk of GORD?
hellers myotomy
what are the epithelial changes seen in barretts oesophagus?
Metaplasia → dysplasia → adenocarcinoma
what are extra oesophageal features of GORD?
Nocturnal asthma
Chronic cough
Laryngitis, sinusits
what are DD for GORD?
oesophagitis
peptic ulcer disease
oesophageal cancer
what PPI should be used for GORD and for how long ?
Lansoprazole 30mg OD
1-2months
what is Ranitidine and whats it used for?
H2RA
- used for GORD
what three criteria has to be met for nissen fundoplication for GORDD?
Severe symptoms
Refractory to medical therapy
Confirmed reflux (pH monitoring)
state some complications of fundoplication?
Gas-bloat syn.: inability to belch / vomit
Dysphagia if wrap too tight
what is a sliding hiatus hernia associated with
GORD
is a sliding or paraoesophagheal hiatus hernia more common?
sliding (80%)
what hiatus hernia requires surgery and why?
paraoesophageal because it may cause strangulation and ischaemia
what makes duodenal ulcers worse and better?
worse before meals and at night
better by eating
what makes gastric ulcers worse and better?
worse on eating (which can result in weight loss)
relieved by antacids
state some risk factors for peptic ulcer disease ?
H pylori NSAIDs, Steroids Smoking EtOH Stress
what causes cushings ulcer?
gastric ulcer associated with elevated intracranial pressure.
what causes curling ulcers ?
complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis
what do peptic ulcers look like?
punched out ulcers
are duodenal ulcers or gastric ulcers more common?
duodenal ulcers are more common
what tests can be done for peptic ulcers ?
FBC, urea
C13 urea breath test
CLO / urease test for H. pylori
Gastrin levels if Zollinger-Ellison suspected
what is gastric acid stimulated by?
gastrin, histamine and ACh from vagus nerve increases acid production
state some features of dumping syndrome ?
Abdo distension, flushing, n/v, fainting, sweating Early: osmotic hypovolaemia
Late: reactive hypoglycaemia
decreased activity of parietal cells will result in what deficiency ?
B 12
what is blind loop syndrome ?
associated with bacterial overgrowth in limb of intestine excluded from flow after a subtotal gastrectomy which causes malabsorption and diarrhoea
what is Mg trisilicate used for?
antacid
what is the management of upper GI bleeds ?
Beta blockers
endoscopic banding
TIPSS (Transjugular Intrahepatic PortoSystemic Shunt)
what is a DD of a perforated peptic ulcer?
pancreatitis
acute cholecystitis
AAA
MI
what is Chailaditi’s sign?
when loop of large intestine (usually transverse colon) in between the diaphragm and the liver
what should be seen on a CXR with a ulcer perforation ?
Air under the diaphragm seen in 70%
state the presentation of gastric outlet obstruction?
Copious projectile, non-bilious vomiting a few hrs after meals.
Contains stale food.
Epigastric distension + succussion splash
what does a AXR show for gastric outlet obstruction?
Dilated gastric air bubble, air fluid level
Collapsed distal bowel
what surgical interventions can be done for gastric outlet obstruction?
Endoscopic balloon dilatation
Pyloroplasty
Stenting
what gender is most affected by hypertrophic pyloric stenosis ?
males
what is the presentation of hypertrophic pyloric stenosis ?
Projectile vomiting minutes after feeding
RUQ mass: olive
Visible peristalsis
what are the 5 criteria for bariatric surgery?
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.
