Upper GI Surgery Flashcards
A 45 year old man with recurrent episodes of confusion is found to have a 1.5cm insulinoma of the pancreatic head. What is the most appropriate management?
Whipples procedure Total pancreatectomy and en bloc splenectomy Pylorus preserving pancreatico duodenectomy Enucleation of the lesion External beam radiotherapy
Enucleation of the lesion
Most insulinomas are benign and radical resection is therefore not justified.
A 56 year old man is admitted with a profuse upper gastro intestinal haemorrhage. He is relatively malnourished and has evidence of gynaecomastia. An upper GI endoscopy is performed and views are limited because of the extensive amount of blood present. What is the most likely underlying cause?
Boerhaave's perforation Mallory Weiss tear Oesophageal varices Oesophageal cancer Oesophagitis
Patients presenting with gastrointestinal bleeding and evidence of established liver disease may have portal hypertension and develop variceal haemorrhage. The patient may have evidence of jaundice, gynaecomastia, spider naevia, caput medusae and ascites. The bleeding is usually profuse and painless.
A 53 year old man presents with dyspepsia. At upper GI endoscopy he has a punched out ulcer on the lesser curve of the stomach. It measures approximately 2cm in diameter and is seen to penetrate muscle with fibrosis present at the base. What is the most likely diagnosis?
Curlings ulcer Cushings ulcer Chronic ulcer Adenocarcinoma Gastric lymphoma
Fibrosis is usually a sign of chronic ulcer. It should be biopsied carefully, a proton pump inhibitor started and re endoscopy should occur at 6 weeks.
A 76 year old man presents with a 5 week history of progressive dysphagia. An upper GI endoscopy is performed and the surgeon notices changes that are compatible with Barretts oesophagus. The oesophagus is filled with food debris that cannot be cleared and the endoscope encounters a resistance that cannot be passed. What is the most likely underlying diagnosis?
Adenocarcinoma Squamous cell carcinoma Achalasia cardia Nutcracker oesophagus Benign peptic stricture
A short history of dysphagia together with food debris and Barretts changes makes adenocarcinoma the most likely diagnosis.
A 82 year old man presents with dysphagia. He is investigated and found to have an adenocarcinoma of the distal oesophagus. His staging investigations have revealed a solitary metastatic lesion in the right lobe of his liver. What is the best course of action?
Arrange a PET CT scan Arrange an endoscopic ultrasound Assess fitness for liver resection prior to oesophagectomy Assess fitness for oesophagectomy followed by liver resection Insertion of metallic stent
The presence of distant disease in the context of oesophageal cancer renders him incurable. Further staging is not needed and surgery is not an option. Palliation is the preferred option and a metallic stent will achieve this.
A 35 year old man is admitted with an episode of collapse and passage of malaena. He has been suffering from post prandial abdominal pain for 5 weeks and this is most marked several hours after eating. What is the most likely cause?
Anterior duodenal ulcer Posterior duodenal ulcer Oesophageal varices Dieulafoy lesion Carcinoma of the stomach
Patients with duodenal ulcers will usually have a history of epigastric pain that occurs several hours after eating. The pain is often improved by eating food. They are most frequently located in the first part of the duodenum. Anteriorly sited ulcers may perforate and result in peritonitis, posteriorly sited ulcers may erode the gastroduodenal artery and present with haematemesis and/ or malaena.
A 45 year old man undergoes an upper gastrointestinal endoscopy for a benign oesophageal stricture. This is dilated and he suffers an iatrogenic perforation at the site. His imaging shows a small contained leak and a small amount of surgical emphysema. What is the most appropriate nutritional option?
Nil by mouth and intravenous fluids alone Intravenous fluids and sips orally Total parenteral nutrition Nasogastric feeding PEG tube feeding
Iatrogenic perforations of the oesophagus may be managed non operatively. This usually involves a nil by mouth regime, tube thoracostomy may be needed. Total parenteral nutrition is the safest option. Insertion of NG feeding tubes and PEG tubes may complicate the process or allow feed to enter the perforation site.
A 38 year old woman undergoes a gastric bypass procedure. Post operatively she attends the clinic and complains that following a meal she develops vertigo and develops crampy abdominal pain. What is the most likely underlying explanation?
Insulin resistance Irritable bowel syndrome Biliary colic Dumping syndrome Enterogastric reflux
Dumping syndrome, which can be divided into early and late, may occur following gastric surgery. It occurs as a result of a hyperosmolar load rapidly entering the proximal jejunum. Osmosis drags water into the lumen, this results in lumen distension (pain) and then diarrhoea. Excessive insulin release also occurs and results in hypoglycaemic symptoms.
A 63 year old man undergoes an upper GI endoscopy and adrenaline injection for a large actively bleeding duodenal ulcer. He remains stable for 6 hours and the nurses then call because he has passed 400ml malaena and has become tachycardic (pulse rate 120) and hypotensive (Bp 80/40). What is the best option?
Reassure that blood trapped in the upper portion of the gastrointestinal system will pass and that this episode will resolve with phosphate enema Perform a repeat upper GI endoscopy Perform a laparotomy and under-running of the ulcer Administer tranexamic acid and intravenous proton pump inhibitors Insert a Minnesota tube
Perform a laparotomy and under-running of the ulcer
The decision as to how best to manage patients with re-bleeding is difficult. Whilst it is tempting to offer repeat endoscopy, this intervention is best used on those with small ulcers. Large posteriorly sited duodenal ulcers are at high risk for re-bleeding and the timeframe of this event suggests that primary endoscopic haemostasis was inadequate. Surgery thus represents the safest way forward.
A 55 year old man presents with symptoms of dyspepsia and on upper GI endoscopy an area of patchy erythematous tissue is identified extending proximally from the gastro oesophageal junction. A biopsy is diagnostic of Barretts oesophagus with low grade dysplasia. Which of the following is the most appropriate next step?
Distal oesophagectomy Upper GI endoscopy with quadrantic biopsies from the region Photodynamic therapy Endoscopic sub mucosal resection of the area Argon plasma coagulation
Upper GI endoscopy with quadrantic biopsies from the region
Low grade dysplasia in conjunction with Barretts oesphagus should be monitored with regular (6 monthly) upper GI endoscopy and quadrantic biopsies. If the disease remains static at 2 years then the screening frequency may be decreased.
A 62 year old man presents with dyspepsia and a tumour of the gastric cardia is diagnosed. He has no evidence of metastatic disease. What is the most appropriate treatment option?
Sub total gastrectomy and Roux en Y reconstruction Total gastrectomy and Roux en Y reconstruction Total gastrectomy and loop jejunostomy reconstruction Proximal gastrectomy and gastric pull up External beam radical radiotherapy
This will require a total gastrectomy. Retention of a gastric remnant is unlikely to achieve acceptable resection margins. Resection of the proximal stomach with pull up of the stomach is not standard oncological practice for gastric cancer.
A 45 year old man has been troubled with dysphagia for many years. He is known to have achalasia and has had numerous dilatations. Over the past 6 weeks his dysphagia has worsened. At endoscopy, a friable mass is noted in the oesophagus. What is the most likely diagnosis?
Adenocarcinoma Squamous cell carcinoma Leiomyoma Barretts oesophagus Sarcoma
The risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia. The condition often presents late and has a poor prognosis.
A 58 year old lady has a two year history of worsening dysphagia. In addition to this she has a nocturnal cough. Over this time she has lost a total of 8kg in weight. Which of the processes below is the most likely explanation for this?
Gastro-oesophageal reflux disease Barretts oesophagus Carcinoma Mallory Weiss tear Achalasia
Such marked weight loss should arouse suspicion of cancer. She is most likely to have a longstanding stricture associated with oesophagitis and Barretts oesophagus. This may progress to carcinoma which will tend to occur in association with worsening dysphagia and weight loss.
A 62 year old man presents with dysphagia and on investigation is found to have a stenosing tumour of the mid oesophagus with a single metastasis in the right lobe of the liver (segment VI). What is the most appropriate treatment?
Radical radiotherapy to the oesophagus and liver resection Insertion of self expanding metallic stent Liver resection and subsequent oesophageal resection Oesophageal resection and subsequent liver resection Combined oesophageal and liver resection if cardiopulmonary exercise testing shows the patient is fit enough
Distant disease in patients with oesophageal cancer is a contra indication to a resectional strategy and downstaging with chemotherapy is not routinely undertaken in this age group as the results are poor. An expanding stent will provide rapid and durable palliation.
A 72 year old man is admitted with an episode of brisk haematemesis. Following resuscitation an upper GI endoscopy is performed and a prominent blood vessel is identified in the mucosa approximately 6 cm from the O-G junction on the lesser curve of the stomach. What is the most likely explanation for the bleeding?
Gastric cancer Portal gastropathy Dieulafoy lesion Linitis plastica Gastritis
Dieulafoy lesion
These small arterial lesions are a rare cause of bleeding and are characterised by a single large tortuous arteriole in the sub mucosa. Extra gastric lesions may occur.
A 55 year old man is reviewed 3 months following a distal gastrectomy and gastro-jejunostomy for carcinoma of the gastric antrum. He complains of symptoms of dizziness, palpitations, sweating and occasional collapse after big meals. What is the most likely explanation for this presentation?
Division of the vagus nerves Increased release of insulin Increased release of cholecystokinin Increased release of gastrin Increased release of glucagon
The effects of gastro-enterostomy (which is how the stomach was reconstructed in this case) have resulted in the late symptoms of dumping syndrome which occur as a result of excessive insulin release. A similar condition can be seen in patients who undergo bariatric procedures such as gastric bypass.
A 56 year old man presents with odynophagia and on investigation is found to have a squamous cell carcinoma of the upper third of the oesophagus. Staging investigations are negative for metastatic disease. What is the most appropriate course of action?
Segmental resection of the proximal oesophagus Radical radiotherapy alone Combined radical radiotherapy and chemotherapy Ivor Lewis oesophagectomy Photodynamic therapy
Oesophageal SCC can be managed with radical chemoradiotherapy. Radiotherapy alone is not usually curative. Segmental resection of the upper oesophagus is not practiced. An Ivor Lewis oesophagectomy would only address distal disease.
An 80 year old lady is being investigated for dysphagia of long duration. An OGD is attempted. The procedure is complicated and there is significant difficulty in intubating the oesophagus. Eventually, the procedure is abandoned and the patient returns to the ward. Here it is noted that a significant amount of surgical emphysema is present. Which of the diagnoses listed below is most likely to explain this presentation?
Globus Barretts oesophagus Squamous cell carcinoma Pharyngeal pouch Schatzki ring
The early difficulty in intubation is most likely to be the result of pharyngeal pouch. Schatzki rings can cause problems but can usually be visualized. Whilst a squamous cell carcinoma can be perforated, it would be unusual for this to occur spontaneously as perforation of cancer typically occurs after attempted therapeutic intervention.
A 45 year old man has a 4 week history of epigastric discomfort which is relieved by eating. He develops haematemesis and undergoes an upper GI endoscopy. An actively bleeding ulcer is noted in the first part of the duodenum. What is the best management?
Whipples procedure Truncal vagotomy and drainage Distal gastrectomy Injection with tranexamic acid Injection with adrenaline
Bleeding duodenal ulcers will usually undergo adrenaline injection. This may be augmented by the placement of endoscopic clips or heat therapy with endoscopic heater probes. Following these interventions patients should receive a proton pump inhibitor infusion. Those who re-bleed, may require surgery. For ulcers in this location, laparotomy, duodenotomy and under-running of the ulcer is usually performed.
Which of the following patients should be referred for 1st line bariatric surgery?
BMI 30 kg/m2 and hypertension BMI 28 kg/m2 BMI 35 kg/m2 and type 2 diabetes BMI 32kg/m2 BMI 70kg/m2, COPD and type 2 diabetes
BMI 35 kg/m2 and type 2 diabetes
With all the other options the patient should have conservative management for a minimum of 6 months first. The patient with COPD should be considered for a less invasive intervention first e.g. intra gastric balloon.
A 73 year old lady presents with progressive dysphagia and is diagnosed with oesophageal cancer and liver metastases, it is located 8cm proximal to the gastro-oesophageal junction. Which of the following treatment options would be the the most appropriate management?
Insertion of Celestin tube Insertion of Minnesota tube Insertion of self expanding metal stent Photodynamic therapy Trans hiatal oesphagectomy
Most cases of malignant oesophageal obstruction can be managed by the placement of self expanding metal stents. The Celestin tube requires a laparotomy and is therefore obsolete. A resectional procedure would be inappropriate in the presence of liver metastasis. The main contra indication to metallic stent placement are very proximal tumours as it can be difficult to get proximal control in this situation and chemotherapy may be more appropriate.
Which of the following statements relating to gastric banding for obesity is false?
It is one of the safest anti obesity operations If successful up to 55% of excess weight may be lost over 2 years Excessively tight gastric bands have increased risk of long term complications It is associated with early satiety It is contra indicated in patients with polycystic ovaries who are trying to conceive
It is contra indicated in patients with polycystic ovaries who are trying to conceive
Adjustable gastric bands are one of the most widely performed anti obesity procedures in the UK. They are relatively easy to insert. Weight loss is slightly slower than with some of the other weight loss procedures. Up to 15% patients may require revisional surgery.
A 32 year old lady presents with dysphagia. She has a 10 year history of anaemia secondary to menorrhagia and has been strongly resistant to treatment. What is the most likely underlying cause?
Candidiasis Globus Squamous cell carcinoma of the oesophagus Adenocarcinoma of the oesophagus Plummer Vinson syndrome
Plummer Vinson syndrome (oesophageal web) may occur in association with iron deficiency anaemia
A patient is suspected of having a pharyngeal pouch, what is the most appropriate investigation?
Upper GI endoscopy with flexible endoscope Upper GI endoscopy with rigid endoscope Upper GI fluoroscopic swallowing study Oesophageal manometry CT scan of the neck
Upper GI fluoroscopic swallowing study
Upper GI endoscopy is contra indicated in pharyngeal pouch.
A 40 year old man is reviewed in the clinic 6 months after a redo fundoplication operation for gastro-oesophageal reflux disease. He complains of abdominal distension and bloating. Endoscopy shows a patent gastro-oesophageal junction and upper GI contrast studies show delayed gastric emptying. What is the most likely explanation for this?
Excessive release of cholecystokinin Excessive release of gastrin Damage to the vagus nerve Damage to the short gastric vessels Excessive release of insulin
Redo fundoplication surgery carries with it a risk of damaging the vagus nerves. If both are damaged, there will be delay to gastric emptying. Its important to exclude issues at the gastro-oesophageal junction ( as these are more common, usually due to overtight wrap) these are excluded here with the OGD showing that it was normal.
A 40 year old lady presents with a gastric carcinoma of the greater curvature of the stomach. Her staging investigations are negative for metastatic disease. What is the most appropriate treatment option?
Radical radiotherapy Sub total gastrectomy, D2 lymphadenectomy and Roux en Y reconstruction Sub total gastrectomy, D2 lymphadenectomy and anterior gastrojejunostomy Oesophagogastrectomy Sleeve gastrectomy
Sub total gastrectomy, D2 lymphadenectomy and Roux en Y reconstruction
This is amenable to potentially curative resection. The proximal stomach can be conserved.
Reconstruction with an anterior gastrojejunostomy will not provide optimal function. A Sleeve gastrectomy is not performed for malignant disease.
An 83 year old lady with long standing Barretts oesophagus is diagnosed with a 1cm focus of high grade dysplasia 3cm from the gastrooesophageal junction. What is the best course of action?
Endoscopic mucosal resection Photodynamic therapy Distal oesophagectomy Total oesophagectomy Radiotherapy
As she is elderly and the disease localised EMR is an appropriate first line step.
The technique involves raising the mucosa containing the lesion and then using an endoscopic snare to remove it. This technique is therefore minimally invasive. However, it is only suitable for early superficial lesions. Deeper invasion would carry a high risk of recurrence.
Which of the following procedures is not performed for obesity?
Sleeve gastrectomy Gastric band Intra gastric balloon Mckeown procedure Small bowel bypass
A McKeown procedure is a total oesophagectomy.
Which of the following variables is not included in the Rockall score?
Congestive cardiac failure Liver failure Systolic blood pressure < 100mmHg Aspirin usage Age
Aspirin usage
A patients should have their Rockall score calculated following endoscopy for upper GI haemorrhage
Mnemonic for Rockall score ABCDE A: Age B: Blood pressure drop (Shock) C: Co-morbidity D: Diagnosis E: Evidence of bleeding
A 42 year old man presents with epigastric pain. At endoscopy, he is found to have a punched out ulcer on the anterior wall of the stomach. It is shallow and measures 1cm in diameter. What is the most likely diagnosis?
Acute peptic ulcer Chronic peptic ulcer Adenocarcinoma Lymphoma Dieulafoy lesion
The absence of fibrosis coupled with small size suggests a more acute ulcer. Management should include biopsy, PPI and repeat endoscopy at 6 weeks.
A 22 year old man presents with a 5 month history of episodic retrosternal chest pain together with episodes of dysphagia to liquids. An upper GI endoscopy is performed and no mucosal abnormality is seen. What is the most likely diagnosis?
Motility disorder Leiomyosarcoma Gastro intestinal stromal tumour Squamous cell carcinoma Benign peptic stricture
Dysphagia that is episodic and varies between solids and liquids is more likely to represent a motility disorder.
Which of the following criteria is not an indication for bariatric surgery to be performed in the UK National Institute of Clinical Excellence Guidelines?
Patients must be non smoking for at least one year Patients must have tried conservative management for at least 6 months Commitment to long-term follow up Surgery to be performed in a specialist unit BMI > 35 kg/m2 and hypertensive
Being a non smoker is not included in the criteria, however poor respiratory function due to smoking may affect fitness for surgery.
A 58 year old man with long standing Barretts oesophagus is found to have a nodule on endoscopic surveillence. Biopsies and endoscopic USS suggest this is at most a 1cm foci of T1 disease in the distal oesophagus 4 cm proximal to the oesophagogastric junction. What is the most appropriate course of action?
Radical radiotherapy alone Total oesophagectomy and gastric pull up Endoscopic mucosal resection Combined radical chemo radiotherapy Sub total oesophagectomy
EMR is an reasonable option for small areas of malignancy occurring on a background of Barretts change. Segmental resections of the oesophagus are not practised and the only resectional strategy in this scenario would be an Ivor- Lewis type resection. The morbidity such a strategy in T1 disease is probably not justified.
A 34-year-old HIV positive man is referred to the surgical out patient department with jaundice and abnormal liver function tests. Liver function tests are as follows:
Albumin 34 g/l
ALP 540 iu/l
Bilirubin 67 µmol/l
ALT 45 iu/l
What is the most likely diagnosis?
Hepatic abscess Fungal obstruction of the bile duct Duodenal adenoma Primary biliary cirrhosis Sclerosing cholangitis
The LFTs clearly show a cholestatic picture. Given the background of HIV the most likely cause is sclerosing cholangitis.
A 24 year old man presents with dysphagia that occurs intermittently and swallowing of both liquids and solids can be difficult at times. An upper gastrointestinal endoscopy is unremarkable. What is the most appropriate next step?
Hellers cardiomyotomy Nissen fundoplication Injection of botulinum toxin into the lower oesophageal sphincter Oesophageal manometry Pneumatic dilatation of the lower oesophageal sphincter
Whilst this is likely to represent achalasia, in the first instance oesophageal manometry is needed. Definitive treatment should not be undertaken until the diagnosis is proven.
A 52 year old man with long standing Barretts oesophagus is diagnosed with high grade dysplasia on recent endoscopy. The lesions are multifocal and mainly distally sited. What is the best course of action?
Endoscopic surveillance at 3 monthly intervals Photodynamic therapy Nissens fundoplication Oesophagectomy External beam radiotherapy
Some may argue for local therapy. However, in young patients who are otherwise fit, multifocal disease such as this should probably be resected.
A 42 year old woman with known multiple gastric ulcers attends the surgical out patient unit. She has not improved despite 2 months of proton pump inhibitor treatment. She is found to have a gastrinoma. Which of the following is false in relation to her diagnosis?
Most commonly found in the pancreas Associated with multiple endocrine neoplasia I Somatostatin sensitive scintigraphy is the most senstive non invasive test for localizing primary tumours Primary tumours can occur in the ovary Secretory diarrhoea is a feature
Most commonly found in the duodenum (in up to 50% patients), then the pancreas (approximately 20%). Other ectopic areas include stomach, spleen, gallbladder and ovary
Greater than 4/5 of gastrinomas are found within the triangle bounded by:
Cystic and common bile duct (Top)
2nd and 3rd part of the duodenum (Bottom)
Neck and body of pancreas (Medial)
Pancreatic gastrinomas are normally solitary and highly malignant.
Zollinger Ellison syndrome is composed of the triad of:
1. Non beta islet cell tumours of the pancreas
2. Hypergastrinaemia
3. Severe ulcer disease
Clinical features related to peptic ulcer disease. Diagnosis is based on 3 criteria:
- Fasting hypergastrinaemia
- Increased basal acid output
- Secretin stimulation test positive
Management
Resection if localised disease
A 45 year old man is admitted with haematemesis. An upper gastrointestinal endoscopy is performed. A large ulcer in the first part of the duodenum is noted. Attempts are made to endoscopically clip and inject the ulcer which is bleeding profusely. These efforts are unsuccessful. What is the most appropriate management option?
Therapeutic angiogram Diagnostic angiography Laparotomy and underrunning of the ulcer Laparotomy and distal gastrectomy Duodenal resection and gastro jejunostomy
The standard surgical option for bleeding peptic ulcers is to underrun them. Resectional surgery is very much the option of last resort and is seldom helpful or easy. An isolated duodenal resection would almost never be performed
Which of the procedures listed below is most strongly associated with delayed gastric emptying?
Posterior gastrojejunostomy Pyloromyotomy Pyloroplasty Anterior gastrojejunostomy Roux en Y gastrojejunostomy
Anterior gastrojejunostomy is one of the easiest gastric bypass procedures to perform and is still often used for reconstruction following distal gastrectomy. It is associated with impairment of gastric emptying and patients may have considerable problems with flatulent dyspepsia. Roux en Y methods provide the best function. Pyloroplasty enhances gastric emptying (and was historically performed following vagotomy for this reason). Pyloromyotomy is not associated with an increase in gastric transit times (though failed procedures may be).
A 63 year old man undergoes a total gastrectomy for carcinoma of the stomach. Which of the sequelae below is least likely to occur?
Metabolic bone disease Bile reflux Dumping syndrome Zinc deficiency B12 deficiency
Zinc is mainly absorbed in the duodenum and jejunum. Bile reflux may occur post gastrectomy. The risk of bile reflux is lower if a Roux en Y reconstruction is used.
A 34 year old woman with morbid obesity is referred for consideration of bariatric surgery. Which of the following options is associated with the highest long term failure rates?
Gastric band Intra gastric balloon Roux en Y bypass Sleeve gastrectomy Duodenal switch
Intra gastric balloon
Intragastric balloon is really only suitable as a bridge to a more definitive surgical solution
A 56 year old lady presents with a 6 month history of dysphagia to solids. She has a long history of retrosternal chest pain that is worse on lying flat and bending forwards. She undergoes an upper GI endoscopy where a smooth stricture is identified. What is the most likely diagnosis?
Globus Adenocarcinoma Leiomyoma Benign stricture Squamous cell carcinoma
A six month history of dysphagia is a relatively long history and makes malignancy less likely. The lesion should be biopsied for histological confirmation. Long standing oesophagitis may be complicated by the development of strictures, Barretts oesophagus or both.
