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Phase 4 > Upper G.I Surgery > Flashcards

Upper G.I Surgery Flashcards

1
Q

Name Etiologies associated with GORD:

A 
Hiatus Hernia 
LOS dysfunction 
Delayed Gastric emptying 
Increased Intra Abdominal Pressures 
Dietary causes
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2
Q

What investigations should be carried out for people with GORD?

A

Endoscopy
24 hour pH study
Esophageal Manometry
Barium Swallow test

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3
Q

What are some serious complications of GORD?

A 
Strictures - malignant/ non- malignant 
Barrett's esophagus
Anaemia 
gastric volvulus  
- usually a hiatus hernia twisting on itself
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4
Q

Dysphagia can be broadly split into oral-pharyngeal and esophageal causes, name some causes of dysphagia associated with dysfunction of the eospheal aspect:

A

Strictures

  • malignant
  • non-malignant

Oesophagitis

  • candidiasis
  • eosinophilic oesophagitis
  • ulceration/ GORD

Dysmotility
- Achalasia

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5
Q

What investigations should be done into dysphagia?

A

Radiology:

  • AP chest - xray
  • Barium swallow test
  • CT/ MRI for tumours

Endoscopy

Esophageal Manometry

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6
Q

What is the best mode to diagnosis chronic Pancreatitis?

A

CT without contrast - it is best for picking up the calcifications

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7
Q

Following pancreatitis, a mass develops is the lesser sac, what is this and what blood marker will be raised?

A

Pseudocyst

Amylase remains high

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8
Q

Following laparoscopic surgery, a patient may become breathless and an x-ray is performed. What may you see and what is it?

A

Surgical subcutaneous emphysema

  • ginkgo leaf sign
  • you can see the pectoralis muscle under the skin
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9
Q

What are the diagnostic tests of choice for gallstones in the common bile duct?

A

Ultrasound
followed by:
MRCP

an ERCP can be used but this is usually reserved more intervention

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10
Q

What are the cause, clinical symptoms of chronic pancreatitis, and what investigations and treatment are available?

A

Causes:

  • alcohol
  • pancreatic ductal obstruction - tumours, cysts, cystic fibrosis

Features:

  • epigastric pain, radiating to the back
  • worse pain with foods and alcohol
  • anorexia
  • weight loss (poor protein intake)
  • steatorrhoea
  • Insulin dependent DM

diagnostic tests:

  • Pancreatic CT
  • ERCP

Treatment:

  • remove cause (alcohol, obstruction)
  • symptom control
  • creon supplements
  • DM control
  • whipples procedure
  • partial pancreatectomy (usually for retractable pain)
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11
Q

Pancreatic Carcinoma:

A

90% adenocarcinomas

Clinical features:

  • Obstructive jaundice
  • palpable gallbladder
  • Pain - epigastric, LUQ
  • Thrombophlebitis migrans - vessel inflammation

Investigations:

  • Ca-19
  • US transabdominally
  • CT with guided FNAC** Most important
  • ERCP
  • Chest/ Abdo/ Pelvis CT

Treatment:
- 95% are not suitable for resection due to metastasis

  • obstructional relief by ERCP stenting
  • Pain control - oramorph or MST
  • Whipple’s resection
    + adjuvant therapy chemotherapy

**Whipples is contraindicated if there is liver/peritoneal or distant mets

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12
Q

In acute pancreatitis, what are the signs called when there is ecchymosis?

A

Grey Turner’s sign - left flank ecchymosis

Cullen’s Sign - periumbilical

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13
Q

What is the glasgow criteria for pancreatitis and when is it considered severe?

A 
PaO2 - <8kpa 
Age - >55 years 
Neutrophils -  >15 
Corrected Ca2+ - <2mmols 
Raised blood urea - >16mmols 
Enzymes - AST >200, LDH >600 
Albulim <32g/L 
Sugar - >10mmol

*>3 or more = severe, admit to ITU.

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14
Q

Whats the most common injury following cholecystectomy?

A

Bile duct injury

- usually presents 1-3 days later

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15
Q

What is a risk factor for cholangiocarcinoma, and is associated with UC?

A

Primary Sclerosing cholangitis

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16
Q

What is the suggested management for pancreatic pseudocyst if there is no significant derangements of the liver?

A

Conservative management

- observe for 12 weeks.

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17
Q

Name some common causes of upper G.I bleeds:

A 
Peptic ulcers 
Oesphageal varices 
Mallory- weiss tears 
Oesophagitis 
Drugs - NSAIDs
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18
Q

What is the most SENSITIVE marker for acute pancreatitis?

A

Serum Lipase

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19
Q

What are the common type of oesophageal tumours and what are they associated with?

A

Adenocarcinoma
- barrett’s esophagus

Squamous Carcinoma

  • smoking
  • chronic achalasia

Rhabdomyosarcoma
- rare skeletal muscle defect

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20
Q

What are the symptoms of esophageal cancer? and how is it is investigated?

A

Often history of dyspepsia due to GORD

Dysphagia
- usually to solids

weight loss

Acute obstruction

**anyone>45 with dysphagia should be investigated for cancer

Investigations:
- endoscopy - with biopsy

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21
Q

What are the types of gastric cancers that can occur?

A 
Adenocarcinoma: 
Intestinal:
- H.Pylori 
- Autoimmune gastritis 
- Pernicious anaemia

Diffuse:

  • Linitus plastica
  • Signet ring morphology

Carcinoid / Gastro-stroma

Lymphoma - MALT (H.Pylori related)

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22
Q

What are some risk factors for developing gastric cancer?

A

Blood A group type
Chronic gastritis
Nitrosamines foods - smoked food

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23
Q

What are the signs and symptoms of gastric carcinoma and how is it investigated?

A

Dyspepsia

  • > 45 years new onset dyspepsia is cancer until proven otherwise
  • this is especially true after eating

Weight loss

Anorexia

Dysphagia
- if affecting the upper area of stomach

Signs:

  • weight loss
  • Acanthosis nigerans Type I
  • Epigastric distension
  • sister Mary Joseph Nodule

Diagnosis:

  • gastroscopy
  • CT for staging
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24
Q

What are the causes of gastritis?

A

Acutely:

  • NSAIDs
  • Alcohol
  • Cushing’s effect - from head injury

Chronic:

  • H. Pylori
  • Hiatus Hernia
  • autoimmune gastritis
  • Menetrier’s disease - TNF- alpha release which promotes stomach to enlarge
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25
Q

What are the symptoms of gastritis?

What investigations are done?

A

Epigastric pain
vomiting

Upper G.I endoscopy

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26
Q

What are the alarm symptoms that require urgent referral related to dyspepsia and peptic ulcer disease?

A

ALARMS:

Anaemia 
Loss of weight 
Anorexia 
Recent change in symptoms 
Melena/ or other bleeding 
Swallowing difficulty
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27
Q

What are the symptoms of GORD?

A 
Heart burn 
Retrosternal pain after meals 
Belching 
Regurgitation 
Odynophagia

Extra-oesophageal:

  • Nocturnal asthma
  • chronic cough
  • laryngitis
  • sinusitis
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28
Q

How does Biliary colic differ from normal colic? and where else might the pain radiate to?

A

usually colic pain gradually rises. Biliary has plateau.

Right shoulder.
Tip of the scapula - T7-T9 fibres

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29
Q

What is the management for biliary colic?

A
  • Rehydration
  • NBM
  • Pethidine (analgesia that doesn’t cause sphincter of oddi spasm) **although this is now debated

Surgical elective: 6-12 weeks following

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30
Q

MRCP:

A

Imaging of the pancreaticobiliary ducts

  • non invasive
  • uses iodine based for contrast

doesn’t allow for any therapeutic intervention

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31
Q

ERCP:

A

Used for diagnostic and therapeutic reasons.

Diagnostics:

  • gallstones
  • acute pancreatitis
  • chronic pancreatitis

Therapeutically:
- widden ampulla to grab stone - either by widening to allow passage into stool or into basket

  • Stent ampulla if tumour

Complications:
- acute pancreatitis

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32
Q

What is a very important landmark to be established on an upper G.I bleed?

A

Ligament of Treitz / Suspensory muscle of the duodenum.

  • found on the flexure of the duodonojejunum flexure, which marks the separation of the upper and lower G.I tracts.
    thus a bleed proximal to it is an upper G.I bleed.

*it also has clinical significance for children who may have malrotation of the gut

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33
Q

What are the most common causes of G.I bleeds in order:

A
  1. Duodenal ulcer
  2. Oesphageal varices
  3. Gastric ulcer
  4. Erosive/ hemorrhagic gastritis
  5. Mallory -weir tears
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34
Q

What cancers are people with achalasia more at risk of?

A

squamous cell

35
Q

Which type of ulcer is associated with pain several hours after eating?

A

Duodenum

36
Q

What syndrome can occur with gastric bypass that leads to abdominal pain, dizziness, nausea and diarrhea?

A

Dumping syndrome.
- hyperosmolar fluids enter jejunum and draw water in, causing distention and pain.
increased osmolality induces diarrhea

37
Q

In the setting of an upper G.I bleed if a person cannot tolerate an endoscopy or the results from it are inconclusive, what addition test can be done to establish where the bleed is?

A

CT abdomen with IV contrast

38
Q

What is the definitive management for esophageal varices?

A

Endoscopic Banding

39
Q

What is the definitive management for peptic ulcer bleeding?

A

Endoscopic adrenaline and cauterisation
+
High Dose PPIs

40
Q

When asking about dysphagia, what other symptoms should you be interested in other than solids and liquids?

A

Pain when swallowing and where?

Sensation of food being stuck

hoarse voice

weight loss

pain radiating to the back

41
Q

What does a Whipple’s procedure consist of?

A

Removal of:

Head of Pancreas

Gall bladder + common bile duct

1st/ 2nd part of duodenum

Lymph nodes

+/-

Antrum of stomach

42
Q

What is the survival rate of pancreatic cancer?

A

5% at 5 years

43
Q

What is the treatment for pancreatic cancer when there is metastasis?

A

Folfirinox regime

44
Q

What is the grading system used for GORD and what is the treatment?

A

Los Angeles Classification of Reflux
- based on the mucosal breaks seen

Lifestyle advice
Bed raise

1st line: PPIs

surgery:
- Nissan Fundoplication

45
Q

What is the gold stand investigation into GORD?

A

24 hours pH monitoring

46
Q

What are the main complications of GORD?

A

Adenocarcinoma

Aspiration pneumonia

Strictures

47
Q

Name some complications of gallstones;

A

Biliary colic

Cholecystitis

Empyema

Cholangitis

Gallstone ileus

Gallbladder perforation

Choledocholithiasis

48
Q

What are the advantages of laparoscopic approach to gallbladder and what are the advantages of open repair?

A

Laparoscopic:

  • less scar formation
  • quicker recovery
  • reduced pain

Open:

  • Low risk of damage to bile duct
  • lower risk of damage to adjacent structures
  • Technically easier
49
Q

What are some complications of Cholecystectomy?

A 
Death 
Bile duct leak 
Bile duct injury 
Adjacent structure injuries 
Retained stones
50
Q

What are some medical causes for increased gastrin production?

A

Zollinger - Ellison

Autoimmune gastritis

PPI use

H.Pylori

51
Q

What are two signs of obstructive jaundice?

A

Steatorrhea

Dark urine
- as conjugated bilirubin can pass into the urine

52
Q

What are the contraindications to whipple’s procedure?

A

Metastatic spread - usually to liver
Superior mesenteric vein involvement
No dissection plane visible

53
Q

What are the clinical signs on pancreatic cancer?

A 
Palpable gallbladder 
Hepatomegaly 
Weight loss
Thrombophlebitis 
Jaundice 
Sister mary Joseph nodules
54
Q

What are some of the complications of GORD?

A

Barrett’s esophagus

Adenocarcinoma

Volvulus

Strictures

Pneumonia

55
Q

What are the risk factors for a hiatus hernia?

A

Increased intraabdominal pressure

Loss of tone to the diaphragm

Obesity

Pregnancy

Ascites

56
Q

What are the symptoms of Hiatus hernia?

A

GORD

Hiccups

Chest pain

Vomiting and weight loss

57
Q

What are the two surgeries used in Hiatus hernia and when are they implicated?

A

Cruroplasty

Fundoplication

  • failure of medical management
  • Risk of volvulus formation
  • Malnutrition
58
Q

What are the complications of fundoplication?

A

Recurrence of hernia

Intra-abdominal pressure/ discomfort
- unable to belch

Dysphagia

Necrosis
- if too tight

59
Q

What are the symptoms of a gastric volvulus?

A

Borchardt’s triad:

  • epigastric pain
  • retching and unable to bring anything up
  • NG tube won’t go down
60
Q

What is the investigation of choice for Hiatus hernia and what will be seen?

A

Endoscopy

- Z - line deformity

61
Q

What are the differential diagnosis of GORD/ Hiatus hernia?

A

Stomach cancer

Pancreatic cancer

Cardiovascular pain

Peptic ulcer

62
Q

What are biopsies of gastric carcinoma sent away for?

A

Histology

HER protein status

H.Pylori testing

63
Q

What are the complications of a gastrectomy?

A

Dumping syndrome

Vitamin B12

Anastomosis leak

64
Q

What clinical signs may be seen with Cholecystitis ?

A

Still in movement
Shallow quick breathing
Temperature

Fullness in right hypochondrium

Murphy’s sign
- 9th intercostal space

Boa’s sign
- hyperesthesia at the tip of scapula

65
Q

What should be done pre-endoscopy?

A

Fast for 3 hours
IV access
Consented
Notes are present

66
Q

List some causes of motility dysphasia:

A

Achalasia
Nutcracker esophagus
Diffuse esophageal spasm

67
Q

How does Cholangiocarcinoma present?

A

Steatorrhea with clay like stools
Weight loss
RUQ mass
Intermittent RUQ pain

68
Q

Anatomically where does the esophagus narrow?

A

Cricoid

Posterior to left bronchus and aorta

Lower esophageal sphincter

69
Q

What is the treatment for achalasia?

A

Calcium channel blockers
PPIs

Surgical:

  • Balloon Dilation
  • Heller’s myotomy
70
Q

Name two surgical approaches to esophageal cancer:

A

Radiofrequency ablation
- via endoscope

Ivor Lewis - abdominal + Right thoracotomy

Trans- Hiatal Approach - abdominal incision

71
Q

What are the complications of a NIssan fundoplication?

A

Bloating
-unable to belch

Esophageal ischemia
- too tight

Dysphagia
- too tight

72
Q

List some complications of peptic ulcers:

A

Bleeding
- acute and chronic

Malignancy

Perforation

Obstruction
- gastric outflow obstruction

73
Q

What are the indications for surgery following an upper G.I bleed?

A

Rebleed
Bleeding despite 6 units transfused
Rockall score >3 initially
Uncontrollable bleeding at endoscopy

74
Q

Which of the peptic ulcers is most likely to perforated?

A

Duodenal

75
Q

What is an abnormal duct dilatation of the biliary tract?

A

6mm + 1mm for every decade after 60

76
Q

What are some causes of gallstone formation?

A 
supersaturation of cholesterol 
Hyperlipidemia
Bowel stasis - TPN 
Malnutrition  
Crohn's disease - lack of bile acid reabsorption
77
Q

When should Barrett’s esophagus be endoscopically checked?

A

No dysplasia - 2-5 years

Low grade dysplasia - 6 months
- biopsies

High grade dysplasia - 3 months

78
Q

If there is high grade dysplasia on Barrett’s esophagus how should it be treated?

A

Endoscopic mucosal resection

79
Q

How is a Boerhaave’s Syndrome investigated and treated?

A

CT with contrast
On table Endoscope

Treatment:

  • Aggressive fluids
  • IV antibiotics
  • High Flow oxygen

Definitive management:

  • Surgical control of leak
  • Removal of contents from mediastinum/ mediastinal wash
  • Decompression of esophagus - NG tube
  • Nutritional control

*some patients can be managed conservatively if it was a iatrogenic cause

80
Q

List some mobility disorders of the esophagus

A

Achalasia

Chagas disease

Diffuse esophageal spasm

Nut cracker esophagus

CREST syndrome

81
Q

Physiological barriers against GORD?

A

Angle of His

Lower Esophageal Sphincter tone

Intra abdominal pressure

Oblique muscle of stomach

Saliva swallowing

82
Q

What are the two new surgical techniques for GORD?

A

Endoscopic surgery:

Linx
- magnetic beads forming a sphincter

Stretta technique
- radioablation

83
Q

What is the gold standard for staging oesphageal cancer?

A

Endoscopic ultrasound

**note that endoscopic ultrasound is gold standard for all upper G.I malignancies

Phase 4 (49 decks)

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