Upper G.I Surgery Flashcards
Name Etiologies associated with GORD:
Hiatus Hernia LOS dysfunction Delayed Gastric emptying Increased Intra Abdominal Pressures Dietary causes
What investigations should be carried out for people with GORD?
Endoscopy
24 hour pH study
Esophageal Manometry
Barium Swallow test
What are some serious complications of GORD?
Strictures - malignant/ non- malignant Barrett's esophagus Anaemia gastric volvulus - usually a hiatus hernia twisting on itself
Dysphagia can be broadly split into oral-pharyngeal and esophageal causes, name some causes of dysphagia associated with dysfunction of the eospheal aspect:
Strictures
- malignant
- non-malignant
Oesophagitis
- candidiasis
- eosinophilic oesophagitis
- ulceration/ GORD
Dysmotility
- Achalasia
What investigations should be done into dysphagia?
Radiology:
- AP chest - xray
- Barium swallow test
- CT/ MRI for tumours
Endoscopy
Esophageal Manometry
What is the best mode to diagnosis chronic Pancreatitis?
CT without contrast - it is best for picking up the calcifications
Following pancreatitis, a mass develops is the lesser sac, what is this and what blood marker will be raised?
Pseudocyst
Amylase remains high
Following laparoscopic surgery, a patient may become breathless and an x-ray is performed. What may you see and what is it?
Surgical subcutaneous emphysema
- ginkgo leaf sign
- you can see the pectoralis muscle under the skin
What are the diagnostic tests of choice for gallstones in the common bile duct?
Ultrasound
followed by:
MRCP
an ERCP can be used but this is usually reserved more intervention
What are the cause, clinical symptoms of chronic pancreatitis, and what investigations and treatment are available?
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)
Pancreatic Carcinoma:
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
In acute pancreatitis, what are the signs called when there is ecchymosis?
Grey Turner’s sign - left flank ecchymosis
Cullen’s Sign - periumbilical
What is the glasgow criteria for pancreatitis and when is it considered severe?
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.
Whats the most common injury following cholecystectomy?
Bile duct injury
- usually presents 1-3 days later
What is a risk factor for cholangiocarcinoma, and is associated with UC?
Primary Sclerosing cholangitis
What is the suggested management for pancreatic pseudocyst if there is no significant derangements of the liver?
Conservative management
- observe for 12 weeks.
Name some common causes of upper G.I bleeds:
Peptic ulcers Oesphageal varices Mallory- weiss tears Oesophagitis Drugs - NSAIDs
What is the most SENSITIVE marker for acute pancreatitis?
Serum Lipase
What are the common type of oesophageal tumours and what are they associated with?
Adenocarcinoma
- barrett’s esophagus
Squamous Carcinoma
- smoking
- chronic achalasia
Rhabdomyosarcoma
- rare skeletal muscle defect
What are the symptoms of esophageal cancer? and how is it is investigated?
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
What are the types of gastric cancers that can occur?
Adenocarcinoma: Intestinal: - H.Pylori - Autoimmune gastritis - Pernicious anaemia
Diffuse:
- Linitus plastica
- Signet ring morphology
Carcinoid / Gastro-stroma
Lymphoma - MALT (H.Pylori related)
What are some risk factors for developing gastric cancer?
Blood A group type
Chronic gastritis
Nitrosamines foods - smoked food
What are the signs and symptoms of gastric carcinoma and how is it investigated?
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
What are the causes of gastritis?
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
What are the symptoms of gastritis?
What investigations are done?
Epigastric pain
vomiting
Upper G.I endoscopy
What are the alarm symptoms that require urgent referral related to dyspepsia and peptic ulcer disease?
ALARMS:
Anaemia Loss of weight Anorexia Recent change in symptoms Melena/ or other bleeding Swallowing difficulty
What are the symptoms of GORD?
Heart burn Retrosternal pain after meals Belching Regurgitation Odynophagia
Extra-oesophageal:
- Nocturnal asthma
- chronic cough
- laryngitis
- sinusitis
How does Biliary colic differ from normal colic? and where else might the pain radiate to?
usually colic pain gradually rises. Biliary has plateau.
Right shoulder.
Tip of the scapula - T7-T9 fibres
What is the management for biliary colic?
- Rehydration
- NBM
- Pethidine (analgesia that doesn’t cause sphincter of oddi spasm) **although this is now debated
Surgical elective: 6-12 weeks following
MRCP:
Imaging of the pancreaticobiliary ducts
- non invasive
- uses iodine based for contrast
doesn’t allow for any therapeutic intervention
ERCP:
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
What is a very important landmark to be established on an upper G.I bleed?
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
What are the most common causes of G.I bleeds in order:
- Duodenal ulcer
- Oesphageal varices
- Gastric ulcer
- Erosive/ hemorrhagic gastritis
- Mallory -weir tears
What cancers are people with achalasia more at risk of?
squamous cell
Which type of ulcer is associated with pain several hours after eating?
Duodenum
What syndrome can occur with gastric bypass that leads to abdominal pain, dizziness, nausea and diarrhea?
Dumping syndrome.
- hyperosmolar fluids enter jejunum and draw water in, causing distention and pain.
increased osmolality induces diarrhea
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?
CT abdomen with IV contrast
What is the definitive management for esophageal varices?
Endoscopic Banding
What is the definitive management for peptic ulcer bleeding?
Endoscopic adrenaline and cauterisation
+
High Dose PPIs
When asking about dysphagia, what other symptoms should you be interested in other than solids and liquids?
Pain when swallowing and where?
Sensation of food being stuck
hoarse voice
weight loss
pain radiating to the back
What does a Whipple’s procedure consist of?
Removal of:
Head of Pancreas
Gall bladder + common bile duct
1st/ 2nd part of duodenum
Lymph nodes
+/-
Antrum of stomach
What is the survival rate of pancreatic cancer?
5% at 5 years
What is the treatment for pancreatic cancer when there is metastasis?
Folfirinox regime
What is the grading system used for GORD and what is the treatment?
Los Angeles Classification of Reflux
- based on the mucosal breaks seen
Lifestyle advice
Bed raise
1st line: PPIs
surgery:
- Nissan Fundoplication
What is the gold stand investigation into GORD?
24 hours pH monitoring
What are the main complications of GORD?
Adenocarcinoma
Aspiration pneumonia
Strictures
Name some complications of gallstones;
Biliary colic
Cholecystitis
Empyema
Cholangitis
Gallstone ileus
Gallbladder perforation
Choledocholithiasis
What are the advantages of laparoscopic approach to gallbladder and what are the advantages of open repair?
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
What are some complications of Cholecystectomy?
Death Bile duct leak Bile duct injury Adjacent structure injuries Retained stones
What are some medical causes for increased gastrin production?
Zollinger - Ellison
Autoimmune gastritis
PPI use
H.Pylori
What are two signs of obstructive jaundice?
Steatorrhea
Dark urine
- as conjugated bilirubin can pass into the urine
What are the contraindications to whipple’s procedure?
Metastatic spread - usually to liver
Superior mesenteric vein involvement
No dissection plane visible
What are the clinical signs on pancreatic cancer?
Palpable gallbladder Hepatomegaly Weight loss Thrombophlebitis Jaundice Sister mary Joseph nodules
What are some of the complications of GORD?
Barrett’s esophagus
Adenocarcinoma
Volvulus
Strictures
Pneumonia
What are the risk factors for a hiatus hernia?
Increased intraabdominal pressure
Loss of tone to the diaphragm
Obesity
Pregnancy
Ascites
What are the symptoms of Hiatus hernia?
GORD
Hiccups
Chest pain
Vomiting and weight loss
What are the two surgeries used in Hiatus hernia and when are they implicated?
Cruroplasty
Fundoplication
- failure of medical management
- Risk of volvulus formation
- Malnutrition
What are the complications of fundoplication?
Recurrence of hernia
Intra-abdominal pressure/ discomfort
- unable to belch
Dysphagia
Necrosis
- if too tight
What are the symptoms of a gastric volvulus?
Borchardt’s triad:
- epigastric pain
- retching and unable to bring anything up
- NG tube won’t go down
What is the investigation of choice for Hiatus hernia and what will be seen?
Endoscopy
- Z - line deformity
What are the differential diagnosis of GORD/ Hiatus hernia?
Stomach cancer
Pancreatic cancer
Cardiovascular pain
Peptic ulcer
What are biopsies of gastric carcinoma sent away for?
Histology
HER protein status
H.Pylori testing
What are the complications of a gastrectomy?
Dumping syndrome
Vitamin B12
Anastomosis leak
What clinical signs may be seen with Cholecystitis ?
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
What should be done pre-endoscopy?
Fast for 3 hours
IV access
Consented
Notes are present
List some causes of motility dysphasia:
Achalasia
Nutcracker esophagus
Diffuse esophageal spasm
How does Cholangiocarcinoma present?
Steatorrhea with clay like stools
Weight loss
RUQ mass
Intermittent RUQ pain
Anatomically where does the esophagus narrow?
Cricoid
Posterior to left bronchus and aorta
Lower esophageal sphincter
What is the treatment for achalasia?
Calcium channel blockers
PPIs
Surgical:
- Balloon Dilation
- Heller’s myotomy
Name two surgical approaches to esophageal cancer:
Radiofrequency ablation
- via endoscope
Ivor Lewis - abdominal + Right thoracotomy
Trans- Hiatal Approach - abdominal incision
What are the complications of a NIssan fundoplication?
Bloating
-unable to belch
Esophageal ischemia
- too tight
Dysphagia
- too tight
List some complications of peptic ulcers:
Bleeding
- acute and chronic
Malignancy
Perforation
Obstruction
- gastric outflow obstruction
What are the indications for surgery following an upper G.I bleed?
Rebleed
Bleeding despite 6 units transfused
Rockall score >3 initially
Uncontrollable bleeding at endoscopy
Which of the peptic ulcers is most likely to perforated?
Duodenal
What is an abnormal duct dilatation of the biliary tract?
6mm + 1mm for every decade after 60
What are some causes of gallstone formation?
supersaturation of cholesterol Hyperlipidemia Bowel stasis - TPN Malnutrition Crohn's disease - lack of bile acid reabsorption
When should Barrett’s esophagus be endoscopically checked?
No dysplasia - 2-5 years
Low grade dysplasia - 6 months
- biopsies
High grade dysplasia - 3 months
If there is high grade dysplasia on Barrett’s esophagus how should it be treated?
Endoscopic mucosal resection
How is a Boerhaave’s Syndrome investigated and treated?
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
List some mobility disorders of the esophagus
Achalasia
Chagas disease
Diffuse esophageal spasm
Nut cracker esophagus
CREST syndrome
Physiological barriers against GORD?
Angle of His
Lower Esophageal Sphincter tone
Intra abdominal pressure
Oblique muscle of stomach
Saliva swallowing
What are the two new surgical techniques for GORD?
Endoscopic surgery:
Linx
- magnetic beads forming a sphincter
Stretta technique
- radioablation
What is the gold standard for staging oesphageal cancer?
Endoscopic ultrasound
**note that endoscopic ultrasound is gold standard for all upper G.I malignancies
