Upper GI surgery Flashcards
GORD
Symptoms or complications due to reflux of gastric contents into oeseophagus
Sx: heartburn, acid regurgitation, dyspepsia (indigestion), Risk fx: older, hiatus hernia, obesity
Causes: increased relaxation of LOS
Ix: PPI trial 8 wks
Upper GI endoscopy (oesophagitis - ulcers, erosions)
Barium swallow - dysphagia
DDx: MI, Achalasia, Peptic ulcer
Tx: PPI (omeprazole) (inhibits K+/H+ pump on parietal gastric cells, causing decreased H+ secretion)
sugery: open/laprascopic fundoplication (wrapping fundus of stomach around oesophagus)
Hiatus hernia
Hernia: protrusion of organ/part of organ through the wall of the cavity that contains it
Hiatus hernia: protrusion of abdo contents through oseophageal hiatus (opening) of diaphragm
Risk fx: increased intra-abdo pressure (pregnancy, obesity), decreased diaphragmatic tone
Sliding: stomach slides through the hiatus
Sx: regurgitation
rolling: stomach rolls up anteriorly through hiatus, whilst
cardia of stomach remains in position. Lies alongside normally positioned gastro-oesopageal junction
Sx: cough, SOB (due to hernia in thorax), reflux, epigastric pain, dysphagia (due to oesophagitis)
Ix: CXR (retrocardiac gas bubble), upper GI endoscopy (displacement of GOJ)
Tx: PPI (symptoms of reflux), laprascopic surgery (fundoplication) - if symptomatic despite medical therapy, rolling (risk of strangulation
Gastritis, duodenitis
Inflammation of gastric mucosa
Non erosive gastritis: H. Pylori
Erosive gastritis: NSAIDs, alcohol
Autoimmune gastritis: autoantibodies to parietal cells leading to pernicious anaemia. Increased risk in autoimmune conditions, Northern European descent
Sx: dyspepsia, epigastric pain, N+V
no symptoms of GI Ca. (weight loss, dysphagia, anaemia)
Ix: FBC (increased WBC), H.pylori urease breathe test, H.pylori faecal antigen test (needs to discontinue PPI for 2 wks, and abx for 4ks)
Endoscopy (biopsy for H.pylori) exclude malignancy
Duodenitis
Causes: H.pylori, NSAIDs, coeliac
Peptic ulcer disease
Break in lining of GI tract, to the muscularis mucosae of bowel wall (more than 5mm)
(Ulcers small than that are called erosions)
Can be anywhere in GI tract but mostly, proximal stomach and duodenum
Causes: imbalance of acid secretion and mucosal barrier. Stomach normally protected by parietal cells. When defence compromised, ulcers form
H.pylori (produces urease which breaks down urea into ammonia which neutralises pH, allowing more acid production. Produce cytotoxins which damage mucosa)
NSAIDs (as reduces prostaglandin synthesis which protects mucosa)
Burns (Curling’s ulcer)
Head injury (Cushing’s ulcer - increased ICP)
Zollinger Ellison syndrome (islet cell tumour of pancreas which doesnt secrete insulin, secretes gastrin like hormone. Multiple ulcers)
Duodenal (80%)
30-40yrs, men, sx: pain can radiate to back (as ulcer penetrates into pancreas)
Gastric: NSAIDs, 40-50yrs
Sx: recurrent epigastric pain, pain 2hrs after eating (so pt thinks pain is before a meal)
pain worse on spicy foods, better with milk
Heartburn, N+V
Ix: Upper GI endscopy (>55yrs + weight loss)
H.pylori urease breathe test (pt ingests c13 labelled urea. H.pylori breaks this down into ammonia and HCO3 and expired CO2 is measured
Tx: PPI (omeprazole) + 2 abx (metranidazole+ amox/clary)
Acid reduction: omeprazole or ranitidine (H2 antagonist)
Bleeding: endoscopy+blood transfusion+PPI
Surgery: complications of ulceration (bleeding, perf)
Gastric ulcers: partial gastrectomy (antrectomy + Roux en Y bypass)
Duodenal ulcers: removed body and lesser curve of stomach (most acid secreting) and Roux en Y bypass
Chronic pancreatitis
Progressive injury to pancreas leading to scarring and loss of function. Reduced exocrine function (malabsorption), endocrine function (diabetes), pancreatic calcifications
Causes: alcohol, idiopathic, genetic (annular pancreas), autoimmune (PBC, PSC), ERCP
Sx: epigastric, dull, radiates to back, obstructive jaundice (compression of bile duct), N+V, weight loss, steatorrhea
Ix: BM (high glucose), faecal fat analysis,
CT (pancreatic calcifications, pancreatic duct dilation)
MRCP/ERCP - beading of pancreatic duct (dilationa and obstruction of duct)
Tx: analgesics, lifestyle changes, pancreatic enzymes+PPI (pancreatin), insulin
Surgery: partial pancreatectomy
Pancreatic carcinoma
60% head of pancreas
25% body
15% tail
Ductal adenocarcinoma (arise from cells in pancreatic duct)
Acinar cell carcinoma
Undifferentiated
Sx: painless progressive jaundice, 50% epigastric pain, diabetes, weight loss
Signs: jaundice, palpable gallbladder, epigastric mass
Spread: direct into CBD (obstructive jaundice), duodenum
blood to liver
Ix: Abdo US (distended CBD, pancreatic mass) CT pancreas (tumour mass)
Tx: symptomatic
Surgery (if localised to periampullary region) - Whipple’s (part of duodenum, pancreatic head, CBD)
Endoscopic stent - across ampulla and through obstructed CBD (palliative)
Oesophageal carcinoma
Postcricoid carcinoma - women, assoc. Plummer Vinson syndrome (oesophageal webs, IDA)
Squamous - smoking, achalasia, alcohol (upper 2/3)
Adenocarcinoma - Barrett’s, obesity, GORD (lower 1/3)
Barret’s oesophagus: strat squamous to columnar
Sx: dyspagia (solids then liquids), cough, hoarse voice, weight loss
Ix: OGD + biopsy (columnar lined epithelium proximal to gastro-oesophageal junction)
Tx: PPI, radiofrequency ablation
Ix: OGD (upper GI endoscopy)
CT thorax, abdo (metastases)
PET-CT
Tx: Endoscopic resection, oesophagectomy
Pailliation: stent (relieve dysphagia), radiotherapy, chemo
Gastric carcinoma
Gastric adenocarcinoma
Gastrointestinal stromal tumour (from interstitial cells of Cajal) assoc. with neurofibromatosis 1
Risk fx: chronic peptic ulcers, H.pylori, smopking, HNPCC (hereditary non-polyposis colon cancer)
Sx: epigastric pain, radiates to back (pancreatic involvement)
Signs: weight loss, anaemia, jaundice (yellow tinge), abdo mass, left supraclavular lymphadenopathy (Virchow’s node)
DDx: gastric ulcer
DDx anaemia, weight loss, yellow tinge:
gastric carcinoma, pancreatic ca, pernicious anaemia, ureamia
Spread: local into oesophagus, duodenum
lymphatic to Virchow’s node
Blood via portal vein to liver
Transcoelomic: Krukenberg’s tumor (to ovary)
Ix: Upper GI endoscopy+biopsy
CT thorax, abdo (mets)
Tx: partial/complete gastrectomy
palliative stent
Tumours of small bowel
Benign: Adenoma
Malignant: Adenomcarcinoma, carcinoid
Sx: intestinal bleeding, obstruction Carcinoid tumours: Neuroendocrine tumours Slow growing Appendix most common Secretes 5-HT (serotonin)
Sx: flushing, palpitations
Ix: urinary 5-HAA
Colon carcinoma
Benign: adenomatous polyp
Malignant: Carcinoma
Risk fx: Age, UC, inherited conditions (FAP, HNPCC)
Famlial adenomatous polyp
Autosomal dominant
Invariably leads to carcinoma
Hereditary non-polyposis colon carcinoma
Autosomal dominant
Mutation in MSH2, MHL1
Sx: change in bowel habits + mucus/bleeding,
obstruction (common in left: descending), perforation
Signs: abdo mass, signs of spread - ascites, hepatomegaly, weight loss
Tumours left side: obstructive (as stool is solid)
Tumours right side: weight loss, anaemia
Ix: faecal occult blood, sigmoidoscopy, colonoscopy, CT colonography, CEA
Tx: surgery, chemo Prognosis: Duke's staging A: mucosa B: muscularis propria C: spread to LNs D: distant mets
Tx:
Right colon: right hemi-colectomy + ileocolic anastomosis
Left colon: left hemi-colectomy or sigmoid colectomy + anastomosis colon with rectum (Hartmann’s (emergency) - distal bowel left in and closed off, proximal part (end colostomy)
Based on blood supply
Superior mesenteric a: caecum, ascending, 2/3 transverse)
Inferior mesenteric a: 1/3 transverse, descending, sigmoid, rectum
Rectal
Upper third: anterior resection (sigmoid and lower rectum anastomosis)
Lower third (near anal verge): abdominoperineal excision of rectum + terminal colostomy
