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Clinical > Upper GI surgery > Flashcards

Upper GI surgery Flashcards

1
Q

Mortality rate of upper GI bleed

A

10%

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2
Q

most common cause of upper GI bleed

A

peptic ulcer 36%

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3
Q

Typical presentation of upper GI bleeds

A

haematemesis and melaena

occasionally haematochezia

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4
Q

Risk factors for upper GI bleed

A 
Alcohol
Smoking
Liver disease
NSAIDs
Vomiting
Steroids
PUD
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5
Q

When can you do an OGD for a patient with an upper GI bleed?

A

first resuscitation if hypotensive
If stable then scope within 24hrs
If unstable then scope urgently to intervene with haemostat clips, adrenaline injections, haemostat powder.
If massive haemorrhage then activate hospital’s transfusion protocol

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6
Q

Summary of massive transfusion protocol

A

O neg until x matched available
then balanced transfusion of RCC, platelets and plasma 1:1:1
Keep Hb above 8 or >9 if cardiac history

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7
Q

drugs that can be given in suspected vatical bleeding

A

IV terlipressin and octreotide to reduce portal hypertension

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8
Q

Scoring system to determine the need for intervention and risk of mortality in GI bleeds

A

Glasgow Blatchford score system

based on blood urea, Hb, Systolic BP, pulse, melena, syncope, hepatic disease, cardiac failure

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9
Q

Intraluminal causes of dysphagia and odynophagia

A

Foreign body
Foreign bolus
Oesophageal webs

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10
Q

Intramural causes of dysphagia and odynophagia

A 
Neoplasm
oesophagitis
GORD
dystmotility disorders
scleroderma
neurological 
stricture
hiatus hernia
volvulus
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11
Q

Extraluminal causes of dysphagia and odynophagia

A

lymphadenopathy
goitre
pharyngeal pouch
haematoma

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12
Q

Purpose of high resolution manometry

A

to evaluate oesophageal motor function when investigating dysmotility

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13
Q

Pathophysiology of hiatus hernia

A

Widening of the diaphragmatic crura at the oesophageal hiatus and stretching the phrenoesophageal membrane

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14
Q

What is a type 1 hiatus hernia?

A

sliding hiatus hernia

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15
Q

What is a type 2-3 hiatus hernia?

A

paraoesophagheal hernias
2 rolling
3 mixed

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16
Q

What is a type 4 hiatus hernia?

A

Intra-thoracic herniation of abdominal viscera into the hernia sac

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17
Q

Type 2 / rolling hernia typically presents with or without reflux?

A

Without

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18
Q

Surgical management of a hiatus hernia?

A

Conservative for type 1

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19
Q

when to repair type 2,3,4 hernias

A

Symptomatic

  • GORD
  • gastric outlet obstruction
  • anaemia
  • Concern for gastric strangulation
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20
Q

Management of emergency presentation of gastric volvulus

A

NG tube decompression

if unsuccessful may need urgent surgical repair

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21
Q

Imaging of choice for diagnosing pancreatitis

A

CT

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22
Q

A plain radiograph of his abdomen demonstrates evidence of sigmoid volvulus. What is the next most appropriate step in management to achieve definitive resolution?

A

Flexible sigmoidoscopy decompression with a flatus tube

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23
Q

possible ddx
A 65-year-old man presents with sudden onset abdominal pain. On further questioning he comments he has not opened his bowels for 3 days and has been vomiting intermittently. On examination his abdomen is grossly distended and he is notably tender throughout.

A

Sigmoid volvulus

- plain film abdo

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24
Q

Treatment of achalasia

A

Hellers

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25
Q

What patients would be suitable for a Nissen’s fundoplication?

A
  • adequate acid control with PPI but don’t want to continue medical tx
  • adequate control with PPI but not tolerant of acid suppression tx
  • complicated reflux disease
  • Stricture formation
  • Chronic cough, laryngitis, sinusitis
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26
Q

What is gas bloat syndrome?

A

Inability to burp or vomit after a gastric procedure

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27
Q

Is partial endoluminal fundoplication more or less successful than traditional procedures?

A

Less

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28
Q

Definition of peptic ulcer disease

A

Erosions in the gastric or duodenal mucosa that extend through the muscularis mucosae

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29
Q

H pylori organism

A

Gram negative rod with flagella reside in gastric-type epithelium beneath the mucus layer

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30
Q

What enzyme do H pylori produce?

A

Urease

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31
Q

What type of PUD is more associated with vomiting?

A

gastric ulcers

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32
Q

Tx of h pylori infection

A 
Triple therapy 
PPI
amoxicillin 
Clarithromycin for 14 days 
then PPI alone for 4 weeks
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33
Q

Define barrett’s oesophagus

A

an oesophagus in which cny portion of the normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium

34
Q

normal distal oesophageal lining

A

Squamoud

35
Q

type of epithelium in barrel’s oesophagus

A

Metaplastic columnar epithelium

36
Q

Medical tx of Barrett’s oesophagus

A

High dose PPI for symptom control

aspirin may reduce progression to high grade dysplasia and carcinoma

37
Q

Indications for Barrett’s endoscopic screening

A 
must have chronic GORD + 3 of:
>50
male
white
high BMI
or 1st degree relative with Barrett's or oesophageal adenocarcinoma
38
Q

How often surveillance for Barrett’s if no dysplasia?

A

depends on segment length
< 3cm then 3-5 yrs
> 3cm then 2-3 yrs

39
Q

How often should Barrett’s with known dysplasia have surveillance?

A

Low grade - 6monthly intervals until 2 consecutive non-dysplastic biopsies
High grade - MDT discussion and eradication

40
Q

management of Barrett’s with mucosal irregularity

A

Endoscopic mucosal resection

41
Q

What grade of oesophageal tumor should be considered for surgery?

A

T1b tumor or greater - oesophagectomy

42
Q

What is the role of anti-reflux surgery in patients with Barrett’s oesophagus?

A

Does not reduce the risk of developing adenocarcinoma

43
Q

What is achalasia?

A

Failure of the LOS to relax ( due to progressive neuronal loss in the myenteric plexus)

44
Q

What is the most common primary motility disorder o the oesophagus?

A

Achalasia

45
Q

Type 3 achalasia chicago

A

Spastic activity of oesophagus - poor response to tx

46
Q

Type 2 achalasia chicago

A

waves >30mmHg throughout the oesophagus in >20% of swallows - good response to tx

47
Q

Type 1 achalasia chicago

A

Very few peristaltic waves, nove>30mmHg - good response to tc

48
Q

medical management of achalasia

A

limited results.

Calcium channel blockers and sildenafil

49
Q

Surgical procedure of choice for achalasia

A

Laparascopic Heller myotomy

- incision through longitudinal and circular muscle to open the LOS

50
Q

How long is botox effective in the tx of achalasia

A

3-6 months

51
Q

Disadvantage of POEM for achalasia

A

Higher rates of reflux due to lack of fundoplication

52
Q

What part of the oesophagus is cut for Heller myotomy?

A

Anterior

53
Q

Cork screw oesophagus

A

diffuse oesophageal spasm

54
Q

Use of pH studies in diffuse oesophageal spasm

A

rule out GORD as an underlying trigger

55
Q

Manometry results in diffuse oesophageal spasm

A

premature contraction but appropriate relaxation of the LOS

56
Q

Oesophageal cancer epidemiology for men and women

A

adenocarcinoma men 5:1

squamous cell carcinoma men 2:1

57
Q

squamous cell carcinoma most commonly affects which portion of oesophagus

A

middle 1/3

58
Q

adenocarcinoma most commonly affects which portion of oesophagus

A

lower

59
Q

hot beverages is a risk factor which type of oesophageal cancer?

A

squamous cell carcinoma

60
Q

sewer classification for surgery in early oesophagogastric junction cancer

A

Type 1 distal - 5cm oesophagectomy and proximal gastrectomy
type 2 cardia - tanshiatial/thoracic oesophagectomy or extended total gastrectomy
Type 3 proximal stomach - transmittal extended total gastrectomy

61
Q

2 types of trans thoracic oesophagectomy

A

Ivor lewis incisions in abdo and thorax

McKeown - incisions in abdo, thorax and neck

62
Q

Advantage of transhiatal vs trans thoracic approach

A

avoids thoracotomy

incisions made in abdomen and neck

63
Q

most common benign tumor of the oesophagus

A

Leiomyoma

64
Q

stomach cancer with spindle cell morphology and c-KIT receptors - what is it?

A

Gastrointestinal stromal tumor
Malignant potential
imatinib if sensitive
surgery to resect with negative margins

65
Q

Tx to induce remission of MALT lymphoma

A

Eradication of H pylori with antibiotics

66
Q

Gastric neuroendocrine tumors most commonly arise in what part of stomach

A

Body

mostly from Enterochromaffin like cells

67
Q

What sort of stomach cancer is associated with zollonger-ellision syndrome?

A

gastric neuroendocrine type 2

associated with MEN1

68
Q

When to refer for urgent OGD suspicious of gastric cancer

A

any of

  1. Dysphagia
  2. Age >55, weight loss +any of;
    • upper abdo pain
    • reflux
    • dyspepsia
  3. Upper abdominal mass
69
Q

A 35-year-old man A&E following an episode of severe vomiting. Sudden onset chest and neck pain. On examination , crepitus in his suprasternal notch. What is the first initial investigation in the emergency department?

A

Dgx = oeso perforation → do CXR

70
Q

A 10-year-old boy, ingestion of household bleach. He complains of severe pain in his mouth and stomach. temperature of 38.5o C, a blood pressure of 105/65mmHg and pulse rate of 135 beats/min. What is the next most appropriate initial investigation?

A

Dgx = corrosive oesophagiits → urgent endoscopic

71
Q

Hiatus hernia. The following are all true with regards to hiatus hernias EXCEPT?

Such hernias are associated with bleeding
Rolling (paraoesophageal) hernias are associated with reflux
Sliding hernias are more common than rolling hernias
Proton pump inhibitors may be useful
Rolling (paraoesophageal) hernias may be associated with gastric volvulus

A

Sliding hernias are more common than rolling hernias
Such hernias are associated with bleeding
Proton pump inhibitors may be useful
Rolling (paraoesophageal) hernias may be associated with gastric volvulus
False = Rolling (paraoesophageal) hernias are associated with reflux

72
Q

The following are all examples of hepatic jaundice EXCEPT?

Viral hepatitis / Crigler–Najjar syndrome / Malaria / Gilbert’s syndrome / Dubin Johnson Rotor syndrome/

A 
True = Viral hepatitis / Crigler–Najjar syndrome / Gilbert’s syndrome / Dubin Johnson Rotor syndrome
False = Malaria
73
Q

Boas sign

A

Boas’ sign which is hyperaesthesia below the right scapula.

Seen in acute cholecystitis

74
Q

Grey turner’s sign

A

Bruising of the flanks = blue

Seen in acute pancreatitis

75
Q

Cullen’s sign

A

Bruising around umbilicus

76
Q

Acute cholangitis organism

A

E coli

77
Q

A long-term alcohol abuser presents with central abdominal pain radiating to his back. Routine blood investigations confirm an amylase of greater than 1000 IU/l. The following are all indicators of a severe attack of pancreatitis EXCEPT?
Age greater than 55
Blood urea concentration greater than 16mmol/l
Blood glucose concentration greater than 5mmol/l
Serum albumin less than 32g/l
Serum calcium concentration less than 2mmol/l
Glucose > 10

A

False = Blood glucose concentration greater than 5mmol/l

78
Q

Elevated in pancreatic cancer

A

Tumor markers . Serum CA 19-9 and serum carcinoembryonic antigen (CEA)

79
Q

malena is the result of bleeding proximal to what

A

ligament of treitz

80
Q

impact of b blockers on patient presenting to ED with upper GI bleed

A

can mask a tachycardia at presentation

81
Q

When should a patient with bleeding varices be brought to endoscopy

A

Early <12hrs

82
Q

Management option for variceal bleed if can’t get patient to surgery

A

Sengstalen Blakemore tube

Clinical (45 decks)

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