Upper GI surgery Flashcards
Mortality rate of upper GI bleed
10%
most common cause of upper GI bleed
peptic ulcer 36%
Typical presentation of upper GI bleeds
haematemesis and melaena
occasionally haematochezia
Risk factors for upper GI bleed
Alcohol Smoking Liver disease NSAIDs Vomiting Steroids PUD
When can you do an OGD for a patient with an upper GI bleed?
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
Summary of massive transfusion protocol
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
drugs that can be given in suspected vatical bleeding
IV terlipressin and octreotide to reduce portal hypertension
Scoring system to determine the need for intervention and risk of mortality in GI bleeds
Glasgow Blatchford score system
based on blood urea, Hb, Systolic BP, pulse, melena, syncope, hepatic disease, cardiac failure
Intraluminal causes of dysphagia and odynophagia
Foreign body
Foreign bolus
Oesophageal webs
Intramural causes of dysphagia and odynophagia
Neoplasm oesophagitis GORD dystmotility disorders scleroderma neurological stricture hiatus hernia volvulus
Extraluminal causes of dysphagia and odynophagia
lymphadenopathy
goitre
pharyngeal pouch
haematoma
Purpose of high resolution manometry
to evaluate oesophageal motor function when investigating dysmotility
Pathophysiology of hiatus hernia
Widening of the diaphragmatic crura at the oesophageal hiatus and stretching the phrenoesophageal membrane
What is a type 1 hiatus hernia?
sliding hiatus hernia
What is a type 2-3 hiatus hernia?
paraoesophagheal hernias
2 rolling
3 mixed
What is a type 4 hiatus hernia?
Intra-thoracic herniation of abdominal viscera into the hernia sac
Type 2 / rolling hernia typically presents with or without reflux?
Without
Surgical management of a hiatus hernia?
Conservative for type 1
when to repair type 2,3,4 hernias
Symptomatic
- GORD
- gastric outlet obstruction
- anaemia
- Concern for gastric strangulation
Management of emergency presentation of gastric volvulus
NG tube decompression
if unsuccessful may need urgent surgical repair
Imaging of choice for diagnosing pancreatitis
CT
A plain radiograph of his abdomen demonstrates evidence of sigmoid volvulus. What is the next most appropriate step in management to achieve definitive resolution?
Flexible sigmoidoscopy decompression with a flatus tube
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.
Sigmoid volvulus
- plain film abdo
Treatment of achalasia
Hellers
What patients would be suitable for a Nissen’s fundoplication?
- 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
What is gas bloat syndrome?
Inability to burp or vomit after a gastric procedure
Is partial endoluminal fundoplication more or less successful than traditional procedures?
Less
Definition of peptic ulcer disease
Erosions in the gastric or duodenal mucosa that extend through the muscularis mucosae
H pylori organism
Gram negative rod with flagella reside in gastric-type epithelium beneath the mucus layer
What enzyme do H pylori produce?
Urease
What type of PUD is more associated with vomiting?
gastric ulcers
Tx of h pylori infection
Triple therapy PPI amoxicillin Clarithromycin for 14 days then PPI alone for 4 weeks
Define barrett’s oesophagus
an oesophagus in which cny portion of the normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium
normal distal oesophageal lining
Squamoud
type of epithelium in barrel’s oesophagus
Metaplastic columnar epithelium
Medical tx of Barrett’s oesophagus
High dose PPI for symptom control
aspirin may reduce progression to high grade dysplasia and carcinoma
Indications for Barrett’s endoscopic screening
must have chronic GORD + 3 of: >50 male white high BMI or 1st degree relative with Barrett's or oesophageal adenocarcinoma
How often surveillance for Barrett’s if no dysplasia?
depends on segment length
< 3cm then 3-5 yrs
> 3cm then 2-3 yrs
How often should Barrett’s with known dysplasia have surveillance?
Low grade - 6monthly intervals until 2 consecutive non-dysplastic biopsies
High grade - MDT discussion and eradication
management of Barrett’s with mucosal irregularity
Endoscopic mucosal resection
What grade of oesophageal tumor should be considered for surgery?
T1b tumor or greater - oesophagectomy
What is the role of anti-reflux surgery in patients with Barrett’s oesophagus?
Does not reduce the risk of developing adenocarcinoma
What is achalasia?
Failure of the LOS to relax ( due to progressive neuronal loss in the myenteric plexus)
What is the most common primary motility disorder o the oesophagus?
Achalasia
Type 3 achalasia chicago
Spastic activity of oesophagus - poor response to tx
Type 2 achalasia chicago
waves >30mmHg throughout the oesophagus in >20% of swallows - good response to tx
Type 1 achalasia chicago
Very few peristaltic waves, nove>30mmHg - good response to tc
medical management of achalasia
limited results.
Calcium channel blockers and sildenafil
Surgical procedure of choice for achalasia
Laparascopic Heller myotomy
- incision through longitudinal and circular muscle to open the LOS
How long is botox effective in the tx of achalasia
3-6 months
Disadvantage of POEM for achalasia
Higher rates of reflux due to lack of fundoplication
What part of the oesophagus is cut for Heller myotomy?
Anterior
Cork screw oesophagus
diffuse oesophageal spasm
Use of pH studies in diffuse oesophageal spasm
rule out GORD as an underlying trigger
Manometry results in diffuse oesophageal spasm
premature contraction but appropriate relaxation of the LOS
Oesophageal cancer epidemiology for men and women
adenocarcinoma men 5:1
squamous cell carcinoma men 2:1
squamous cell carcinoma most commonly affects which portion of oesophagus
middle 1/3
adenocarcinoma most commonly affects which portion of oesophagus
lower
hot beverages is a risk factor which type of oesophageal cancer?
squamous cell carcinoma
sewer classification for surgery in early oesophagogastric junction cancer
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
2 types of trans thoracic oesophagectomy
Ivor lewis incisions in abdo and thorax
McKeown - incisions in abdo, thorax and neck
Advantage of transhiatal vs trans thoracic approach
avoids thoracotomy
incisions made in abdomen and neck
most common benign tumor of the oesophagus
Leiomyoma
stomach cancer with spindle cell morphology and c-KIT receptors - what is it?
Gastrointestinal stromal tumor
Malignant potential
imatinib if sensitive
surgery to resect with negative margins
Tx to induce remission of MALT lymphoma
Eradication of H pylori with antibiotics
Gastric neuroendocrine tumors most commonly arise in what part of stomach
Body
mostly from Enterochromaffin like cells
What sort of stomach cancer is associated with zollonger-ellision syndrome?
gastric neuroendocrine type 2
associated with MEN1
When to refer for urgent OGD suspicious of gastric cancer
any of
- Dysphagia
- Age >55, weight loss +any of;
- upper abdo pain
- reflux
- dyspepsia
- Upper abdominal mass
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?
Dgx = oeso perforation → do CXR
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?
Dgx = corrosive oesophagiits → urgent endoscopic
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
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
The following are all examples of hepatic jaundice EXCEPT?
Viral hepatitis / Crigler–Najjar syndrome / Malaria / Gilbert’s syndrome / Dubin Johnson Rotor syndrome/
True = Viral hepatitis / Crigler–Najjar syndrome / Gilbert’s syndrome / Dubin Johnson Rotor syndrome False = Malaria
Boas sign
Boas’ sign which is hyperaesthesia below the right scapula.
Seen in acute cholecystitis
Grey turner’s sign
Bruising of the flanks = blue
Seen in acute pancreatitis
Cullen’s sign
Bruising around umbilicus
Acute cholangitis organism
E coli
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
False = Blood glucose concentration greater than 5mmol/l
Elevated in pancreatic cancer
Tumor markers . Serum CA 19-9 and serum carcinoembryonic antigen (CEA)
malena is the result of bleeding proximal to what
ligament of treitz
impact of b blockers on patient presenting to ED with upper GI bleed
can mask a tachycardia at presentation
When should a patient with bleeding varices be brought to endoscopy
Early <12hrs
Management option for variceal bleed if can’t get patient to surgery
Sengstalen Blakemore tube
