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Imperial Medicine Year 3 > Upper GI Surgery - AS > Flashcards

Upper GI Surgery - AS Flashcards

1
Q

Oesophageal anatomy

A
  • 25cm long muscular tube
  • Starts at level of cricoid cartilage (C6)
  • In the neck lies the visceral column
  • Runs in posterior mediastinum and passes through right crus of diaphragm @ T10
  • Continues for 2-3cm before entering the cardia
  • 3 locations of narrowing
    Level of cricoid
    Posterior to left main bronchus and aortic arch
    LOS
  • Divided into 3rds: reflects change in musculature from striated –> mixed –> smooth.
  • Lined by non-keratinising squamous epithelium
  • Z-line: transition from squamous –> gastric columnar

For other dysphagia differentials - go to GASTRO

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2
Q

What is plummer-vinson syndrome?

A

Severe IDA –>
- hyperkeratinisation of upper 3rd of oesophagus –> Web formation

  • triad of dysphagia, glossitis, iron-deficiency anaemia.
  • Pre-malignant: 20% risk of SCC.
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3
Q

What is an oesophageal rupture caused by?

A

Iatrogenic (85%-90%) - endoscopy, biopsy, dilatation

Violent emesis: Boerhaave’s syndrome

Carcinoma

Caustic ingestion

Trauma: surgical emphysema ± pneumothorax

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4
Q

What are the features of oesophageal rupture ?

A

Odonophagia
Mediastinitis: tachypnoea, dyspnoea, fever, shock
Surgical emphysema

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5
Q

Management of rupture of oesophagus?

A

Iatrogenic: PPI, NGT, Abx

Other: Resus, PPI, antifungals, debridement and formation of oesophago-cutaneous fistula with T-tube.

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6
Q

What is the epidemiology of oesophageal cancer?

A

Incidence: 12/100,000, increasing (increased change of Barrett’s.

Age: 50-70 yrs
Sex: M>F = 5:1

Geo: increased in iran, transkei, china

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7
Q

What are the risk factors for oesophageal cancer?

A
  • ETOH
  • Smoking
  • Achalasia
  • GORD –> Barrett’s
  • Plummer-Vinson
  • Fatty diet
  • Decreased Vit A and C
  • Nitrosamine exposure
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8
Q

What is the pathophysiology of adenocarcinoma?

A

65% adenocarcinoma

35% SCC

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9
Q

Where does adenocarcinoma occur?

A

Lower 3rd

GORD –> Barrett’s –> Dysplasia –> Ca

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10
Q

Where does squamous cell carcinoma occur?

A

Upper and middle 3rd
Associated with ETOH and smoking. Achalsaia increases risk of squamous cell carcinoma
Commonest type worldwide.

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11
Q

Presentation of oesophageal cancer?

A
  • Progressive dysphagia: solid leading to liquids
  • Often altered dietary habits –> soft foods –> exacerbation of weight loss.
  • Weight loss
  • retrosternal chest pain
  • Lymphadenopathy
  • Upper 3rd
  • Hoarseness: recurrent laryngeal nerve invasion
  • Cough ± aspiration pneumonia
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12
Q

Spread of oesophageal cancer?

A
  • Direct extension, lymphatic and blood

- 75% of pts have mets @ Dx.

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13
Q

Investigations of oesophageal cancer?

A

Bloods

  • FBC: anaemia
  • LFTs: hepatic mets, albumin

Diagnosis

  • Upper GI endoscopy: allows biopsy
  • Ba swallow: not often used, apple-core stricture.

Staging for oesophageal cancer

  • CT
  • EUS - Aids visualisation of local invasion as it displays layers of the wall.

Laparoscopy/mediastinoscopy: Mets.

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14
Q

Staging for TNM?

A 
Tis: Carcinoma in situ
T1: Submucosa
T2: muscularis propria (circ/long) 
T3: Adventicia 
T4: adjacent structures 
N1: regional nodes
M1: distant mets
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15
Q

Management of oesophageal cancer?

A

Discuss in an MDT

  • Upper GI surgeon + gastroenterologist
  • Radiologist
  • Pathologist
  • Oncologist
  • Specialist nurses
  • Macmillan nurses
  • Palliative care
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16
Q

Surgical management of oesophageal cancer?

A

Only 25-30% habe resectable tumours
May be offered neo-adjuvant chemo before surgery to downstage tumour e.g cisplatin + 5FU

Approaches
-Ivor-Lewis (2 stages): abdominal + R thoracotomy

  • McKeown (3 stags): abdominal + R thoracotomy + left neck incision
  • Trans-hiatal: abdominal incision

Progronisis
- Stage dependent
~15% 5 yrs.

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17
Q

Palliative treatment of oesophageal cancer?

A
  • Majority of patients
  • Laser coagulation
  • Alcohol injection + decreased ascites with spironolactone).
  • Stenting and secretion reduction (hyoscine patch)
  • Analgesia: e.g fentanyl patches
  • Radiotherapy: external or brachytherapy
  • Referral
    Palliative care team
    Macmillan nurses

Prognosis

  • 5yrs <5%
  • Median: 4 months
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18
Q

What are the benign oesophageal tumours?

A

Leiomyoma
Lipomas
Haemangiomas
Benign polyps

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19
Q

What is the pathophysiology of a perforated peptic ulcer

A

Perforated duodenal ulcer is commonest

  • 1st part of the duodenum; highest acid conc
  • Ant perofration –> air under diaphragm
  • Posterior perforation can erode into GDA –> bleed.
  • 3/4 of duodenum retroperitoneal therefore no air under diaphragm if perforated.

Perforated GU
Perforated Gastric Ca.

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20
Q

Presentation of perforated peptic ulcer?

A
  • Sudden onset severe pain, beginning in the epigastrium and then becoming generalised
  • Vomiting
  • Peritonitis
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21
Q

Differential for perforated peptic ulcer?

A

Pancreatitis
Acute Cholecystitis
AAA
MI

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22
Q

Investigations for Perforated Peptic Ulcer?

A

Bloods: FBC, U+E, Amylase, CRP, G+S, clotting.
ABG: ?mesenteric ischaemia

Urine Dipstick

Imaging 
- Erect CXR 
Must be erect for ~15 mins first 
- Air under the diaphragm seen in 70% 
-False +ve in Chailaditi's sign - Chilaiditi syndrome is a rare condition when pain occurs due to transposition of a loop of large intestine

AXR
- Rigler’s: Air on both sides of bowel wall. This is indicative of pneumoperitoneum.

CT is preferred method for detecting free air in the abdomen. Whenever you see this THIS IS A PERFORATION.

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23
Q

Management of Perforated Peptic Ulcer? Resuscitation

A

Resuscitation

NBM
Aggressive fluid resuscitation
- Urinary catheter ± CVP line

Analgesia: morphine 5-10mg/2hr max. ± cyclizine.

Abx: cef and met

NGT

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24
Q

Management of Perforated Peptic Ulcer? Conservative

A
  • May be considered if patient isn’t peritonitic
  • Careful monitoring, fluids +Abx.
  • Omentum may seal perforation spontaneously preventing operation in 50%.
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25
Management of perforated peptic ulcer? Surgical?
- Surgical: laparotomy DU: abdominal washout + omental patch repair. Large bites using 0 Vicryl are taken above and below ulcer base to occlude vessel. GU: Excise ulcer and repair defect. Partial/gastrectomy may rarely be required. Send specimen to histo: exclude Ca. Test and treat - 90% of Perforated PU associated with H.pylori.
26
Gastric outlet obstruction causes?
- Late complication of PUD --> fibrotic stricture | - Gastric Cancer
27
Presentation of gastric outlet obstruction?
Hx of bloating, early satiety and nausea Outlet obstruction - Copious projectile non-bilious vomiting a few hrs after meals. - Contains stale food. - Epigastric distention + succussion splash.
28
Investigations for Gastric Outlet Obstruction?
ABG: Hypochloraemic hypokalaemic met alkalosis AXR: dilated gastric air bubble, air fluid level. Collapsed distal bowel. OGD Contrast meal.
29
Management of Gastric Outlet Obstruction?
Correct metabolic abnormality: 0.9% NS + KCL. Benign - Endoscopic balloon dilatation - Pyloroplasty or gastroenterostomy Malignant - Stenting - Resection In children with pyloric stenosis - consider ramstedt pyloromyotomy.
30
Gastric cancer incidence?
23/100,000 Primary in 50s Sex: M>F. Mainly in japan, eastern europe, china, S.america.
31
Risk factors for gastric cancer?
Atrophic gastritis (--> Intestinal metaplasia) - Pernicious anaemia/AI gastritis - H.pylori Diet: Increased nitrates --> smoked, pickled, salter (Increased in Japan). Nitrates --> carcinogenic nitrosamine in GIT. - Smoking - BLood group A (gAstric cAncer) - Low SEC - Familail: E.cadherin abnormality - Partial gastrectomy cancer.
32
Pathology of gastric cancer?
- Mainly adenocarcinoma - Usually located on gastric antrum - H.Pylori may --> MALToma -Histology: Signet ring cells may be seen in gastric
33
Classification of gastric cancer
Depth of invasion - Early gastric Ca; mucosa or submucosa - Late gastric ca: muscularis propria breached. Microscopic appearance - Intestinal: bulky, glandular tumour, heaped ulceration - Diffuse: Infiltrativie with signet ring cell morphology
34
Borrmann Classification of gastric cancer?
1. Polypoid/fungating 2. Excavating 3. Ulcerating and raised 4. Linitis plastica: leather bottle like thickening with flat rugae. Tumours of gastro-oesophageal junction are classified below - Type 1 = True oesophageal cancer + may be associated with Barrett's oesophagus - Type 2 = Carcinoma of the cardia, arising from cardiac type epithelum.
35
Symptoms of gastric cancer?
- Usually present late - Wt loss + anorexia - Dyspepia: epigastric or retrosternal pain/discomfort - Dysphagia - N/V.
36
Signs of gastric cancer?
- Anaemia - Epigastric mass - Jaundice - Ascites - Hepatomegaly - Virchow's node (=Troisier's sign) - Acanthosis nigricans
37
Complications of gastric cancer?
Perforation Upper GI bleed: haematemesis, melaena Gastric outlet obstruction --> Succussion splash
38
Spread of gastric cancer?
w/i stomach. Linitis plastica Direct invasion: pancreas Lymphatic: Virchow's node Blood: Liver and lung Transcoelomic - Ovaries: Krukenberg Tumour (Signet ring morph) - Sister Mary Joseph nodule: Umbilical mets
39
Investigations for gastric cancer/
Investigations - Bloods FBC: anaemia LFTs and clotting Imaging - CXR: mets - USS: Liver mets - Gastroscopy + biopsy - Ba meal Staging - Endoluminal US - CT/MRI (normally 1st line staging investigations) - Diagnostic laparoscopy
40
Management of Gastric Cancer? Palliation
Medical palliation - Analgesia - PPI - Secretion control - Chemo: epirubicin, 5FU, cisplastin - Palliative care team
41
Surgical palliation for gastric cancer?
Pyloric stenting | Bypass procedures
42
Curative surgery for gastric cancer?
EGC may be resected endoscopically Partial or total gastrectomy with roux-en-Y to prevent bile reflux - Spleen and part of pancreas may be removed Proximally sited disease greater than 5-10 cm from OG junction can be treated with subtotal gastrectomy Total gastrectomy if tumour is <5cm from OG junction.
43
What are the other gastric neoplasms? Benign
Benign polyps Leiomyoma Lipomas Haemangiomas
44
What are the malignant gastric neoplasms.
Lymphoma Carcinoid GIST
45
What is a Gastrointestinal Stromal Tumour?
Commonest mesenchymal tumour of the GIT | >50% occur in the stomach.
46
Pathology of GIST?
Arise from intestinal cells of Cajal - Located in muscularis propria - Pacemaker cells OGD: well-demarcated spherical mass with central punctum
47
Presentation of GIST?
Mass effect: abdo pain, obstruction | Ulceration --> Bleeding
48
Poor prognosis of GIST?
Increased size Extra-gastric location Increased mitotic index
49
Management of GIST?
Medical - For unresectable, recurrent or metastatic disease - Imatinib: kit selctive tyrosine kinase inhibitor Surgical - Resection
50
Gastric lymphoma?
Commonest site for extranodal lymphoma - Most commonly MALToma due to chronic H.Pylori gastritis H.pylori eradication can be curative.
51
What is Zollinger-Ellison Syndrome?
Pathophysiology - Gastrin secreting tumour most commonly found in the small intestine or pancreas - Increased Gastrin --> Increased HCL --> PUD + chronic diarrohea due to inactivation of pancreatic enzymes. ECL proliferation can --> carcinoid tumours. 60-90% of gastrinomas are malignant 25% association with MEN1
52
Presentation of Zollinger-Ellison Syndrome?
- Abdo pain + dyspepsia - Chronic Diarrhoea/Steatorrhoea - Refractory PUD
53
Management of ZE Syndrome?
High dose PPI Surgery - Tumour resection - May do subtotal gastrectomy with Roux en Y
54
Bariatric Surgery benefits?
``` Sustained weight loss Symptom improvement - Sleep apnoea - Mobility - HTN - DM ```
55
Indications of bariatric surgery
All criteria must be met - BMI >40 or >35 with significant comorbidities that could improve with weight - Failure of non-surgical Mx to achieve and maintain clinically beneficial weight loss for 6 months. - Fit for surgery and anaesthesia - Diet, physical activity, psychosocial concerns medical monitoring If BMI >50, surgery is 1st line Management
56
What are the two types of bariatric surgery?
Laparoscopic Gastric Banding | Roux -en- Y
57
Laparoscopic gastric banding?
Inflatable silicone band around proximal stomach - limits food intake + slows digestion
58
Roux-en-Y gastric bypass
- Oesophagojejunostomy allows bypass of stomach duodenum and proximal jejunum. - Alters secretion of hormones influencing glucose regulation + perception of hunger - Greater weight loss and lower reoperation rates Complications - Dumping syndrome - Wound infection - Hernias - malabsorption - Diarrhoea - Mortality
59
Raised Urea and normocytic anaemia?
Upper GI bleed.
60
Imatinib?
GIST | CML
61
Basiliximab?
Renal transplant
62
Adalimumab, INfliximab, Etanercept?
TNF alpha inhibitor Crohns RA
63
Trastuzumab?
HER receptor | Breast Cancer
64
Cetuximab
EGF positive colorectal cancer
65
Categorisation of a Upper GI bleed?
Ligament of Treitz. Found at the duodenojejunal flexure. Marks boundary between first and second parts of the small intestine and formal boundary of Upper GI and lower GI bleed.

Imperial Medicine Year 3 (35 decks)

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