Upper GI Tract

Question 1

What investigation would you carry out next?

Case 1

45 yr ♂︎ carpenter

Hx

• 1 yr history of intermittent upper abdominal pain
• “My stomach is always worse when I’m hung over”
• A&E with worsening abdo pain for 3 hours & one vomit of gastric contents

PMHx – lower back pain.

SHx - smoker

DHx – ibuprofen PRN for past 2 yrs

O/E Afebrile HR 75, BP 130/75

• Abdomen soft, tender in epigastrium
• No J/ Cl / An / Cy
• CVS, RS, CNS, PNS – NAD
• Urine - NAD
• WCC 13.4
• Hb 15.1
• Plts 250
• INR & APTR Normal
• LFTs Normal
• CRP 15
• Amylase 71

ECG - Sinus rythm

Answer 1

Chest X ray, Abdominal X ray.

With the chest X ray you are looking for whether or not their is air under the diaphragm. With the abdominal X ray you are looking for free air but also whats going on with the large and small bowel.

Question 2

Patient goes home as symptoms ease with mild analgaesics. Pain regresses two days later and is worsening and constant. His abdomen is rigid and he has tenderness in all four quadrants. Blood tests are done with whitE cell count and CRP raised. ECG shows sinus tachychardia. Further CXR &AXR are done. What do you think the most likely diagnosis is ?

Answer 2

Perforated discus, as CXR shows free subdiaphhragmatic air. Furthermore, AXR shows Riglers sign (Free intraperitoneal air)

Question 3

What is the most likely perforated organ ?

Answer 3

Duodenum, commonest thing that perforates, as well as his alcohol and smoking history.

Question 4

How do you manage a perforated viscus ?

Answer 4

Preoperative;

• Naso gastric tube to empty gastric contents, and prevent them going into the abdomen. IV fluids, antibiotics, NBM.
• ABX

Operative;

• Identification of aetology of peritonitis
• Eradication of the peritoneal source of contamination
• Peritoneal lavage and drainage

Treatment can range from conservative (Taylors approach) to more radical surgery (vagotomy, gastrectomy)

Question 5

What is the most likely site of perforation ?

Answer 5

Anterior/Superior surface of first part of duodenum or pylorus. Duodenal perforation is 10x more likely than gastric perforation. You can get acute ulcers in patients with no history of ulcers.

Question 6

What surgery do you have to mend a duodenal perforation ?

Answer 6

Laparascopic Omental Patch, typical place at d1.You take some omentum and cover the whole and then stitch it up. Very important to have alot of peritoneal lavage.

Question 7

What is the ost likely postoperative diagnosis ?

• Stable and normal observations for first 48 hrs
• Day 3 post-op
• Complaining of SOB
• O2 sats drop from 99% to 87% on 2L nasal specs
• Spike of temperature to 385
• Sinus tachycardia 100 (no ECG changes)
• Bibasal creps on auscultation R>L
• pO2 8.2 on FiO2 of 0.35

Answer 7

Pneumonia

Question 8

What is the most appropriate diagnosis ?

Case 1

Represents 2 days later with abdominal pain & vomiting

• Febrile 38, HR 110, BP 100/60, Sats 98% RA
• Abdomen soft but tender & guarding in epigastrium
• Hb 14.1, WCC 18, CRP 209, LFTs & U&Es normal
• ECG sinus tachycardia
• CXR & AXR unremarkable

Answer 8

Intra abdominal collection, treat with drainage and IV antibiotics.

Question 9

What is the most likely diagnosis ?

Case 2

• 45 yr ♀♀︎
• Upper abdo pain intermittently for 1yr especially after eating Mars bars
• Now 2/7 severe upper abdominal pain associated with vomiting
• Overweight but otherwise fit and well
• O/E Temp 378, HR 100, BP 110/65
• Tender & guarding in epigastrium
• No J/ Cl / An / Cy
• CVS, RS, CNS –NAD
• Urine - NAD
• WCC 20, neutrophilia
• Hb 14
• Plts 230
• MCV 80
• INR & APTR Normal
• LFTs bilirubin 35, Alk phos 366
• CRP 150
• Amylase 2150

Answer 9

Gallstone pancreatitis, due to raised liver function tests which iondicate something is going on in the bile ducts, most common cause is gall stone getting stuck in the bile duct. Amylase is > 2000.

Question 10

What is the criteria for the assesment of the severity of pancreatitis ?

Answer 10

Modified Glasgow criteria

Question 11

What does PANCREAS stand for in Modified Glasgow criteria?

Answer 11

P - PO₂<8KPa

A - age>55yrs

N - WCC>15

C - calcium<2mmol/L

R - renal: urea>16mmol/L

E - enzymes: AST>200iu/L, LDH>600iu/L

A - albumin<23g/L

S - sugar >10mmol/L

Question 12

What score suggests severe pancreatitis?

Answer 12

3 or more within 48 hours of onset

Question 13

What is an independent predictor of severe pancreatitis?

Answer 13

CRP > 200

Question 14

What is the management for Acute pancreatitis?

Answer 14

4 principles of management;

• Fluid resuscitation; IV fluids, urinary catheter, strict fluid balance monitoring
• Analgesia
• Pancreatic rest; +/- nutritional support if prolonged recovery
• Determining underlying cause

95% settle with conservative treatment, surgery is very rare.

Question 15

Would you prescribe antibiotics for severe pancreatitis ?

Answer 15

Only if it was necrotic pancreatitis / infected necrosis.

Question 16

What would be your next investigation after inspecting gallstone pancreatitis?

Answer 16

Ultrasound scan of the abdomen.

Question 17

After 5 days of treatment LFTs still not normal, what is your next investigation ?

Answer 17

MRCP

Question 18

MRCP shows stones in the bile duct, what is your next investigation ?

Answer 18

ERCP

Question 19

Patient still unwell after 7 days, low urine output, tachycardic, what is the best thing to do next ?

Answer 19

CT scan , mainly looking for complications of pancreatitis e.g. perforations, collections that need draining, necrosis and ischaemic large bowel.

Question 20

Patient is discharged home as CT scan doesnt show anything other than the known pancreatitis, but returns with severe RUQ pain, soft tender abdomen and guarding in RUQ. Positive for Murphys sign, what do you do next ?

Answer 20

Cholecystisis, almost definately due to Murphys sign.

Question 21

What is Murphys sign ?

Answer 21

Putting 2 fingers below subcostal margin on the right and ask patient to take a deep breath in, pushing the liver + gall bladder down if it is inflamed and hits your finger they go Oww.

Question 22

What does Murphy’s sign suggest ?

Answer 22

Cholecystitis

Question 23

What is the treatment for cholecystitis ?

Answer 23

• No acute laparoscopic cholecystectomy because of duration of symptoms
• Treated conservatively with fluid resuscitation & IV ABx
• Pain improving
• Inflammatory markers coming down (CRP 10)
• No fevers or tachycardia for 24 hrs
• Discharge with laparoscopic cholecystectomy set for 6/52

Question 24

What are the two structures that you MUST identify and divide in a laparoscopic cholecystectomy ?

Answer 24

Cystic duct and Cystic artery.