Upper GI Surgery Flashcards
A 45 year old man with recurrent episodes of confusion is found to have a 1.5cm insulinoma of the pancreatic head. What is the most appropriate management?
Whipples procedure Total pancreatectomy and en bloc splenectomy Pylorus preserving pancreatico duodenectomy Enucleation of the lesion External beam radiotherapy
Enucleation of the lesion
Most insulinomas are benign and radical resection is therefore not justified.
A 56 year old man is admitted with a profuse upper gastro intestinal haemorrhage. He is relatively malnourished and has evidence of gynaecomastia. An upper GI endoscopy is performed and views are limited because of the extensive amount of blood present. What is the most likely underlying cause?
Boerhaave's perforation Mallory Weiss tear Oesophageal varices Oesophageal cancer Oesophagitis
Patients presenting with gastrointestinal bleeding and evidence of established liver disease may have portal hypertension and develop variceal haemorrhage. The patient may have evidence of jaundice, gynaecomastia, spider naevia, caput medusae and ascites. The bleeding is usually profuse and painless.
A 53 year old man presents with dyspepsia. At upper GI endoscopy he has a punched out ulcer on the lesser curve of the stomach. It measures approximately 2cm in diameter and is seen to penetrate muscle with fibrosis present at the base. What is the most likely diagnosis?
Curlings ulcer Cushings ulcer Chronic ulcer Adenocarcinoma Gastric lymphoma
Fibrosis is usually a sign of chronic ulcer. It should be biopsied carefully, a proton pump inhibitor started and re endoscopy should occur at 6 weeks.
A 76 year old man presents with a 5 week history of progressive dysphagia. An upper GI endoscopy is performed and the surgeon notices changes that are compatible with Barretts oesophagus. The oesophagus is filled with food debris that cannot be cleared and the endoscope encounters a resistance that cannot be passed. What is the most likely underlying diagnosis?
Adenocarcinoma Squamous cell carcinoma Achalasia cardia Nutcracker oesophagus Benign peptic stricture
A short history of dysphagia together with food debris and Barretts changes makes adenocarcinoma the most likely diagnosis.
A 82 year old man presents with dysphagia. He is investigated and found to have an adenocarcinoma of the distal oesophagus. His staging investigations have revealed a solitary metastatic lesion in the right lobe of his liver. What is the best course of action?
Arrange a PET CT scan Arrange an endoscopic ultrasound Assess fitness for liver resection prior to oesophagectomy Assess fitness for oesophagectomy followed by liver resection Insertion of metallic stent
The presence of distant disease in the context of oesophageal cancer renders him incurable. Further staging is not needed and surgery is not an option. Palliation is the preferred option and a metallic stent will achieve this.
A 35 year old man is admitted with an episode of collapse and passage of malaena. He has been suffering from post prandial abdominal pain for 5 weeks and this is most marked several hours after eating. What is the most likely cause?
Anterior duodenal ulcer Posterior duodenal ulcer Oesophageal varices Dieulafoy lesion Carcinoma of the stomach
Patients with duodenal ulcers will usually have a history of epigastric pain that occurs several hours after eating. The pain is often improved by eating food. They are most frequently located in the first part of the duodenum. Anteriorly sited ulcers may perforate and result in peritonitis, posteriorly sited ulcers may erode the gastroduodenal artery and present with haematemesis and/ or malaena.
A 45 year old man undergoes an upper gastrointestinal endoscopy for a benign oesophageal stricture. This is dilated and he suffers an iatrogenic perforation at the site. His imaging shows a small contained leak and a small amount of surgical emphysema. What is the most appropriate nutritional option?
Nil by mouth and intravenous fluids alone Intravenous fluids and sips orally Total parenteral nutrition Nasogastric feeding PEG tube feeding
Iatrogenic perforations of the oesophagus may be managed non operatively. This usually involves a nil by mouth regime, tube thoracostomy may be needed. Total parenteral nutrition is the safest option. Insertion of NG feeding tubes and PEG tubes may complicate the process or allow feed to enter the perforation site.
A 38 year old woman undergoes a gastric bypass procedure. Post operatively she attends the clinic and complains that following a meal she develops vertigo and develops crampy abdominal pain. What is the most likely underlying explanation?
Insulin resistance Irritable bowel syndrome Biliary colic Dumping syndrome Enterogastric reflux
Dumping syndrome, which can be divided into early and late, may occur following gastric surgery. It occurs as a result of a hyperosmolar load rapidly entering the proximal jejunum. Osmosis drags water into the lumen, this results in lumen distension (pain) and then diarrhoea. Excessive insulin release also occurs and results in hypoglycaemic symptoms.
A 63 year old man undergoes an upper GI endoscopy and adrenaline injection for a large actively bleeding duodenal ulcer. He remains stable for 6 hours and the nurses then call because he has passed 400ml malaena and has become tachycardic (pulse rate 120) and hypotensive (Bp 80/40). What is the best option?
Reassure that blood trapped in the upper portion of the gastrointestinal system will pass and that this episode will resolve with phosphate enema Perform a repeat upper GI endoscopy Perform a laparotomy and under-running of the ulcer Administer tranexamic acid and intravenous proton pump inhibitors Insert a Minnesota tube
Perform a laparotomy and under-running of the ulcer
The decision as to how best to manage patients with re-bleeding is difficult. Whilst it is tempting to offer repeat endoscopy, this intervention is best used on those with small ulcers. Large posteriorly sited duodenal ulcers are at high risk for re-bleeding and the timeframe of this event suggests that primary endoscopic haemostasis was inadequate. Surgery thus represents the safest way forward.
A 55 year old man presents with symptoms of dyspepsia and on upper GI endoscopy an area of patchy erythematous tissue is identified extending proximally from the gastro oesophageal junction. A biopsy is diagnostic of Barretts oesophagus with low grade dysplasia. Which of the following is the most appropriate next step?
Distal oesophagectomy Upper GI endoscopy with quadrantic biopsies from the region Photodynamic therapy Endoscopic sub mucosal resection of the area Argon plasma coagulation
Upper GI endoscopy with quadrantic biopsies from the region
Low grade dysplasia in conjunction with Barretts oesphagus should be monitored with regular (6 monthly) upper GI endoscopy and quadrantic biopsies. If the disease remains static at 2 years then the screening frequency may be decreased.
A 62 year old man presents with dyspepsia and a tumour of the gastric cardia is diagnosed. He has no evidence of metastatic disease. What is the most appropriate treatment option?
Sub total gastrectomy and Roux en Y reconstruction Total gastrectomy and Roux en Y reconstruction Total gastrectomy and loop jejunostomy reconstruction Proximal gastrectomy and gastric pull up External beam radical radiotherapy
This will require a total gastrectomy. Retention of a gastric remnant is unlikely to achieve acceptable resection margins. Resection of the proximal stomach with pull up of the stomach is not standard oncological practice for gastric cancer.
A 45 year old man has been troubled with dysphagia for many years. He is known to have achalasia and has had numerous dilatations. Over the past 6 weeks his dysphagia has worsened. At endoscopy, a friable mass is noted in the oesophagus. What is the most likely diagnosis?
Adenocarcinoma Squamous cell carcinoma Leiomyoma Barretts oesophagus Sarcoma
The risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia. The condition often presents late and has a poor prognosis.
A 58 year old lady has a two year history of worsening dysphagia. In addition to this she has a nocturnal cough. Over this time she has lost a total of 8kg in weight. Which of the processes below is the most likely explanation for this?
Gastro-oesophageal reflux disease Barretts oesophagus Carcinoma Mallory Weiss tear Achalasia
Such marked weight loss should arouse suspicion of cancer. She is most likely to have a longstanding stricture associated with oesophagitis and Barretts oesophagus. This may progress to carcinoma which will tend to occur in association with worsening dysphagia and weight loss.
A 62 year old man presents with dysphagia and on investigation is found to have a stenosing tumour of the mid oesophagus with a single metastasis in the right lobe of the liver (segment VI). What is the most appropriate treatment?
Radical radiotherapy to the oesophagus and liver resection Insertion of self expanding metallic stent Liver resection and subsequent oesophageal resection Oesophageal resection and subsequent liver resection Combined oesophageal and liver resection if cardiopulmonary exercise testing shows the patient is fit enough
Distant disease in patients with oesophageal cancer is a contra indication to a resectional strategy and downstaging with chemotherapy is not routinely undertaken in this age group as the results are poor. An expanding stent will provide rapid and durable palliation.
A 72 year old man is admitted with an episode of brisk haematemesis. Following resuscitation an upper GI endoscopy is performed and a prominent blood vessel is identified in the mucosa approximately 6 cm from the O-G junction on the lesser curve of the stomach. What is the most likely explanation for the bleeding?
Gastric cancer Portal gastropathy Dieulafoy lesion Linitis plastica Gastritis
Dieulafoy lesion
These small arterial lesions are a rare cause of bleeding and are characterised by a single large tortuous arteriole in the sub mucosa. Extra gastric lesions may occur.
A 55 year old man is reviewed 3 months following a distal gastrectomy and gastro-jejunostomy for carcinoma of the gastric antrum. He complains of symptoms of dizziness, palpitations, sweating and occasional collapse after big meals. What is the most likely explanation for this presentation?
Division of the vagus nerves Increased release of insulin Increased release of cholecystokinin Increased release of gastrin Increased release of glucagon
The effects of gastro-enterostomy (which is how the stomach was reconstructed in this case) have resulted in the late symptoms of dumping syndrome which occur as a result of excessive insulin release. A similar condition can be seen in patients who undergo bariatric procedures such as gastric bypass.
