Upper GI Flashcards
Post Gastectomy complications
Rapid emptying of food from stomach into the duodenum: diarrhoea, abdominal pain, hypoglycaemia
Complications: Vitamin B12 and iron malabsorption, osteoporosis
Treatment: High protein, low carbohydrate diet. Replace B12/Fe/Ca
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.
Feeding in CVA with unsafe swallow
PEG
Will be jejenostomy if oesophagectomy
Tx of 50yo with Barretts oesophagus is diagnosed with high grade dysplasia on recent endoscopy. The lesions are multifocal and mainly distally sited
Oesophgectomy
Tx of Barrets with dysplasia in elderly with localised lesion
Endoscopic mucosal resection
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.
Ivor Lewis procedure
Combined laparotomy and right thoracotomy
Laparotomy To mobilize the stomach
The greater omentum is incised away from its attachment to the right gastroepiploic vessels
The left gastric vessels are then ligated,
Right Thoracotomy Oesophageal resection and oesophagogastric anastomosis
Through 5th intercostal space
Indication
Lower and middle third oesophageal tumours
Acute vs chronic ulcer on endoscopy
Acute- small and no fibrosis
Chronic- large and fibroses
Proximal Oesophageal SCC mx
managed with radical chemoradiotherapy
Mx of oesophageal cancer if distant disease
Palliate with metallic stent
Cholestatic picture with HIV dx
HIV is sclerosing cholangitis due to infections such as CMV, Cryptosporidium and Microsporidia
Iatrogenic perforations of the oesophagus management
TPN
This usually involves a nil by mouth regime, tube thoracostomy may be needed. Total parenteral nutrition is the safest option.
Mx of UGI bleeds
Admission to hospital careful monitoring, cross match blood, check FBC, LFTs, U+E and Clotting (as a minimum)
Patients with on-going bleeding and haemodynamic instability are likely to require O negative blood pending cross matched blood
Patients with suspected varices should receive terlipressin prior to endoscopy
Ideally all should undergo Upper GI endoscopy within 24 hours of admission.
Varices should be banded or subjected to sclerotherapy.
If this is not possible owing to active bleeding then a Sengstaken- Blakemore tube (or Minnesota tube) should be inserted. This should be done with care; gastric balloon should be inflated first and oesophageal balloon second.
Remember the balloon will need deflating after 12 hours (ideally sooner) to prevent necrosis. Portal pressure should be lowered by combination of medical therapy +/- TIPSS.
Patients with erosive oesophagitis / gastritis should receive a proton pump inhibitor.
Mallory Weiss tears will typically resolve spontaneously
Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment.
All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate.
Cellular origin of pancreatic tumours
Ductal epithelium
Gastrinoma most common locatin
Duodenum
Most commonly found in the duodenum (in up to 50% patients), then the pancreas (approximately 20%)
Within triangle
-junction of common and cystic BD, junction of 2nd/3rd part od duodenum, junction of body and neck of pancreas
Epigastric discomfort and episodes of migratory thrombophlebitis. On examination he is mildly jaundiced
Adenocarcinoma of the pancreas
Trousseau’s sign: migratory superficial thrombophlebitis
What is usually divided during an Ivor Lewis Oesophagectomy
Azygous vein
Types of bariatric surgery
Gastric banding: band applied to upper stomach which can be inflated or deflated with normal saline. This affects satiety. Over a 5 year period complications requiring further surgery occur in up to 15% cases.
Roux-en-Y gastric bypass: a gastric pouch is formed and connected to the jejunum. Patients achieve greater and more longterm weight loss than gastric banding.
Sleeve gastrectomy: body and fundus resected to leave a small section of stomach
Biliopancreatic diversion +/- duodenal switch: bypass the small bowel. Greatest weight loss but a very complex procedure associated with malnutrition and diarrhoea.
Vertical banded gastroplasty (stomach stapling): rarely performed due to longterm failure rate.
Gastric balloon- highest failure rate- really only suitable as a bridge to a more definitive surgical solution.
