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FRACS exam > Upper GI > Flashcards

Upper GI Flashcards

1
Q

What is the Classification of ERCP perforation and management

A

Stapler Classification 1. Free bowel wall perforation - laparotomy (if recognised during endoscopy can be managed endoscopically) 2. Retroperitoneal duodenal perforation secondary to periampullary injury (most common) 3. Pancreatic/bile duct injury 4. Retroperitoneal air only (can be normal after sphincterotomy)

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2
Q

What are the indications for surgical management in Stapler 2-4 ERCP perforations and what oprtions are available

A

Major Contrast leak

Persistent biliary obstruction

Cholangitis

No improvement with non-operative management

  • Repair primarily, drainage of abscess, choledochojejunostomy or whipples
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3
Q

List worrisome and high risk features of Pancreatic IPMN

A

High risk - MPD >9mm

Solid enhancing nodule >5mm

obstructive jaundice

Worrisome features-

MPD 5-9mm non-enhancing murla nodule/thickened enhancing wall size >3cm abrupt cutoff of pancreatic duct lymphadenopathy

Resect if high risk or if MPD 5-9mm plus worrisome features (BD or MPD IPMN)

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4
Q

What is borderline resectable and unresectable for pancreatic head cancer

A

Borderline <180 degree encasement of SMA >180 degree encasement of SMV Contact of common hepatic artery but not the coeliac or proper hepatic A Unresectable Metastatic disease/organ involvement Occludded SMV/portal vein - un-reconstrunctionable >180 encasement of SMA Involvement of aorta/IVC Involvement of coeliac axis Contact with first jejunal branch of SMV

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5
Q

What is the demeester score and what is the main mechanism of reflex

A

Score significant reflux in oesophageal reflux. Score> 14.2 is consistent with reflux score components - % total/upright/supine time ph<4, number of symptomatic reflux episodes, number of reflux episodes >5mins, longest reflux episode Main cause of reflux is due to transient relaxation of lower oesophageal sphincter

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6
Q

What are the 5 goals of anti-reflux surgery

A

maintain tissue planes don’t damage the vagus identify try OGJ for wrap placement have sufficient length of intra-abdominal oesophagus (3cm at least) re-establish angle of His

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7
Q

what are indications for urgent gastroscopy removal of foreign body (within 2-6 hours vs within 24h)

A
  • complete obstruction - battery - sharp objects
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8
Q

What is grading of oesophageal varies

A
  1. Short straight varices 2. Enlarged tortuous varices Less than 1/3 circumference 3. More that 1/3
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9
Q

Grading of oesophagitis

A

LA grade A. minimal erosions less than 5 mm B. erosions more than 5mm non contnious C. continuous erosions between folds 4. Continuous erosions more than 75% of circumference involved

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10
Q

What is the size cutoff for treatment of hydatid cysts

A

PAIR for more than 5cm Otherwise albendzole Surgery for complex cysts = with evidence of biliary fistula, or rupture, or greater than 10cm or compression of vital structures

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11
Q

what is the forrest classification of upper GI blleds

A

Appearance of ulcer which risk stratifies bleeding risk without intervention. Recommended to do two types of intervention on an ulcer - e.g. haemoclip, injection, coagulation. brackets show risk of rebleed with medical therapy alone. 1. a - active arterial haemorrhage (90%) b -oozing blood (10-20%) 2. a. non bleeding oozing vessell (50%) b. adherent clot (25-30%) c. flat pigmented spot (7-10%) 3 - clean ulcer base (3-5%)

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12
Q

What are the 3 types of gastric NET and treatment implications

A

Type 1 Secondary to atrophic gastritis and prolonged hypergastrinemia Type 2 Secondary to high gastrin from gastronoma Type 3 Sporadic (20%) - aggressive Type 1 and 2 indolent- endoscopic resection

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13
Q

What is the differential diagnosis for a sub epithelial gastric tumour

A

GIST

Leiomyoma

Leiomyosarcoma

Nerve sheath tumour schwannoma

Desmond

Myofibroblastic tumour

Stain GIST - DOG 1, CD117, CD 34

S100 for schwannoma

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14
Q

What are the most common Mets to the spleen

A

Breast, lung, malenoma, ovarian, stomach, prostate

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15
Q

What are the clinical radiological And blood signs for portal htn

And what is hepatic venous pressure gradient which will be clinically significant

A

Clinical - splenomegaly, ascites, varies

Radiological - spleen larger than 13cm and portal vein diameter greater than 13mm
Bloods - platelet <150

HVPG

Risk for varice bleeding and ascites at more than 12.

10 or more is high risk for decompensation with surgery.

5 or more defines portal hypertension

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16
Q

What are the components of the Rockall score

A

This is a score to risk stratify patients with upper GI bleed into low and high risk for further bleeding or death -

age - shock - Major comorbidities -Diagnosis (mallory weis vs non malignant vs cancer) -Recent bleed

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17
Q

Johnson classification of ulcers and surgical management

A

type 1 - in lesser curvature near junction of fundus and antrum = acid hyposecretion - treat with distal gastrectomy (treat disease + check for occult malignancy)

type 2 - synchronous duodenal and pyloric +/-scarring. - acid hypersecretion - antrectomy + vagotomy

type 3 - prepyloric - increased acid secretion - treat same as tyoe 1 and 2 - may present with GOO.

type 4 - close to GOJ high on lesser curve acid hyposecretion. difficult to resect - may need roux en y

type 5 - throughout stomach - associated with NSAID use

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18
Q

What is borchardt’s triad

A

For gastric volvulus in 70% of patients Pain Vomiting Unable to pass NGT

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19
Q

What are the indications for cholecystectomy for asymptomatic gallstones

A

Size greater than 3cm Anomalous BPD Adenoma Porcelain gallbladder

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20
Q

Bismuth classification of perihilar lesions

A

1 - below confluence 2 - at confluence 3 - extending into right (a) or left (b) duct 4 - both right and left ducts involved

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21
Q

Strasburg bile duct injury

A

A; leak from cystic duct stump/ “duct of lushka” B; clipped off right posterior sectoral duct C; leak from right posterior sectoral duct D; side hole in CBD E1 - CBD transected >2cm from confluence 2- <2cm 3- at confluence 4 - Right and left ducts separated 5 - combination of injury to common hepatic duct and right posterior sectoral

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22
Q

How are choledocholcysts classified

A

todani classification 1 - dilatation of CBD (50-85%) - Need to resect and hepaticojejunostomy 2 - saccular dilation of CBD- true diverticulum (2%)- can transect the sac 3 - Intraduodenal dilatation of the CBD (1-5%)- can be managed endoscopically. 4 (15-35%) - mainly type b a - both intra and extra hepatic cysts b - multiple extrahepatic cysts 5 - rare- one or more intrahepatic cysts (caroli disease) - if on single side can do hepatectomy, but may need transplant

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23
Q

what is the differential of a solid pancreatic lesion

A

Adenocarcinoma NET Lymphoma focal pancreatitis autoimmune pancreatitis (IgG4) metastases (rare - RCC, malenoma) Suspect autoimmune in young patients, alcoholism, other autoimmune disease, diffuse ductal changes or multifocal biliary strictures

24
Q

what is the ‘double duct sign’

A

both pancreatic and biliary duct dilatation - signifies likely ampullary lesion

25
Q

what is the overall 5 years survival of R0 N0 pancreatic cancer

A

30%

26
Q

Grading of pancreatic leak/fistula

A

>3x upper limit of normal amylase in drain on or after day 3

A - Spike in drain amylase, resolves without intervention

B - Persistent drainage >3 weeks, or changes management, or perc/endoscopic management, or angio for bleeding, or signs of infection

C - B + infection with organ failure, or reoperation or Death related to fistula

B and C are clinically relevant leaks

27
Q

Complications of pancreatitis

A

<4 weeks - acute necrotic collection, peripancreatic fluid collection

>4weeks - walled of necrosis, pseudocyst

Suspect infection if sudden deterioration - will require percutaneous drainage - try to avoid operative intervention within 4 weeks. Need antibiotic that can penetrate the necrosum - fluoroquinolone, ceftazadime, ertapenem

Vascular complications - venous thrombosis. pseudoaneurysm (suspect pseudoaneuryms if sudden drop in Hb, increase in pseudocyst or GI bleeding)

28
Q

What are the goals of surgery for pancreatic necrosis and what are management options

A

clear/debride necrotic/infected tissue

preserve functional pancreatic tissue

control duct disruption/fistula

  • 1/3 successful - perc drainage (note pancreatic fistula will form), retroperitoneal video assisted debridement
  • endoscopic frainage through stomach 69% effective
  • open/laparoscopic debridement if others fail (can do transgastric with WON)
29
Q

what are the diagnostic criteria for IgG4 disease

A

HiSORT

Histology - plasma cells with IgG4

S - serology - IgG4 level high

O - other organ involvement (cholangitis, retroperitoneal fibrosis, mediastinal fibrosis, sjogren syndrome, IBD)

RT- response to glucocorticoid therapy

30
Q

what are the forms of hereditary pancreatitis

A

PRSS! - serine protease 1 gene mutation - autosomal dominant. Gene encoding for cationic trypsinogen - easier activation of trypsinogen

SPINK1 - trypsin inhibitor. Found in pancreatic acinar cells. Autosomal recessive. Loss of function leads to decreased protection from inappropriate acitvation

CFTR gene

31
Q

Causes of chronic pancreatitis

A

TIGAR - O

Toxins (alcohol, cigarette smoke, triglycerides - form FFA from Lipase)

Idiopathic

Genetic

Autoimmune

Recurrent acute pancreatitis

Obstructive

32
Q

What are the indications for referral for liver transplant in chronic liver failure

A

2 of 5

  1. Complications of portal HTN - ascites, variceal bleeding
  2. Encephalopathy
  3. intractable pruritis
  4. Severe impairment of quality of life
  5. Impaired synthetic function - low albumin and deranged coagulation

MELD score 15 or more (exceptions - HCC, metabolic liver disease, acute liver failure,)

33
Q
A
34
Q

what are the indications for cholecystectomy in asymptomatic cholelithaisis

A

Gallstone >3cm

porcelain gallbladder

gallbladder polyps/adenoma

abberent pancreticobiliary duct junction

If haemolytic disorder and having abdominal surgery for another reason (e.g. splenectomy for spherocytosis)

35
Q

Gallbladder cancer tnm staging

A

T1a - invasion of lamina propria

1b- invasion of muscular layer

2- a perimuscular connective tissue invasion on peritoneal side - serosa ok

b - invasion on liver side - liver not involved

3 - invason through serosa or into liver or adjacent organ

4 - invasion of major vasculature or x2 organs

36
Q

gallbladder cancer treatment

A

1a - cholecystectomy alone ok

1b and above - extended cholecysectomy (or formal central liver resection of segment IVb and V)

remove all lymph nodes around porta hepatis and hepaticoduodenal ligament

Rememeber staging laparoscopy - if has not had a laparoscopy recently.

Unresectable disease - extensive involvement of the porta hepatis, involvement of ceoliac/sma/cava, distant mets, liver mets, malignant ascites,

Note that direct invasion of colon/stomach/duodenum/liver is not a contraindication for treatment

37
Q

siewart -stein classificatio

A

1-5cm above GOJ

1-2 cm around GOJ

2-5cm distal

38
Q

What are the indications for anti-reflux surgery

A

medically refractory reflux

noncompliance to meds

severe oesophagitis

barrett’s oesophigitis

benign stricutre

high volume reflux

39
Q

grading of oesophageal caustic injury and significance

A

Grade 1-3

1 - superficial mucousal oedema

2- a - superficial ulceration

b - deep or circumferential ulceration

3-a patches of necrosis

b - extensive necrosis

1 and 2a will heal with no issues - no muscularis involvment

2b and 3a will likely stricture

3b usually need operation (70% mortality)

2b/3 will need NG feeding - perforation risk for 7 days

40
Q

CROSS protocol

+ “definitive chemordatiation”

A

Craboplatin + placitaxel + RTx

Deifinitive is an extra 20Gy of radiation + additional cycles of chemo

41
Q

siewert-stein

A

1- >1-5cm

2- 1-2cm

3 - >2-5cm

42
Q

complications of peptic ulcer disease

A

bleeding

perforation

gastric outlet obstruciton

penetrating/fistula disease

43
Q
A
44
Q

GIST immunohistochemistry

A

CD 117 - c-kit

CD34

DOG -1 (positive regardless of c-kit and PDGFRA

45
Q

prognostic factors in GIST (best categories)

A

Size (<2cm),

Site (stomach)

mitotic rate (<5)

46
Q

what is the pathophys for pernicious anaemia

A

H+/K+ ATPase pump destroyed in parietal cells by immune cells.

Increased gastrin, risk of NET (Type 1) and cancer

47
Q

steps for band removal and how do band erosions present

A

expsore the band

mobilise and define the buckle

stay on the band

cut the buckle and remove

DECOMPRESS PROXIMAL STOMACH (cut the eschar)

ERosion prsents - loss of satiety, port injection, epigastric pain,

48
Q

complications of gastric sleeve

A

leak (1%)

stenosis

volvulus

bleeding

portal venous thrombosis

obstruction at incisura

dilatation and weight regain

chronic reflux/hiatus hernia

49
Q
A
50
Q

indications for imatinib

A

neoadjuvant - borderline/unresectable tumour/large

Adjuvant - >5/50HPF mitoses, >5cm tumour (risk of recurrence)

Metastases

Recurrent

Remember C-kit/PDGFRA

51
Q

ADVERSE effects of obesity

A

Metainflammation - release of inflammatory mediators from adipocytes - leads to dysfunction of peripheral tissue leading to metabolic disease, insulin resistance, predisposition to malignancy. TNF-a, IL-6, Il-1B

Free fatty acids - proinflammatory. Disordered lipolysis; free fatty acids deposit in liver - fatty liver + muscle - insulin resistance

Adipokines - hormones - leptinm adiponectin,

52
Q
A
53
Q

what are indications for imatinib for GIST tumour

A

need to be c-kit/PDGFRA mutation positve

size>10cm

mitotic rate>10

size >5 + mitotic rate>5

incomplete resection/perforated tumour

neoadjuvant treatment for unresectable tumour to downstage it

54
Q

mechanisms of reflux

A

transient lower oesophageal relaxations

weak lower oesophageal sphincter

anatomical - hiatus hernia

55
Q

Classification of caustic injury to oesophagus

A

Acid - coagulative necrosis

Alkali - Liquefactive necrosis

Zargar’s classification

1 - Erythema, mucosal oedema

2a - superficial ulceration, small areas

b - deep ulceration/continuous circumferential

3- a Focal areas of necrosis + ulcerations

b - extensive necrosis (+other organs involved)

1 and 2a minimal stricture rate with very good prognosis

2b and 3a high rate of stricture 70%

3b - mortality 65% and need resection

56
Q

Causes of splenomegaly

A

Congestive - portal hypertension/cirrhosis, splenic vein thrombosis

malignancy - metastases (malenoma, breast, stomach, ovarian, lung), lymphoma, leukiemia, thrombocythemia

Infections - Tb, salmonella, abscess, EBV/CMV, malaria, hydatid cyst

Inflammatory - SLE, Sarcoid, RA

haematological - sickle cell aneamia, hereditary spherocytosis, thalassemia

Traumatic cyst,

FRACS exam (13 decks)

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