Flashcards in Upper GI Surgery Deck (35):
How do you manage dysphagia?
Barium swallow and esophagoscopy with biopsy
DDx achalasia, Zenker diverticulum, esophageal cancers, strictures
What are the types of esophageal cancers?
SCC in upper 2/3 due to cigarettes and EtOH, adenocarcinoma in the lower 1/3 due to Barrett's
Sx: progressive dysphagia and weight loss
How do you manage esophageal cancer?
Esophagoscopy and biopsy, then staging via endoscopic ultrasound and CT scan, then specific tx
How do you treat esophageal cancer?
Upper 1/3: chemo and radiation only
Middle 1/3: chemo and radiation to shrink the tumor, then esophagectomy
Lower 1/3: esophagectomy and proximal gastrectomy
Never operate on stage IV cancer
What is Zenker diverticulum?
Pulsion diverticulum that develops at upper esophagus due to abnormal coordination of cricopharyngeal constriction; Sx dysphagia, regurgitation, and bad breath
Manage by barium swallow, cricopharyngeus myotomy
What is a traction diverticulum?
Diverticulum at the middle esophagus due to LN traction, indicates cancer
What are the esophageal motility disorders?
Achalasia: hypertonic and non-relaxing LES with poorly relaxing esophagus, sx of dysphagia of lipids>solids
Nutcracker esophagus: painful swallowing due to high amplitude action potentials, tx with nifedipine
Diffuse esophageal spasms: uncoordinated third degree peristalsis, tx medically
hypertensive LES: high LES pressure at baseline but relaxes with swallow, tx medically
How do you manage achalasia?
Dx bird's beak on barium swallow and increase LES pressure on manometry, tx with Heller myotomy
What is on the differential for acute epigastric pain?
DDx acute pancreatitis, GERD, PUD (gastric ulcers or duodenal ulcers), cholelithiasis, gastroenteritis
gallstones or alcoholism = acute pancreatitis
NSAIDs or steroid use = PUD
How do you manage esophageal varices?
Present as UGIB due to portal HTN, often alongside coagulopathy (liver failure)
-management: band the bleeding varices, correct any coagulopathy, IV octreotide to lower portal pressure --> if bleeding continues, repeat endoscopic banding --> if bleeding continues, TIPS or gastric balloon tamponade
Follow up with beta blockers to lessen chance of rebleeding
How does Mallory-Weiss syndrome present?
UGIB due to retching lacerating the lower esophagus, bleeding usually stops spontaneously
How does Boerhaave syndrome present?
Presents as epigastric pain and fever due to retching perforating the esophagus
Dx contrast swallow, tx emergent surgical repair
How do you treat GERD?
PPIs -- if persistent after six weeks, do EGD with biopsy
How do you treat esophagitis?
Multiple, nonulcerating erosions in the stomach; mild to moderate esophagitis --> PPIs for 8-12 weeks, severe esophagitis --> lap Nissen, uncontrollable esophagitis --> subtotal gastrectomy
How do you treat Barrett esophagus?
intestinal metaplasia of esophageal epithelium
no dysplasia --> tx PPIs or lap Nissen
low grade dysplasia --> tx lap Nissen + annual surveillance
high grade dysplasia --> esophagectomy
What is Lap Nissen dundoplicaiton?
Wraps fundus of stomach around LES to keep it in the abdominal cavity
Contraindicated in morbidly obese patients (do gastric bypass instead)
What are the types of hiatal herias?
Hernia from abdominal cavity, through diaphragm, into chest cavity
Type 1: sliding hernia, risk of reflux esophagitis, Tx PPIs
Type 2: paraesophageal hernia, risk of incarceration/strangulation, surgical repair as tx
Type 3: presence of both types 1 + 2, tx surgical repair
What are the indications for PUD surgery?
Intractability, perforation, obstruction, bleeding
Caused by increased acid secretion; most commonly in 1st part of the duodenum, DU in 2nd-4th part indicates Zollinger-Ellison syndrome (gastrinoma)
types: posterior ulcers bleed due to gastroduodenal artery, anterior ulcers perforate
Tx: triple therapy-- if ulcer persists, surgery is indicated, also get serum gastrin levels to rule out ZE syndrome
What do you see on CXR if there is a DU?
free air under the diaphragm
How do you treat a perforated DU?
Use omentum to patch the ulcer, then stop acid with PPIs or HSV
If with sepsis, also give IV abx
if bleeding due to posterior ulceration into GDA, oversew the ulcer
Caused by decreased mucosal protection
Type 1: lesser curvature at incisure
Type 2: duodenum and stomach
Type 3: pylorus
Type 4: GE junction
Tx: PPIs, if ulcer persists after six weeks, do endoscopy and multiple marginal biopsies for possibility of gastric cancer. If persists after 18 weeks, surgery is indicated
If the GU is bleeding, then tx is excision
What is GU surgery?
Wedge resection or distal gastrectomy (due to possibility of cancer), TV +P for types II and III due to increased acid production
What are the types of gastric cancers?
Gastric adenocarcinoma: often spreads to left supraclavicular node and ovaries
Linitis plastica: infiltrating carcinoma with desmoplastic reaction causing stomach to look fixed and rigid
GIST: any soft tissue tumor of stomach
How do you treat the gastric cancers?
Adenocarcinoma: if proximal, total gastrectomy
if distal, distal gastrectomy with anastomosis, take out D1 LN at lesser curvature
Linitis plastica: total gastrectomy with splenectomy
Gastric lymphoma: determine cancer stage, partial thickness--> radiation, full thickness --> surgical resection
GIST: wedge resection with 1 cm negative margins
How do gastric varices present?
UGIB due to portal HTN
Tx uncontrollable bleeding with TIPS or splenectomy instead of banding
What are the four complications of gastric ulcers?
3) Gastro-pancreatic fistula
4) Gastric dysmotility
When do you worry about a gastric ulcer that does not go away after six weeks?
What causes duodenal ulcers?
Which ulcer type gets better with food?
What are the types of ulcers?
Type II: lesser curvature of the stomach
Type IV: diffuse, due to NSAIDs
If anywhere else, then you are concerned for a malignant process
What is a Sister Mary Joseph node?
Metastatic node from abdominal cancer at the umbilicus
What is Vircov's node?
Visceral cancer that has crossed the diaphragm.
Will also see acanthosis nigricans and Bloomer's node (metastasis in the pouch of Douglas)
What are the types of gastric cancer?
2) intestinal type
3) superficial spreading
4) MALToma (associated with H. pylori)
5) GIST cell tumor