Upper GI surgery Flashcards by Ellie Hayes

Mortality rate of upper GI bleed

10%

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most common cause of upper GI bleed

peptic ulcer 36%

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Typical presentation of upper GI bleeds

haematemesis and melaena

occasionally haematochezia

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Risk factors for upper GI bleed

Alcohol
Smoking
Liver disease
NSAIDs
Vomiting
Steroids
PUD

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When can you do an OGD for a patient with an upper GI bleed?

first resuscitation if hypotensive
If stable then scope within 24hrs
If unstable then scope urgently to intervene with haemostat clips, adrenaline injections, haemostat powder.
If massive haemorrhage then activate hospital’s transfusion protocol

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Summary of massive transfusion protocol

O neg until x matched available
then balanced transfusion of RCC, platelets and plasma 1:1:1
Keep Hb above 8 or >9 if cardiac history

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drugs that can be given in suspected vatical bleeding

IV terlipressin and octreotide to reduce portal hypertension

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Scoring system to determine the need for intervention and risk of mortality in GI bleeds

Glasgow Blatchford score system

based on blood urea, Hb, Systolic BP, pulse, melena, syncope, hepatic disease, cardiac failure

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Intraluminal causes of dysphagia and odynophagia

Foreign body
Foreign bolus
Oesophageal webs

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Intramural causes of dysphagia and odynophagia

Neoplasm
oesophagitis
GORD
dystmotility disorders
scleroderma
neurological 
stricture
hiatus hernia
volvulus

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Extraluminal causes of dysphagia and odynophagia

lymphadenopathy
goitre
pharyngeal pouch
haematoma

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Purpose of high resolution manometry

to evaluate oesophageal motor function when investigating dysmotility

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Pathophysiology of hiatus hernia

Widening of the diaphragmatic crura at the oesophageal hiatus and stretching the phrenoesophageal membrane

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What is a type 1 hiatus hernia?

sliding hiatus hernia

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What is a type 2-3 hiatus hernia?

paraoesophagheal hernias
2 rolling
3 mixed

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What is a type 4 hiatus hernia?

Intra-thoracic herniation of abdominal viscera into the hernia sac

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Type 2 / rolling hernia typically presents with or without reflux?

Without

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Surgical management of a hiatus hernia?

Conservative for type 1

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when to repair type 2,3,4 hernias

Symptomatic

GORD
gastric outlet obstruction
anaemia
Concern for gastric strangulation

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Management of emergency presentation of gastric volvulus

NG tube decompression

if unsuccessful may need urgent surgical repair

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Imaging of choice for diagnosing pancreatitis

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A plain radiograph of his abdomen demonstrates evidence of sigmoid volvulus. What is the next most appropriate step in management to achieve definitive resolution?

Flexible sigmoidoscopy decompression with a flatus tube

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possible ddx
A 65-year-old man presents with sudden onset abdominal pain. On further questioning he comments he has not opened his bowels for 3 days and has been vomiting intermittently. On examination his abdomen is grossly distended and he is notably tender throughout.

Sigmoid volvulus

- plain film abdo

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Treatment of achalasia

Hellers

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What patients would be suitable for a Nissen's fundoplication?

* adequate acid control with PPI but don't want to continue medical tx * adequate control with PPI but not tolerant of acid suppression tx * complicated reflux disease * Stricture formation * Chronic cough, laryngitis, sinusitis

What is gas bloat syndrome?

Inability to burp or vomit after a gastric procedure

Is partial endoluminal fundoplication more or less successful than traditional procedures?

Less

Definition of peptic ulcer disease

Erosions in the gastric or duodenal mucosa that extend through the muscularis mucosae

H pylori organism

Gram negative rod with flagella reside in gastric-type epithelium beneath the mucus layer

What enzyme do H pylori produce?

Urease

What type of PUD is more associated with vomiting?

gastric ulcers

Tx of h pylori infection

``` Triple therapy PPI amoxicillin Clarithromycin for 14 days then PPI alone for 4 weeks ```

Define barrett's oesophagus

an oesophagus in which cny portion of the normal distal squamous epithelial lining has been replaced by metaplastic columnar epithelium

normal distal oesophageal lining

Squamoud

type of epithelium in barrel's oesophagus

Metaplastic columnar epithelium

Medical tx of Barrett's oesophagus

High dose PPI for symptom control | aspirin may reduce progression to high grade dysplasia and carcinoma

Indications for Barrett's endoscopic screening

``` must have chronic GORD + 3 of: >50 male white high BMI or 1st degree relative with Barrett's or oesophageal adenocarcinoma ```

How often surveillance for Barrett's if no dysplasia?

depends on segment length < 3cm then 3-5 yrs > 3cm then 2-3 yrs

How often should Barrett's with known dysplasia have surveillance?

Low grade - 6monthly intervals until 2 consecutive non-dysplastic biopsies High grade - MDT discussion and eradication

management of Barrett's with mucosal irregularity

Endoscopic mucosal resection

What grade of oesophageal tumor should be considered for surgery?

T1b tumor or greater - oesophagectomy

What is the role of anti-reflux surgery in patients with Barrett's oesophagus?

Does not reduce the risk of developing adenocarcinoma

What is achalasia?

Failure of the LOS to relax ( due to progressive neuronal loss in the myenteric plexus)

What is the most common primary motility disorder o the oesophagus?

Achalasia

Type 3 achalasia chicago

Spastic activity of oesophagus - poor response to tx

Type 2 achalasia chicago

waves >30mmHg throughout the oesophagus in >20% of swallows - good response to tx

Type 1 achalasia chicago

Very few peristaltic waves, nove>30mmHg - good response to tc

medical management of achalasia

limited results. | Calcium channel blockers and sildenafil

Surgical procedure of choice for achalasia

Laparascopic Heller myotomy | - incision through longitudinal and circular muscle to open the LOS

How long is botox effective in the tx of achalasia

3-6 months

Disadvantage of POEM for achalasia

Higher rates of reflux due to lack of fundoplication

What part of the oesophagus is cut for Heller myotomy?

Cork screw oesophagus

diffuse oesophageal spasm

Use of pH studies in diffuse oesophageal spasm

rule out GORD as an underlying trigger

Manometry results in diffuse oesophageal spasm

premature contraction but appropriate relaxation of the LOS

Oesophageal cancer epidemiology for men and women

adenocarcinoma men 5:1 | squamous cell carcinoma men 2:1

squamous cell carcinoma most commonly affects which portion of oesophagus

middle 1/3

adenocarcinoma most commonly affects which portion of oesophagus

lower

hot beverages is a risk factor which type of oesophageal cancer?

squamous cell carcinoma

sewer classification for surgery in early oesophagogastric junction cancer

Type 1 distal - 5cm oesophagectomy and proximal gastrectomy type 2 cardia - tanshiatial/thoracic oesophagectomy or extended total gastrectomy Type 3 proximal stomach - transmittal extended total gastrectomy

2 types of trans thoracic oesophagectomy

Ivor lewis incisions in abdo and thorax | McKeown - incisions in abdo, thorax and neck

Advantage of transhiatal vs trans thoracic approach

avoids thoracotomy | incisions made in abdomen and neck

most common benign tumor of the oesophagus

Leiomyoma

stomach cancer with spindle cell morphology and c-KIT receptors - what is it?

Gastrointestinal stromal tumor Malignant potential imatinib if sensitive surgery to resect with negative margins

Tx to induce remission of MALT lymphoma

Eradication of H pylori with antibiotics

Gastric neuroendocrine tumors most commonly arise in what part of stomach

Body | mostly from Enterochromaffin like cells

What sort of stomach cancer is associated with zollonger-ellision syndrome?

gastric neuroendocrine type 2 | associated with MEN1

When to refer for urgent OGD suspicious of gastric cancer

any of 1. Dysphagia 2. Age >55, weight loss +any of; - upper abdo pain - reflux - dyspepsia 3. Upper abdominal mass

A 35-year-old man A&E following an episode of severe vomiting. Sudden onset chest and neck pain. On examination , crepitus in his suprasternal notch. What is the first initial investigation in the emergency department?

Dgx = oeso perforation → do CXR

A 10-year-old boy, ingestion of household bleach. He complains of severe pain in his mouth and stomach. temperature of 38.5o C, a blood pressure of 105/65mmHg and pulse rate of 135 beats/min. What is the next most appropriate initial investigation?

Dgx = corrosive oesophagiits → urgent endoscopic

Hiatus hernia. The following are all true with regards to hiatus hernias EXCEPT? Such hernias are associated with bleeding Rolling (paraoesophageal) hernias are associated with reflux Sliding hernias are more common than rolling hernias Proton pump inhibitors may be useful Rolling (paraoesophageal) hernias may be associated with gastric volvulus

Sliding hernias are more common than rolling hernias Such hernias are associated with bleeding Proton pump inhibitors may be useful Rolling (paraoesophageal) hernias may be associated with gastric volvulus False = Rolling (paraoesophageal) hernias are associated with reflux

The following are all examples of hepatic jaundice EXCEPT? Viral hepatitis / Crigler–Najjar syndrome / Malaria / Gilbert’s syndrome / Dubin Johnson Rotor syndrome/

``` True = Viral hepatitis / Crigler–Najjar syndrome / Gilbert’s syndrome / Dubin Johnson Rotor syndrome False = Malaria ```

Boas sign

Boas’ sign which is hyperaesthesia below the right scapula. | Seen in acute cholecystitis

Grey turner’s sign

Bruising of the flanks = blue | Seen in acute pancreatitis

Cullen's sign

Bruising around umbilicus

Acute cholangitis organism

E coli

A long-term alcohol abuser presents with central abdominal pain radiating to his back. Routine blood investigations confirm an amylase of greater than 1000 IU/l. The following are all indicators of a severe attack of pancreatitis EXCEPT? Age greater than 55 Blood urea concentration greater than 16mmol/l Blood glucose concentration greater than 5mmol/l Serum albumin less than 32g/l Serum calcium concentration less than 2mmol/l Glucose > 10

False = Blood glucose concentration greater than 5mmol/l

Elevated in pancreatic cancer

Tumor markers . Serum CA 19-9 and serum carcinoembryonic antigen (CEA)

malena is the result of bleeding proximal to what

ligament of treitz

impact of b blockers on patient presenting to ED with upper GI bleed

can mask a tachycardia at presentation

When should a patient with bleeding varices be brought to endoscopy

Early <12hrs

Management option for variceal bleed if can't get patient to surgery

Sengstalen Blakemore tube

Upper GI surgery Flashcards

(82 cards)