Phase 4 > Upper G.I Surgery > Flashcards

Upper G.I Surgery Flashcards

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1
Q

Name Etiologies associated with GORD:

A 
Hiatus Hernia 
LOS dysfunction 
Delayed Gastric emptying 
Increased Intra Abdominal Pressures 
Dietary causes
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2
Q

What investigations should be carried out for people with GORD?

A

Endoscopy
24 hour pH study
Esophageal Manometry
Barium Swallow test

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3
Q

What are some serious complications of GORD?

A 
Strictures - malignant/ non- malignant 
Barrett's esophagus
Anaemia 
gastric volvulus  
- usually a hiatus hernia twisting on itself
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4
Q

Dysphagia can be broadly split into oral-pharyngeal and esophageal causes, name some causes of dysphagia associated with dysfunction of the eospheal aspect:

A

Strictures

  • malignant
  • non-malignant

Oesophagitis

  • candidiasis
  • eosinophilic oesophagitis
  • ulceration/ GORD

Dysmotility
- Achalasia

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5
Q

What investigations should be done into dysphagia?

A

Radiology:

  • AP chest - xray
  • Barium swallow test
  • CT/ MRI for tumours

Endoscopy

Esophageal Manometry

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6
Q

What is the best mode to diagnosis chronic Pancreatitis?

A

CT without contrast - it is best for picking up the calcifications

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7
Q

Following pancreatitis, a mass develops is the lesser sac, what is this and what blood marker will be raised?

A

Pseudocyst

Amylase remains high

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8
Q

Following laparoscopic surgery, a patient may become breathless and an x-ray is performed. What may you see and what is it?

A

Surgical subcutaneous emphysema

  • ginkgo leaf sign
  • you can see the pectoralis muscle under the skin
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9
Q

What are the diagnostic tests of choice for gallstones in the common bile duct?

A

Ultrasound
followed by:
MRCP

an ERCP can be used but this is usually reserved more intervention

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10
Q

What are the cause, clinical symptoms of chronic pancreatitis, and what investigations and treatment are available?

A

Causes:

  • alcohol
  • pancreatic ductal obstruction - tumours, cysts, cystic fibrosis

Features:

  • epigastric pain, radiating to the back
  • worse pain with foods and alcohol
  • anorexia
  • weight loss (poor protein intake)
  • steatorrhoea
  • Insulin dependent DM

diagnostic tests:

  • Pancreatic CT
  • ERCP

Treatment:

  • remove cause (alcohol, obstruction)
  • symptom control
  • creon supplements
  • DM control
  • whipples procedure
  • partial pancreatectomy (usually for retractable pain)
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11
Q

Pancreatic Carcinoma:

A

90% adenocarcinomas

Clinical features:

  • Obstructive jaundice
  • palpable gallbladder
  • Pain - epigastric, LUQ
  • Thrombophlebitis migrans - vessel inflammation

Investigations:

  • Ca-19
  • US transabdominally
  • CT with guided FNAC** Most important
  • ERCP
  • Chest/ Abdo/ Pelvis CT

Treatment:
- 95% are not suitable for resection due to metastasis

  • obstructional relief by ERCP stenting
  • Pain control - oramorph or MST
  • Whipple’s resection
    + adjuvant therapy chemotherapy

**Whipples is contraindicated if there is liver/peritoneal or distant mets

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12
Q

In acute pancreatitis, what are the signs called when there is ecchymosis?

A

Grey Turner’s sign - left flank ecchymosis

Cullen’s Sign - periumbilical

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13
Q

What is the glasgow criteria for pancreatitis and when is it considered severe?

A 
PaO2 - <8kpa 
Age - >55 years 
Neutrophils -  >15 
Corrected Ca2+ - <2mmols 
Raised blood urea - >16mmols 
Enzymes - AST >200, LDH >600 
Albulim <32g/L 
Sugar - >10mmol

*>3 or more = severe, admit to ITU.

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14
Q

Whats the most common injury following cholecystectomy?

A

Bile duct injury

- usually presents 1-3 days later

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15
Q

What is a risk factor for cholangiocarcinoma, and is associated with UC?

A

Primary Sclerosing cholangitis

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16
Q

What is the suggested management for pancreatic pseudocyst if there is no significant derangements of the liver?

A

Conservative management

- observe for 12 weeks.

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17
Q

Name some common causes of upper G.I bleeds:

A 
Peptic ulcers 
Oesphageal varices 
Mallory- weiss tears 
Oesophagitis 
Drugs - NSAIDs
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18
Q

What is the most SENSITIVE marker for acute pancreatitis?

A

Serum Lipase

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19
Q

What are the common type of oesophageal tumours and what are they associated with?

A

Adenocarcinoma
- barrett’s esophagus

Squamous Carcinoma

  • smoking
  • chronic achalasia

Rhabdomyosarcoma
- rare skeletal muscle defect

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20
Q

What are the symptoms of esophageal cancer? and how is it is investigated?

A

Often history of dyspepsia due to GORD

Dysphagia
- usually to solids

weight loss

Acute obstruction

**anyone>45 with dysphagia should be investigated for cancer

Investigations:
- endoscopy - with biopsy

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21
Q

What are the types of gastric cancers that can occur?

A 
Adenocarcinoma: 
Intestinal:
- H.Pylori 
- Autoimmune gastritis 
- Pernicious anaemia

Diffuse:

  • Linitus plastica
  • Signet ring morphology

Carcinoid / Gastro-stroma

Lymphoma - MALT (H.Pylori related)

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22
Q

What are some risk factors for developing gastric cancer?

A

Blood A group type
Chronic gastritis
Nitrosamines foods - smoked food

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23
Q

What are the signs and symptoms of gastric carcinoma and how is it investigated?

A

Dyspepsia

  • > 45 years new onset dyspepsia is cancer until proven otherwise
  • this is especially true after eating

Weight loss

Anorexia

Dysphagia
- if affecting the upper area of stomach

Signs:

  • weight loss
  • Acanthosis nigerans Type I
  • Epigastric distension
  • sister Mary Joseph Nodule

Diagnosis:

  • gastroscopy
  • CT for staging
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24
Q

What are the causes of gastritis?

A

Acutely:

  • NSAIDs
  • Alcohol
  • Cushing’s effect - from head injury

Chronic:

  • H. Pylori
  • Hiatus Hernia
  • autoimmune gastritis
  • Menetrier’s disease - TNF- alpha release which promotes stomach to enlarge
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25
What are the symptoms of gastritis? What investigations are done?
Epigastric pain vomiting Upper G.I endoscopy
26
What are the alarm symptoms that require urgent referral related to dyspepsia and peptic ulcer disease?
ALARMS: ``` Anaemia Loss of weight Anorexia Recent change in symptoms Melena/ or other bleeding Swallowing difficulty ```
27
What are the symptoms of GORD?
``` Heart burn Retrosternal pain after meals Belching Regurgitation Odynophagia ``` Extra-oesophageal: - Nocturnal asthma - chronic cough - laryngitis - sinusitis
28
How does Biliary colic differ from normal colic? and where else might the pain radiate to?
usually colic pain gradually rises. Biliary has plateau. Right shoulder. Tip of the scapula - T7-T9 fibres
29
What is the management for biliary colic?
- Rehydration - NBM - Pethidine (analgesia that doesn't cause sphincter of oddi spasm) **although this is now debated Surgical elective: 6-12 weeks following
30
MRCP:
Imaging of the pancreaticobiliary ducts - non invasive - uses iodine based for contrast doesn't allow for any therapeutic intervention
31
ERCP:
Used for diagnostic and therapeutic reasons. Diagnostics: - gallstones - acute pancreatitis - chronic pancreatitis Therapeutically: - widden ampulla to grab stone - either by widening to allow passage into stool or into basket - Stent ampulla if tumour Complications: - acute pancreatitis
32
What is a very important landmark to be established on an upper G.I bleed?
Ligament of Treitz / Suspensory muscle of the duodenum. - found on the flexure of the duodonojejunum flexure, which marks the separation of the upper and lower G.I tracts. thus a bleed proximal to it is an upper G.I bleed. *it also has clinical significance for children who may have malrotation of the gut
33
What are the most common causes of G.I bleeds in order:
1. Duodenal ulcer 2. Oesphageal varices 3. Gastric ulcer 4. Erosive/ hemorrhagic gastritis 5. Mallory -weir tears
34
What cancers are people with achalasia more at risk of?
squamous cell
35
Which type of ulcer is associated with pain several hours after eating?
Duodenum
36
What syndrome can occur with gastric bypass that leads to abdominal pain, dizziness, nausea and diarrhea?
Dumping syndrome. - hyperosmolar fluids enter jejunum and draw water in, causing distention and pain. increased osmolality induces diarrhea
37
In the setting of an upper G.I bleed if a person cannot tolerate an endoscopy or the results from it are inconclusive, what addition test can be done to establish where the bleed is?
CT abdomen with IV contrast
38
What is the definitive management for esophageal varices?
Endoscopic Banding
39
What is the definitive management for peptic ulcer bleeding?
Endoscopic adrenaline and cauterisation + High Dose PPIs
40
When asking about dysphagia, what other symptoms should you be interested in other than solids and liquids?
Pain when swallowing and where? Sensation of food being stuck hoarse voice weight loss pain radiating to the back
41
What does a Whipple's procedure consist of?
Removal of: Head of Pancreas Gall bladder + common bile duct 1st/ 2nd part of duodenum Lymph nodes +/- Antrum of stomach
42
What is the survival rate of pancreatic cancer?
5% at 5 years
43
What is the treatment for pancreatic cancer when there is metastasis?
Folfirinox regime
44
What is the grading system used for GORD and what is the treatment?
Los Angeles Classification of Reflux - based on the mucosal breaks seen Lifestyle advice Bed raise 1st line: PPIs surgery: - Nissan Fundoplication
45
What is the gold stand investigation into GORD?
24 hours pH monitoring
46
What are the main complications of GORD?
Adenocarcinoma Aspiration pneumonia Strictures
47
Name some complications of gallstones;
Biliary colic Cholecystitis Empyema Cholangitis Gallstone ileus Gallbladder perforation Choledocholithiasis
48
What are the advantages of laparoscopic approach to gallbladder and what are the advantages of open repair?
Laparoscopic: - less scar formation - quicker recovery - reduced pain Open: - Low risk of damage to bile duct - lower risk of damage to adjacent structures - Technically easier
49
What are some complications of Cholecystectomy?
``` Death Bile duct leak Bile duct injury Adjacent structure injuries Retained stones ```
50
What are some medical causes for increased gastrin production?
Zollinger - Ellison Autoimmune gastritis PPI use H.Pylori
51
What are two signs of obstructive jaundice?
Steatorrhea Dark urine - as conjugated bilirubin can pass into the urine
52
What are the contraindications to whipple's procedure?
Metastatic spread - usually to liver Superior mesenteric vein involvement No dissection plane visible
53
What are the clinical signs on pancreatic cancer?
``` Palpable gallbladder Hepatomegaly Weight loss Thrombophlebitis Jaundice Sister mary Joseph nodules ```
54
What are some of the complications of GORD?
Barrett's esophagus Adenocarcinoma Volvulus Strictures Pneumonia
55
What are the risk factors for a hiatus hernia?
Increased intraabdominal pressure Loss of tone to the diaphragm Obesity Pregnancy Ascites
56
What are the symptoms of Hiatus hernia?
GORD Hiccups Chest pain Vomiting and weight loss
57
What are the two surgeries used in Hiatus hernia and when are they implicated?
Cruroplasty Fundoplication - failure of medical management - Risk of volvulus formation - Malnutrition
58
What are the complications of fundoplication?
Recurrence of hernia Intra-abdominal pressure/ discomfort - unable to belch Dysphagia Necrosis - if too tight
59
What are the symptoms of a gastric volvulus?
Borchardt's triad: - epigastric pain - retching and unable to bring anything up - NG tube won't go down
60
What is the investigation of choice for Hiatus hernia and what will be seen?
Endoscopy | - Z - line deformity
61
What are the differential diagnosis of GORD/ Hiatus hernia?
Stomach cancer Pancreatic cancer Cardiovascular pain Peptic ulcer
62
What are biopsies of gastric carcinoma sent away for?
Histology HER protein status H.Pylori testing
63
What are the complications of a gastrectomy?
Dumping syndrome Vitamin B12 Anastomosis leak
64
What clinical signs may be seen with Cholecystitis ?
Still in movement Shallow quick breathing Temperature Fullness in right hypochondrium Murphy's sign - 9th intercostal space Boa's sign - hyperesthesia at the tip of scapula
65
What should be done pre-endoscopy?
Fast for 3 hours IV access Consented Notes are present
66
List some causes of motility dysphasia:
Achalasia Nutcracker esophagus Diffuse esophageal spasm
67
How does Cholangiocarcinoma present?
Steatorrhea with clay like stools Weight loss RUQ mass Intermittent RUQ pain
68
Anatomically where does the esophagus narrow?
Cricoid Posterior to left bronchus and aorta Lower esophageal sphincter
69
What is the treatment for achalasia?
Calcium channel blockers PPIs Surgical: - Balloon Dilation - Heller's myotomy
70
Name two surgical approaches to esophageal cancer:
Radiofrequency ablation - via endoscope Ivor Lewis - abdominal + Right thoracotomy Trans- Hiatal Approach - abdominal incision
71
What are the complications of a NIssan fundoplication?
Bloating -unable to belch Esophageal ischemia - too tight Dysphagia - too tight
72
List some complications of peptic ulcers:
Bleeding - acute and chronic Malignancy Perforation Obstruction - gastric outflow obstruction
73
What are the indications for surgery following an upper G.I bleed?
Rebleed Bleeding despite 6 units transfused Rockall score >3 initially Uncontrollable bleeding at endoscopy
74
Which of the peptic ulcers is most likely to perforated?
Duodenal
75
What is an abnormal duct dilatation of the biliary tract?
6mm + 1mm for every decade after 60
76
What are some causes of gallstone formation?
``` supersaturation of cholesterol Hyperlipidemia Bowel stasis - TPN Malnutrition Crohn's disease - lack of bile acid reabsorption ```
77
When should Barrett's esophagus be endoscopically checked?
No dysplasia - 2-5 years Low grade dysplasia - 6 months - biopsies High grade dysplasia - 3 months
78
If there is high grade dysplasia on Barrett's esophagus how should it be treated?
Endoscopic mucosal resection
79
How is a Boerhaave's Syndrome investigated and treated?
CT with contrast On table Endoscope Treatment: - Aggressive fluids - IV antibiotics - High Flow oxygen Definitive management: - Surgical control of leak - Removal of contents from mediastinum/ mediastinal wash - Decompression of esophagus - NG tube - Nutritional control *some patients can be managed conservatively if it was a iatrogenic cause
80
List some mobility disorders of the esophagus
Achalasia Chagas disease Diffuse esophageal spasm Nut cracker esophagus CREST syndrome
81
Physiological barriers against GORD?
Angle of His Lower Esophageal Sphincter tone Intra abdominal pressure Oblique muscle of stomach Saliva swallowing
82
What are the two new surgical techniques for GORD?
Endoscopic surgery: Linx - magnetic beads forming a sphincter Stretta technique - radioablation
83
What is the gold standard for staging oesphageal cancer?
Endoscopic ultrasound **note that endoscopic ultrasound is gold standard for all upper G.I malignancies
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