Upper GI Surgery- 4th Year Medic

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gtaang
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244531
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Upper GI Surgery- 4th Year Medic
Updated:
2013-11-02 18:38:06
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Medicine surgery student finals Upper GI
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Upper GI learning objectives for finals.
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  1. Causes of Gastro-oesophageal Reflux Disease
    • Hiatus Hernia
    • LOS dysfunction
    • Foods - fat, chocolate, caffeine
    • Smoking
    • Obesity
    • Alcohol
  2. Symptoms of GORD
    • Heartburn - retrosternal chest pain, particularly after meals
    • Regurgitation
    • Waterbrash
    • Choking at night
    • Dysphagia - secondary to strictures
  3. Investigations for GORD - When?
    • Diagnosis is clinical in all patients <45, in the absence of RED FLAGS:
    • Weight loss
    • Iron deficiency anaemia
    • GI bleeding
    • Persistent vomiting
    • Dysphagia
    • Empigastric Mass
  4. Investigations for GORD - How?
    Barium Swallow

    24hr luminal pH and manometry - pH below 4 for 6-7% of the period = GORD

    Endoscopy - can assess levels of inflammation and allow biopsies to be taken.
  5. Complications of GORD
    • Barrett's oesophagus - squamous metaplasia, predisposing to oesophageal cancer
    • Anaemia - Rule out colorectal Ca.
    • Benign Stricture
    • Gastric Volvulus
    • Webs
  6. Treatment of GORD- Behavioural
    • Raising the head when lying flat
    • Weight loss
    • Smoking and alcohol reduction
  7. Treatment for GORD - Medical
    • Antacids - Magnesium tricilitate or Aluminium hydroxide
    • Alginate containing antacids
    • PPIs - e.g. omeprazole
    • Prokinetic Agents - increase the rate of gastric emptying e.g. metocloperamide
    • H. Pylori erradication
  8. Surgical Treatment of GORD
    • Only indicated in medically unresponsive disease
    • Most common type of surgery is Nissen Fundoplication
  9. LNF Complications
    • Dysphagia
    • Dumping
    • Excessive scarring
    • Bloating
    • Achalasia
    • Reversal
  10. Pharyngeal / Oesophageal causes of Dysphagia
    • Motor Neurone Disease
    • Myasthenia Gravis
    • Upper Oesophageal Achalasia
    • Infection - Botulism / Polio
    • CVA - Damage to CN IX, X and XII *

    *Most common cause
  11. Oesophageal causes of Dysphagia
    • Achalasia
    • Oesophageal spasm
    • Luminal obstruction - stricture, bolus or carcinoma
  12. External Causes of Dysphagia
    • Retrosternal Goitre
    • Lung Cancer
    • Pharyngeal Diverticulum
    • Vascular Anomalies e.g. AAA and cardiomegaly
    • Mediastinal mass
  13. Factors in dysphagia that point towards a diagnosis:
    - Progressive Dysphagia
    - Difficulty with solids > liquids
    - Retrosternal pain and regurgitation
    - Weight Loss
    • Progressive Dysphagia = Malignancy
    • Difficulty with solids > liquids = Muscular inco-ordination
    • Retrosternal pain and regurgitation = suggests stricture / carcinoma
    • Weight Loss = Malignancy
  14. Investigations for Dysphagia
    • Barium Swallow - often negative and therefore rarely used
    • Oesophageal Endoscopy - First line, allows visualistation, biopsy and diagnosis of cancer.
    • CT scan - used to stage malignancy
  15. Treatment of Diseases that cause Dysphagia:

    - Pharyngeal Pouches

    - Achalasia

    - Oesophageal Spasm
    Pharyngeal Pouches - 

    Occurs in the elderly. Treat with endoscopic stapled pharyngoplasty.

    Achalasia - 

    • Barium swallow shows "rat's tail / bird beak" sign. Treatment can include:
    •       - Balloon Dilation
    •       - Botox injection
    •       - Surgical Myotomy

    Oesophageal Spasm - 

    • Characterised by odynophagia (esp. with extreme temps). Treatments:
    •      - Calcium channel blockers
    •      - Smooth muscle relaxants
    •      - Surgical myotomy rarely done.
  16. Pathological Types of Oesophageal Cancer
    • - Squamous Carcinoma - Upper 1/2
    • - Adenocarcinoma - Lower 1/2 

    2:1, adeno:squamous
  17. Risk Factors for Squamous Carcinoma of the Oesophagus:
    • Smoking
    • Alcohol
    • Increased nitrosamines intake
    • Vitamin A deficiency
    • Iron Deficiency Anaemia
  18. Risk Factors for Adenocarcinoma of the Oesophagus:
    • Acid Reflux
    • Barrett's Oesophagus
  19. Presentation in Oesophageal Cancer
    • Symptoms are ill defined in early disease
    • Progressive Dysphagia 
    • Weight Loss
    • Acute obstruction
    • Pain
    • Productive cough - aspiration / fistula
    • Hoarseness - Recurrent Laryngeal nerve involvement
    • Haematemasis
  20. Investigations in Oesophageal Ca.
    • Barium swallow
    • Endoscopy - biopsies can be take
  21. Staging Oesophageal Cancer
    • T - Endoscopic Ultrasound scanning
    • N - CT scan
    • M - PET CT scan
  22. Treatment of Oesophageal Cancer (Surgical)
    • Endoscopic submucosal resection*
    • Radio-frequency ablation*
    • Surgical resection - only if no spread, locally accessible and patient fit for GA.
    • *high risk of local recurrence therefore follow-up scope advised.
  23. Treatment of Oesophageal Cancer (medical)
    Chemotherapy with 5-fluorouracil and cystplatin can be used on local tumour
  24. Treatment of Oesophageal Cancer (Palliative)
    • Endoscopic insertion of metal stend can improve dysphagia
    • Beam radiotherapy
    • possible role of chemotherapy in metastatic disease
  25. Prognosis in Oesophageal Cancer
    • Prognosis is good in tumours confined to the mucosa. 
    • Prognosis falls steeply to 5% 5yr-survival in full thickness tumour.
  26. Causes and Contributing factors in Peptic Ulcer Disease
    • H. Pylori - Gram -ve bacillus that produces alkaline environment. This increases acid production and a damaging immune response
    • Drugs - NSAIDS and steroids disrupt prostoglandin synthesis in the gastric mucosa, leaving it open to damage from acidic environment.
    • Stress Ulcers:
    • Burns = Curlings
    • Surgery = Cushings
    • Hypersecretory States - Zollinger-Ellison syndrome caused by gastrinoma.
    • Hypercalcaemia - Cirrhosis, CRF, COPD and hyperparathyroidism.
  27. Presentation of Gastric Ulcers
    • Epigastric Pain, ? relieved by eating
    • Weight loss
    • N+V
    • Iron deficiency anaemia
    • Bleeding
    • 10% proceed to malignancy
  28. Presentation of Duodenal Ulcers
    • Epigastric Pain
    • 10% painless
    • Nocturnal Pain
    • Relapsing/Remitting
    • Bleeding
  29. Investigations
    • OGD - Visualise ulcers and confirm diagnosis.
    •        - If gastric ulcer is found, at least 6                  biopsies should be taken
    •        - Repeat post-therapy  to check ulcer                healing.
  30. Diagnosing H. Pylori
    • Culture
    • Serology
    • CLO - takes 24 hours. false negatives on PPIs and requires OGD.
    • Breath test - Carbon 14 tagged urea ingested. If Carbon 14 present in breath then it was broken down in stomach = H. Pylori present.
  31. Complications of Peptic Ulcers
    • Bleeding - can be severe, causing shock
    • Perforation
    • Pyloric outlet obstruction
  32. Medical Treatment of Peptic Ulcers
    • Acid Suppression - PPI or H2-antagonists
    • H. Pylori erradication - PPI + two antibiotics
    • Acid Neutralisation
    • Barrier Drugs - Succralfate or Bisthmus Compounds
  33. Surgical Treatment of Peptic Ulcers (RARE)
    • Resection of the ulcer and reconstruction with Bilroth I/II for example.
    • In duodenal disease, vagotomy of varying degree is the surgery of choice.
  34. Presentation of Gastric Adenocarcinoma
    • General Features - Anorexia, Weight Loss and Anaemia
    • Local Signs and Symptoms:
    •         - Epigastric Pain
    •         - Vomiting
    •         - Dysphagia
    •         - Perforation / Haemorrhage
    •         - Mass
    • Signs of Metastasis - e.g Jaundice, ascites and bone pain.
  35. Risk Factors for Gastric Adenocarcinoma
    • Blood Group A
    • H. Pylori infection
    • Previous gastric surgery
    • Family History
    • Pre-malignant disease
  36. Pre-malignant Gastric conditions
    • Polyps
    • ulcers
    • Chronic Gastritis
    • Pernicious anaemia
    • Hypertrophic Gastropathy - large gastric folds
  37. Investigations of Gastric Adenocarcinoma
    • OGD
    • Barium Meal - linitis plastica
    • CT / PET CT for staging
    • EUS to assess depth of invasion
    • Diagnostic laparoscopy
  38. Surgical Treatment of Gastric Cancer
    • Partial / subtotal gastrectomy - for distal tumours
    • Total gastrectomy - for middle and upper tumours. Reconstruct with Roux-en-Y or oesophagojejunostomy
  39. Palliative Surgery in Gastric Carcinoma
    • Bypass of obstruction
    • Stenting
    • Naso-jejunal feeding

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