Upper Gi Flashcards

Question

How would you manage bleeding peptic ulcer?

Answer 1

HEMODYNAMIC RESUS MEDICAL * High dose PPI eNDOSCOPY * Adrenaline injection PLUS * Clips or * Diathermy (gold probe) INTERVENTIONAL RADIOL SURGERY

Answer 2

**Endoscopy** * rules out cancer * if it shows reflux, then severity grading can be done and, pH studies are not needed **pH studies** (Use pre-op or for uncertain diagnosis) * establish presence of reflux * Can help establish casualty **Impedance** * to diagnose non-acid reflux e.g. bile reflux, post prandial reflux **Manometry (**Used pre-op) * to rule out motility disorder before surgery **Imaging** * Not used routinely but can help establish motility or show hiatus hernia

Answer 3

DeMeester score is a composite score calculated from pH studies and is used to diagnose reflux. A score of \>14.7 is diagnostic of reflux. The components include (a reflux episode is defines as pH \<4) * Total time * Upright time * Supine time * Number of episodes * No. of episodes \>5 mins * Duration of longest episode DeMeester score only diagnoses the presence of reflux but cannot establish causality. For establishing causality we need to calculate symptom index or symptom sensitivity index SI - no. of reflux-related symptom episodes/n**o. of symptom episode** x 100 (\>50% is considered positive) SSI - no. of reflux-related symptom episodes/ **no. of reflux episodes** x 100 (\>10% is positive)

Answer 4

ACID SUPRESSION * Antacids * H2 receptor blocker * PPI MUCOSAL PROTECTION * Sucralfate ERADICATION * PPI + Amoxicillin + clarithromycin (2 weeks) * For penicillin allergy - use metronidazole for amoxycillin SURGERY * for complications - perf, stricture, bleeding

Answer 5

T stage 1a= lamina propria -\> EMR 1b = Submucosa (SM1 - 3 like colorectal) -\> surgery first (**?neo-adj** if high grade) T2 = muscularis propria -\> neoadjuvant-\> Sx -\> **?adj** T3 = Adventitia -\> Neo -\> Sx -\> adj T4a - spread into resectable structures -\> Neo -\> Sx -\> Adj T4b -\> definitive chemorads N stage 1 = 1-2 nodes -\> neo-\> sx -\> adj 2 = 3-6 nodes 3 = 7 or more M0 M1 -\> palliative

Answer 6

1. BMI \>40 kg/m2 2. BMI \>35 with obesity related co-morbidities (HTN, DM, OSA, NASH, Arthritis, Cardiac disease. 3. Failed non-operative measures of weight loss 4. cleared by dietician and mental health professional 5. No other contraindications to surgery

Answer 7

ZD is a pulsion diverticulum due to failure of co-ordinated relaxation of the cricopharyngeous. It occurs through a natural weakness in the posterior pharyngeal wall through the Killian's dehiscence (Inferior constrictor and the cricopharyngeous). Most commonly it is on the left side of the neck. Management options: Endoscopic vs surgical Endoscopic is suitable for diverticulum \>3cm - specialised stapler is used to staple and divide the cricopharyngeus. Surgical - access via ant SCM incision on left. divide omohyoid and Middle thyroid vein. Dissect the diverticulum, open it to allow passing a finger into the esophagus. the cricopharyngeous is then divided under vision. diverticulum is stapled off.

Answer 8

it is classified by LA grade on endoscopy A - \< 5mm not across folds B- \> 5 mm not across folds C- across 2 or more folds but \< 75% circumference D - \> 75% circumference

Answer 9

Chicago classification * Gastroesophageal outflow obstruction * Achalasia types I – III (hellers myotomy + anti-reflux procedure) * Hypertensive lower oesophageal sphincter (balloon dilation or surgery) * Major motility disorders * Absent motility * Diffuse oesophageal spasm (uncoordinated contraction, medical therapy) * Hypercontractile (nutcracker) oesophagus (normal LES relaxation, very high amplitude coordinated contraction, medical therapy) * Minor * Ineffective/fragmented contractions

Answer 10

Johnson anatomic classification Type 1 \>\> lesser curve incisura (60%)\>\> acid output = normal \>\> no vagotomy Type 2 \>\> body \>\> high acid \>\> vagotomy Type 3 \>\> pre-pyloric \>\> high acid \>\> vagotomy Type 4 \>\> High in lesser curve \>\> low acid \>\> no vagotomy Type 5 \>\> anywhere - NSAID use LESSER CURVE ULCERS = LOW ACID ULCERS = HIGHER CANCER RATE

Answer 11

It is graded using the Prague C&M system C - circumferential extent (distance from incisors at GEJ - distance to proximal circumferential Barrett’s) M - maximal extent (distance from incisors at GEJ - distance to max proximal extent of Barrett’s)

Answer 12

LES - not a structural sphincter but a dynamic high pressure zone Diaphragmatic sphincter - right crus fibres make a pinchcock Distal esophageal compression - by abdo pressure closes lumen Acute angulation of OGJ - acts as a flap valve

Answer 13

**CDH1 mutation** * diffuse stomach cancer, young females, also have ILC of breast **Le Fraumeni** * p53 mutation (tumour suppressor gene) - multiple other malignancies, most commonly soft tissue and bony sarcomas, brain tumours, breast tumours, GI tract tumours, Lung, thyroid. **Lynch** * colon cancer (MMR gene) **FAP** * APC gene, colon cancer **Peutz Jeghers** **Juvenile polyposis (SMAD4)**

Answer 14

1. Cricopharyngeus (15 cm from incisors) - cerv esophagus starts 2. Sternal notch (20cm) - upper thoracic esophagus starts 3. Azygous vein (25cm) - mid part of thoracic esophagus starts 4. Inferior pulm vein (30 cm) - lower thoracic esophagus starts 5. GEJ (37cm) - abdominal esophagus starts

Answer 15

Filter out atypical reflux and refer for investigation to other specs as needed. Typical symptoms \>\>\> trial PPI (if no alarm signs) \>\>\> endoscopy (if it shows reflux changes pH not needed) otherwise \>\>\> pH studies (if if confirms causality then impedance not needed) \>\>\> impedance (if reflux still not diagnosed then diagnose functional GORD and don't operate) otherwise \>\>\> manometry \>\>\> swallow only if concern about motility or hiatus hernia \>\>\> assess for surgical suitability

Answer 16

H pylori is a helical gram neg rod that lives in gastric mucosa/submucosa. It needs gastric mucosa to live and can be found in ectopic gastric tissues like duodenal gastric metaplastic tissues, Barrett’s, Meckel’s. It creates an alkaline microenvironment by urease production that cleaves urea into ammonia and bicarbonate. **Mechanism of gastric damage** * **local tissue injury** by urease activity * Promoting **local inflammation by mucosal damage** * **Increased gastric acid production** by damage to antral D cell \>\> decreased somatostatin\>\> increased gastrin\>\>\> increased acid * Inducing **metaplastic changes** due to increased acid \>\>\> gastric metaplasia of duodenum/ esophagus\>\>\> increases colonization area

Answer 17

Type 1 (sliding) - GEJ lies above hiatus Type 2 - (rolling) - part of stomach herniates past GEJ which remains intra-abdominal Type 3 - combined type 4 - other organs herniate. Most commonly transverse colon Giant - where \>50% of stomach has herniated. Types 2-4 need surgical correction

Answer 18

Midline laparotomy \>\>\>\> Longitudinal duodenotomy extending into the pylorus\>\>\> ulcer bleeding usually in the posterior wall from GDA \>\>\> control with 3 stiches in U fashion (proximal, distal and medial) - the medial controls the transverse pancreatic branch or other medial branches \>\>\> transverse closure of duodenotomy Be careful not to damage the CBD with suture - if needed pass a probe via the ampulla

Answer 19

Neoadjuvant * FLOT - 5FU, Leucovorin, oxaliplatin, docetaxel - for fit patients who can tolerate intense chemo * ECF - Epirubicin, cisplatin, 5FU - used in MAGIC trial for fit patients * FOLFOX - 5FU, folic acid, oxaliplatin - less fit patients * CAPOX - capecitabine (oral FU) and oxaliplatin - less fit patient Adjuvant * ECF * FOLFOX

Answer 20

Have endoscopy available in theatre Ulcer can usually be palpated by feeling (if not -\> endoscopy) Principles are: stop bleeding, get tissue for histology and restore continuity Depending on the location and size of ulcer the options are to * wedge resect (unwell, co-morbid patient) * Gastrostomy \>\> oversew and biopsy (unwell, co-morbid patient) * Gastrectomy (distal/partial / total depending on site and size of ulcer) with gastroduodenostomy or gastrojejunostomy (well, stable patient) * Vagotomy may be performed (can cause dumping) (bleeding recurs in 20% without vagotomy, truncal is preferred) * Truncal + pyloroplasty (vagotomy above hepatic and celiac branches) * Selective + pyloroplasty (vagotomy below hepatic and celiac branches) * Highly selective )laterjet and criminal nv of Grassi 7 cm proximal to pylorus to 5 cm prox to GEJ

Upper Gi Flashcards

(45 cards)