Upper GI and Hepatobiliary Surgery

What is reflux?

The excessive flow of gastric contents back into the oesophagus

What are the two components of the oesophageal sphincter mechanism?

Functional but not anatomical sphincter immediately above the diaphragm, and the smooth muscle at the gastric cardia

How do you manage reflux oesophagitis? (15)

Mainly conservative
Weight reduction
Changes in diet
Reduce alcohol intake
Smaller, more frequent, drier meals
Elevation of the head at night
Smoking cessation
Wearing loose fitting clothing
Avoid bending or straining after meals
Alginate drugs
Dopamine antagonists to increase motility
H2 receptor antagonists
Proton pump inhibitors
Promotility drugs
Laparoscopic fundoplication

How do you manage oesophageal strictures? (2)

Balloon dilation
Anti-reflux operation

What are the risk factors of reflux oesophagitis? (6)

Excess alcohol consumption
Drugs
Previous surgery
Coughing
Delayed gastric emptying
Large meals

What investigations should be done for reflux oesophagitis? (2)

Endoscopy with possible biopsy
24 hour pH study

What is the pathophysiology of reflux oesophagitis?

The sphincter malfunction causes reflux and if this is persistent and severe there can be significant mucosal destruction and inflammation which is reflux oesophagitis

What is the pathophysiology of oesophageal strictures?

Chronic reflux oesophagitis causes scarring that causes a stricture

What are the clinical features of reflux oesophagitis? (6)

Heartburn
Chest pain
Dyspepsia
Oesophageal spasm
Acid in the pharynx
Worse at night or after a large meal

What is the main clinical feature of an oesophageal stricture?

Dysphagia

What is a peptic ulcer?

A breakdown in the mucosal defence that leads to a breach

Where can be affected by peptic ulcers? (3)

Oesophagus
Stomach
Duodenum

What happens in a chronic peptic ulcer?

There is a balance formed between resistance to the acid due to scarring, and acid-pepsin attack

What is protective against peptic ulcers?

Prostaglandins. They protect the mucosa and so NSAIDs can induce acute illness

When can stress peptic ulcers occur?

Acutely in seriously ill patients as a complication of extensive burns, systemic sepsis, multiple trauma, major head injuries, uraemia, and terminal illness

What is the presentation of a peptic ulcer? (20)

Epigastric pain
Reflux
Nausea
Dysphagia
Vomiting
Upper GI bleeding
Pain exacerbated by food, especially acidic or spicy
Central back pain
Anorexia
Weight loss if gastric
Weight gain if duodenal
Chronic anaemia
Haematemesis
Dehydration
Shock
Electrolyte disturbance
Melaena
Abdominal fullness
Bloating

What investigations should be done for H.pylori infection? (4)

Stool antigen tests
Serum IgG
Hydrogen breath tests
Endoscopic biopsies with immediate testing for urase

What investigations should be done in peptic ulceration? (4)

H. pylori testing
Gastroscopy
Endoscopy
Barium meal

What are the emergency presentations of peptic ulcers? (3)

Acute haemorrhage
Perforation
Pyloric stenosis

How do you manage peptic ulcers? (7)

Control risk factors
Antibiotics and PPI to eradicate H. pylori
Mucosal protective agents
PPI or H2 receptor antagonist
Partial gastrectomy
Dilation of oesophageal strictures
Surgery for pyloric stenosis and hiatus hernia

What are the risk factors for peptic ulcers? (6)

H. pylori infection
Aspirin use
NSAID use
Elevated gastrin
Smoking
Alcohol excess

What are the complications of peptic ulcers? (7)

Erosion of posterior tissues
Perforation
Chronic peptic ulcer
Strictures
Gastric outlet obstruction
Chronic anaemia
Barrett's oesophagus

How do you manage upper GI bleeding? (4)

PPI - IV if an emergency
Blood transfusion if needed
Possible surgery
Discontinue NSAIDs, aspirin, antiplatelets, and anticoagulants

How do you manage varices? (2)

Endoscopic coagulation or banding
IV vasopressin

What are the causes of upper GI bleeding? (8)

Peptic ulcers
Oesophageal varices
Oesophageal ulcers
Oesophageal trauma
Vascular malformations or lesions
Gastric carcinoma
Leiomyoma
Aortoenteric fistula

What investigations should be done in an upper GI bleed? (2)

OGD
Angiography in active bleeding

How do you diagnose gallstones? (11)

FBC
U&Es
LFTs
Blood cultures
Serum amylase
Abdominal x-ray
Ultrasound
Hepatobiliary iminodiacetic acid scan if ultrasound is inconclusive
MRCP if ultrasound is inconclusive
ERCP
PTC if ultrasound is inconclusive

How do you manage gallstones? (5)

Cholecystectomy
Percutaneous drainage of the gallbladder
Dissolution therapy
Extracorporeal shockwave lithotherapy
ERCP

What are the risk factors for gallstones? (20)

Age
Female
Pregnancy
Use of the oral contraceptive pill
Obesity
Multiparity
Chronic haemolytic disorders for pigment stones
Long term parenteral nutrition
Previous surgery or disease involving the distal small bowel
Genetics
Environment
Native American ethnicity
Rapid weight loss due to low calorie diet
High cholesterol, fatty acid, or carb diet
Diet low in unsaturated fats, fibre, vitamin C, calcium, coffee, and nuts
Diabetes
Cystic fibrosis
Crohn's disease
Cirrhosis
Drugs

What is the presentation for gallstones in the bladder? (5)

Biliary colic
Dyspepsia
Acute cholecystitis
Mucocele
Empyema

What is a mucocele?

A stone in the neck of the gallbladder that means bile is absorbed but mucus secretion continues. This produces a large tense globular mass in the right upper quadrant

What is an empyema?

Abscess of the gallbladder

What is the presentation of gallstones in the common bile duct? (4)

Asymptomatic
Obstructive jaundice
Ascending cholangitis
Acute pancreatitis

What are the differential diagnoses for gallstones? (4)

Acute appendicitis
Gastro-oesophageal reflux disease
Cholecystitis
Ascending cholangitis

What is biliary colic?

Severe pain that rises to a plateau over a few minutes and then continues . Patients can be in agony until the pain resolves spontaneously after a few hours or pain relief is given

How do you manage biliary colic? (5)

Manage at home
One injection of opioids
Hospitalisation in severe cases
Cholecystectomy is definitive management
Low fat diet for symptom relief

What is pancreatitis?

An inflammatory process that has a cascade of inflammatory cytokines and pancreatic enzyme release

What is used to divide pancreatitis between mild and severe?

Glasgow criteria

What is the pathophysiology of pancreatitis?

Obstructions cause a backpressure in the pancreatic ductal system that leads to enzymatic activation in the pancreas due to a reduction in exocytosis of the cells

How does alcohol increase the risk of pancreatitis?

It causes dysfunction of the pancreatic cells and can cause accumulation of intracellular enzymes. It also increases acinar cell sensitivity to CCK which increases the risk of excess enzymatic activation

What is the presentation for pancreatitis? (14)

Abdominal pain
Guarding and rigidity
Pain radiating to the back
Abdominal distension
Vomiting
Nausea
Inability to get comfortable
Pain relieved by leaning forwards
Movement may be painful
Mild jaundice
Dehydration
Fever
Hypotension
Tachycardia

What are the causes of pancreatitis? (14)

Idiopathic
Gallstones
Ethanol excess
Trauma - including surgery
Steroids
Mumps
Malignancy
Autoimmunity
Scorpion sting
Snake bites
Hyperlipidaemia
Hypercalcaemia
ERCP
Drugs

Which drugs can cause pancreatitis? (4)

Azathioprine
Didonosine
Pentamidine
Bactrim

What are the clinical signs of pancreatitis? (6)

Swollen or oedematous pancreas on CT or ultrasound
Decreased blood calcium level
Activation of complement
Acute peripancreatic fluid collections on CT
Pancreatic necrosis in severe cases
Absent bowel sounds

What are the differential diagnoses for mild pancreatitis? (5)

Biliary colic
Acute cholecystitis
Acute exacerbation or perforation of a peptic ulcer
Lower lobe pneumonia
Inferior myocardial infarction

What are the differential diagnoses for severe pancreatitis? (3)

Perforated large bowel
Leaking aortic aneurysm
Ruptured ectopic pregnancy

What is the management for mild pancreatitis? (3)

Fluids
Analgesia
Treat the cause

What is the management for severe pancreatitis? (6)

Oxygen
Fluids
NG tube in severe vomiting
TPN if needed
ERCP
Biliary stenting

What are the complications of pancreatitis? (10)

Death
Pancreatic necrosis
Pancreatic infection
Peripancreatic fluid collection
Pancreatic abscess
Multiorgan failure
Portal vein thrombosis
Bowel ischaemia
Pseudoaneurysms
Internal pancreatic fistulae

What investigations should be done in pancreatitis? (4)

Plasma amylase - increased
Plasma lipase - increased
Ultrasound of biliary tree
ERCP

What bloods should be frequently assessed in pancreatitis? (10)

Haemoglobin
White cell count
Arterial blood gas
Blood sugar
U&Es
Creatinine
LFTs
Calcium
Phosphate
CRP

What are the causes of chronic pancreatitis? (2)

Pancreatic carcinoma
Chronic pancreatic inflammation

What are the clinical features of chronic pancreatitis? (4)

Pancreatic swelling
Pancreatic atrophy
Parenchymal calcification
Dilated pancreatic duct

What are the long term effects of chronic pancreatitis? (2)

Diabetes
Malabsorption

What is the management for chronic pancreatitis? (2)

Surgery in structural abnormalities
Stenting of the pancreatic duct

What are the features of adenocarcinoma of the oesophagus? (3)

Found in the lower third
Normally derived from Barrett's oesophagus
Very aggressive

What are the risk factors for oesophageal cancer? (7)

Male
Age
Smoking
High alcohol intake
Frequent hot drinks above 65 degrees
Functional and structural disorders of the oesophagus
Low fruit and vegetable intake

What investigations should be done for oesophageal cancer? (8)

OGD and biopsy
Ultrasound
Chest CT
Chest ultrasound
Staging laparoscopy
Staging thoracoscopy
Endoscopic ultrasound
PET scan

How do you manage oesophageal cancer? (5)

Surgery
Chemotherapy
Radiotherapy
Palliation
Palliative ablation of the tumour

What is the presentation of oesophageal cancer? (14)

Dysphagia
Odynophagia
Wasting
Vomiting
Haematemesis
Weight loss
Dyspepsia
Epigastric mass
Chronic GI bleeding
Iron deficiency anaemia
Hepatomegaly
Virchow node metastasis
Hoarse voice
Obstructive jaundice

At what stage do gastric cancers typically present at?

T3 with nodal spread and metastasis

What are the risk factors for gastric cancer? (4)

Age
Male
Lower socioeconomic status
Mainly environmental

What is the presentation for gastric cancers? (14)

Asymptomatic
Obstructive symptoms
Vomiting if gastric outlet is obstructed
Dysphagia
Pain
Nausea
Anorexia
Early satiety
Anaemia
Cachexia
Epigastric mass
Virchow node mass
Obstructive jaundice
Pelvic masses due to metastasis

What are the features of intestinal type gastric cancers? (4)

Histologically similar to intestinal epithelium
Cells grow in clumps
Lots of inflammatory infiltrate
Better prognosis

What are the features of diffuse type gastric cancer? (3)

Cells are singular
Cells are arranged single file and surrounded by marked stromal reaction
Tumour cells have large intracellular mucin droplets that displace the nucleus to the periphery of the cell and make it look like a signet ring

What are the features of fungating gastric tumours? (2)

Produced by intestinal type cells
Polypoid lesions that can grow to a large size

What are the features of a malignant ulcer? (3)

Produced by intestinal type cells
Result from necrosis in broad based solid tumours
Larger than peptic ulcers and have heaped up hardened margins

What are the features of infiltrating gastric carcinomas? (2)

Produced by diffuse type cells and spread widely below the mucosa and invades the muscle wall
Causes thickening and rigidity that makes the stomach contract known as linitis plastica

What are the features of early gastric cancers? (3)

Limited to the mucosa and submucosa
Mainly found on screening or investigating another issue
High cure rate

What is the management for gastric cancer? (6)

Radical surgery
Chemotherapy
Radiotherapy
Neoadjuvant chemoradiotherapy
Stenting in palliation
Laparoscopic bypass in palliation

What investigations should be done for gastric cancer? (6)

Endoscopy and biopsy
Barium meal
CT
Staging laparoscopy
Endoscopic ultrasound
PET scan

What is cholecystitis?

Acute inflammation of the gallbladder that is normally due to an obstructed cystic duct due to a gallstone

What is the presentation of cholecystitis? (12)

Unremitting right upper quadrant pain
Nausea
Vomiting
Fever
Chills
Anorexia
Palpable gallbladder
Jaundice
Tachycardia
Rebound tenderness
Guarding
Murphy sign positive

What is Murphy's triad?

Right upper quadrant pain
Fever
Jaundice

What does Murphy's triad indicate?

Cholecystitis

What are the causes of cholecystitis? (4)

Gallstones causing obstruction
Physical obstruction of the cystic duct
Direct inflammation of the gallbladder
Bile stasis

What is the management for cholecystitis? (6)

Cholecystectomy
Drain the gallbladder if cholecystectomy cannot be done
Conservative management in mild disease
Antibiotics
Analgesia
IV fluids

What are the differential diagnoses for cholecystitis? (4)

Biliary colic
Pancreatitis
Acute myocardial infarction
Acute cholangitis

What are the complications of cholecystitis? (5)

Perforation of the gallbladder
Biliary peritonitis
Pericholecystic abscess
Biliary fistula
Multiple organ dysfunction

What is the pathophysiology of cholecystitis?

The gallbladder is physically and chemically irritated and then as the episode progresses it becomes bacterially irritated

What investigations should be done in cholecystitis? (6)

Ultrasound
CRP
FBC
CT
MRI
HIDS scintigraphy

What are the risk factors for cholecystitis? (3)

Obesity
Aids
Medications that increase gallstone formation

What are the risk factors for acalculous cholecystitis? (6)

Sepsis
Shock
Burns
Prolonged fasting
Trauma leading to hospitalisation
Critical illness leading to ITU care

What are the features of oedematous cholecystitis? (2)

Occurs in days 2-4
Wall of the gallbladder is oedematous

What are the features of necrotising cholecystitis? (3)

Occurs in days 3-5
The gallbladder has oedematous changes with areas of haemorrhage and superficial necrosis
No full thickness involvement

What are the features of suppurative cholecystitis? (4)

Occurs in days 7-10
Areas of necrosis and suppuration
The gallbladder wall thickens and fibroses so it begins to contract
Intramural and pericholecystic abscesses are present

What is a hiatus hernia?

Occurs when the proximal stomach passes through the diaphragmatic hiatus and into the chest

Which type of hiatus hernia can have reflux?

Sliding hernia

What are the differential diagnoses for a hiatus hernia? (5)

Achalasia
Peptic ulcer disease
Oesophageal carcinoma
Ischaemic heart disease
Gastro-oesophageal reflux disease

What is the presentation of a sliding hiatus hernia? (7)

Asymptomatic
Reflux
Substernal chest pain
Epigastric pain
Acid regurgitation
Oesophagitis
Oesophageal scarring that can cause stricture and dysphagia

What is the presentation of a rolling hiatus hernia? (9)

Asymptomatic
Epigastric pain
Hiccough
Pressure in the chest
Dysphagia
Breathlessness due to lung compression
Nausea
Postprandial fullness
Postprandial chest pain

What investigations should be done in a hiatus hernia? (3)

Endoscopy
Oesophageal manometry studies
Barium oesophagography

What is the management for any type of hiatus hernia? (3)

Smoking cessation
Weight loss
Reduction of alcohol consumption

What is the management for a sliding hiatus hernia? (4)

None if asymptomatic
Symptom relief
Promotilants
Surgery in severe cases

What is the management for a rolling hiatus hernia?

Emergency surgery

What are the complications of sliding hiatus hernia? (8)

Oesophagitis
Oesophageal ulcer
Oesophageal stricture
Oesophageal bleeding
Iron deficiency anaemia
Barrett's oesophagus
Oesophageal cancer
Pulmonary and upper airway disorders

What are the complications of rolling hiatus hernia? (6)

Upper GI bleeding
Iron deficiency anaemia
Gastric outlet obstruction
Gastric volvulus
Strangulation of the stomach
Respiratory compromise

What is the pathophysiology of a sliding hiatus hernia?

Laxity of the phreno-oesophageal membrane and a widening of the hiatus

What is the pathophysiology of a rolling hiatus hernia?

Defect in the phreno-oesophageal membrane and laxity of the gastrosplenic and gastrocolic ligament

What are the acute investigations for a hiatus hernia? (3)

Chest x-ray
CT chest
CT abdomen