Fwd: Bambury tutorial Upper GI Surgery

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From: UCD Graduate '09 None <ucdgrad09@gmail.com&gt;
Date: 2009/2/12
Subject: Bambury tutorial Upper GI Surgery
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Fwd: Bambury tutorial Upper GI Surgery

  1. 1. Upper GI surgery Ms. N. Bambury 12/02/2009
  2. 2. Overview <ul><li>Stomach </li></ul><ul><li>Duodenum </li></ul><ul><li>Oesophagus </li></ul><ul><li>Pancreas </li></ul>
  3. 3. Anatomy of the stomach
  4. 4. Anatomy of the stomach
  5. 5. Physiology of the stomach <ul><li>Reservoir for digestion </li></ul><ul><li>Endocrine functions </li></ul><ul><ul><li>Secretion of gastrin(from antral cells) </li></ul></ul><ul><ul><li>Gastrin acts on parietal cells to increase acid production </li></ul></ul><ul><li>Exocrine functions </li></ul><ul><ul><li>Acid secretion </li></ul></ul>
  6. 6. Peptic Ulcer Disease <ul><li>Peptic ulcers are defects in the gastric or duodenal mucosa that extend through the muscularis mucosa. </li></ul><ul><li>Occur when defensive mechanisms ie. tight intercellular junctions, mucus, and epithelial renewal, are overcome by aggressive factors </li></ul>
  7. 7. PUD <ul><li>Aggressive factors/Causitive factors </li></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><ul><li>H.Pylori </li></ul></ul><ul><ul><li>Severe physiologic stress </li></ul></ul><ul><ul><ul><li>Burns </li></ul></ul></ul><ul><ul><ul><li>CNS trauma </li></ul></ul></ul><ul><ul><ul><li>Surgery </li></ul></ul></ul><ul><ul><li>Hypersecretory states </li></ul></ul><ul><ul><ul><li>Gastrinoma (Zollinger-Ellison syndrome) </li></ul></ul></ul><ul><ul><ul><li>multiple endocrine neoplasia (MEN-I) </li></ul></ul></ul>
  8. 8. Patient Factors <ul><li>40-70 years </li></ul><ul><li>Men </li></ul><ul><li>Duodenal ulcers>gastric ulcers </li></ul>
  9. 9. Gastric ulcers <ul><li>Same age group </li></ul><ul><li>Males </li></ul><ul><li>Located in prepyloric pyloric or coexist </li></ul><ul><li>70% located in lesser curvature </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Alcolhol </li></ul></ul><ul><ul><li>Burns </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>NSAIDS/steroids </li></ul></ul>
  10. 10. Gastric ulcers <ul><li>Symptoms </li></ul><ul><ul><li>Epigastric pain </li></ul></ul><ul><ul><li>Transiently relieved by food </li></ul></ul><ul><ul><li>May be associated with nausea , vomiting and decreased appetite </li></ul></ul>
  11. 11. Duodenal ulcers <ul><li>Same age,sex </li></ul><ul><li>Located mostly 2cm from pylorus-duodenal bulb </li></ul><ul><li>Caused by increase in gastric acid </li></ul>
  12. 12. Duodenal ulcers <ul><li>Symptoms </li></ul><ul><ul><li>Burning or aching several hours after a meal </li></ul></ul><ul><ul><li>Haematemesis,FOB+ve </li></ul></ul><ul><ul><li>Back pain </li></ul></ul><ul><ul><li>Nausea, vomiting,decreased appetite </li></ul></ul>
  13. 13. Differential Diagnosis <ul><li>Biliary Colic </li></ul><ul><li>Cholecystitis </li></ul><ul><li>Cholelithiasis </li></ul><ul><li>Pancreatitis </li></ul><ul><li>Pancreatic Cancer </li></ul><ul><li>Acute Gastritis </li></ul><ul><li>Myocardial Infarction </li></ul><ul><li>Gastroesophageal Reflux Disease </li></ul><ul><li>Mesenteric Artery Ischemia </li></ul>
  14. 14. Diagnosing ulcers <ul><li>Outpatient setting </li></ul><ul><ul><li>Bloods </li></ul></ul><ul><ul><li>OGD </li></ul></ul><ul><ul><li>In the case of gastric ulcers biopsy should always be taken to outrule carcinoma. Patient should be treated and rescoped in approx 6 weeks to ensure healing. Biopsies are taken on all walls at 2 cm intervals </li></ul></ul>
  15. 15. Medical treatment <ul><li>Treat H pylori infection with triple therapy </li></ul><ul><ul><li>PPI Clarithromycin penecillin </li></ul></ul><ul><ul><li>PPI Metronidazole Ampicillin </li></ul></ul><ul><ul><li>PPI Metronidazole Clarithromycin </li></ul></ul><ul><li>Those not found to be H. Pylori free </li></ul><ul><ul><li>Treat with PPI or H2 receptor blockers </li></ul></ul>
  16. 16. Complications of PUD <ul><li>Bleeding </li></ul><ul><li>Perforation </li></ul><ul><li>Pain </li></ul><ul><li>Obstruction </li></ul><ul><ul><li>Secondary to repeated inflammation and subsequent scarring namely gastric outlet obstruction </li></ul></ul>
  17. 17. Indications for surgery <ul><li>Similar in both types of ulceration </li></ul><ul><ul><li>Refractory to treatment </li></ul></ul><ul><ul><li>Haemorrhage </li></ul></ul><ul><ul><li>Perforation </li></ul></ul><ul><ul><li>Obstructive symptoms </li></ul></ul><ul><li>Surgery is less common now since the introduction of PPIs </li></ul>
  18. 18. Surgical management of Gastric ulcers <ul><li>Principles </li></ul><ul><ul><li>Remove ulcer </li></ul></ul><ul><ul><li>remove gastrin secreting antrum </li></ul></ul><ul><li>Two operations described </li></ul>
  19. 19. Gastric Surgery <ul><li>Billroth 1-remove </li></ul><ul><li>distal third </li></ul><ul><li>of stomach and </li></ul><ul><li>anastomose </li></ul><ul><li>remainder to </li></ul><ul><li>duodenum </li></ul>
  20. 20. Gastric surgery <ul><li>Billroth 2- remove </li></ul><ul><li>distal 2/3rds of </li></ul><ul><li>stomach and perform </li></ul><ul><li>gastro-jejunostomy </li></ul>
  21. 21. Surgical management of Duodenal ulcers <ul><li>Principles </li></ul><ul><ul><li>Reduce acid secretion by dividing the vagus nerve </li></ul></ul><ul><ul><li>called a vagotomy. </li></ul></ul><ul><li>Vagotomy denervates the stomach and therefore the pylorus which will lead to gastric outlet obstruction. </li></ul><ul><li>Therefore a drainage procedure is performed called a pyloroplasty. </li></ul><ul><li>2 surgical operations </li></ul><ul><ul><li>Truncal vagotomy and pyloroplasty </li></ul></ul><ul><ul><li>Selective vagotomy and pyloroplasty </li></ul></ul>
  22. 22. Vagotomy complications <ul><li>Decreased acid secretion (aim of the game) </li></ul><ul><li>Faster gastric emptying (loss of vagally mediated) </li></ul><ul><ul><li>Diarrhoea </li></ul></ul><ul><ul><li>Dumping syndrome </li></ul></ul><ul><li>Gastric outlet obstruction(unless pyloroplasty performed) </li></ul>
  23. 23. Vagotomy complications <ul><li>Remember proximal vagotomy denervates from the stomach to the distal transverse colon including the pancreas and gallbladder </li></ul><ul><li>Gallbladder denervation leads to stasis and which increases the chance of gallstones. </li></ul><ul><li>Decrease in pancreatic and gallbladder secreations leading to undigested fats-steatorrhoea </li></ul>
  24. 24. Complications of gastrectomy <ul><li>Dumping syndrome </li></ul><ul><ul><li>Early v’s late </li></ul></ul><ul><ul><li>Cardiovascular and GI symptoms due to vagotomy and pyloroplasty or gastrectomy </li></ul></ul><ul><ul><li>Early DS due to hypovolaemia </li></ul></ul><ul><ul><li>Late DS due to hypoglycaemia </li></ul></ul>
  25. 25. Early Dumping Syndrome <ul><li>No intact pylorus leads to dumping of large amounts of chyme,biliary and pancreatic secretions into duodenum at once </li></ul><ul><li>Results in large fluid shift </li></ul><ul><li>Occurs within 40 minutes of ingestion </li></ul><ul><li>Symptoms include </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><ul><li>Palpitations </li></ul></ul><ul><ul><li>Diarrhoea </li></ul></ul><ul><ul><li>Abdominal pain </li></ul></ul>
  26. 26. Late Dumping Syndrome <ul><li>Due to rebound hypoglycaemia </li></ul><ul><li>Occurs 2-4 hours post op </li></ul><ul><li> CHO  enterglucagon  sensitizes islet cells  overproduction of insulin </li></ul><ul><li>Symptoms include </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Palpitations </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul>
  27. 27. Complications of gastrectomy continued <ul><li>Anaemia( Intrinsic factor essential for binding of Vit B12 for absorption in the terminal ileum) </li></ul><ul><li>Early satiety </li></ul><ul><li>Hypocalcaemia- reduced HCl prod interferes with absorption of calcium and Fe in the duodenum </li></ul><ul><li>Gastric Stump carcinoma? Due to chronic irritation of stump by acid duodenal secretions </li></ul>
  28. 28. Specific management <ul><li>Patient presenting with Haematemesis </li></ul><ul><ul><li>History and Examination </li></ul></ul><ul><ul><li>Vital signs </li></ul></ul><ul><ul><li>2 large bore cannulae </li></ul></ul><ul><ul><li>Bloods including </li></ul></ul><ul><ul><ul><li>FBC </li></ul></ul></ul><ul><ul><ul><li>U&E </li></ul></ul></ul><ul><ul><ul><li>Coag screen </li></ul></ul></ul><ul><ul><ul><li>Group and X match for 6 units </li></ul></ul></ul><ul><ul><ul><li>Inflammatory markers </li></ul></ul></ul><ul><ul><ul><li>Amylase </li></ul></ul></ul>
  29. 29. Specific management <ul><li>If greater than 6 units required urgent scope warranted. </li></ul><ul><li>Oversewing of bleeding vessel. </li></ul><ul><li>In the case of gastric ulceration distal gastrectomy may be warranted to excise the ulcer. </li></ul><ul><li>No vagotomy required </li></ul>
  30. 30. Perforated Duodenal Ulcer <ul><li>Presentation </li></ul><ul><ul><li>Acute onset of epigastric pain </li></ul></ul><ul><ul><li>Patients Vitals are ‘off’patient generally is unable to settle </li></ul></ul><ul><ul><li>Nausea, vomiting </li></ul></ul><ul><ul><li>O/E decreased bowel sounds, tenderness/rigidity of abdomen </li></ul></ul><ul><ul><li>May complain of lower abdo pain as free fluid tracks down the paracolic gutters and causes local irritative symptoms. </li></ul></ul>
  31. 31. Management of Perforated DU <ul><li>2 large bore cannulae </li></ul><ul><li>Fluid resuscitation </li></ul><ul><li>NG insertion </li></ul><ul><li>Urinary catheter insertion </li></ul><ul><li>Analgesia and antibiotics </li></ul><ul><li>Bloods as before </li></ul><ul><li>Erect CXR-Free air </li></ul><ul><li>PFA- may see free air also </li></ul>
  32. 32. Perforated DU <ul><li>CT abdomen- use water soluble contrast. Given 1 hour prior to scan to allow it to move along the GIT tract. </li></ul><ul><li>CT Abdomen findings include </li></ul><ul><ul><li>Free air </li></ul></ul><ul><ul><li>Free fluid </li></ul></ul><ul><ul><li>Contrast may not fill small intestine </li></ul></ul>
  33. 33. Surgical Management <ul><li>Graham patch </li></ul><ul><ul><li>Mini laparotomy from below umbilicus to epigastrium </li></ul></ul><ul><ul><li>Stomach is identified and duodenum </li></ul></ul><ul><ul><li>Perforation sought </li></ul></ul><ul><ul><li>Omentum mobilised so that it is easily applied to site of perforation </li></ul></ul><ul><ul><li>Suturedin 2 layers to peration site </li></ul></ul><ul><ul><li>Closure </li></ul></ul>
  34. 34. Definitions you should know <ul><li>Cushings Ulcer- ulcer associated with trauma, tumour or neurology </li></ul><ul><li>Curlings ulcer- associated with major burns </li></ul><ul><li>Marginal ulcer- ulceration at the site of a GI anastomosis </li></ul><ul><li>Dieulafoys ulcer-underlying gastric malformation </li></ul>
  35. 35. Gastric Ca <ul><li>Adenocarcinoma </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>Blood group A, male </li></ul></ul><ul><ul><li>Pernicious anaemia (Autoimmune disease) </li></ul></ul><ul><ul><li>Hypogammaglobulinaemia </li></ul></ul><ul><ul><li>Previous partial gastrectomy </li></ul></ul><ul><ul><li>Helicobacter pylori infection </li></ul></ul><ul><ul><li>Atrophic gastritis </li></ul></ul><ul><ul><li>Intestinal metaplasia </li></ul></ul>
  36. 36. Gastric Ca <ul><li>Presentation </li></ul><ul><ul><li>Age group>60 </li></ul></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Loss of appetite </li></ul></ul><ul><ul><li>Palpable epigastric mass </li></ul></ul><ul><ul><li>Melaena </li></ul></ul><ul><ul><li>Most present late and are not amenable to radical surgery </li></ul></ul>
  37. 37. Gastric Ca <ul><li>Investigations/Staging </li></ul><ul><ul><li>CEA </li></ul></ul><ul><ul><li>OGD confirms diagnosis with a tissue biopsy </li></ul></ul><ul><ul><li>Endoscopic ultrasound may allow assessment of intramural tumour penetration </li></ul></ul><ul><ul><li>CT will assess nodal spread and extent of metastatic disease </li></ul></ul><ul><ul><li>Laparoscopy will identify peritoneal seeding </li></ul></ul><ul><li>Survival </li></ul><ul><ul><li>Overall 5 year survival is approximately 5% </li></ul></ul>
  38. 38. Gastric Ca <ul><li>Surgical options </li></ul><ul><li>No real role for adjuvant therapy </li></ul><ul><li>Billroth 2 or Roux en Y anastomosis </li></ul><ul><ul><li>Antrum-Distal subtotal(75%) gastrectomy </li></ul></ul><ul><ul><li>Body- total gastrectomy </li></ul></ul><ul><ul><li>Proximal- total gastrectomy </li></ul></ul>
  39. 39. Roux en Y anastomosis <ul><li>Y-shaped anastomosis </li></ul><ul><li>After division of the </li></ul><ul><li>small intestine,the </li></ul><ul><li>distal end is implanted </li></ul><ul><li>into the stomach </li></ul><ul><li>and the proximal end into </li></ul><ul><li>the small intestine </li></ul><ul><li>below the anastomosis </li></ul><ul><li>to provide drainage </li></ul><ul><li>without reflux. </li></ul>
  40. 40. Gastric Ca <ul><li>Virchow’s node </li></ul><ul><ul><li>Metastatic gastric carcinoma in the left supraclavicular fossa </li></ul></ul><ul><li>Krukenburg tumour </li></ul><ul><ul><li>Gastric ca which has metastasized to the ovaries </li></ul></ul>
  41. 41. Gastric lymphoma <ul><li>The Stomach is the commonest extranodal primary site for non-Hodgkin's lymphoma </li></ul><ul><li>Secondary Lymphoma is commonly seen in stomach from another site </li></ul><ul><li>Accounts for 5% of gastric malignancies </li></ul><ul><li>Presentation is similar to gastric carcinoma </li></ul><ul><ul><li>Anaemia and epigastric mass are common </li></ul></ul><ul><li>Age of presentation is approx 60 years </li></ul><ul><li>Investigations </li></ul><ul><ul><li>EUS is the best modality </li></ul></ul>
  42. 42. Gastric Lymphoma <ul><li>Treatment </li></ul><ul><ul><li>70% of tumours are resectable </li></ul></ul><ul><ul><li>5-year survival is approximately 25% </li></ul></ul><ul><ul><li>Treatment modalities are discussed on a case by case basis at an MDT </li></ul></ul><ul><ul><li>Treatments range from chemotherapy alone, H pylori eradication or surgery and chemotherapychemotherapy may be useful </li></ul></ul>
  43. 43. MALT lymphoma <ul><li>A type of primary gastric lymphoma </li></ul><ul><li>The stomach does not usually contain lymphoid tissue </li></ul><ul><li>MALT follicles found in the stomach are associated with H pylori infection </li></ul><ul><li>Patients can be completely cured by H pylori eradication or else use it in conjunction with chemotherapy </li></ul>
  44. 44. GIST tumours <ul><li>Gastrointestinal sromal tumours </li></ul><ul><li>Previously classified as Leiomyosarcomas, Leiomyomas or sarcomatous lesions ie they originate from smooth muscle. </li></ul><ul><li>There are classified according to the degree of differentiation towards different cells </li></ul>
  45. 45. GIST tumours <ul><li>Classification </li></ul><ul><ul><li>Benign </li></ul></ul><ul><ul><ul><li>Differentiation toward muscle cells </li></ul></ul></ul><ul><ul><ul><li>Differentiation toward neural elements </li></ul></ul></ul><ul><ul><li>Malignant </li></ul></ul><ul><ul><ul><li>Dual differentiation </li></ul></ul></ul><ul><ul><ul><li>Lacking differentiation </li></ul></ul></ul><ul><ul><ul><li>1% of stomach cancers </li></ul></ul></ul>
  46. 46. GIST tumours <ul><li>Presentation </li></ul><ul><ul><li>Haemetemsis </li></ul></ul><ul><ul><li>Melaena </li></ul></ul><ul><ul><li>Epigastric mass </li></ul></ul><ul><li>Investigation </li></ul><ul><ul><li>EUS + biopsy </li></ul></ul><ul><ul><li>Endoscopy </li></ul></ul>
  47. 47. GIST tumours <ul><li>Treatment </li></ul><ul><ul><li>Surgery-local excision of tumour </li></ul></ul><ul><ul><li>Lymph node clearance unnecessary as spread is not common </li></ul></ul><ul><ul><li>Large tumours may need formal gastrectomy+/- adjuvant therapy </li></ul></ul><ul><ul><li>Trials on a new drug Glivec have been shown to be effective </li></ul></ul>
  48. 48. Sister Mary Joseph Nodule <ul><li>A 'nodule' in the umbilicus often associated with advanced malignancy </li></ul><ul><li>Presents as firm, red, non-tender nodule </li></ul><ul><li>Results from spread of tumour within the falciform ligament </li></ul><ul><li>90% of tumours are adenocarcinomas </li></ul><ul><li>Commonest primaries are stomach and ovary </li></ul><ul><li>Primary tumour is almost invariably inoperable </li></ul>
  49. 49. Oesophageal Anatomy <ul><li>Superior 1/3rd-smooth muscle </li></ul><ul><li>Middle 1/3rd-mixed </li></ul><ul><li>Inferior 1/3rd-smooth muscle </li></ul><ul><li>Length -25cm </li></ul>
  50. 50. Oesophageal constrictions <ul><li>Superiorly: level of cricoid cartilage, juncture with pharynx-cricopharyngeal sphincter @15 cm </li></ul><ul><li>Middle: crossed by aorta and left main bronchus @22cm </li></ul><ul><li>Middle; L main Bronchus@27cm </li></ul><ul><li>Inferiorly: diaphragmatic sphincter @37cm </li></ul>
  51. 51. Why are constrictions important <ul><li>Areas where foreign bodies lodge </li></ul><ul><li>Common sites of carcinoma </li></ul><ul><li>Difficulty passing scope on OGD may occur </li></ul>
  52. 52. Dysphagia <ul><li>Definition-difficulty swallowing </li></ul><ul><li>Typical presentation in oesophageal Ca is one of progressive dysphagia starting with solids followed by fluids </li></ul><ul><li>Odynophagia- pain on swallowing </li></ul>
  53. 53. Differential diagnosis -dysphagia <ul><li>Asnatomical causes </li></ul><ul><ul><li>Intrinsic to wall </li></ul></ul><ul><ul><ul><li>Carcinoma </li></ul></ul></ul><ul><ul><ul><li>Cricoid web </li></ul></ul></ul><ul><ul><ul><li>Inflammatory lesions </li></ul></ul></ul><ul><ul><li>Extrinsic lesions </li></ul></ul><ul><ul><ul><li>Bronchial Ca </li></ul></ul></ul><ul><ul><ul><li>Mitral stenosis leading to L atrial enlargement </li></ul></ul></ul>
  54. 54. Differential diagnosis -dysphagia <ul><li>Functional lesions </li></ul><ul><ul><li>Neurological causes </li></ul></ul><ul><ul><ul><li>Post CVA </li></ul></ul></ul><ul><ul><ul><li>MND </li></ul></ul></ul><ul><ul><ul><li>Globus hystericus-constriction of the lower part of the oeophagus associated with anxiety </li></ul></ul></ul><ul><ul><li>Dysmotility </li></ul></ul><ul><ul><ul><li>Achalasia </li></ul></ul></ul><ul><ul><ul><li>Diffuse oesophageal spasm </li></ul></ul></ul><ul><ul><ul><li>Scleroderma </li></ul></ul></ul>
  55. 55. Assessment-dysphagia <ul><li>History and Examination </li></ul><ul><li>OGD+/-biopsy </li></ul><ul><li>Barium swallow </li></ul><ul><li>CT if suspect extrinsic compression is the cause. </li></ul><ul><li>Other tests </li></ul><ul><ul><li>Oesophageal manometry </li></ul></ul><ul><ul><li>pH studies </li></ul></ul>
  56. 56. Oesophageal manometry <ul><li>NG tube passed into oesophagus </li></ul><ul><li>Pressure transducer on tip of it measures resting and squeezing pressures at different levels of the oesophagus </li></ul><ul><li>Normal peristaltic waves travel at a rate of 5cm/sec through oesophagus </li></ul><ul><li>Normal resting pressure of LOS is 10-15mmHg </li></ul><ul><li>Squeeze pressures should generate up to 100mmHg </li></ul>
  57. 57. pH studies <ul><li>Naos oesophageal wire containing a pH probe is left in oesophagus for a 24 hour period </li></ul><ul><li>If oesophageal pH is greater than 4 for >4% of the time this indicates reflux </li></ul>
  58. 58. GORD <ul><li>3 factors exist to keep gastric juices out of the oesophagus </li></ul><ul><ul><li>LOS competence </li></ul></ul><ul><ul><li>Oesophageal motility </li></ul></ul><ul><ul><li>Clearance into stomach </li></ul></ul>
  59. 59. GORD presentation <ul><li>Symptoms </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><ul><li>Epigastric </li></ul></ul></ul><ul><ul><ul><li>Retrosternal </li></ul></ul></ul><ul><ul><ul><li>Interscapular </li></ul></ul></ul><ul><ul><li>Odynophagia </li></ul></ul><ul><ul><li>Reflux of food especially on bending </li></ul></ul><ul><ul><li>Pulmonary aspiration </li></ul></ul><ul><ul><ul><li>Nocturnal coughing </li></ul></ul></ul><ul><ul><ul><li>Hoarse voice </li></ul></ul></ul>
  60. 60. GORD <ul><li>Investigations </li></ul><ul><ul><li>pH monitoring is the gold standard investigation </li></ul></ul><ul><ul><li>Rule out MI </li></ul></ul><ul><ul><li>OGD + biopsy-5cm above GOJ shows increased eosinophils and hypoplasia </li></ul></ul><ul><ul><li>See if patient has a hiatus hernia (1/3 of patients with h.h have GORD) </li></ul></ul>
  61. 61. Complications of GORD <ul><li>Oesophageal stricture </li></ul><ul><ul><li>Commonest cause </li></ul></ul><ul><ul><li>Treat by balloon dilatation via OGD </li></ul></ul><ul><ul><li>Surgery options-Lap Nissan fundoplication </li></ul></ul><ul><li>Barrett’s oesophagus </li></ul><ul><ul><li>Increased risk of malignant transformation </li></ul></ul>
  62. 62. Treatment of GORD <ul><li>Conservative mgt- </li></ul><ul><ul><li>Antacids, lose weight, raise head of bed etc. </li></ul></ul><ul><ul><li>Metoclopramide,H2 blockers, PPIs </li></ul></ul><ul><li>Surgical </li></ul><ul><li>Nissan fundoplication </li></ul><ul><ul><li>Fundus of stomach is mobilised,wrapped around the oesophagus </li></ul></ul>
  63. 63. Motility disorders <ul><li>Primary versus secondary </li></ul><ul><li>Primary </li></ul><ul><ul><li>Achalasia </li></ul></ul><ul><ul><li>Diffuse oesophageal spasm </li></ul></ul><ul><li>Secondary </li></ul><ul><ul><li>Autoimmune rheumatic disorders(scleroderma) </li></ul></ul><ul><ul><li>Chagas disease(chronic infection with T cruzi associated with mega disorders) </li></ul></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>Amyloid </li></ul></ul>
  64. 64. Achalasia <ul><li>HighLOS pressure leading to failure of the sphincter to relax  poor peristalsis </li></ul><ul><li>Presents with dysphagia and retrosternal chest pain </li></ul><ul><li>Affects 30-60 years age group </li></ul><ul><li>Investigation;Barium swallow  bird’s beak, lack of gastric air bubble, contrast may not enter stomach </li></ul>
  65. 65. Achalasia <ul><li>Treatment </li></ul><ul><ul><li>Balloon dilatation </li></ul></ul><ul><ul><li>Heller’s cardiomyopathy-release of muscle at the GOJ, reflux common post op </li></ul></ul><ul><ul><li>Injection of botulinum toxin at ultrasound </li></ul></ul>
  66. 66. Diffuse oesophageal spasm <ul><li>Part of the differential of MI </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>Retrosternal chest pain radiating to jaw </li></ul></ul><ul><li>Invest; </li></ul><ul><ul><li>Manometry-nutcracker oesophagus </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>Nifedipine </li></ul></ul>
  67. 67. Scleroderma <ul><li>CREST syndrome </li></ul><ul><ul><li>Calcinosis </li></ul></ul><ul><ul><li>Raynauds </li></ul></ul><ul><ul><li>Oesphagitis </li></ul></ul><ul><ul><li>Scleroderma </li></ul></ul><ul><ul><li>Telangiectasia </li></ul></ul>
  68. 68. Scleroderma <ul><li>Srticture formation occurs due to inflammation and GORD </li></ul><ul><li>Investigations </li></ul><ul><ul><li>Manometry- incompetent LOS </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Partial fundoplication </li></ul></ul>
  69. 69. Autoimmune diseases <ul><li>Rheumatoid Arthritis </li></ul><ul><li>SLE </li></ul><ul><li>Dermatomyositis </li></ul><ul><li>Polymyositis </li></ul><ul><li>May all be associated with oesophageal dysmotility </li></ul>
  70. 70. Oesophageal carcinoma <ul><li>Adenocarcinoma>SCC </li></ul><ul><li>Adeno seen in lower 1/3rd </li></ul><ul><li>SCCs can be any site </li></ul><ul><li>Males>Females </li></ul><ul><li>Age;>40 </li></ul><ul><li>Most common at sites of physiological narrowing </li></ul><ul><li>Lower 1/3rd and GOJ most common sites </li></ul>
  71. 71. Oesophageal carcinoma <ul><li>Risk factors </li></ul><ul><ul><li>Adeno </li></ul></ul><ul><ul><ul><li>Barretts </li></ul></ul></ul><ul><ul><ul><li>GORD </li></ul></ul></ul><ul><ul><ul><li>Obesity </li></ul></ul></ul><ul><ul><ul><li>Alcohol </li></ul></ul></ul><ul><ul><ul><li>Cigarette smoking </li></ul></ul></ul>
  72. 72. Oesophageal carcinoma <ul><li>Risk factors </li></ul><ul><ul><li>SCC </li></ul></ul><ul><ul><ul><li>Alcohol </li></ul></ul></ul><ul><ul><ul><li>Smoking </li></ul></ul></ul><ul><ul><ul><li>Coeliac </li></ul></ul></ul><ul><ul><ul><li>Achalasia </li></ul></ul></ul><ul><ul><ul><li>PUD </li></ul></ul></ul>
  73. 73. Oesophageal carcinoma <ul><li>Symptoms </li></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><ul><li>Retrosternal pain </li></ul></ul><ul><ul><li>Coughing during eating </li></ul></ul><ul><ul><li>Pseudo-achalasia </li></ul></ul>
  74. 74. Oesophageal carcinoma <ul><li>Pre-operative </li></ul><ul><ul><li>U&Es, FBC </li></ul></ul><ul><ul><li>Optimise nutrition-NG feed </li></ul></ul><ul><ul><li>Stop smoking etc </li></ul></ul>
  75. 75. Oesophageal carcinoma <ul><li>Surgical management </li></ul><ul><ul><li>Ivor Lewis procedure </li></ul></ul><ul><ul><ul><li>Laparotomy and mobilisation of stomach </li></ul></ul></ul><ul><ul><ul><li>Right thoracotomy- resection of tumour and reanastomosis of stomach to healthy oesophagus </li></ul></ul></ul><ul><li>5 year survival 25% and only 30% patients suitable for surgery! </li></ul>
  76. 76. Oesophageal carcinoma <ul><li>Palliative treatment </li></ul><ul><ul><li>Intubation with metal stent under radiological control </li></ul></ul><ul><ul><li>Chemotherapy-adeno </li></ul></ul><ul><ul><li>Radiotherapy-SCC </li></ul></ul>
  77. 77. Pancreatic Anatomy <ul><li>The pancreas is a retroperitoneal organ </li></ul><ul><li>Consists of head body neck and tail </li></ul><ul><li>Duct of Wirsung drains most of the pancreas </li></ul><ul><li>Duct of Santorini drains the uncinate process into the 2nd part of the duodenum </li></ul><ul><li>Note the pancreas shares a common blood supply with the duodenum! </li></ul>
  78. 78. Structure of the pancreas <ul><li>Exocrine </li></ul><ul><ul><li>Serous secretory cells make up lobules which drain via ductules into main ducts </li></ul></ul><ul><li>Endocrine </li></ul><ul><ul><li>Islets of Langerhans secrete insulin(Beta), glucagon(Alpha) and somatostatin (Delta) directly into circulation </li></ul></ul>
  79. 79. Pancreatitis <ul><li>Presentation </li></ul><ul><ul><li>Epigastric pain </li></ul></ul><ul><ul><li>Radiating through to back or interscapular area </li></ul></ul><ul><ul><li>Pain score 10/10 </li></ul></ul><ul><ul><li>May be associated with nausea, vomiting diaphoresis </li></ul></ul>
  80. 80. Acute Pancreatitis <ul><li>Signs </li></ul><ul><ul><li>Jaundice </li></ul></ul><ul><ul><li>Ascites </li></ul></ul><ul><ul><li>Grey-Turners sign </li></ul></ul><ul><ul><li>Cullens sign </li></ul></ul><ul><ul><li>Shock(Hypovolaemia) </li></ul></ul><ul><ul><li>ARDS </li></ul></ul><ul><ul><li>Renal failure(hypovolaemia) </li></ul></ul>
  81. 81. Acute Pancreatitis <ul><li>Aetiology </li></ul><ul><ul><li>Gallstones </li></ul></ul><ul><ul><li>Alcohol </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Mumps </li></ul></ul><ul><ul><li>Autoimmune(SLE) </li></ul></ul><ul><ul><li>Hypothermia. ↑Ca,↑lipids/TRG </li></ul></ul><ul><ul><li>ERCP </li></ul></ul><ul><ul><li>Drugs-Azathioprine,diuretics,thiazides, NSAIDS </li></ul></ul>
  82. 82. Acute Pancreatitis <ul><li>Investigations </li></ul><ul><ul><li>FBC </li></ul></ul><ul><ul><li>U&E, Magnesium, Calcium </li></ul></ul><ul><ul><li>Amylase, glucose </li></ul></ul><ul><ul><li>LFTs </li></ul></ul><ul><ul><li>Coag screen </li></ul></ul><ul><ul><li>Albumin </li></ul></ul>
  83. 83. Amylase and its role in diagnosis <ul><li>Amylase is a digestive enzyme that normally acts extracellularly to cleave starch into monosaccharides,. </li></ul><ul><li>The pancreas and the salivary glands account for almost all serum amylase </li></ul><ul><li>Used as a diagnostic tool </li></ul><ul><li>10% of cases amylase is normal, especially in acute on chronic pancreatitis </li></ul><ul><li>Low specificity </li></ul>
  84. 84. Amylase and its role in diagnosis <ul><li>Renal failure and liver disease result in decreased metabolic clearance </li></ul><ul><li>IBD, mesenteric infarction- ↑amylase absorption </li></ul><ul><li>Gut perforation-leaks into peritoneum and absorbed across inflamed peritoneum </li></ul><ul><li>Ectopic amylase production by lung, ovary, pancreas, and colon malignanciesand breast cancer (increased pancreatic amylase) are miscellaneous </li></ul>
  85. 85. Acute pancreatitis <ul><li>Investigations </li></ul><ul><ul><li>Erect CXR, PFA </li></ul></ul><ul><ul><ul><li>May see ‘sentinel node’ of proximal jejunum </li></ul></ul></ul><ul><ul><li>CT pancreatic protocal </li></ul></ul><ul><ul><ul><li>Look for fat streaking around the pancreas, fluid in the lesser sac, necrosis, pseudocyst </li></ul></ul></ul><ul><ul><li>U/S to o/r gallstones as cause </li></ul></ul><ul><ul><li>ABG-hypoxia, lactic acidosis </li></ul></ul>
  86. 86. Acute Pancreatitis <ul><li>Scoring systems </li></ul><ul><ul><li>Ranson’s criteria </li></ul></ul><ul><ul><li>At admission time and 48 hours into admission </li></ul></ul><ul><ul><li>A higher score is associated with a poorer prognosis </li></ul></ul>
  87. 87. Ranson’s admission criteria <ul><li>Glucose >11 </li></ul><ul><li>Age >55 </li></ul><ul><li>LDH >350 </li></ul><ul><li>AST>250 </li></ul><ul><li>WCC>16 </li></ul>
  88. 88. Ranson’s criteria 48 hours later <ul><li>Calcium <2 </li></ul><ul><li>Haematocrit  10% </li></ul><ul><li>pO2<60 </li></ul><ul><li>Base deficit >4 </li></ul><ul><li>BUN>1.8 </li></ul><ul><li>>3 positive  severe attack </li></ul>
  89. 89. Sequelae <ul><li>Hypo/Hyperglycaemia </li></ul><ul><li>Hypocalcaemia- saponification of omental fat by pancreatic lipases chelates calcium </li></ul><ul><li>Hypomagnesaemia </li></ul><ul><li>Chronicity </li></ul><ul><li>DM </li></ul>
  90. 90. Sequelae <ul><li>ARDS/MODS </li></ul><ul><li>Abscess formation </li></ul><ul><li>Pancreatic necrosis </li></ul><ul><li>Pseudocysts </li></ul>
  91. 91. Acute pancreatitis <ul><li>Management </li></ul><ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>2 large bore cannulae </li></ul></ul><ul><ul><li>Fluid resuscitation </li></ul></ul><ul><ul><li>Analgesia </li></ul></ul><ul><ul><li>NG(large bore) for drainage if vomiting </li></ul></ul><ul><ul><li>Urinary catheter- measure input output </li></ul></ul><ul><ul><li>Bloods </li></ul></ul>
  92. 92. Pancreatic Ca <ul><li>Management </li></ul><ul><ul><li>Antibiotics only if evidence of pyrexia or positive blood cultures Imipenem antibiotic of choice </li></ul></ul><ul><ul><li>Surgery indicated only in presence of abscess /pseudocyst or massive infected pancreatic necrosis </li></ul></ul><ul><ul><li>Mortality significanty increased in the context of laparotomy </li></ul></ul>
  93. 93. Pancreatic Carcinoma <ul><li>Ductal adenocarcinoma </li></ul><ul><li>60-80 years </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>Smokers </li></ul></ul><ul><ul><li>DM </li></ul></ul><ul><ul><li>FAP </li></ul></ul><ul><ul><li>Gardner syndrome </li></ul></ul>
  94. 94. Pancreatic Carcinoma <ul><li>70% occur at the head </li></ul><ul><li>20% in the body </li></ul><ul><li>10% in the tail </li></ul><ul><li>Presentation </li></ul><ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Jaundice </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Trousseaus sign-superficial thrombophlebitis assoc with Panc Ca </li></ul></ul>
  95. 95. Pancreatic Ca <ul><li>Head tumours </li></ul><ul><ul><li>Present with painless jaundice and earlier </li></ul></ul><ul><ul><li>Palpable non tender gallbladder(Courvosier’s sign) </li></ul></ul><ul><li>Body and tail </li></ul><ul><ul><li>Presents later </li></ul></ul><ul><ul><li>Tends to present as pain, weight loss and hepatomegaly </li></ul></ul>
  96. 96. Pancreatic Ca <ul><li>Investigations </li></ul><ul><ul><li>Contrast enhanced CT-pancreatic protocol </li></ul></ul><ul><ul><li>ERCP- useful for insertion of stent in context of jaundice and tissue diagnosis </li></ul></ul><ul><ul><li>MRI to seek extent of local invasion </li></ul></ul><ul><ul><li>Endoscopic ultrasound </li></ul></ul><ul><ul><li>Laparoscopy </li></ul></ul>
  97. 97. Surgical management <ul><li>Head of pancreas/peri-ampullary tumours </li></ul><ul><ul><li>Whipples operation </li></ul></ul><ul><ul><ul><li>Resect specimen including distal stomach duodenum to jejunum head of pancreas </li></ul></ul></ul><ul><ul><ul><li>Gastroenterostomy </li></ul></ul></ul><ul><ul><ul><li>Choledochojejunostomy </li></ul></ul></ul><ul><ul><ul><li>Pancreaticojejunostomy </li></ul></ul></ul>
  98. 98. Pancreaticoduodenectomy
  99. 99. Surgical management <ul><li>Body and Tail tumours </li></ul><ul><ul><li>Distal resection </li></ul></ul><ul><ul><li>Resection rate <7% </li></ul></ul><ul><ul><li>No place for adjuvant therapy </li></ul></ul><ul><ul><li>Tissue diagnosis important </li></ul></ul><ul><li>Neo adjuvant/adjuvant chemotherapy and radiotherapy have a role in the management of both tumours </li></ul>
  100. 100. Palliative care <ul><li>Alleviate symptoms only </li></ul><ul><ul><li>Stenting via ERCP </li></ul></ul><ul><ul><li>Bypass procedures </li></ul></ul><ul><ul><li>Chemotherapy </li></ul></ul><ul><ul><li>Radiotherapy </li></ul></ul>
  101. 101. Other definitions you should know <ul><li>Annular pancreas </li></ul><ul><ul><li>Pancreas surrounding the duodenum </li></ul></ul><ul><ul><li>Congenital </li></ul></ul><ul><ul><li>May present with duodenal obstruction </li></ul></ul><ul><li>Pancreatic divisum </li></ul><ul><ul><li>Failure of the two ducts to fuse </li></ul></ul>
  102. 102. Benign Panc Tumours MCQ stuff! <ul><li>Gastrinoma </li></ul><ul><ul><li>Tumour of non beta islet cells </li></ul></ul><ul><ul><li>May be multiple </li></ul></ul><ul><ul><li>Overproduction of gastrin </li></ul></ul><ul><ul><li>Leads to multiple metastases in some instances </li></ul></ul><ul><ul><li>May also occur in duodenum </li></ul></ul><ul><ul><li>60% are malignant at diagnosis </li></ul></ul><ul><ul><li>30% are associated with MEN1 </li></ul></ul>
  103. 103. Gastrinoma <ul><li>Presentation </li></ul><ul><ul><li>Peptic ulcers </li></ul></ul><ul><ul><li>May be treatment resistant </li></ul></ul><ul><ul><li>Diarrhoea </li></ul></ul><ul><ul><li>Haematemesis </li></ul></ul><ul><ul><li>Perforation </li></ul></ul>
  104. 104. Gastrinoma <ul><li>Investigations </li></ul><ul><ul><li>Pentagastrin secretory studies </li></ul></ul><ul><ul><li>Fasting serum gastrin levels </li></ul></ul><ul><ul><li>U/S, CT-localizes tumour </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>PPIS </li></ul></ul><ul><ul><li>Resection only if localised </li></ul></ul><ul><ul><li>Total gastrectomy if poorly defined </li></ul></ul>
  105. 105. Insulinoma <ul><li>Solitary tumours of Beta cells of the pancreas </li></ul><ul><li>Presentation </li></ul><ul><ul><li>Usually related to hypogylcaemia </li></ul></ul><ul><ul><ul><li>Altered consciousness </li></ul></ul></ul><ul><ul><ul><li>Uncharacteristic behaviour </li></ul></ul></ul>
  106. 106. Insulinoma <ul><li>Diagnosis </li></ul><ul><ul><li>Glucose </li></ul></ul><ul><ul><li>Glucagon test </li></ul></ul><ul><ul><li>Plasma insulin </li></ul></ul><ul><ul><li>U/S, CT </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Resection as malignant potential </li></ul></ul><ul><ul><li>Distal pancreatectomy if tumour cannot be found </li></ul></ul>
  107. 107. Next week <ul><li>Upper GI surgery to include </li></ul><ul><ul><li>Liver </li></ul></ul><ul><ul><li>Spleen </li></ul></ul><ul><ul><li>Gallbladder and Biliary tree </li></ul></ul><ul><ul><li>Small intestine </li></ul></ul>

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