Image based questions- upper git

IMAGE BASED QUESTIONS
UPPER GIT Image No:1
Dr.B.Selvaraj MS; Mch; FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia

A 50-year-old man underwent emergency
surgery for epigastric pain of acute onset.
A. What pathology can be seen in picture
A and what surgery is being performed
in picture B?
B. What physical signs would the patient
have presented with?
C. How can we confirm the need for
emergency surgery?
D. What further procedures need to be
carried out during the surgery?
E. What post-operative management
should be considered?

A. What pathology can be seen in picture
A and what surgery is being performed
in picture B?
ANS:
 A. Picture A shows an upper midline
incision with the liver at the superior aspect.
A perforated duodenal ulcer is seen.
 Picture B shows a Graham omental patch
repair

B. What physical signs would the patient
have presented with?
ANS:
 B. Peritonitis leading to
 Generalised abdominal tenderness
 Abdominal wall board-like rigidity
 Obliteration of liver dullness
 Absent bowel sounds- silent abdomen

C. How can we confirm the need for
emergency surgery?
ANS:
 C. Presence of free gas in the abdomen on an
erect chest X-ray.

D. What further procedures need to be
carried out during the surgery?
ANS:
 D. Peritoneal lavage of the subphrenic
spaces, paracolic gutters and pelvis.
 Inadequate lavage would give rise to intra-
abdominal abscesses Pelvic or subphrenic

E. What post-operative management
should be considered?
ANS:
 E. Helicobacter pylori eradication therapy
 Follow-up gastroscopy to ensure healing of
the ulcer.

THANK YOU
LIKE
SHARE
SUBSCRIBE

This equipment can be found in
the surgical ward.
A. What is this?
B. What is it used for?
C. How is it deployed?
D. Name the potential complication
associated with the larger balloon.
E. What precautionary measure can one
take to avoid this complication?

the surgical ward.
A. What is this?
ANS:
 A. Sengstaken-Blakemore tube.

the surgical ward.
B. What is it used for?
ANS:
 B. It is an oro or nasogastric tube used in the
management of upper gastrointestinal
haemorrhage due to bleeding from esophageal
varices.

the surgical ward.
C. How is it deployed?
ANS:
 C. The gastric balloon is inflated in the stomach
with 150 mls of dilute contrast for radiological
confirmation of position. The inflated balloon is
gently pulled up against the gastro-oesophageal
junction. The oesophageal balloon is then inflated.
Markings on the tubing indicate the distance from
the distal end of the oesophageal balloon.

the surgical ward.
D. Name the potential complication
associated with the larger balloon.
ANS:
 D. Prolonged deployment of the balloon will lead to
pressure necrosis or rupture of
the oesophagus

the surgical ward.
E. What precautionary measure can one
take to avoid this complication?
ANS:
 E. Releasing the oesophageal balloon at intervals.

ANS:
 1.Narrowing/Stricture of the
oesophagus

ANS:
 2. Dysphagia, regurgitation and vomiting

ANS:
 3. Benign: Chronic GERD, Anastomotic Stricture,
Ingestion of corrosives
Malignant: Ca oesophagus

ANS:
 4. Insertion of a guidewire and subsequent balloon
dilatation of the oesophagus

ANS:
 5. Early: Bleeding and perforation
Late: Renarrowing

ANS:
 Self Expanding Metallic Stenting- SEMS

70 yrs old male presented with progressive
dysphagia for solids who underwent neoadjuvant
chemoradiotherapy.
1.Describe the abnormal endoscopic findings in
picture A
2.What is your diagnosis?
3.What investigations were performed in picture
B & C and what are the findings?
4. Which kind of additional investigations would
be useful?
5. What is the most likely histological type?
6. What is the alternative to surgical treatment?
7. What is neoadjuvant therapy and what are its
advantages and disadvantages?

chemoradiotherapy.
1.Describe the abnormal endoscopic findings in
picture A
ANS:
 1.There is an ulcerated irregular mass
arising from the esophagus and almost
occluding it.

chemoradiotherapy.
ANS:
 2.Carcinoma of Esophagus. Most esophageal
carcinomas fall into two types: Squamous cell
carcinoma, which are associated with tobacco
and alcohol consumption, and
adenocarcinomas, which are associated with
chronic GERD and Barrett’s esophagus.

chemoradiotherapy.
ANS:
 3.PictureB: Barium swallow showing
narrowing of esophagus with shouldering
effect- “Rat tail appearance”.
PictureC: Endoscopic ultrasound (EUS) helps to
determine T stage of disease ( depth of tumor
growth) which influences choice of management
between surgery and chemoradiation
3.What investigations were performed in
picture B & C and what are the findings?
A
B
C

chemoradiotherapy.
ANS:
 4.Endoscopic ultrasound, CT of thorax and
abdomen may be used to stage the disease.
A
B
C
4. Which kind of additional investigations would
be useful?

chemoradiotherapy.
ANS:
 5. Upper 2/3rd esophagus Squamous cell
carcinoma
Lower 1/3rd esophagus Adenocarcinoma
A
B
C
5. What is the most likely histological type?

chemoradiotherapy.
ANS:
 6. Radiotherapy: supervoltage external beam
RT may be curative or palliative to relieve
dysphagia. Brachytherapy may be another
option.
Chemotherapy: most regimens have 5FU with or
without leucovorin
Palliative procedures: Laser vaporization of the
growth(recanalization) and self expanding metallic
stents- SEMS or just intubation with a stent.
A
B
C
6. What is the alternative to surgical treatment?

chemoradiotherapy.
7. What is neoadjuvant therapy and what are its
advantages and disadvantages?
ANS:
 7.Treatment with chemotherapy and/or radiation to the
primary lesion before surgery is called Neoadjuvant
therapy.
Advantages: There is potential downstaging( to shrink the
tumor), early treatment of micrometastatic disease,
treatment is better tolerated before surgical stress and
verification of the tumor sensitivity to this particular therapy.
Disadvantages: Delay in treatment of the primary lesion,
selection for chemoresistant cell lines and potentially cause
the tissue around the tumor to be inflamed
A
B
C

A 50-year-old man present with progressive
dysphagia initially for solids and then for liquids
as well
1.What can be seen in picture A?
2.What is shown in picture B?
3.What surgery did the patient undergo?
4.Which other organ may be used as a conduit for
the reconstruction of gastrointestinal continuity?
5.What are the risks of this surgery?
A
B

as well
1.What can be seen in picture A?
A
B
ANS:
 1.A resected specimen of an esophageal tumor
with adequate macroscopic proximal and
distal margins

as well
2.What is shown in picture B?
A
B
ANS:
 2.Radiological evidence of a gastric pull-up
in the mediastinum

as well
3.What surgery did the patient undergo?
A
B ANS:
 3.Ivor-Lewis esophagectomy with esophago-
gastric anastomosis in the right chest.
Other areas of anastomosis include the neck or
abdomen; depending on the site of tumor; and the
length of the esophagus to be resected; for
proximal and distal clearance

as well
4.Which other organ may be used as a conduit for
the reconstruction of gastrointestinal continuity?
A
B
ANS:
 4.Free colon interposition

as well
5.What are the risks of this surgery?
A
B ANS:
 5.This surgery is associated with high
morbidity. Complications include hemorrhage,
anastomotic leak,empyema,chyle leak,chest
infection and anastomotic sricture

dysphagia, foul breath and gurgling in throat.
H/O Weight loss and aspiration pneumonia++
Food particles can be expressed by squeezing
sides of neck.
1. What is the investigation done in
Fig A and finding?
3.What investigation is performed in Fig B and
what is the finding?
4.What is the cause for this pathology?
5.What are the clinical features of this condition?
6. What is the treatment for this condition?

sides of neck.
1. What is the investigation done in
Fig A and finding?
ANS:
 1.Barium swallow- showing esophageal
diverticulum in upper esophagus.
Diverticula almost always are demonstrated on
the left side of the neck.

sides of neck.
ANS:
 2. Zenker’s diverticulum or Pharyngeal pouch
or Pharyngoesophageal diverticulum

sides of neck.
3.What investigation is performed in Fig B and
what is the finding?
ANS:
 3. Upper GI Endoscopy. Showing the
diverticulum in the upper esophagus.
It should be avoided because of its risk of
perforation of the diverticulum. It is indicated
only if an esophagram demonstrates findings
consistent with neoplasia within the
diverticulum.

sides of neck.
4. What is the cause for this pathology?
ANS:
 4. Zenker’s diverticulum is a pulsion (false)
diverticulum arising at the junction of the
pharynx and the cervical esophagus, in the area
known as Killian triangle , a relatively weak area
in the posterior hypopharynx between the
thyropharyngeus muscle superiorly and the
cricopharyngeus muscle inferiorly.
Two potential causes are increased
hypopharyngeal pressure accompanied by poor
UES opening or cricopharyngeal incoordination.

sides of neck.
5.What are the clinical features of this condition?
ANS:
 5. Patients with a Zenker diverticulum are
usually elderly males and present with
complaints of cervical dysphagia, regurgitation
of food recently chewed, halitosis,"globus"
sensation in throat, and a left-sided neck mass.
Usually there is H/O loss of weight. Aspiration
and pneumonia are infrequent.

sides of neck.
6.What is the treatment for this condition?
ANS:
 6. Treatment involves surgery because there is no
effective medical therapy.
Diverticulectomy with Cricopharyngeal myotomy or
diverticulopexy is classically performed through a left neck
incision.
Endoscopic myotomy- An operating laryngoscope is used
to expose the neck of the diverticulum, and a myotomy is
performed using an endoscopic linear stapler. With this
technique , the diverticulum becomes part of a common
channel with the cervical esophagus- “Dohlman’s
procedure”.

20 year old man presented with worsening
dysphagia, regurgitation and chest pain.
1.What investigation was performed as shown in
FigA?
2.What is the radiological appearance and
diagnosis?
3.What is the definition of this disorder?
4. What other investigation can be done to confirm
the disorder as shown in Fig B?
5.How may this condition be treated?

1.What investigation was performed as shown in
FigA?
ANS:
 1.Barium Swallow

dysphagia, regurgitation and chest pain
2.What is the radiological appearance and
diagnosis?
ANS:
 2.Dilatation of the proximal esophagus
with a “bird’s beak like” tapering distally
is highly suggestive of achalasia cardia

3.What is the definition of this disorder?
ANS:
 3.It is the most common primary
esophageal motility disorder caused by
inflammation of the myenteric plexus,
leading to fibrosis with decrease and loss
of myenteric ganglion cells.

4. What other investigation can be done to confirm
the disorder as shown in Fig B?
ANS:
 4.Manometric studies would reveal absence of
peristaltic contractions and incomplete
relaxation and abnormally high pressures of
the lower esophageal sphincter.

5.How may this condition be treated?
ANS:
 5.Botulinium toxin injection provides temporary relief
and symptomatic improvement..
Pneumatic dilatation is more effective but is associated
with recurrence within 5 years.
Surgical myotomy- Heller’s Cardiomyotomy- is
considered after failure of the previous non-surgical
treatments, younger patients and when there is other co-
existing pathology requiring surgical intervention.
POEM- Per oral endoscopic myotomy is a novel recent
technique

A 40-year-old male presented with
sudden onset of severe epigastric pain.
A. What does this chest X-ray show?
B. What is your diagnosis?
C. What do you expect to find on clinical
examination?
D. What other radiological signs may be
present?
E. What are the possible causes of this
condition?
F. Outline your management.

A. What does this chest X-ray show?
A. The sitting/erect film shows free gas
under the diaphragm
Pneumoperitoneum

B. What is your diagnosis?
B. Perforated hollow viscus.

C. What do you expect to find on clinical
examination?
C. -Generalised tenderness of abdomen
and board like rigidity of abdomen.
- Obliteration of liver dullness
- Absent bowel sounds Silent
abdomen

D. What other radiological signs may be
present?
D. -A visible falciform ligament
-Rigler’s sign both sides of the bowel
are seen due to the free gas
- Foot ball bladder sign seen in cases
of massive pneumoperitoneum, where the
abdominal cavity is outlined by gas from
a perforated viscus

E. What are the possible causes of this
condition?
E.1. It is due to a perforated hollow viscus
- Perforated peptic ulcer disease (most
common)
- Diverticular disease
- Colonic Carcinoma
2. After laparotomy or laparoscopy
3.Tubal insufflation in females
4.Chilaiditi’s syndrome

F. Outline your management.
F. This patient will have systemic
sepsis. He will be dehydrated due to
poor oral intake and the loss of fluid
into the 3rd space. Resuscitation
includes fluid resuscitation,
intravenous antibiotics, urinary
catheterisation and emergency
exploratory laparotomy to find out the
cause.

This is an erect chest X-ray of a 70-year-
old man.
A. What can be seen in the X-ray in
picture A?
B. What sign is this?
C. What other condition can mimic the
appearance of a pneumoperitoneum?
D. What can be seen in the mediastinum?

old man.
A. What can be seen in the X-ray in
picture A?
A. The appearance of intra-colonic air
under the right diaphragm. This is often
due to a shrunken liver. Gas under the
right hemidiaphragm is often mistaken
as free intraperitoneal gas suggestive of a
perforated viscus.

old man.
B. What sign is this?
B. Chilaiditi’s sign transverse colon
lying in between liver and diaphragm
simulating free gas.

old man.
C. What other conditions can mimic the
appearance of a pneumoperitoneum?
C. Subphrenic abscess, basal atelectasis
that mimics the contours of the
hemidiaphragm and cysts in
pneumomatosis coli.

old man.
D. What can be seen in the mediastinum?
D. An aortic stent in place (as seen by the
radio-opaque wire mesh). This was
performed for a thoracic aortic aneurysm.

The patient is a 46-year-old man with a
history of hepatitis C, who presented
with hematemesis
A. What is being performed?
B. What is the pathogenesis?
C. What is the most common cause of the
condition?
D. What factors are predictive of bleeding
in this context?
E. How can the bleeding be stopped?
F. How can we prevent recurrent bleeds?
G. What other options can be considered
if endoscopic treatments fail?

with hematemesis
A. What is being performed?
A. Emergency upper GI endoscopy and
banding of esophageal varices (blue
rubber bands) is performed

with hematemesis
B. What is the pathogenesis?
B. Portal hypertension leading to
porto-systemic shunting.

with hematemesis
C. What is the most common cause of the
condition?
C. Cirrhosis Liver (alcohol and hepatitis
B or C).

with hematemesis
D. What factors are predictive of bleeding
in this context?
D. -Size of varices (directly proportionate
to the vessel wall tension),
-Red whale markings on the varices
(from decreased wall thickness),
-Severity of liver disease and
-Persistent alcohol abuse.

with hematemesis
E. How can the bleeding be stopped?
E. -Terlipressin or Octrotide injections
-Endoscopic Injection Sclerotherapy
-Endoscopic Variceal Band Ligation
-Balloon tamponade using a
Sengstaken Blakemore tube.

with hematemesis
F. How can we prevent recurrent bleeds?
F. -70% of patients re-bleed within the
first year.
-Beta-blockers reduce this risk by half.
-With variceal treatment like injection
scelerotherapy and band ligation the
incidence is reduced by a further half.

with hematemesis
G. What other options can be considered
if endoscopic treatments fail?
G. -Transjugular Intrahepatic
Portosystemic Shunting (TIPS),
- Surgical shunt – Mesocaval or
Splenorenal(partial/selective)
-Esophageal transaction

The patient underwent surgery on his
small intestine and this lesion was found.
A. What can be seen in this intra-
operative picture?
B. What is its origin?
C. Where is it usually located?
D. What are the rules of 2s?
E. How do they present?

A. What can be seen in this intra-
operative picture?
A. Meckel’s diverticulum in the anti-mesenteric
border of terminal ileum.

B. What is its origin?
B. Remnant of the omphalomesenteric
duct/vitello-intestinal duct, which
connects the yolk sac with the primitive
midgut in the embryo.

C. Where is it usually located?
C. About 2 feet from the ileocaecal valve on
the anti-mesenteric border of the small
bowel.

D. What are the rules of 2s?
D. Incidence of 2%, Male 2 times more
common, present before the age of 2
years, 2 inches long and its location 2 feet
from the ileocaecal valve.

E. How do they present?
E. Most are asymptomatic
-Occasionally they may present with
Intestinal haemorrhage Melena
-Intestinal obstruction Band or
volvulus
-Peptic ulcer disease or diverticulitis
-Umbilical fecal discharge in neonates

Image based questions- upper git

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Image based questions- upper git

Similar to Image based questions- upper git (20)

More from Selvaraj Balasubramani

More from Selvaraj Balasubramani (20)

Recently uploaded

Recently uploaded (20)

Image based questions- upper git