Regarding Upper GI symptoms

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Upper Gastro-Intestinal Surgery - 1
Endoscopy
• Oesophago-gastro-duodenoscopy (OGD)
• Endoscopic retrograde cholangiopancreatography (ERCP)
OGD ERCP
Diagnostic
indications
• Dysphagia
• Dyspepsia, reflux disease, upper abdominal pain
• Acute or chronic upper GI bleeding
o Malaena, massive rectal bleeding
• Iron deficiency anaemia (with colonoscopy)
• Biliary disease
o Common bile duct stones
o Biliary strictures
o Biliary tumors
o Biliary injuries
o Intrahepatic biliary disease
• Pancreatic disease
o Pancreatic duct strictures
o Pancreatic duct abnormalities
Therapeutic
indications
• Balloon dilatation of benign strictures
• Endoluminal stenting of malignant strictures
• Injection, coagulation, or banding of bleeding sources
o Ulcers
o Varices
o Tumours
o Vascular malformations
• Stenting
o Common bile duct stones
o Strictures
o Tumours
• Sphincterotomy for the extraction of biliary stones
Preparation • Informed written consent
• Fasting for 6h (except in emergency indications)
• IV access
• Local anaesthetic throat spray
o Lignocaine
• IV sedation if necessary
o Midazolam
• Informed written consent
• Fasting for 6h
• IV access
• Need IV sedation
o Propofol
o Midazolam
• Analgesia
o Pethidine
o Fentanyl
• X-ray screening guidance
• IV antibiotics: If the system is obstructed
• Correction of,
o Liver: correct INR
o Kidney: Hydration, Stop drugs like metformin and any nephrotoxic
drugs

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Complications • Perforation (usually the oesophagus)
o In elderly, with oesophageal pathology
o During therapeutic interventions
• Bleeding
o After biopsies
o Therapeutic procedures
• Respiratory depression and arrest
o Overmedication with sedative
! Frail, low body weight, elderly patients
• Perforation (oesophagus or duodenum)
o During therapeutic interventions
! Sphincterotomy
• Bleeding
o After biopsies
o Therapeutic procedures
! Sphincterotomy
• Respiratory depression and arrest
o Overmedication with sedative
! Frail, low body weight, elderly patients
• Acute pancreatitis
• Acute cholangitis
• Radiations side effects: To the patient and to staff

3. Banagala
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Visualization of Small Inestine
Enteroscopy Capsule Endoscopy
• Often termed ‘push endoscopy’
• Can visualize up to the ileum
• Indications
o Undiagnosed upper GI bleeding
o Abdominal pain
o Upper small bowel Crohn's disease
• Preparation
o As for OGD
• Complications
o As for OGD
• Capsule with a camera and transmitter which is swallowed
• Receiver is kept on the anterior abdominal wall
• Information from the receiver is sent to a computer
• Can visualize both the small and large bowel
• Disadvantages
o Takes time
o Can take only pictures
o Not ideal to detect focal lesions. Vs. Good for macroscopic disease: eg –
Crohn’s disease.
Strictures
• Benign
o Ingestion of corrosive (strong acid/alkali)
o Peptic stricture: GORD
o Radiation
o Trauma
o Congenital
o Post-operative
! Oesophagectomy
! Surgery for tracheo-oesophageal fistula
• Malignant
o Oesophageal cancer
Investigations
• OGD
• Ba swallow
Treatment
• Nil by mouth
• Gastroscopy feeding
• Neutralize
• Never induce vomiting: Can rupture the already damaged oesophagus
• Dilatation using dilators
• Endoscopic dilatation
• Systaemic steroids to reduce scar formation
• Surgery
o Resect and replace with jejunum/colon
Where in SL do we see a higher incidence of oeasophageal strictures?
Why?

4. Banagala
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Oesophageal Motility Disorders
Overview
• A spectrum of diseases
• Failure of coordination or contraction of the oesophagus
• Pathological features
o No structural abnormality
Achalasia Cardia Vs. Oesophageal Spasm
Achalasia Cardia
What is Achalasia Cardia?
Oesophageal Spasm
Introduction • 2 main types
o Diffuse oesiphageal spasm
! Contractions are of normal amplitude but they are
uncoordinated, simultaneous and rapidly propagated
o Nutcracker oesophagus/hypertensive peristalsis
! Contractions proceed in a coordinated manner but the
amplitude is excessive
• Young adults
• Male > Female

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Clinical Features • Acute pain along the length of the oesophagus
• Induced by ingestion, especially of hot or cold substances (odynophagia)
Complications • Aspiration pneumonia
Investigations • OGD
o Exclude underlying associated malignancy
• Barium swallow
o ‘Corkscrew’ appearance
• Oesophageal manometry
o Diffuse hypertonicity
o Failure of relaxation
o Little or no evidence of coordinated progressive peristalsis
during epsiodes
o Normal peristalsis when asymptomatic

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Treatment • Endoscopically guided controlled balloon dilatation (fixed
pressure)
• Botulinum toxin injections
• Surgical myotomy (Heller's cardiomyotomy)
o Division of the lower oesophageal muscle fibres
o Laparocsopic or laparotomy
• Oral calcium channel blockers, or relaxants
o Benzodiazepines
• Long-acting nitric oxide donors
o Smooth muscle relaxant
• Widespread oesophageal pneumatic dilatations
• Long surgical open myotomy
o Rarely
Oesophageal Web
Introduction
• Membranes of mucosa
• Causes
o Congenital: Middle 1/3 of oesophagus
o Acquired: Post-cricoid
• Acquired/Plummer-Vinson/Patterson-Kelly
o Middle aged women
o Fe deficiency
o Koilonychia: Spoon shaped nails
o Dysphagia
o Glossitis
Investigations
• OGD
Treatment
• Endoscopic oesophageal dilatation
Complications
• Post-cricoid oesophageal cancer
o Therefore, need to follow up for cancer
What is the treatment of choice in post-cricoid oesophageal cancer?

7. Banagala
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Pharyngeal Pouch
Introduction
• Aacquired diverticulum between the thropharyngeus and cricopharyngeus
components of the inferior constrictor muscles: ‘Killian's dehiscence’
• Usually left side
• Failure of appropriate coordinated relaxation
• Elderly > 65 years
• Associated with lower cranial nerve dysfunction
o Motor neuron disease
o Previous CVA
• Clinical features
o Upper cervical dyspahgia
o Regurgitation of undigested food
o Intermittent ‘lump’ on swallowing
! Posterior triangle of the neck
Investigations
• Barium swallow: Retained contrast in the pouch
• Endoscopy is contraindicated
o Risk of perforation
Treatment
• Surgical resection of pouch
• Division of the cricopharyngeus
Gastro-Oesophageal Reflux Disease
Introduction
• Symptomatic excessive entry of gastric contents into the oesophagus
• One of the most common disorders
• Gastric acid reflux in to the oesophagus
Contributory Factors Risk Factors
What are the contributory factors? What are the risk factors?

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Complications
• Reflux oesophagitis
• Stricture
• Oesophageal metaplasia: ‘Barrett's oesophagus’
• Adenocarcinoma
Reflux Oesophagitis Stricture Oesophageal Meatplasia:‘Barrett's Oesophagus’
• Inflammation
• From minor mucosal erythema and erosions
to
• Extensive circumferential ulceration and stricturing
• Chronic fibrosis
• Shortening of the lower oesophagus
• Narrowing
• Intestinal/columnar metaplasia
• Result of gastro-oesophageal reflux
• Dysplasia and malignant (adenocarcinoma)
change may occur in the columnar epithelium
Clinical Features
• Heartburn: Retrosternal burning type pain
• Regurgitation
• Odynophagia in advanced cases
• Nocturnal cough
Investigations
• < 40 years
o Only if failed medical therapy
• > 40 years
o OGD
o Biopsy: If mucosal changes are seen.
o 24h continuous pH monitoring
! Peaks of pH change must correspond to symptoms
o Oesophageal manometry
o Ba swallow and screening: Can see reflux
Treatment
Medical Vs. Surgical
Medical Surgical
• Dietary modifications
o Small frequent meals
o Avoid chocolate, caffeine
• Life style modifications
o Elevate head end of bed
o Do not go to bed soon after meals
o Reduce alcohol intake
o Stop smoking
o Avoidance of NSAIDs
• Drus:
o Protect the mucosal barrier
! Bismuth
! Sucrulfate
o Neutralize already secreted acid
! Topical antacids
o Stop scretion of acid
! H2 blockers
! PPI
• Nissen’s fundoplication: Wrapping
fundus of the stomach around the
intraabdominal oesophagus
• Rarely required
• Indications
o Persistent symptoms despite
maximal medical therapy
o Young patients: Otherwise
they will need medication for a
long time
o Patient preference
o Stringent life style
modification
o Large volume reflux with risk
of aspiration pneumonia

9. Banagala
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Hiatus Hernia
Introduction
• The presence of part or all of the stomach within the thoracic cavity, usually
by protrusion through the oesophageal hiatus in the diaphragm
• Very common
• Female > Male
• Majority are asymptomatic
• May or may not be associated with gastro-oesophageal reflux disease (GORD)
• Predisposing factors
o Obesity
o Previous surgery
Types
What are the differences?
Sliding Hernia Rolling (Para-Oesophageal) Hernia
Sy
Investigations
• OGD
o ‘J’ maneuver: Gap between the gastro-oesophageal junction and the scope
o Mucosal junction is higher than the gastro-oesophageal junction
• Chest X-ray
o Air-fluid level in the chest
o Widening of the mediastinum in severe cases
• CT scan of thorax
• Barium swallow
• Oesophageal manometry
Treatment
• Symptomatic medical management of GORD
• Surgery: Nissen’s fundoplication
o Indications:
! Persistent symptoms of GORD despite maximal medical therapy
! Young patients: Otherwise they will need medication for a long
time
! Patient preference
! Stringent life style modification
! Large volume reflux with risk of aspiration pneumonia
! Rolling type hiatus hernia: If high risk of obstruction and
strangulation
o Laparoscopic or laparotomy

10. Banagala
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Carcinoma of the Oesophagus
Introduction
• Epidemiology
o 35/100,000 in Northern China, Iran, Japan, South Africa
o 2-8/100,000 in Europe and America
• Male : Female : 2.5:1
• Age > 45 years
• Types
o Squamous cell carcinoma
o Adenocarcinoma
Risk Factors
Adenocarcinoma
• GORD
o Barrett’s oesophagus
Squamous cell carcinoma
• Diets rich in nitrosamines
o Pickled vegetables
o Smoked salmon
o Vit A and C deficiency
• Life style
o Alcohol
o Smoking: Tobacco
• Strictures
o Radiation
o Lye
• Premalignant conditions
What are the premalignant conditions?
Pathology
What are the differences?
Upper 1/3 Middle 1/3 Lower 1/3
• Macroscopy
o Polypoidal growth
o Ulceration: Bleeds
o Sricture: Annular constriction

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Spread
Local Lymphatic Haematogenous
• Aorta
• Trachea: Tracheo-oesophageal fistula
• Pleura
• Bronchi: Empyema, Lung abscess, Pneumonia
• Pericardium: Pericarditis, effusion
• L/RLN: Hoarseness of voice
• Stomach
• Coeliac LN: Bad prognosis
• Mediastinal LN
• Supraclavicular LN
• Subdiaphragmatic LN
• Lung
• Liver
• Bone
• Brain
Is there any other way oesophageal cancer can spead?
Clinical Features
• Risk factors
• Dysphagia
o Oesophagial dysphagia Vs. Oropharngeal
o First for solids then for liquids
o Progressive
• Odynophagia
• Weight loss and cachexia
• Normal appetite
• Long standing GORD symptoms
o Retrosternal chest pain
o Epigastric pain
o Regurgitation
• Symptoms due to local spread
o Respiratory symptoms
o Hoarseness of voice
• Symptoms of distal metastasis
o Loss of appetite: Liver
• Symptoms of advanced disease
o Dysphagia
o Loss of weight
o Lymphadenopathy
o Hoarseness of voice
ALARM Symptoms
What are ALARM symptoms?
M
Investigations
• Confirm the diagnosis
• Assess spread
• Assess fitness for treatment

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Investigations
Confirm the diagnosis Assess spread/Stage the disease Assess fitness for treatment
• UGIE/OGD
o Visualize
! Polyp
! Ulcer
! Stricture
o Biopsy
• Ba Swallow
o Rat’s tail in Ca Vs. Parrot’s beak/Bird’s
beak in achalasia
• Liver
o CECT abodomen
o USS abdomem
• Lung, bronchi, aorta, mediastinal LN
o Chest X-ray
o CECT thorax
• Bone
o Bone scan
• Brain
o CT scan
• Local depth of invasion
o Endoscopic USS
• Trachea
o Bronchoscopy
• FBC
• FBS
• ECG & 2D Echo
• Chest X-ray & Lung function test
• Blood urea & serum creatinine
• Serum electrolytes
• Arterial blood gas
Rat Tail Appearance

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Treatment
Curative Vs. Palliative
Curative Palliative
• Surgery
• Radiotherapy
• Chemotherapy
• Surgery
o Trans-hiatal oesophagectomy: Orringer’s
! No opening into the thorax
• Less lung complications
! No LN removal
! Anastamosis in the neck
• No meastinitis
o Trans-thoracic oesophagectomy: Ivor Lewis
! 2 stage oesophagectomy
• Laparotomy
• Thoracotomy
! Anastamosis in the thorax
• Medistinitis
o 3 stage oesophagectomy: McKeown
o McKeown + LN dissection: Akiyama
• Stenting
• Dilatation: Baloon tamponade
• Endoscopic laser ablation
o Burns the tumour to widen the passage
• Ethanol injection
• Bipolar diathermy
• Ar Beam
• Radiotherapy
o Brachytherapy: Intraluminal radiotherapy
o External beam radiotherapy
• Atkin’s tube insertion
• Photodynamic therapy
• Chemotherapy
What do you palliate?

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On what basis do you select the treatment option?
Pre-Operative Management
• High calorie, liquid diet
• High protein diet
• Jejunostomy feeding
• Dental referral
• Chest preparation
o Steam inhalation
o Incentive spirometry
o Bronchodilator
o Sputum culture & ABST
o Pysiotherapy
• Psychological counseling
• ICU bed
• Inter-costal tube
• Naso-gastric tube
• Blood for grouping and DT
Prognosis
• Poor prognosis
• Only 1/3 fit for surgery
• Palliative care mean survival: 4 months
• LN involvement: Bad prognosis
• Local recurrence is common
Vs.
• Metastasis is common in other GI tumours
Feeding Jejunostomy
Incentive Spirometer

15. Banagala
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Peptic Ulcer Disease
Introduction
• ‘Peptic’ refers to ulcers in columnar mucosa of the GI tract due to the action of acid
o Stomach
o Duodenum
o Small bowel: Rare
• Breakdown of balance between acid production and mucosal defense mechanisms
Acid Production Mucosal Defense Mechanisms
• Helicobactor pylori
o Suppresses the inhibitory peptide somatostatin
How does this suppression lead to ulcers?
o Bacterial enzymes
How does bacterial enzymes cause ulcers?
o Host inflammatory response
! Cytokines
How does host inflammatory response cause ulcers?
• Alcohol
• Smoking
• NSAIDs
o Inhibits cyclo-oxygenase type 1 (COX-1)
! Decreases prostaglandin
Will giving NSAID suppositories solve this problem?
• Mucosal barrier
o Mucus
o HCO3-
o Channels for HCL
• Mucosal cells
o Apical membrane is thick
o Tight junction between cells
o Fast turnover of cells
• Trefoil peptides
How does trefoil peptides protect the mucosa?
• High blood supply
How does a high blood supply protect the mucosa?

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Classification
• Gastric ulcers
• Duodenal ulcers
• Atypical ulceration
Gastric Ulcers Vs. Duodenal Ulcers
What are the differences?
Gastric Ulcers Duodenal Ulcers
Why do patients with duodenal ulcers gain weight?
During what time of the day do they get the pain?
Why during that time?

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Investigations
• UGIE/OGD
o Commonest diagnostic test
• Double contrast barium meal
o If OGD contraindicated
• Tests for H.Pylori
o Urease testing on antral biopsies from OGD
o CO2 breath test
o Faecal antigens
o Histology
• Fasting serum gastrin levels
o Zollinger-Ellison syndrome
Double Contrast Ba Meal
Treatment
Medical Vs. Surgical
Medical Surgical: To manage complications
• Life style modifications
o Reduce alcohol intake
o Stop smoking
o Avoidance of NSAIDs
• Drugs:
o Protect the mucosal barrier
! Bismuth
! Sucrulfate
o Neutralize already secreted acid
! Topical antacids
o Stop secretion of acid
! H2 blockers
! PPI
• H. pylori eradication therapy: Triple therapy
o Metronidazole
o Clarithromycin
o PPI
• Emergency indications
o Perforation
o Bleeding
• Elective indications
o Failure to respond to maximal medical treatment
o Gastric outlet obstruction not responsive or suitable for endoscopic
dilatation
• Procedures
o Gastric ulcer
! Omental patch repair
! Wedge excision
! Partial gastrectomy
! Antrectomy
o Doudenal ulcer
! Highly selective vagotomy
Complications
• Acute upper GI bleeding
o Haematemesis
o Malaena
• Iron deficiency anaemia
o Chronic low level bleeding
• Perforation
o Perotonitis
• Gastric outlet obstruction
o Chronic scarring at or around the pylorus
• Malignany
o Gastric ulcers
• Recurrence

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Atypical Ulceration
• Atypical sites of gastric acid secretion
o Ectopic gastric mucosa in a Meckel's diverticulum
• Abnormally high levels of acid secretion
o Zollinger-Ellison syndrome
• Multiple ulcers
• Ulcers in abnormal locations
o Distal duodenum
o Jejunum
• Fails to respond to maximal medical therapy
Zollinger-Ellison Syndrome
• Hypergastrinaemia
o Extensive, persistent, atypical ulceration
• Causes
o Benign secretory gastrinoma
! Usually Intra-pancreatic
o Malignant gastrinoma
! Associated with MEN syndromes
• Presentation
o Gastro-intestinal bleeding
! Occult
! Apparent: Malaena of fresh bleeding.
o Anaemia
• Investigations
o Investigations for chronic GI bleeding
o Raised serum gastrin level
o CECT scan abdomen
o Octreotide scan: To localize gastrinoma
• Treatment
o Resection of pancreatic tissue containing tumour