Upper GI surgery
Cancer of the Oesophagus
Epidemiology The epidemiology of oesophageal cancer shows that the UK is
not a high risk cancer for the development of this type of cancer there are areas
in Iran, Japan and South Africa that are high risk but in the UK the risk is 45/100,000. The cancer is normally developed between the ages of 50-70 and is
more prevalent in men than women. In the UK the most common form of
oesophageal cancer is an adenocarcinoma followed by a squamous cell
carcinoma.
Risk Factors There are a number of risk factors for the development of
oesophageal cancer including alcohol, smoking, and nutrition deficiency in
vitamins A, B and many more. There has also been found to be an increase risk
for those who are exposed to fugal contamination, consume a lot of nitrates and
are involved in Betel nut chewing.
There are also some conditions which can increase the risk that someone will
develop oesophageal cancer these are, long standing oesophagitis, Achalasia
which is when the oesophagus doesn’t correctly relax following swallowing,
Plummer-Vinson syndrome is when there is a web of mucosal tissue across the
oesophagus. The main oesophageal problem which leads to cancer is having a
Barretts oesophagus which is when there is metaplastic changes in the
oesophagus as a result of long term acid exposure there is a 1% chance each
year that someone with barrets oesophagus will develop an adenocarcinoma.
Carcinoma of the stomach
Factors influencing carcinoma of the stomach There are a number of very
important factors which impact upon the development of gastric cancers.
Enviromental factors such as a diet including large amounts of nitrates, smoked
and salted food and pickled vegetables is highly influential along with smoking.
There are also a number of host factors which can increase the risk of
developing cancer such as hypochlorhydria, H.pylori infection, a previous partial
gastrectomy, gastric adenomas and Barretts oesophagus. There is a genetic
impact in the development of gastric cancers which isn’t fully understood but if
you are blood group A, have a family history of gastric cancers or a hereditary
nonpolyposis colon cancer syndrome you are at increased risk.
Pathology Two types of tumour make up most of the cases of gastric cancer
they are a gastric lymphoma and a gastric adenocarcinoma. Early gastic cancer
has a good five year survival rate of 90% however the more of the organ which is
effected the worse the prognosis.
Clinical features There are a number of types of onset when it comes to gastric
cancer. First you have the people who present with new dyspepsia after the age
of 40 which should set alarm bells off. Then you have the insidious onset of the 3
A’s anaemia, anorexia and asthenia. Finally you have the obstructive group who
can present with a vast number of symptoms including jaundice, ascites,
trousseau’s sign, a palpable virchows node (troisiers sign) and sister Josephs
umbilical nodule.
Investigations General blood tests should be done including LFT’s, CEA as well
as the other standard blood tests. There should also be an OGD, US and CT
carried out.
Treatment Surgery is the only curative treatment for gastric cancers the options
are a total gastrectomy, or a partial gastrectomy
Post operative complications There are many post operative complications
following gastrectomy including small gastric pouch syndrome, chronic
gastroparesis, alkaline reflux, early dumping syndrome, duodenal stump leak and
postvagotomy diarrhoea.
Benign Disorders of the Oesophagus and Stomach
Gastro-oesophageal reflux
This is a condition characterised by a number of symptoms including heartburn,
regurgitation/vomiting, epigastric pain and dysphasia it can also present with
hoarseness, a cough or chest pain though this is less common. You would
investigate it by doing a Ba swallow and a GI endoscopy looking for underlying
causes such as reflux oesophagitis, hiatus hernia, barretts oesophagus and a
peptic stricture.
Treatment of GORD The treatment of gastro-oesophageal reflux can be lifestyle modifications, medical, endoscopic or surgical. The life-style modifications
that care carried out can be weight reduction, avoidance of acidic foods and
foods which promote reflux such as high fat or caffeinated foods and raising the
head to sleep. The medical interventions would be the use of antacids, H2
receptor agonist and PPI’s. Endoscopic treatment involves reinforcing the
sphincter using a Endocinch, injecting bio-polymer to reinforce the LOC or the
stretta procedure which damages the LOC causing a reduction in transient
relaxations. The first option is to do a surgical procedure, you could do a
Laproscopic Nissen fundoplication this is when the fundus of the stomach is
wraped around the base of the oesophagus to reinforce the sphincter.
There are two physiological studies which have to be done before there can be a
surgical procedure to fix GORD. Manometry ensures that there is no achalasia
and that there is peristalsis and ambulatory 24 hour PH ensures that there is a
baseline for post operative comparison.
Oesophageal Dysphasia
There are a huge number of possible causes for oesophageal dysphasia
including a pharyngeal pouch high up and a benign stricture lower down. With a
pharyngeal pouch the symptoms will surround regurgitation of food. The
investigations that you will do are a contrast swallow. You would then close the
pouch using one of a number of procedures such as criptopharyngeal Myotomy
or pouch resection. Another cause of dysphasia is Achalasia which is impaired
peristalsis. This would be investigated using a swallow and an upper GI
endoscopy, and would be treated using dilatation using a balloon.
Oesophageal Rupture
This normally occurs following a substantial meal or bout of drinking, it will be
followed by retrosternal chest pain, or dyspnoea. In this situation a contrast
swallow is essential as the patient may have a very varied differential diagnosis
list and this is a definitive test. They must then be taken to surgery and have the
tear repaired.
Peptic ulcer disease
With peptic ulcer disease there may be epigastric pain which is alleviated by food
and worse at night. If the ulcer has ruptured there maybe a sudden onset of
epigastric pain and signs of peritonism. A rupture is a surgical emergency.
Gallstone Problems
Causes of Jaundice
The causes of jaundice in a patient can be divided into three main groups. Prehepatic, hepatic and post hepatic. Pre-hepatic causes are normally related to the
blood cells being haemolysed for example hereditary spherocytosis. Hepatic
causes are related to a failure of the liver and post hepatic causes are things like
sepsis.
Obstructive jaundice
The patient with obstructive jaundice with present with right upper quadrant pain
if it is caused by gallstones and weight loss if caused by malignancy. They are
also likely to have pale stools and dark urine. It is also important that you think
about Courvoisier’s Law when looking at obstructive jaundice, if you can feel an
enlarged gall bladder the cause is unlikely to be gall stones. The investigations
that you would do in the patient presenting with obstructive jaundice are bilirubin,
liver enzymes as you would expect ATL and AFT to be raised, INR and also a
live ultrasound.
Biliary colic
Gallstones have an incidence of 5-10% within the population and there are three
types pigmented, cholesterol and mixed. A typical pain history of a patient with
biliary colic may well look like
Site = Right upper quadrant Radiation = Back/shoulder tip Onset = Rapid
Character = Sharp/colicky Duration = Minutes – hours Severity = +++
Exacerbating/relieving factors = ↑ by fatty food Periodicity = Intermittent
Associated symptoms = Nausea, vomiting
There are a number of complications that can arise from gallstones you can have
a mucocele, empyema or cancer in the gall bladder. You can have acute
pancreatitis or gallstone ileus. The treatment of gallstones is mostly conservative
manage with painkillers and wait for the stone to pass. However in acute
pancreatitis or when the patient is presenting with obstructive jaundice and
ERCP needs to be carried out.
Acute pancreatitis
To remember the possible causes for pancreatitis remember get smashed.
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Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpion bites
Hypothermia/hypolipidaemia
Elevated calcium
Drugs.
There are a number of possible implications of a bout of acute pancreatitis it can
locally cause pancreatic infarction/necrosis, a pseudocyst, or an abscess.
Systemically it can cause hypovolaemia, acute renal failure, acute respiratory
distress syndrome and paralytic ileus. If you were going to take a pain history
from someone with acute pancreatitis you may well find.
Site = Epigastric Radiation = Back Onset = Gradual Character = Constant/dull
Duration = Hours – days Severity = +++ Exacerbating/relieving factors = ↑ by
movement Periodicity / Associated symptoms = Vomiting +++
Colorectal Surgery
Constipation
Constipation is defined as either excessive straining at stool or the passage of
two of fewer stools in a week. It is important to ask the patient about their normal
bowel habit as what is normal for some may be abnormal for others..
Causes of constipation 1) Inadequate dietary fibre 2) Neoplasm of the colon,
rectum or anus 3) Benign lesion of the anus 4) Endocrine disease 5) Drugs 6)
Hirschsprungs disease (neonates) 7) Slow transit constipation 8) Psychological
9) Neurological/behaviour 10) Spinal e.g. MS
Constipation should be investigated with sigmoidoscopy and barium enema to
rule out a malignancy. There should also be blood tests for endocrine and
metabolic abnormalities such as hypothyroidism and hypocalcaemia.
Slow transit constipation this is when a patient (usually female does not respond
to an increase in dietary fibre or to laxatives. This is the result of a slow transit
time and may need to have a surgical total colectomy and anastamosis of ileum
to rectum
The treatment of constipation can take the form of lifestyle based interventions
for example making sure that the patient is taking in adequate fibre and being
well hydrated. Their drug regime could be modified to look at causes that may
come from there. If these methods fail laxatives could be tried to address the
issue.
Rectal Bleeding
This is when the patient complains of rectal bleeding not when a random stool
test happens to find blood.
Possible causes of rectal bleeding include 1) Haemorrhoids 2) Diverticular
disease 3) Large bowel polyps/carcinoma 4) Angiodysplasia- small bleeding
bowel capillaries 5) IBS 6) Ulcer
The investigations that must be done for rectal bleeding are sigmoidoscopy and if
nothing is found then colonoscopy should be done as soon as possible if this is
also negative then do a technetium scintiscan to look for lesions.
The management depends on what the diagnosis is.
Abdominal pain
When a patient presents with abdominal pain it is important that you take a full
history including Socrates.
Causes of abdominal pain 1) Acute appendicitis 2) Bilary colic 3) Colon
carcinoma 4) Diverticular disease 5) Gastic carcinoma 6) Pancreatitis 7)
Dissection aortic aneurysm
You would have to do a number of tests as there are a number of possible
differentials for acute abdominal pain. These includes blood tests like and FBC,
serum amylase, U’s and E’s, glucose, LFT’s, calcium, and a clotting studies.
Imaging studies are also important an abdominal x-ray and ultrasound for
pancreatitis.
Irritable bowel syndrome
Pathogenesis: It isn’t really known what causes IBS there have been
abnormalities discovered in the lower GI tract, patients have been found to have
previously had a low fibre diet. There are abnormal intraluminal pressures.
Genetics and psychological factors are also thought to play a role.
Clinical features Patients with IBS will classically present with left iliac fossa
pain relieved by defecation. This pain is not related to meals. There will also be
an abnormal bowel habit of alternating constipation and loose stools.
Investigations IBS is a diagnosis of exclusion so it is important to rule our
diagnosis which might be more sinister in origin you would do a FBC, CRP,
LFT’s, TFT’S, faecal occult blood test, serological markers for celiac disease. If
thought necessary then CT scan, sigmoidoscopy and other method of looking for
tumours.
Management The management of IBS is usually provided by systematic relieve
of symptoms. Patients should increase their dietary fibre. Drug therapy in the
form of antispasmotics, antidepressants, bulk forming agents and hypnotherapy
Acute appendicitis
Pathology The pathology of appendicitis is thought to be obstruction of the
appendix. This causes the blood supply to be reduced and gangrene can be a
problem.
Clinical features The history will often describe central abdominal pain which is
quite generalised and accompanied by anorexia, nausea and vomiting. The pain
will then become localised to the RIF.
Investigations You would want to do the normal blood tests as well as a
pregnancy test in women of child baring age. You may do an ultrasound and a
CT scan.
Management Once the diagnosis has been made the likely progression of the
disease means that it is important that the appendix is removed. This can be
done through either a small transverse incision in the RIF or laproscopically. You
may also decide to watch a wait keeping the patient nil by mouth and on pain
killers.
Haemorrhoids
Pathology Haemorrhoids are engorgement of the haemorrhoidal venous plexus
with redundancy of their covering.
Clinical features Haemorrhoids can present in a number of ways including
bleeding, discharge, discomfort, prolapse, pain and a change in bowel habit.
Management Patients can be helped quite a lot by reassuring them and
alleciating the dear of a more sinister diagnosis. The regulation of bowel habit
can help and constipation appears to exacerbate haemorrhoids. You can use
suppositories containing corticosteroids, local anaesthetic and antibiotics. There
are a number of surgical procedures too.
Diverticular disease
Pathology Diverticula have a narrow neck and faeces may accumulate within
them causing inflammation and increasing the risk of inflammation.
Clinical features There are very few symptoms however there maybe left lower
abdominal pain, and long standing irregularity or bowel habit.
Investigations Barium enemas are the usual methods of confirming the
diagnosis. The diverticular openings may also be seen on colonoscopy.
ManagementThere is no evidence to suggest that if you increase the amount of
dietary fiber then diveticular disease is less likely to develop however mild
symptoms seem to benefit. Resection of the affected area might be considered in
sever disease.
Complications The main possible complications of Diverticular disease are
inflammation leading to a risk of perforation and fistulation.
Ulcerative colitis
Pathology The major feature of is inflammation of the mucosa with increased
vascularity and haemorrhage. It is rare for the whole of the large bowel to be
involved.
Clinical features Bloody diarrhoea associated with social embarrassment and
physical discomfort. This is a relapsing and remitting condition
Complications Toxic megacolon is quite a serious condition which can evolved
as a result of ulcerative colitis which means that perforation is a big risk. It is
treated with blood transfusions, water and electrolyte replacement. Massive
haemorrhage is a rare complication. There can also be systemic complications
such as urinary calculus.
Investigations Sigmoidoscopy and biopsy of the rectal mucosa. If an infective
cause is suspected then stool samples may be carried out. A barium enema and
colonoscopy may be necessary.
Management Management can be medical or surgical. Minimal disease can be
managed by a combination of prednesilone and oral sulfasalazine. Surgical
treatment can be the fitting of an illiostomy which divert faeces away from the
effected area, an ileorectal anastomosis after a colectomy can be done finally a
continent ileostomy could be done.
Crohns disease
Pathology It is not known exactly what causes this condition although it is
thought that it might be inflammation caused by unusual strains of bacteria. The
pathological features of this disease is that there is transmural inflammation with
oedema and fissures. Skip lesions can occur throughout the whole bowel.
Oedema and fibrosis can cause obstruction. Fistulae may form.
Clinical features Acutely it may present as RIF pain and tenderness. However
chronically there are symptoms of general ill health such as weight loss, colicky
abdominal pain and diarrhoea.
Investigations Imaging may be done most commonly a barium meal which may
show mucosal irregularities, strictures and skip lesions. A biopsy will also be
done.
Management There is no specific treatment of crohns disease and management
is often symptomatic with steroids. Surgical management is also sometimes
required when there is an intestinal obstruction, abscess or fistula. Surgery
normally takes the form of resection.
Vascular Surgery
Carotid Artery disease
Carotid dissection
Background This is a rare thing to happen, the mean age that it happens is 45
and the main causes are spontaneous, traumatic and iatrogenic.
Risk factors Predisposing factors are the oral contraceptive pill, marfans,
hypertension and fibromuscular dysplasia.
Clinical features The patient can prevent with a large number of symptoms
including headache, TIA/CVA, syncope and cranial nerve lesions.
Investigation You would investigate this patient with duplex, ct and mri
Management They would have to be on anticoagulation for 3-6 months,
Carotid aneurysm
Risk factors Previous infection with TB or syphilis
Causes Atherosclerosis, trauma, marfans, fibromuscular dysplasia and previous
caroid endarterectomy
Clinical features Lump, pain, dysphasia and TIA
Investigation Duplex, angiography, CT and MRI
Management Aspirin, ligation, resection and repair
Carotid body tumours
Pathology Chemodectoma, Glomus tumour and paraglangionoma which can be
neural crest tissue or neuropeptide hormones.
Clinical features Lump (pulsatile), headache, tinnitus and vocal cord paralysis
Investigations Duplex ultrasound, CT, MRI, angiography
Management Surgical incision
Carotid occlusive disease
Pathology Athroma at carotid bifurcation, Emboli from carotid plaque
Risk factors Age, smoking, hyperlipidaemia, hypertention and diabetes
Clinical features Amaurosis fugax, TIA, CVA
Management Control risk factors that are modifiable, prevent emboli with
antiplatelet therapy e.g. asprin, clopidogrel, LMWH and warfarin.
Endarterectomy,
Post-operative complications Cerebral hyperperfusion, risk of nerve damage to
transverse cutaneous nerve or greater auricular nerve.
Varicose Veins, Venous thromboembolism and Venous
Ulceration
Varicose Veins
Definition A varicose vein is a vein that is tortuous and dilated
Aetiology Caused by a defect in the venous valve or a defect in the vein wall.
Clinical presentation Aching, cosmetic, ankle swelling, eczema, bleeding,
ulceration. All the way down the inside of the leg suggests LSV, bellow the knee
in the calf area suggests SSV.
Investigation Hand held Doppler, duplex ultrasound, radiological
Management Need to establish if superficial or deep? If superficial can be
corrected by surgery or injection, new techniques include use of ablation and
lasers. If deep pressure stockings are main form of treatment.
Venous thromboembolism
Background For venous thromboembolism to form there has to be one of blood
stasis, altered coagulability and injury to the vessel wall.
Risk factors These are age/sex/pregnancy, injury/surgery, malignant disease,
previous DVT, VV, obesity, OCP and long distance travel.
Clinical presentation Pain, swelling, calf tenderness, blue discoloration and
rarely gangrenous changes.
Investigation Screening ultrasound, D-dimer, plebography
Management Mobilise, anticoagulants LMWH then warfarin consider surgery but
rarely done.
Pulmonary embolism
Clinical presentation Will present with collapse, SOB, pleuritic chest pain and
haemoptysis
Investigation CXR, ECG, ABG, CT.
angiography, test for DVT see above.
VQ
mismatch
scan,
pulmonary
Management Anticoagulant, thrombolysis, inferior vena cava filter and rarely
surgery
Peripheral vascular disease
Leg ulcers
Leg ulcers can either be arterial or venous Venous= VV/DVT, sloping sides,
painful, medial, normal pulses normal ABPI Arterial= Smoking, a lot of pain,
lateral, punched out, necrotic, low ABPI, absent pulses.
Treatment Venous Compression bandages
Acute ischemia
Causes Embolism due to cardiac/atrial fibrillation, no previous claudication
history
Clinical presentation = 5 P’s
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Pain
Pulseless
Pale
Parathetic
Perishing cold
Treatment Heparin, ECG, Duplex angiography (if
streptokinase, embolectomy, possibly faciotomy
time), Thrombolyse,
Chronic arterial disease
Clinical presentation Pain in calf on walking, relived by rest, pain in toes feet at
rest, ulcers, gangrene
Investigation Hb, FBC, U’s and E’s, lipids, ABPI, Duplex, MRA, angiography, CT
Treatment Lifestyle modification, Asprin, statin, consider surgery (angioplasty) in
sever cases,