MBChB Year 5 CHM5003W: Surgery Lower Gastrointestinal SurgeryJason Harry (HRRJAS005)

Upper Gastrointestinal Surgery:

Core Curriculum:
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1. Applied Anatomy and Physiology:

Definition:
Xxxx

2. Acute Upper Abdominal Pain:

Definition:
Rapid onset of severe abdominal pain
Non-traumatic; signifies intra-abdominal pathology

Upper Gastrointestinal Bleeding (UGIB):

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 MBChB Year 5 CHM5003W: Surgery Lower Gastrointestinal SurgeryJason Harry (HRRJAS005)

OVERVIEW: DEFINITION AND AETIOLOGY Standard crystalloid and colloid solutions blood Ulcers cyclical Serological
UGIB: bleeding derived from a source proximal to the loss must be replaced adequately and promptly Dyspepsia Tests:
with whole blood Epigastric fullness, mild cramps, (fasting) For suspected Zollinger Ellison
ligament of Treitz (suspensory ligament of the
Administer small dose of opiate analgesic (e.g. belching Serum Syndrome (> 500 pg/mL)
duodenum)
Potentially dangerous all patients require admission morphine) Both Nocturnal upper abdominal pain Gastrin:
Patients with oesophageal varices should NOT be related to meals
and management requires a multidisciplinary approach
given sodium-containing crystalloid solutions, but Associated heartburn, nausea and * urease testing = to assess for presence of H. pylori on
Most common causes = peptic ulcer disease and
rather blood and 5% dextrose, FFP and Octreotide vomiting, weight loss antral biopsy
oesophageal varices
to lower portal hypertension Duodenal Pain relieved by food; often cyclical
Oesophagus: Oesophageal varices Ulcers Complications:
Diagnostic Investigations:
Mallory-Weiss tear Acute upper GI bleeding
Endoscopy: urgent endoscopy is indicated when
Stomach: Gastric ulcer oesophageal varices are suspected/continuing
Classification: Iron deficiency anaemia due to chronic low level
Erosive haemorrhagic gastritis haemorrhage Gastric Ulcers Duodenal Atypical bleeding
Small Duodenal ulcer Angiography: continued bleeding, failed Ulcers Ulceration Perforation
Intestine: Erosive duodenitis endoscopy Type I, body, Type II, Usually due to Gastric outlet obstruction due to chronic scarring at or
Other: Tumours Risk stratification: the Rockall Risk Score fundal prepyloric either atypical around the pylorus
Stomal/anasmotic ulcers :, 3:1; peak :, 5:1; sites of gastric
Vascular malformation TREATMENT: age of peak age of acid secretion Treatment:
Oesophagitis incidence 50y. incidence (e.g.
Oesophageal ulcers
Medical treatment
Associated 2530y. ectopic gastric alcohol intake, stop smoking, avoid NSAIDs
Endoscopic interventions
with Associated mucosa in a PPIs or H2 blockers if intolerant to PPI
Surgery
EARLY MANAGEMENT: Helicobacter with H. Meckels
H. pylori eradication therapy = usually triple therapy
History clinical examination resuscitation (H.) pylori in pylori in 85% diverticulum)
Peptic Ulcer Disease: of PPI, metronidazole and clarithromycin
diagnostic investigations definitive treatment 45% of cases of cases and or abnormally
Surgery rarely necessary. Indications include gastric
and with high with high high
Epidemiology and Pathogenesis: outlet obstruction not responsive or suitable for
History: may disclose source of bleeding alcohol intake, acid levels of acid endoscopic dilatation PYLOROPLASTY or type II
Periodic dyspepsia related to meals or excessive Breakdown in the mucosal defence of the stomach or smoking, secretion, secretion (e.g. partial gastrectomy; emergency indications include
analgesic ingestion may implicate peptic ulcer duodenum mucosal breach NSAID use, smoking, Zollinger PERFORATION and BLEEDING
disease (PUD) Peptic refers to ulcers in columnar mucosa in the normal or low NSAID use. Ellison
Excessive alcohol intake and known liver disease lower oesophagus, stomach, duodenum, or small acid secretion. syndrome; see
may suggest oesophageal varices bowel. b p. 285).
ZollingerEllison syndrome
Attempt to estimate amount of blood lost Pathogenesis: Associated
Due to hypergastrinaemia causing extensive,
Aggresive Mechanisms: with ulceration persistent, or typical
Clinical Examination: that fails to
H. pylori infection, NSAID ulceration.
Haemodynamic status respond to
(ab)use, acid hypersecretion Commonest cause is benign secretory gastrinoma
Cardiovascular, respiratory, hepatic and renal maximal (usually
status medical intrapancreatic); occasionally cause is malignant
Protective Mechanisms: therapy, gastrinoma (associated
Major bleeding: hypotension, pallor, weak and rapid multiple ulcers, with MEN syndromes).
pulse, poor peripheral perfusion, cool extremities Mucus production,
mucosal prostaglandins, ulcers in Diagnosed by raised serum gastrin level, tumour
tissue growth factors abnormal located by CT
Liver failure: encephalopathy, jaundice, spider naevi, locations (e.g. scanning, angiography, selective pancreatic venous
palmar erythema, foetor hepaticus, flapping tremor, distal cannulation at
ascites duodenum or surgery.
small bowel). Treatment. Resection of pancreatic tissue containing
tumour.
Resuscitation:
Establish IV access (and CVP in severely shocked Diagnosis and Special Investigations:
patients)
Urinary catheter Endoscopy Confirms diagnosis
Baseline biochemical and haematological Allows for biopsy
investigations (including cross-match) Clinical Features:
Barium meal seldom used (only if
gastroscopy is contraindicated)
Gastric Pain precipitated by food; less Breath and For H. pylori in selected cases

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MBChB Year 5 CHM5003W: Surgery Lower Gastrointestinal SurgeryJason Harry (HRRJAS005)