5th Year General Surgery Notes - Lower GIT Surgery

MBChB MBChB Year ear 5

CHM500 CHM5003W 3W:: Surger Surgery y – Lower Lower Gastro Gastroint intest estina inall Surg Surgery eryJas Jason on Harry Harry (HJ! (HJ!S00 S005" 5"

#$$er Gastrointestinal Surgery: Core Curri%ulu&: •

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' !$$lie) !nato&y an) *hysiology: +e,inition: •

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- !%ute #$$er !.)o&inal *ain: +e,inition: • •

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

#$$er Gastrointestinal Blee)ing (#G/B":

MBChB Year 5

CHM5003W: Surgery – Lower Gastrointestinal SurgeryJason Harry (HJ!S005" 

121/2W: +2/4//4 !4+ !2/LGY •

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#G/B: bleeding derived from a source proximal to the

ligament of Treitz (suspensory ligament of the duodenum) otentially dangerous ! all patients re"uire admission and management re"uires a multidisciplinary approach #ost common causes $ peptic ulcer disease and oesophageal varices eso$hagus: Sto&a%h: S&all /ntestine: ther:

%esophageal varices #allory-&eiss tear  'astric ulcer  rosive haemorrhagic gastritis uodenal ulcer  rosive duodenitis Tumours *tomal+anasmotic ulcers ,ascular malformation %esophagitis %esophageal ulcers

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+iagnosti% /n6estigations: 

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ndoscopy urgent endoscopy is indicated /hen oesophageal varices are suspected+continuing haemorrhage 6ngiography continued bleeding1 failed endoscopy Ris. stratification the Roc.all Ris. *core 2!M24:

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2!LY M!4!G2M24:

istory  clinical examination  resuscitation diagnostic investigations  definitive treatment

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*tandard crystalloid and colloid solutions  blood loss must be replaced ade"uately and promptly /ith /hole blood 6dminister small dose of opiate analgesic (e7g7 morphine) atients /ith oesophageal varices should N%T be given sodium-containing crystalloid solutions1 but rather blood and 89 dextrose1 :: and %ctreotide to lo/er portal hypertension

#edical treatment ndoscopic interventions *urgery

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*e$ti% #l%er +isease:

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2$i)e&iology an) *athogenesis:

History: may disclose source of bleeding 

eriodic dyspepsia related to meals or excessive analgesic ingestion may implicate $e$ti% ul%er )isease (*#+"

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xcessive alcohol inta.e and .no/n liver disease may suggest oeso$hageal 6ari%es

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!tte&$t to esti&ate a&ount o, .loo) lost

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5rea.do/n in the mucosal defence of the stomach or duodenum  mucosal breach <eptic= refers to ulcers in columnar mucosa in the lo/er oesophagus1 stomach1 duodenum1 or small  bo/el7 

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uodenal 4lcers

cyclical yspepsia pigastric fullness1 mild cramps1  belching Noc tu rna l u ppe r ab domi na l pa in related to meals 6ssociated heartburn1 nausea and vomiting1 /eight loss ain relieved by food; often cyclical

Classi,i%ation: !ty$i%al #l%eration

Type 31 body1 fundal >?1 @A; pea.  age of incidence 8By7 C 6ssociated /ith

Type 331  prepyloric >?1 8A;  pea. age of incidence E8!@By7 C 6ssociated /ith H.  pylori in F89 of cases and /ith high acid secretion1 smo.ing1  N*63 use7

4sually due to either atypical sites of gastric acid secretion (e7g7 ectopic gastric mucosa in a #ec.el=s diverticulum) or abnormally high levels of acid secretion (e7g7

D89 of cases and /ith high alcohol inta.e1 smo.ing1  N*63 use1 normal or lo/ acid secretion7

 Zollinger–   Ellison  syndrome; see

 b p7 EF8)7 C 6ssociated /ith ulceration that fails to respond to maximal medical therapy1 multiple ulcers1 ulcers in abnormal locations (e7g7 distal duodenum or small bo/el)7

Protective Mechanisms: Mucus production, mucosal prostaglandins, tissue groth factors

esus%itation:

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stablish 3, access (and 0, in severely shoc.ed  patients) 4rinary catheter  5aseline biochemical and haematological investigations (including c ross-match)

+iagnosis an) S$e%ial /n6estigations: 2n)os%o$y Clini%al eatures:

'astric

ain precipitated by food; less

J urease testing $ to assess for presence of  H. pylori on antral biopsy

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+ uo )e na l #l%ers

 Helicobacter (H.) pylori in

Breath an)

:or suspected Gollinger llison *yndrome (H 8BB pg+mI)

Co&$li%ations:

G as tr i% # l% er s

Li6er ,ailure: encephalopathy1 2aundice1 spider naevi1  palmar erythema1 foetor hepaticus1 flapping tremor1 ascites

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Serologi%al ests: (,asting" Seru& Gastrin:

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 Agg resiv e Me cha nism s: H. pylori infection, NSAID (ab)use, acid hypersecretion

aemodynamic status 0ardiovascular1 respiratory1 hepatic and renal status

Ma8or .lee)ing: hypotension1 pallor1 /ea. and rapid  pulse1 poor peripheral perfusion1 cool extremities

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*athogenesis:

Clini%al 27a&ination: 

4lcers

0onfirms diagnosis 6llo/s for biopsy 5arium meal seldom used (only if gastroscopy is contraindicated) :or H . pylori in selected cases

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6cute upper '3 bleeding 3ron deficiency anaemia due to chronic lo/ level  bleeding erforation 'astric outlet obstruction due to chronic scarring at or around the pylorus reat&ent:

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 alcohol inta.e1 stop smo.ing1 avoid N*63s

3s or E bloc.ers if intolerant to 3  H. pylori eradication therapy $ usually triple therapy

of 31 metronidazole and clarithromycin *urgery rarely necessary7 3ndications include gastric outlet obstruction not responsive or suitable for endoscopic dilatation  KI%R%I6*TK or type 33  partial gastrectomy; emergency indications include R:%R6T3%N and 5I3N' 

9ollinger–2llison syn)ro&e

C ue to hypergastrinaemia causing extensive1  persistent1 or typical ulceration7 C 0ommonest cause is benign secretory gastrinoma (usually intrapancreatic); occasionally cause is malignant gastrinoma (associated /ith #N syndromes)7 C iagnosed by raised serum gastrin level1 tumour located by 0T scanning1 angiography1 selective pancreatic venous cannulation at surgery7 C Treatment7 Resection of pancreatic tissue containing tumour7

MBChB Year 5

CHM5003W: Surgery – Lower Gastrointestinal SurgeryJason Harry (HJ!S005"