1111490
| Question | Answer |
| Blood supply around stomach, duodenum and pancreas | Important blood supply of stomach: - lesser curve: right, left gastric - greater curve: right, left gastroepieploic (GE) - fundus: short gastric artery = extensive arterio-arterial and arterio-venous anastomosis --> only right GE a. needed to supply whole stomach Duodenum (~25cm long) and pancreas: - anterior and posterior superior pancreaticoduodenal from GDA - ant and post inferior PDA from SMA = important anastomosis between celiac trunk and SMA Branches of celiac: 1. left gastric --> right and left GE 2. splenic --> short gastric etc. 3. common hepatic --> hepatic artery proper, right gastric, GDA |
| Histology of stomach | - oxyntic = parietal cells: for secretion of HCL and intrinsic factor (vit. B absorption - chief cells: for secretion of pepsinogen --> actives by acid --> pepsin - enterochromaffin-like cells: for secretion of histamine --> paracrine --> parietal cells acid secretion - somatostatin secreting D cells: inhibit acid - pyloric G cells: for secretion of gastrin --> endocrine --> acid - also vagal stimulation via acetylcholine --> acid secretion |
| Classification of gastritis | Sydney-Houstin classification: I: normal II: non-atrophic: mainly at antrum and D1, higher risk of HP +ve PUD and acid secretion III: atrophic: mainly at pyloric region, lower acid secretion but higher risk of intestinal metaplasia --> CA IV: special form: erosive, stress and reflux gastritis |
| Clinical features of PUD | - Giant ulcer = >3cm increased risk of CA 30% - overall only 10% CA are GU-related, DU seldom - environmental factors: 1. HP: in 90%DU, 50%GU 2. chemical e.g. smoking, NSAIDs 3. diet - presentation: - dyspepsia - UGIB - perforation: commonest anterior D1 ulcer - GOO |
| classification of GU | Modified Johnson classification: type I: near lesser curative commonest associated with chronic atrophic gastritis, hence not acid hyper secretion type II: GU + DU i.e. GU secondary to DU type III: pre pyloric GU - acid type IV: high lesser curative near OGJ - similar to type I type V: any position - related to NSAIDs Ix: OGD: ANTRAL Bx for H.pylori, Bx any abnormal mucosa e.g. ulcer for HP and R/O malignancy |
| Mx for PUD | - type II and III GU: must suppress acid secretion Conservative: 1. acid suppression: H2 antagonist, PPI 2. HP eradication: triple therapy PPI + amoxicillin + clarithromycin/metronidazole for 7/14 days OR quadruple therapy bismuth + PPI + tetracycline + metronidazole 3. mucosal defence: sucralfate Surgical: 1. vagotomy +/- drainage procedure 2. subtotal gastrectomy with removal of antral gastrin releasing source 3. combination |
| More on surgical Mx for PUD (mostly in emergency cases now due to good drugs) | Subtotal gastrectomy: - remove 75% of stomach + antrum - bilroth I (gastroduodenostomy) or Polya type bilroth II (gastrojejunostomy) reconstruction - for type I and IV GU Vagotomy: - truncal vagotomy for division between anterior and posterior (LARP) of vagus nerve at hiatus level - drainage: pyloroplasty/gastrojejunostomy - highly selective (HSV) only divide gastric branches: no drainage needed but higher recurrence of PU - in addition for type II and III |
| Mx for bleeding, perforated and obstructing PUD | bleeding: - GU: subtotal gastrectomy - DU: ulcer plication + truncal vagotomy + pyloroplasty perforation: - conservation: NPO, TPN, antibiotics IF consealed and stable - surgical: omentopexy + Bx of ulcer obstruction: - since possibility of malignancy --> surgery - DU: truncal vagotomy + antrectomy - GU: antrectomy |
| Cx of PUD surgery | Vagotomy: - early: visceral, pneumothorax, lesser curvative necrosis specific to HSV, delayed gastric emptying due to stasis - late: diarrhoea, GERD, gallstone, recurrence Partial gastrectomy: - early: leakage, haemorrhage, pancreatic leakage, bile duct injury - late: post-prandial symptoms e.g. early satiety/dumping/diarrhoea/reflux, malnutrition of vit. B, calcium, Fe, obstruction, recurrence due to reflux gastritis |
| Causes of UGIB | (in order) - PUD ~50% DU - gastritis - mallory-weiss tear - vacieal bleeding - tumor - dieulafoy's lesion History must ask: - history of PUD - liver disease/alcoholic - NSAIDs |
| Classification of acute upper UGIB (endoscopic stigmata) | Forrest classfication: Ia: arterial spurting Ib: active oozing IIa: visible vessel at the base of ulcer IIb: adherent clot = higher risk of rebreeding with I being 55% IIc: pigmented spot III: clean-based ulcer = lower risk of rebleeding |
| Risk factor for rebleeding of PUD | Patient factor: - >60 y/o - co-morbiditiy Local factor: - chronic ulcer - GU - malignancy - varices - unknown Clinical factor: - shock / low Hb (<10) on admission - > 5 units of blood transferred |
| Endoscopic Mx of active UGIB | - Injection: adrenaline (sclerotherapy i.e. glue usually reserved for variceal bleeding) - arterial clip (banding = ligation usually reserved for variceal bleeding) - heat probe coagulation - laser coagulation - bipolar diathermy |
| Clinical feature of CA stomach | - proximal migration: from distal (HP related, low socioeconomic status) to proximal - 90% adenocarcinoma - atrophic gastritis, GU, CA stomach: related to longstanding inflammation - MALT: chemotactic effect of HP - gastroduodenitis, DU: hypergastrinemia --> increased acid - Correa hypothesis: atophic gastritis -> intestinal metaplasia -> dysplasia -> adenoCA |
| Polyps in stomach | 1. Hyperplastic: - 80% - multiple <1cm in size in antrum - small malignant potential risk 2. Fundal: - multiple sessile confined to body - harmatomatous - no malignant potential 3. Adenomatous: - usu in antrum <2cm in size - asso with atrophic gastritis -> intestinal metaplasia - malignant potential 5-10% - with co-exiting CA in 3-25% |
| Vienna classification for GIT neoplasia Lauren classification for advanced CA | Vienna: 1: negative 2. indefinite 3. non-invasive low-grade 4. non-invasive high-grade 5. invasive Lauren: - intestinal: overall 5 year survival 20%, well-differentiated glandular - diffuse: overall 5 year survival <10%, poorly-differentiated signet ring cell |
| Metastasis of CA stomach | - hematogenous: liver, lung - lymphatic: lymphoma, porta hepatis -> MBO -> jaundice, malignant ureteric obstruction -> ARF - peritoneal: malignant ascites (carcinomatosis peritonei), sister joseph's nodule, blummer's shelf (rectovesical pouch/POD), bilateral ovary transcoelomic (Krukenberg's tumor) |
| Ix of CA stomach for diagnosis and staging | - OGD: for >40 y/o for new-onset dyspepsia, for T staging - CXR: for lung met - CT thorax and abd: distant +/- nodal staging i.e. N and M staging - laparoscopy: for T3/4 tumor, most accurate for peritoneal met - options for lap: extended diagnostic, lap USG, peritoneal larvae cytology for picking up IFCC - PET |
| TNM staging for CA stomach | Tis: carcinoma in-situ T1: invades mucosa/submucosa T2: invades muscularis propria (2a)/subserosa (2b) T3: invades serosa w/o adjacent structure T4: invades into adjacent structure Tier 1 LN: perigastric Tier 2 LN: celiac, spleen Tier 3 LN: para-aortic |
| Prognostic factor for CA stomach apart from TNM staging | Tumor factor: - macroscopic: resection margin, size >10cm in diameter, >2cm invasion into serosa, site cardia and proximal 1/3 worse - microscopic: diffuse type, lymphovascular invasion etc. Nodal status: - extra-capsular extension Patient factors: - age >70 |
| Surgery for CA stomach | - distal 1/3: partial gastrectomy removing 75% of stomach + 1st part of duodenum up to the level of GDA - middle 1/3: partial gastrectomy if timor at least 7-8cm from OGJ, if not total - proximal 1/3: total gastrectomy/esophagogastrectomy - if invasion up to submucosa: resection margin of 5cm - if penetrated through serosa: resection margin of 6cm total VS subtotal: - total 2x mortality due to anastomosis leakage since short gastric preservation can reduce the rate - more post-op feeding/nutritional problem - poorer QoL Lymphadenectomy: - loco-regional control (improves survival) + accurate staging - D1: limited, only Tier 1 - D2: systemic, Tier 1 + 2 - D3: extended, all Tiers |
| Reconstruction | - Billroth I: gastroduodenostomy Cx: bile reflux and easy obstruction if tumour recurs - Billroth II: polya type (higher chance of bile reflux) / regular gastrojejunostomy (40-60cm of proximal jejunum - Roux-en-Y: different from billroth II (duodenal end-to-side anastomosis with jejunum and end-to-end anastomosis of gastrojejunostomy) |
| Indication for EMR/wedge excision | - T1 well-differentiated early gastric cancer - size <3cm - non-ulcerative - EUS showing no suspicious LNs (T1 has <5% LN met) |
| Cx of gastrectomy | Early: - leakage: duodenal stump/gastrojejunostomy - haemorrhage - pancreatic leakage/bile duct injury - post-splenectomy (if done) -> infection Late: - post-prandial: early satiety, early dumping (GI upset e.g. diarrhoea, epigastric fullness + CVS Sx e.g. sweating, palpitation), late dumping (hypoglycaemic attacks), diarrhoea, bile reflux - malnutrition: vit. B12, calcium, iron - obstruction - recurrence: especially if reflux of bile -> reflux gastritis -> CA |
| Use of neoadjuvant therapy and palliation | - downstage tumor - reduce incidence of micro metastasis - reduce intraoperative spillage of timor cells - higher rate of curative resection palliation: - stenting/bypass/intubation - recanalization for CA cardia/antrum with obstruction - 5FU palliative chemo (VS cisplatin-based as adjuvant for CA) |
| GOO presentation | - vomiting after meal - hypochloremic hypokalemic alkalosis - dehydration -> hypovolemia -> pre-renal renal failure - prolonged alkaline urine -> paradoxical aciduria - worsening alkalosis -> hypocalcemia -> tetany |
| Clinical features of GIST | malignant/benign: - site: stomach least malignant, small bowel most malignant - mitotic rate - size >5cm = large Mx: - -ve margin 1-2 cm - smaller lesion: wedge excision - bigger lesion: formal gastrectomy +/- lymphadenectomy Overall 5 year survival: 30-60% |
| Clinical feature of GERD | - Sx: heart burn, acid regurgitation specificity 90% but poor sensitivity - Savary Miller/LA/MUSE classification - Mx: PPI/ARS - Pre-op ARS assessment: 1. general fitness of patient 2. document acid reflux by 24-hr pH study 3. OGD for disease severity and oesophageal length +/- barium swallow for eso shortening 4. manometry to exclude motility disorder - ARS: Nissen fundoplication (complete posterior short 1-2cm wrap) w/o short gastric artery ligation |
| Cx of Nissen fundoplication for ARS | Dissection-related: - post-op paraoesophageal hiatus hernia - pneumothorax: up to 2% due to injury of left pleural membrane - bleeding - esophageal/gastric perforation: 1% Fundoplication-related: - dysphagia - gas-related problem - bilobed stomach General: - DVT and PE |
| Ix and Mx of Barrett's esophagus | Seattle protocol: 1. multiple oesophageal Bx if squamocolumnar junction (the Z line) is migrated proximal to OGJ i.e. systemic four quadrant Bx of Barrett's segment 2. Bx of abnormal epithelial surface e.g. stricture, ulcer, nodule, erosion - No dysplasia: confirmed by 2OGDs and Bx --> surveillance every 3 years - low-grade dysplasia: highest grade on repeat OGD --> surveillance every 1 year - high-grade dysplasia: rate of developing cancer 22% 1. focal: surveillance every 3 months 2. diffuse: consider esophagectomy 3. mucosal nodularity: consider EMR |
| Clinical features of oesophageal perforation | - Causes: instrumentation, barotrauma, trauma, underlying pathology e.g. tumor, malignancy, infection - Presentation: severe chest pain +/- fever/tachycardia/leukocytosis; surgical emphysema; peritonitis if abdominal oesophagus - on CXR: pneumomediastinum/pleural effusion/pneumothorax - Conservative Mx: NPO, TPN, IVF, IV antibiotics, analgesics, bedrest, chest drain if severe pleural effusion - Surgical Mx: operative debridement + primary repair |
| Anatomy of esophagus | - 25cm long - cervical: from cricopharyngeus (C6) to thoracic inlet, 5cm long - thoracic: from inlet to diaphragmatic hiatus (T10) -> superior (T1 to carina), middle (carina to midpoint), inferior (midpoint to hiatus) - abdominal: T10 to OGJ, 1-2cm long - 3 narrowings: 1. cricopharyngeus: 15cm from incisor 2. aortic arch and left main bronchus compression: 25cm 3. diaphragmatic hiatus and LES: 40cm - upper eso: cervical nodes, upper mediastinal nodes - mid eso: whole mediastinal nodes, left gastric, celiac - lower eso: lower mediastinal nodes, left gastric, celiac |
| Causes of oesophageal dysphagia | Mechanical: intrinsic: - tumor - FB - benign stricture - sideropenic web (plummer-vinson/paterson-kelly disease) extrinsic: - goitre - mediastinal LN - CA bronchus - thoracic aneurysm - paraoesophageal hernia Neuromuscular: - inadequate LES relaxation: achalsia - uncoordinated contraction: diffuse oesophageal spasm - hypercontraction: nutcracker syndrome - hypocontraction - secondary to SLE, MS, scleroderma |
| Statistics on CA oesophagus | - only 1/3 presented with resectable disease - T1 has a 5 year survival of 80% - but most resectable tumours only have a 5 year survival of 20% - up to 70% presented with LN met - 25% presented with hematogenous spread to liver, lung, bone - middle 1/3 eso upwards: SCC; downwards: AC - polypoid 60%, stenotic 15%, ulcerative 25% |
| Ix of CA oesophagus | - OGD: T staging - EUS: best for local and nodal staging (T and N staging accuracy up to 90%, overall assessment on resectability up to 100%), superficial mucosa (hyper), deep mucosa (hypo), submucosa (hyper), muscularis propia (hypo), adventitia (hyper) - CT abd and thorax: M staging 70-90% accuracy if lesion >2cm - USG: cervical neck LN - bronchoscopy: if invasion to trachea/bronchotracheal fistula - PET scan - also crucial to assess general fitness of patient for operation - cardiopulmonary function |
| Surgical Mx of CA oesophagus | Surgical: - 2-staged Ivor Lewis transthoracic operation - 3-staged Mckeown transthoracic operation - Grey-turner transmittal operation - must preserve right GE artery, RGA variable if necessary can be sacrificed to further lengthen gastric tube - transthoracic: more pulmonary Cx, but thoracotomy better for lymphadenectomy - transhiatal: careful of injury to azygous vein, left bronchus and RLN - Cx: 1. anastomotic leakage: can be reduced by tension-free mobilisation of stomach + preservation of right GE 2. gastroesophageal reflux --> anastomotic stricture/PUD (mimic tumor recurrence) Lymphadenectomy: - standard for subcarinal mid to distal 1/3 tumour: two fields 1+2 - extended for supracarinal prox 1/3 tumor: three fields 1+2+3 - Cx: RLN palsy |
| Other Mx of CA oesophagus | - RT CI in tumor >9cm + presence of bronchoesophageal fistula - 50% develops post-RT stricture - neoadjuvant therapy aim: 1. increase curative resection rate 2. improve survival 3. identify those responders suitable for post-op - for stage IV: neoadjuvant chemoRT to downstage tumour -> restage -> curative - stenting better than bypass (up to 30% mortality) |
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