UPPER GI IN A NUTSHELL

Dafydd LoughranCT1 Upper GI surgery

Key presentations

• Dysphagia• Pancreatitis• Gallstone disease

Dysphagia case• 83 yr old male smoker presents with progressive

dysphagia to solids over 6 weeks. He gives a history of weight loss over the last 4 weeks.

• 1) What would be the most appropriate initial investigation?• CT chest and abdomen• Barium swallow• Oesophago-gastro duodenoscopy• Barium meal• Abdominal ultrasound

Dysphagia case• 83 yr old male smoker presents with progressive

dysphagia to solids over 6 weeks. He gives a history of weight loss over the last 4 weeks.

• 1) What would be the most appropriate initial investigation?• CT chest and abdomen• Barium swallow• Oesophago-gastro duodenoscopy• Barium meal• Abdominal ultrasound

Oesophago-gastro duodenoscopy – able to diagnose smaller tumours and biopsies can be taken for

histology

Dysphagia case• 83 yr old male smoker presents with progressive dysphagia

to solids over 6 weeks. He gives a history of weight loss over the last 4 weeks.

1. What would be the most appropriate initial investiagation?• Oesophago-gastro duodenoscopy

2. On OGD shows an area of malignant cells in the distal oesophagus. Given that he is a British man what is the most likely cell type?• Adenocarcinoma • GI stromal tumour• Lipoma• Rhabdomyosarcoma• Squamous cell carcinoma

Adenocarcinoma – most common in developed world

Oesophageal cancer• Progressive dysphagia to solids• Weight loss

• OGD is investigation of choice – adenocarcinoma, squamous cell

• Risk factors – Adenocarcinoma: Smoking, GORD/Barrett's Squamous cell: Smoking, Alcohol

• If cancer confirmed then staging CT chest, abdo & pelvis

• Poor prognosis, 10-15% 5yr survival

• Oesophagectomy if caught early, various chemo/radio options, decision made at MDT

Developed world Developing world

Other causes of dysphagia• Peptic stricture

• Benign, secondary to gastro-oesophageal reflux disease (GORD)• Usually treated with dilatation at OGD

GORD Retrosternal burning,Worse at night, following spicy meals & alcoholImproved with antacids/PPI

Strong correlation with Helicobacter pylori – requires triple eradication

Conservative (PPI) or Surgical (Nissen fundoplication) management

Risk of developing Barrett's oesophagus – metaplasia of lower oesophageal cells from stratified squamous to columnar. Cancer risk needing surveillance.

Other causes of dysphagia• Achalasia

• Disorder of peristalsis of lower oesophagus & failure of lower oesphageal sphincter to fully relax

• Dysphagia to solids +/- fluids• Regurgitation• Retrosternal chest pain

• Diagnosis via barium swallow (bird beak/rat’s tail) and manometry.

• Conservative: Reduce sphincter pressure - CCB/nitrates/botox

• Surgical: Balloon dilatation – may lead to GORD & requires repeating Heller myotomy – cut through external layers, risk of GORD

Epigastric pain case• A 46 yr old woman presents with acute epigastric pain &

nausea, radiating to the back. Amylase is 1830.

• Which is the most likely aetiology?• Combined oral contraceptive pill• Alcohol• Hyperlipidaemia• Gallstones• Steroids

Gallstones

Epigastric pain case• A 46 yr old woman presents with acute epigastric pain &

nausea, radiating to the back. Amylase is 1830.

1. Which is the most likely aetiology?• Gallstones

2. Given the results opposite, what is her Glasgow score?• 2• 4• Severe• 5• 6

Hb 133 g/LWBC 13.2 x109/LUrea 7.8 mmol/LCalcium 1.98 mmol/LAlbumin 35 g/LLDH 233 units/LGlucose 13.0 mmol/L

pH 7.42pO2 9.1 kPaHCO3 25mmol/L

Acute Pancreatitis• Severe epigastric pain & vomiting, radiating through to back and worse on

lying flat.

• Most commonly Gallstones, then alcohol.• Minority caused by other GETSMASHED causes.• Lipids, trauma, steroids, ERCP

• Diagnosed only with raised amylase, >300 suggestive

• Prognostic scoring – Glasgow most used, be aware of Ranson’s

• Wide range of prognosis but management is supportive: analgesia, IVI

• Complications: Pancreatic necrosis, psuedo-cyst, fluid collections

Glasgow score

P pO2<8A Age>55N WBC>15C Calcium<2R Urea>16E LDH>600, ALT>200A Albumin<32S Glucose>10

CT at around 5 days

≥3 = Severe

Gallstone disease case• 47yr old woman has 12hr history of progressive epigastric

pain, rigors, T39.2C. Heart rate is 102bpm. Mild jaundice.

1. What is the most likely diagnosis?• Ascending cholangitis • Biliary colic• Acute Cholecystitis• Gallbladder empyema• Hepatic failure

– biliary history, pyrexia, jaundice

Gallstone disease case• 47yr old woman has 12hr history of progressive epigastric

pain, rigors, T39.2C. Heart rate is 102bpm. Mild jaundice.

1. What is the most likely diagnosis?• Ascending cholangitis

2. What is the initial definitive treatment for ascending cholangitis?• Abdominal ultrasound• MRCP• ERCP• Cholecystectomy• Supportive management

ERCP – note the wording - definitive, and treatment. Ascending cholangitis is due to obstructing stone.

Differentiating between the diagnosesBiliary colic

Pain following impaction of gallstone in gallbladder neck or cystic duct

Epigastric / RUQ painLasting a few hours & N/VPreceded by fatty meals

WBC & LFT’s normal

Analgesia, USS abdoIf USS shows gallstones delayed

laparoscopic cholecystectomy

Acute CholecystitisInflammation of the gallblader usually following

obstruction of cystic duct by a gallstone

Epigastric / RUQ painLasting a few hours & N/V

↑WBC, LFT’s may be mildly elevatedMurphy’s positive

Analgesia, IVI, IV antibiotics, USS abdoIf USS shows gallstones usually laparoscopic

cholecystectomy – hot/delayed (72hr)

Ascending CholangitisBiliary system infection due to a stone in the common bile duct

Charcot’s triad: Abdo pain (RUQ), Jaundice (↑Bili), FeverReynolds’ pentad: Charcot’s + septic shock, confusion

In reality these are not always present but the diagnosis is suspected if biliary type history & septic.

↑WBC & obstructive LFT’s (↑↑bili & ↑↑ALP, ↑ALT)Murphy’s negative

IVI & IV abx. Initial ultrasound. If some diagnostic doubt MRCP to assess for CBD stone, if not proceed to ERCP. Delayed lap chole.

MRCP / ERCP / Lap Chole

MRCP (Magnetic Resonance CholangioPancreatography)

MRIDiagnostic not therapeuticNo ass. mortality/morbidity

Visualises biliary tree to assess for CBD stones that

would require ERCP

ERCP (Endoscopic Retrograde CholangioPancreatography)

EndoscopyDiagnostic & therapeutic

Allows removal of stones, insertion of stents, and cutting of sphincter of

Oddi to ease drainage.

Complications: Death (0.4%), Pancreatitis (4%), Perforation (0.1%)

Laparoscopic cholecystectomy

DaycaseOnly thing you may be asked about is the

important structures:

Calot’s triangle – between cystic duct, common hepatic duct & cystic artery.

Cystohepatic triangle – cystic duct, common hepatic duct & inferior border of

liver

Important so that CBD isn’t cut.

Remember:

1. Learn the best investigations for dysphagia causes

2. Learn Glasgow scoring for Pancreatitis

3. Remind yourself how to differentiate between biliary diagnoses