1

UPPER GASTRO-INTESTINAL TRACT

DR. K. DILEEPA BANAGALA

Clinical Surgery
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A 50 year old obese female presents with a history of long standing retrosternal burning type chest pain and regurgitation of partially digested food.

What is the most likely diagnosis?

Introduction4:280 Risk Factors

• Pathologically excessive entry of gastric contents into the oesophagus • Obesity1:1066

• Commonest in middle aged adults • Smoking6
• Usually due to gastric acid • Alcohol4:280
o Smoking and alcohol both reduce the lower oesophageal sphincter
• Contributory Factors pressure6
o Reduced tone in the LOS • Dietary habits: Chocolate, caffeine, dairy products6
§ Idiopathic
§ Hiatus hernia1:1066
§ Previous surgery: Oesophagectomy, gastrectomy1:1094
o Increased intra-gastric pressure
§ Delayed gastric emptying (eg. Fat and spicy food) 1:1067
§ Large meal
Clinical Features1:1067

• Classical triad • Less typical symptoms

o Heartburn: Retrosternal burning type pain worse on lying down4:280, o Angina-like chest pain
stooping and exercise o Pulmonary or laryngeal symptoms
o Epigastric pain (sometimes radiating through to the back)
o Regurgitation: Made worse by stooping or exercise

• Odynophagia with hot beverages, citrus drinks or alcohol
• Severe GORD
o Nocturnal reflux (Nocturnal cough)
o Food reflux in to the mouth

Clinical Surgery

Management

• IF • IF,1:1077
4:280
o < 45 years o > 45 years4:280
o Doubtful diagnosis
o Does not respond to PPI
o Presence of dysphagia
Medical Management Investigations
1:1078,1079

• Dietary modifications • OGD

o Small frequent meals o Biopsy: If mucosal changes are seen6
o Avoid chocolate6, caffeine o Sliding hernia
• Life style modifications § ‘J’ maneuver/ retroflexed view: >2 cm separation between
o Elevate head end of bed the squamocolumnar junction and the diaphragmatic
o Do not go to bed soon after meals: Wait at least 2-3 hours before impression6
sleeping6 o Rolling hernia
o Reduce alcohol intake § ‘J’ maneuver/ retroflexed view shows a portion of the
o Stop smoking stomach herniating upward through the diaphragm adjacent
o Avoidance of NSAIDs to the endoscope6
o Reduce weight • 24h continuous pH monitoring4:280
• Drugs: o Peaks of pH change must correspond to symptoms
o Protect the mucosal barrier6 • Ba swallow and screening
§ Bismuth, Sucralfate o Can see reflux7:221
o Neutralize already secreted acid • Oesophageal manometry1:1077
§ Topical antacids
o Stop secretion of acid
§ H2 blockers, PPI
o Increase gastric and oesophageal emptying4:281
§ Promotilants: Metoclopramide

An upper GI endoscopy was performed, which showed a hiatus hernia.

Hiatus Hernia
Introduction4:278
• The presence of part or all of the stomach within the thoracic cavity
• Very common
• Female > Male
• Majority are asymptomatic
• May or may not be associated with GORD

Clinical Surgery

Types

Sliding Hernia4:278 Rolling (Para-Oesophageal) Hernia

1:1083,1084

• Axial displacement of the upper stomach (gastro-oesophageal junction6) • Displacement of part or all of the fundus and body of the stomach, which
through the oesophageal hiatus comes to lie alongside the normal oesophgus4:278

• By far the commonest: 95%6 • Much less common: 5%6
• May result in GORD symptoms • Symptoms
o Hiccough4:278, ‘pressure’ in the chest, dysphagia, odynophagia4:278,
incarceration which can cause obstruction, strangulation, gastric
perforation

• Medical management of GORD symptoms 6
• Surgical management

The patient is prescribed maximum medical therapy, but she still complains The patient refused surgery and fails to return for follow up. 10 years layer
of symptoms, which disturbs her day to day activities. she returns with progressive dysphagia, associated with LOA and LOW.

What other options are available for the management of this patient? What is the most likely diagnosis? What are the other complications?

• Wrapping fundus of the stomach around the intraabdominal oesophagus Complications1:1080-1082

(fundoplication)1:1079
• Laparoscopy or laparotomy1:1080 • Reflux oesophagitis
• Stricture
• Rarely required4:281
• Oesophageal metaplasia: ‘Barrett's oesophagus’
• Indications1:1079 • Adenocarcinoma: Due to intestinal metaplasia of the oesophagus
o Persistent symptoms despite maximal medical therapy
o Young patients: Otherwise they will need medication for a long
time7:221
o Patient preference
o Stringent life style modification required to control symptoms
o Large volume reflux with risk of aspiration pneumonia4:281

Clinical Surgery

DYSPHAGIA
What are the causes of dysphagia?

Causes7:218

Neuro-Muscular Causes1:1095
(When swallowing is tried, food
fails to enter oesophagus, stays in Mechanical Causes
mouth, or enters the airway, (Characterized by a sensation of "food sticking"1:1069)
causing coughing and
spluttering1:1069)
• Achalasia cardia Wall Lumen Extrinsic Compression
• CVA: Pseudo-bulbar palsy Neoplasm Benign • Foreign body • Mediastinal tumours: Bronchial tumours
• Myasthenia gravis • Malignancy • Corrosive • Enlarged LNs
• Multiple sclerosis • Post-traumatic • Thoracic aortic aneurysm, abnormal
• Parkinson’s disease • Post-radiotherapy subclavian artery (dysphagia lusoria)
• Inflammatory stricture: Chronic • Pharyngeal pouch
reflux oesophagitis • Retro-sternal goitre
• Oesophageal web: Plummer- • Rolling type hiatus hernia
Vinson syndrome
• Scleroderma

Clinical Surgery

Mr. X, a 76 year old laborer who is a smoker with 40 pack years and a betel chewer, presents with painless progressive dysphagia for solids and then liquids for 4
months associated with feeling of obstruction at mid-sterna level and loss of weight despite good appetite, but no nasal regurgitation, cough or history of corrosive
ingestion. Except for recurrent respiratory infections with aspiration there is no history evidence of local or distant spread. He is a poorly controlled diabetic for
10 years on oral hypoglycaemics. His past surgical, family, drug and allergic histories are not significant. Being able to take only liquid food he is unable to
purchase supplements due to financial constraints but has a good social support.

What is the most likely diagnosis?

Introduction 1:1085-1086
• 6th most common cancer in the world • Most common types
• Poor prognosis o Squamous cell carcinoma
o 5 year survival is 5-10% § Most common world wide
§ Upper 2/3 of the oesophagus
o Adenocarcinoma
§ More common in the west
§ Lower 1/3 of the oesophagus
§ Dramatic increase since the mid-70’s: 5-10% per annum
• More than any other cancer
Clinical Features
3:351, 1:1087

Patient Profile Symptoms and Signs

• Geography1:1086 • Dysphagia
o Asian ‘cancer belt’ o Initially for solids then liquids7:223
• Male : Female o Progressive6
o Adenocarcinoma 5:1 • Regurgitation
o Squamous cell carcinoma 3:14:282 • Odynophagia
• Age > 45 years • Weight loss and cachexia
o Highest risk in 60s and 70s • Normal appetite

Clinical Surgery

Etiological / Risk Factors 1:871 Complications/ Metastasis4:240
Adenocarcinoma
• GORD leading to Barrett’s oesophagus1:1087 Symptoms of Advanced Disease
o Intestinal metaplasia: Goblet cells
• Obesity6 • A: Aneamia: Starvation, chronic low-grade blood loss6
• Smoking6 • L: Loss of weight > 20%, LN + (Supra-Clavicular)1:1087
• A: Anorexia1:1087, chronic low-grade blood loss
Squamous cell carcinoma • R: Recurrent progressive symptoms: RLN palsy, Horner’s syndrome,
• Geography 1:1086 chronic spinal pain, diaphragmatic paralysis1:1087
o Asian ‘cancer belt’ • M: Malaena, Haematemesis6
• Life style1:1086
o Alcohol
o Smoking
• Diets rich in nitrosamines 6

o Pickled vegetables
o Smoked salmon
• Vit A and C deficiency6 (fresh fruits and vegetables) 4:282
• Strictures 4:282
o Radiation
o Lye
• Premalignant conditions (What are the premalignant conditions?)
o Achalasia cardia 4:282
o Hereditary tylosis6
o Plummer-Vinson syndrome: Dysphagia, IDA (koilonychia,
glossitis), oesophageal webs, middle aged women, post-cricoid
cancer7:224
o Leucoplakia
o Celiac disease
Summary Spread

Local6 Lymphatic Haematogenous1:1087

• Aorta7:223 • Lymph channels • Lung
• Trachea: Tracheo-oesophageal fistula o Lamina propria 5:92 • Liver
1:1087
• Pleura o Submucosa: Longitudinal spread • Bone
• Bronchi: Empyema, Lung abscess, Pneumonia • Nodes6 • Brain
• Pericardium: Pericarditis, effusion o Coeliac LN: Bad prognosis
• L/RLN: Hoarseness of voice1:1087 o Mediastinal LN
• Stomach o Supraclavicular LN7:223
o Subdiaphragmatic LN
• Tumours arising from the intra-abdominal portion of the oesophagus may also disseminate transperitoneally1:1087
Clinical Surgery

How will you investigate this patient?

Investigations
Confirm The Diagnosis Assess Spread/Stage the Disease1:1088-1091 Assess Fitness For Treatment
• UGIE/OGD1:1088 • Chest X-ray • Blood 7:223

o Visualize6 o Lung metastasis7:223 o FBC

§ Polyp o Widening of the mediastinum7:223 o FBS
§ Ulcer o Aspiration pneumonia • Heart
§ Stricture • USS abdomen o ECG7:70
o Biopsy (+ brush cytology to increase o Liver metastasis o 2D Echo
accuracy6) o Para-aortic LNs • Lungs
• Ba Swallow o Ascites o Chest X-ray7:70
o For failed intubation or suspected post- • CECT of thorax and abdomen o Lung function test
cricoid cancer4:282 o Spread to lung, bronchi, aorta, mediastinal o Arterial blood gas (ABG)
o Rat’s tail in Ca Vs. Parrot’s beak/Bird’s LN, liver • Kidneys7:223
beak in achalasia o Details of spread o Blood urea
o "Shouldered" stricture7:223,1:1086 • Endoscopic USS: Local depth of invasion o Serum creatinine
• Bronchoscopy: Trachea, bronchi o Serum electrolytes
• Laparoscopy • Nutrition1:279
o Peritoneal metastasis o Albumin
o Liver metastasis
• Bone scan: Bone metastasis
• CT scan of brain: Brain metastasis
• PET Scan: Positron Emission Tomography

How do you prepare this patient for the UGIE and what is the procedure?

UGIE

• Admit on the day of the procedure following 6 hours fasting to empty the • White balance
stomach6 • Lubricate and insert the endoscope after insertion of mouth piece
• Explain the procedure and get the informed consent1:218 • Ask the patient to swallow
• Exclude denture/ remove • Take at least 4 – 6 biopsies from the lesion
• Accompany the patient to the endoscopy room;
• Put the patient in the left lateral position6
• 2 puffs of 10% lignocaine spray to the pharynx4:272
• If patient is restless give midazolam 2-5 mg IV for sedation after
connecting the saturation probe1:219,4:272
Clinical Surgery

How do you prepare this patient for a CECT? Why do brain mets cause headache with straining?

CECT • The metastatic lesions are associated with significant peri-lesional

• Date for the investigation oedema1:663
• Informed written consent • Worsening headaches may follow maneuvers that raise intrathoracic
• Exclude allergy and bronchial asthma pressure, such as coughing, sneezing and the Valsalva maneuvre6
• If BA+, start oral prednisolone/steroids 10mg/tds/3days
• Investigations
o FBC The MDT has decided on palliative management. How will you break bad
o RFT: Serum creatinine, Serum electrolytes news to the patient?
o PT/INR
• Overnight fasting: 6 hours SPIKES Protocol6
• Good hydration: 1 L saline for 6 hours before and 12 hours after the S – Setting: Maintain privacy, but can involve significant others
procedure P – Perception: What do you think about your illness and its seriousness
• Omit metformin
• IV access
I – Invitation: Do you want to know about the illness
• Send to the Radiology department K – Knowledge: Give information to the patient and answer all questions
appropriately
How will you assess nutritional deficit clinically? E – Empathy and Emotions: Respond to patients emotions and show empathy
S – Strategy and Summary: Discuss the next plan
• Through history1:280
o 24 hour diet recall and food frequency
• Examination
o General1:279
§ Weight, BMI1:260
§ Skin fold thickness
§ Mid arm circumference
o Examining for specific nutritional deficiencies
§ Glossitis
§ Angular stomatitis
§ Nail atrophy
§ Ankle oedema
§ Pigmentation/ rashes
• Investigations
o Serum proteins, albumin1:279

What main system is important to assess if you are going to do surgery?

• Respiratory system with chest x-ray and lung function test

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Treatment
1:1091-1095

• MDT management
o Surgeon, Pathologist, Radiologist, Oncologist, Anesthetist,
Councellor
• Curative option is radical oesophagectomy + LN dissection
o If confined to the oesophagus and fit for surgery
• Palliative
o If already spread or unfit for surgery
§ Local infiltration
• Aorta, Trachea, Bronchi, Pericardium
§ Positive LNs
• Palpable cervical lymphadenopathy1:1087
• Para-aortic nodes6
• Mesenteric nodes6
§ Distant metastasis
o At the time of diagnosis 2/3 of all patients will have incurable
disease
Curative Vs. Palliative

Curative Palliative
• Neoadjuvant chemoradiotherapy for both adeno and squamous carcinoma • Stenting: Self-Expanding Metal Stents (SEMS)4:283
(BSG and BASO joint guidelines) 5:93 • Dilatation: Balloon tamponade
o Improves survival Vs. Surgery alone • Endoscopic methods
• Surgery o Laser ablation
o Trans-hiatal oesophagectomy: Orringer’s o Ethanol injection
o Trans-thoracic oesophagectomy (2 stage oesophagectomy): Ivor Lewis o Bipolar diathermy
o 3 stage oesophagectomy: McKeown o Ar beam plasma coagulation
• Radiotherapy • Radiotherapy
o Post-cricoid / upper most squamous cell carcinomas1:741 o Brachytherapy: Intraluminal radiotherapy
o Post-operatively when adequate proximal, distal and circumferential o External beam radiotherapy 5:98
margins cannot be achieved (specially in squamous cell carcinoma) • Atkin’s tube insertion
1:1091, 5:97
• Photodynamic therapy 5: 98
• Chemotherapy

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Surgical Options

Surgery Advantage Disadvantage

• Trans-hiatal oesophagectomy: Orringer’s
• Trans-thoracic oesophagectomy (2 stage
oesophagectomy): Ivor Lewis
• Less lung/ thoracic complications: No opening into • No LN removal in upper and middle mediastinum
the thorax • Blind dissection
• No mediastinitis: Anastomosis in the neck6
• Can remove LN • Mediastinitis: Anastomosis in the thorax
• Not a blind dissection

• 3 stage oesophagectomy: McKeown6 • No mediastinitis: Anastomosis in the neck • Lung/ thoracic complications: Opens into thorax
• Can remove LN
• Not a blind dissection

What complications do you anticipate after surgery? How will you prepare this patient for surgery?
Pre-Operative Management
Complications After Surgery • Psychological counseling
• Respiratory • Informed written consent7:70
• Anastomotic leakage • Nutrition
• Chylothorax o High calorie, liquid diet
• Injury to the recurrent laryngeal nerves o High protein diet
• Anastomotic stricture: Late o Jejunostomy feeding
o TPN
• Dental referral
• Chest preparation
o Steam inhalation
o Incentive spirometry1:266
o Bronchodilator1:266
o Sputum culture & ABST
o Physiotherapy1:266
• ICU bed
• Inter-costal tube
• Naso-gastric tube
• Blood for grouping and DT7:71
• Anesthetist referral7:71
• Arrange epidural analgesia
• DVT prophylaxis
o Graduated compression stockings7:71
o Calf pumps/ foot pumps
• Catheterize the patient before sending to the theatre
Clinical Surgery

How do you manage this patient post-operatively? • Care of drains and IC tubes
o IC tube
Post-Operative Management § See whether its functioning: Swinging of fluid level
• ICU management § Is the patient clinically improving (no dyspnea, cyanosis)
• Monitoring7:71 § Auscultate the chest
o Vital parameters + pulse oxymetry § When to remove
o Hourly UOP • Patient is clinically stable
o Continuous cardiac monitoring • Lung fields expanded: Clinically and radiologically
o Monitor for complications • Drain < 50 ml within 24 hours
• Patient comes out from theatre with multiple tubes o NG tube can be removed when the absence of an anastomotic leak is
o ET tube demonstrated6
o NG tube - for draining purposes6
o Drains
o 2 IC tubes
o Urinary catheter The patients relatives inquires about prognosis. What do you know anout
o Epidural catheter prognosis in Oesophageal cancer?
o 2 IV cannulas
o Central venous line Prognosis
o Jejunostomy tube6 • Poor prognosis 1:1087

• Adequate analgesia1:275 • Only 1/3 fit for surgery

o Epidural (Bupivacaine + Fentanyl) • Palliative care mean survival: 4 months
o Patient controlled analgesics o Most survive less than 4 months if the primary is non-resectable7:223
• IV fluids to maintain good urine output7:71 • LN involvement: Bad prognosis6
• Keep nil by mouth • Local recurrence is common
• Pulmonary care: Physiotherapy4:68 o Vs. Metastasis is common in other GI tumours
• Consider DVT prophylaxis6
o Early mobilization
o Graduated compression stockings
o Pharmacological
• GI care6
o Start feeding from day 2 once the flatus is passed via jejunostomy
tube
o 7- 10 days post-op confirm intact anastomosis by performing a
water soluble gastrographin study
o Start oral feeding, starting with clear fluids

Clinical Surgery

A 35 year old female presents with dysphagia for both solids and liquids. She has A 50 year old obese female, with a history of long standing GORD, presents with
recently noticed a nocturnal cough, which disturbs her sleep. progressive dysphagia for the past 6 months.
What is the most likely diagnosis? What is the most likely diagnosis?

Introduction1:1096 Introduction
• 2 characteristics • Acquired narrowing of the oesophagus
o LOS fails to relax
§ Selective loss of inhibitory neurones and ganglion cells in the Clinical Features
myenteric plexus History of
o Deficient oesophageal peristalsis • Ingestion of corrosive (strong acid/alkali)1:1075
• GORD1:1080
Clinical Features7:222,1:1097 • Radiation6
• Age: 30 – 50 years • Trauma
• Female : Male = 1:1 • Post-operative
• Dysphagia o Oesophagectomy7:219
o Initially for fluids then solids4:274 o Surgery for tracheo-oesophageal fistula
o Intermittent
o For both solids and liquids Investigations
• Regurgitation of undigested food • OGD 7:224

• Nocturnal cough due to overspill of regurgitated food into the trachea • Ba swallow6
• Loss of weight6 Treatment
Investigations1:1097-1098
• OGD Acute Treatment: If corrosive7:224 Definitive Treatment
o Hugging of the scope • Nil by mouth: Rest the oesophagus • Endoscopic dilatation1:1071
o Undigested food particles • Feeding jejunostomy1:1075 • Surgery1:1076
• Barium swallow • Neutralize o Resect and replace with
o ‘Bird beak’ appearance o Alkali: Vinegar jejunum/colon
• Chest X-ray o Acid: Bicarbanate
o Dilated oesophagus • Never induce vomiting: Can rupture
o Fluid level behind the heart the already damaged oesophagus
o No gastric air bubble
• Oesophageal manometry

Treatment1:1098-1099
• Endoscopic balloon dilatation
• Botulinum toxin injections
• CCB (nifedipine) gives transient relief of symptoms
• Surgical myotomy (Heller's cardiomyotomy)
o Laparoscopic or laparotomy

Clinical Surgery

A 60 year old male presents with upper abdominal pain for the past 2 years associated with dyspeptic symptoms. Further questioning revealed a chronic knee pain
for which he’s on NSAIDs. What is the most likely diagnosis?

• Breakdown of balance between acid production and mucosal defense mechanisms

Acid Production1:1116 Mucosal Defense Mechanisms1:1109

• Helicobacter pylori • Mucosal barrier
o Hydrolyses urea to produce ammonia, which neutralizes gastric acid. o Mucus
Therefore gastrin secretion is stimulated1:1114 o HCO3-
o Disrupts the mucous layer, making it more susceptible to acid damage6 o Channels for HCl
• Alcohol4:284 • Mucosal cells
• Smoking • Trefoil peptides
• NSAIDs • High blood supply: HCl is removed easily
o Inhibits cyclo-oxygenase type 1 (COX-1)6
§ Decreases prostaglandin

Will giving NSAID suppositories solve this problem?

Clinical Surgery

Classification1:1116
• Gastric ulcers: MALIGNANT UNTIL PROVEN OTHERWISE 1:1118

• Duodenal ulcers
• Atypical ulceration
Gastric Ulcers Vs. Duodenal Ulcers
Gastric Ulcers: 20% Duodenal Ulcers: 75%
1:1116-1118, 4:284 1:1116-1119, 4:284

• In the lesser curvature of the stomach • In the 1st part of the duodenum
• Both sexes equally affected1:1117 • Male : Female = 5:1
• Age > 50 years • Age < 50 years
• More in blood group A • More in blood group O
• Common in developing countries • Common in developed countries
• Due to breakdown of defense mechanisms • Due to increased acid secretion
• Associations • Associations
o Helicobacter pylori – 45% o Helicobacter pylori – 85%
o High alcohol intake o Smoking
o Smoking o NSAIDs
o NSAIDs
• Normal/low acid secretion • High acid secretion
• Pain • Epigastric pain
o With meals: Due to visceral sensitization and GI dysmotility6 o Relieved by food
o Relieved by vomiting7:225 o May radiate to the back
• Erosion • Erosion
o Pancreas o Anterior wall: Perforates
o Left gastric artery7:226 / Splenic artery o Posterior wall: Bleeds
§ Bleeding § Gastroduodenal artery
o Perforation • Kissing ulcers
o Anterior wall
o Posterior wall
• Rarely malignant • No malignant potential

Why do patients with duodenal ulcers gain weight? During what time of the day do patients with duodenal ulcers get the pain?
• The "classic" pain of duodenal ulcers occurs 2-5 hours after a meal and at
night (11:00pm-2:00am)6

Why during that time?6

• Because acid is secreted in the absence of a food buffer
• Because the circadian stimulation of acid secretion is maximal at night
Clinical Surgery

How will you investigate and treat this patient?

Investigations Treatment
• UGIE/OGD 1:1119
• Life style modifications
o Commonest diagnostic test o Reduce alcohol intake4:285
o Stop smoking1:1119
• Double contrast barium meal4:284 o Avoidance of NSAIDs1:1120
o If OGD contraindicated • Drugs:4:285
o Protect the mucosal barrier
• Tests for H. pylori (Converts urea to ammonia and CO2)1:1114 § Bismuth
o Antral biopsies from OGD § Sucralfate
§ Histology: Gold standard o Neutralize already secreted acid
§ Rapid urease test (CLO test) § Topical antacids
o CO2 breath test (Urease breath test) o Stop secretion of acid1:1119
§ Stop antibiotics and acid reducing drugs before test6 § H2 blockers
o Faecal antigen test § PPI
§ Stop antibiotics and acid reducing drugs before test6 • H. Pylori eradication therapy: Triple therapy1:1114
o Serology: IgG o PPI
o Amoxycillin (Metronidazole if Penicillin allergy)
o Clarithromycin

This patient suddenly presents to the surgical casualty with severe abdominal pain. On examination you notice obliteration of the liver dullness.
What is the most likely diagnosis? How do you manage this patient?












Complication of PUD
• Perforation1:1125 • GOO due to pyloric scarring1:1129
• Acute upper GI bleeding1:1126 • Erosion into adjacent organs1:1117
o Haematemesis o Pancreas
o Malaena o Transverse colon
• Malignancy: Gastric ulcers1:1118
• Chronic low level bleeding: Iron deficiency anaemia4:285
Clinical Surgery

This patient suddenly presents to the surgical casualty with haematemesis and malaena?
How do you manage this patient?

Resuscitation1:1126-1127, 4:294 Definitive

• Stabilize the patient • Drugs 6

o IV access: Large bore canula o IV PPI4:295

o Grouping & DT o IV Terlipressin/Vasopressin
o IV fluid o IV Octreotide
o Blood transfusion o IV Somatostatin
o Maintain/establish airway6
o Correct coagulation Next step…
§ FFP • UGIE at least within 24 hours 4:294

§ Vitamin K • As soon as possible once the patient is stabilized1:1127

• Catheterization
• Fluid balance chart Varices1:1129 Peptic Ulcers1:1127
• Monitor: PR, BP, RR, Urine output • Sclerotherapy • Adrenaline injection
• Inform ICU • Variceal banding • Bipolar diathermy7:227
• Do NOT give patient anything by mouth6 • Clips
What are the causes of upper GI bleeding? • Ar-Plasma coagulation7:227
• Oesophageal cases
o Oesophageal varices: Portal hypertension4:294 If still bleeding…
o Mallory-Weiss tear: Tear at the cardia of the stomach Next step…
following violent vomiting1:1128 • Repeat UGIE
o Reflux oesophagitis7:231
o Oesophageal cancer7:231 If still bleeding…
• Gastric causes Next step…
o Gastric ulcer1:1126
o Gastric cancer4:294 Varices
o Acute gastritis6 • Balloon tamponade: TO BUY TIME1:1129,6
• Duodenal Causes1:1126 o Sengstaken-Blakemore tube
o Duodenal ulcer
• Other causes If still bleeding…
o Dengue fever Next step…
o Angio-dysplasia6 • Surgery
o Haemangioma
o Coagulopathy1:1127 Varices Peptic Ulcers1:1127-1128
§ Congenital • Transjugular intrahepatic • Under-running of the ulcer
§ Acquired: Liver disease portosystemic shunt1:1129 • Left gastric artery / Gastro-
§ Inadequately controlled warfarin therapy • Oesophageal resection7:232 duodenal artery ligation
• Partial / total gastrectomy
Clinical Surgery

Atypical Ulceration Zollinger-Ellison Syndrome
1:1141-1142

• Atypical sites of gastric acid secretion1:1116 • Hypergastrinaemia4:285

o Ectopic gastric mucosa in a Meckel's diverticulum o Extensive, persistent, atypical ulceration

• Abnormally high levels of acid secretion1:1116 • Causes

o Zollinger-Ellison syndrome o Benign secretory gastrinoma
§ Usually in the duodenal loop or intra-pancreatic
• Multiple ulcers4:284 o Malignant gastrinoma
§ Associated with MEN syndromes (MEN Type 1)6
• Ulcers in abnormal locations4:284
o Distal duodenum • Presentation7:228
o Jejunum o Gastro-intestinal bleeding
§ Occult: Anaemia
• Fails to respond to maximal medical therapy1:1120 § Apparent: Malaena or fresh bleeding
o Recurrent ulcers after surgery for peptic ulcer
o Ulcers resistant to medical therapy
o Chronic diarrhoea6
§ Exceedingly low pH in the intestine inactivates pancreatic
enzymes and damages the intestinal epithelium and villi
§ High serum gastrin levels inhibit absorption of sodium and
water by the small intestine

• Investigations
o Investigations for chronic GI bleeding
o Raised serum gastrin level
o CECT scan abdomen4:285
o Octreotide scan: To localize gastrinoma6

• Treatment
o Resection of pancreatic tissue-containing tumour

Clinical Surgery