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5/27/2014 Kaplan General Surgery - Microsoft OneNote Online

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Upper GI
Saturday, May 24, 2014 12:08 PM
Esophagus:

GERD
If vague sx --> uncertain dx --> pH monitoring
Typical case: overweight pt complains of burning retrosternal pain & 'heartburn' when bending
over, wearing tight clothing, lying flat in bed at night, relieved by ingestion of antacids or OTC
H2 blockers
Long-standing hx --> concern for damage to lower esophagus (peptic esophagitis) & possibility
of Barrett esophagus --> endoscopy & bx
Indications for surgery:
Long-standing symptomatic disease that cannot be controlled by medical means
In pts who have developed complications (ulceration, stenosis)
If there are severe dysplastic changes --> resection (in others, lap Nissen fundoplication)
Motility problems
Patterns --> crushing pain w/swallowing in uncoordinated massive contraction; dysphagia seen
in achalasia (solids swallowed easier than liquids)
Mgmt --> barium swallow --> manometry studies (definitive dx)
Achalasia
MC in women
Sx --> dysphagia worse for liquids (pt finds siting up straight & waiting helps), occasional regurg
of undigested food
X-ray --> mega-esophagus
Dx --> manometry
Tx --> balloon dilatation via endoscopy
Esophageal CA
Progression of dysphagia: meat --> other solids --> soft foods --> liquids --> saliva (in mos)
Significant weight loss
SCC --> M w/hx of smoking & drinking (esp blacks)
ADCA --> pts w/long hx of GERD
Dx: barium swallow --> endoscopy (swallow done 1st to prevent perforation) & bx
CT will assess operability but most cases get palliative surgery
Mallory-Weiss tear
After prolonged forceful vomiting --> bright red blood
Dx: endoscopy --> photocoagulation (laser)
Boerhaave syndrome
Prolonged, forceful vomiting --> esophageal perforation
Continuous, severe wrenching epigastric & low sternal pain of sudden onset --> fever,
leukocytosis, sick-looking pt
Dx: contrast swallow (Gastrografin, then barium if neg) --> emergency surgical repair
Instrumental perforation of esophagus
MC reason for esophageal perforation (i.e. endoscopy)
Sx similar to Boerhaave syndrome, also may have emphysema in lower neck (dx)
Must do contrast studies & prompt repair

Stomach:

Gastric ADCA
MC in elderly: anorexia, weight loss, vague epigastric distress, early satiety, sometimes
hematemesis
Dx: endoscopy & bx
CT helps assess operability
Surgery is best therapy
Gastric lymphoma
Almost as common as gastric ADCA; similar presentation & dx
Tx is based on chemo or radiotherapy
Indication for surgery --> if perforation is feared as tumor melts away
Low-grade lymphomatoid transformation (MALToma) reversed by eradication of H. pylori