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Questions and Answers
What is the score range for Class B in the Child Pugh score system?
Which criterion is assessed for Encephalopathy in the Child Pugh score?
What bilirubin level corresponds to Score 2 in the Child Pugh system?
In the Endoscopic Classification of Bleed Risk, which class indicates a low risk?
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Which mechanism is primarily responsible for weight loss after bariatric surgery?
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What is a significant complication of both Biliopancreatic Division (BPD) and Duodenal Switch (DS) surgeries?
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What INR value corresponds to Score 3 in the Child Pugh score system?
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What distinguishes the Duodenal Switch surgery from the Biliopancreatic Division?
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What effect does bariatric surgery have on the hormone Ghrelin?
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Which of the following is NOT a characteristic of irreversible surgeries like BPD and DS?
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What is the primary function of the TIPSS procedure?
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Which complication is most commonly associated with TIPSS procedures?
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Which of the following is NOT an indication for using TIPSS?
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What are the components of the Minnesota balloon and Linton tube?
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What initial complication may occur due to the TIPSS procedure?
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Which type of shunt primarily shunts only splenic blood?
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What is an example of a non-selective shunt?
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What is the main goal of the Sugiura Procedure?
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Which procedure would most likely lead to low risk of encephalopathy?
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Which complication is associated with upper GI hemorrhage and portal hypertension?
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What condition is most likely to lead to hepatic vein outflow obstruction?
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Which of the following is NOT a characteristic feature of liver failure?
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Which of the following is a pre-hepatic cause of upper GI hemorrhage?
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What is a common clinical feature associated with caput medusae?
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Which of the following conditions is likely to present with a gradual course leading to portal hypertension?
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What is the minimum BMI required in the general population for a candidate to qualify for bariatric surgery without obesity complications?
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Which of the following obesity complications would allow a patient with a BMI of 35 kg/m² to qualify for bariatric surgery?
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What is a key component of the liver shrinkage diet recommended before bariatric surgery?
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Which of the following factors contributes to the OS-MRS score in assessing the mortality risk for obesity surgery?
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What is an important pre-operative consideration for patients with obstructive sleep apnea (OSA) preparing for bariatric surgery?
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What is the primary mechanism by which sclerotherapy works?
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What is the first step in using a Sengstaken-Blakemore tube for managing upper GI haemorrhage?
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What should be done if there is ongoing bleeding after the use of a Sengstaken-Blakemore tube?
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What is a significant disadvantage of the Sengstaken-Blakemore tube?
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What is the appropriate action to take if re-bleeding does not occur within 24 hours after initial management?
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What is the primary cause of splenic vein thrombosis leading to portal hypertension?
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Which of the following statements about Budd Chiari syndrome is correct?
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Which treatment option is considered the best for managing variceal gastrointestinal hemorrhage?
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What is the primary purpose of performing upper GI endoscopy in the case of variceal hemorrhage?
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Why is the use of Propranolol avoided in the management of variceal GI hemorrhage?
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What is the earliest clinical manifestation of Menetrier's disease?
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Which of the following describes the method for measuring hepatic venous pressure gradient (HVPG)?
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What is the significance of a hepatic venous pressure gradient (HVPG) of ≥10 mm Hg?
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Which factor is primarily responsible for the development of esophageal varices due to portal hypertension?
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Which treatment is recommended for Menetrier's disease if the initial therapy is ineffective?
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What is the primary location of a Mallory-Weiss tear?
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Which artery is primarily involved in a Mallory-Weiss tear?
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Which treatment is most commonly associated with Gastric Antral Vascular Ectasia (GAVE)?
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What is a distinguishing feature of Boerhaave syndrome compared to Mallory-Weiss tear?
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What appearance is noted in endoscopy for portal gastropathy?
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Which patient population is more commonly affected by Dieulafoy lesions?
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What characteristic appearance does portal gastropathy present with?
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What is a clinical feature of a Mallory-Weiss tear?
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Study Notes
Bariatric Surgery
- Biliopancreatic division (BPD) and Duodenal Switch (DS) are irreversible surgeries that cause maximum weight loss and diabetes resolution.
- BPD and DS have high rates of malabsorption and post-operative complications. They are no longer commonly performed.
- BPD: A portion of the stomach is bypassed, and the biliopancreatic limb is connected to the Roux limb, which then connects to the common channel (50cm) that joins the small intestine.
- DS: A portion of the stomach is removed (Sleeve), the biliopancreatic limb is connected to the common channel (100cm), and the common channel joins the small intestine.
- Bariatric surgery is indicated for a BMI ≥ 40 kg/m² in the general population, or ≥ 35 kg/m² with obesity complications, including diabetes, hypertension, and hyperlipidemia; with type 2 diabetes within 10 years, it is indicated for BMI 30-34.9 kg/m².
- Asian population: BMI ≥ 37.5 kg/m² or ≥ 32.5 kg/m² with complications like OSA or osteoarthritis.
- Pre-operative considerations include proper counselling, dietary and lifestyle changes, liver shrinkage diet (low carbohydrate, high protein) for at least 2 weeks, smoking cessation 4-6 weeks in advance, and oxygen for OSA patients.
Child Pugh Score
- The Child Pugh score assesses the severity of liver dysfunction.
- Five criteria are evaluated: Encephalopathy, Ascites, Bilirubin, Albumin, and Prothrombin Time/INR.
- Scores range from 1-3 for each criteria, with higher scores indicating a more severe condition.
- A total score classifies a patient's liver dysfunction: Class A (5-6) mild, Class B (7-9) moderate, Class C (10-15) severe.
Endoscopic Classification of Bleed Risk
- Forrest's endoscopic classification assesses the risk of re-bleeding:
- Class Ia (spurt) and Ib (ooze): High bleeding risk.
- Class IIa (non-bleeding visible vessel) and IIb (adherent clot): Medium bleeding risk.
- Class IIc (flat pigmented spot) and a clean ulcer base: Low bleeding risk.
Gastrointestinal and Abdominal Surgery Instruments
- Minnesota Balloon has 1 balloon and 4 channels for balloon and aspiration.
- Linton Tube has 1 balloon and 3 channels for esophageal aspiration, gastric aspiration, and balloon inflation.
Shunts
- Transjugular Intrahepatic Portosystemic Shunt (TIPSS) is the most common shunt, creating a non-specific shunt to reduce portal pressure.
- Early complications of TIPSS include rupture of the liver capsule.
- Most common complications of TIPSS are blockages which increase pressure and cause upper GI hemorrhage.
- Blockages in TIPSS lead to toxin buildup which causes encephalopathy.
- TIPSS is indicated for variceal bleeding and intractable ascites related to portal hypertension.
Non-selective Shunts
- These shunts bypass gut and splenic blood.
- Examples include TIPSS, Linton shunt (Proximal Lienorenal shunt), and ECK fistula (End-to-side portocaval shunt).
Selective Shunts
- These shunts bypass only splenic blood and have a lower risk of encephalopathy.
- Examples include: Inokuchi (L) gastric venocaval shunt, Warren shunt and Distal lienorenal shunt.
Proximal Lienorenal Shunt with Splenectomy (Linton Shunt)
- This is a type of selective shunt.
Sugiura Procedure
- This procedure involves devascularizing the lower esophagus (5-10 cm) to reduce variceal bleeding.
- It is a rarely performed esophageal devascularization procedure.
Other Procedures
- Selective vagotomy and Pyloroplasty are other procedures used in gastrointestinal and abdominal surgery.
Upper GI Hemorrhage
- Retroperitoneal shunting can occur in the bare area of the liver (Segment VII), rectum, umbilicus, and caput medusae.
- Clinical features include splenomegaly, ascites, and features of liver failure, such as jaundice and deranged liver enzymes.
Causes of Portal Hypertension
- Post-Hepatic: Budd-Chiari syndrome, inferior vena caval obstruction, hepatic vein outflow obstruction.
- Cardiac Causes: Restrictive cardiomyopathy, constrictive pericarditis, severe congestive heart failure, severe tricuspid regurgitation.
-
Intra-Hepatic:
- Post Sinusoidal: Hepatic sinusoidal obstruction (venoocclusive syndrome).
- Sinusoidal: Cirrhosis due to various causes including alcohol, NAFLD, viral hepatitis, cryptogenic cirrhosis, hepatocellular carcinoma, and amyloidosis.
-
Pre-Hepatic:
- Presinusoidal: Sarcoidosis, Schistosomiasis.
- Extra hepatic portal venous thrombosis: First and second decades of life, cavernous change in portal vein, web formation leading to blockage.
Portal Hypertension Course
- Fulminant: Rapid progression to liver failure, requiring transplantation.
- Gradual: Leads to portal hypertension, variceal bleeds, splenomegaly, and ascites.
Splenic Vein Thrombosis
- Causes sided portal hypertension (HTN).
- Often secondary to pancreatitis, resulting in splenic vein thrombosis and portal hypertension.
- Treatment usually involves splenectomy.
Budd Chiari Syndrome
- Describes hepatic venous outflow obstruction, blocking hepatic veins and causing blood accumulation in the liver.
- Predisposing factors: Female predominance, pregnancy, protein C and S deficiency, and tumors.
- Segment 1, the caudate lobe, has independent venous drainage and is often hypertrophied, directly draining into the inferior vena cava (IVC).
Management of Variceal GI Hemorrhage
- Stabilize with IV lines, blood (cross-matching), judicious IV fluids (permissive hypotension), airway management (to prevent aspiration), and IV agents like terlipressin (best) and octreotide (most common).
- Perform upper GI endoscopy; if varices are present, consider banding or sclerotherapy.
- Avoid propranolol and give PPI after endoscopy.
Upper GI Hemorrhage Conditions
- Mallory-Weiss Tear: Occurs after retching or vomiting, at the gastroesophageal junction, involving the left gastric artery. Usually self-limiting and diagnosed with UGI endoscopy.
- Boerhaave Syndrome: Spontaneous esophageal perforation, often presenting with full-thickness perforation, chest pain, Mackler's triad (chest pain, subcutaneous emphysema, and shock).
- Gastric Antral Vascular Ectasia (GAVE): Dilated venules in the antrum of the stomach, more common in females and associated with collagen vascular diseases. Treated with Argon Photocoagulation (APC).
- Portal Gastropathy: Dilated vessels in the body of the stomach, giving a snake skin or strawberry appearance. Described as "watermelon stomach" in endoscopy.
- Dieulafoy Lesions: Dilated submucosal arterioles, more common in elderly patients. Treated with coagulation of vessels.
Menetrier's Disease
- Occurs due to overexpression of TGF α.
- Presenting symptoms: Protein-losing enteropathy (earliest manifestation), upper GI hemorrhage, increased risk of cancer.
- Diagnosed with endoscopy.
- Treatment: Cetuximab (anti-EGFR), total gastrectomy if no response to treatment.
Gastrointestinal Stromal Tumors (GIST)
- Are tumors of the gastrointestinal tract.
Portal Hypertension
- Measured by the Hepatic Venous Pressure Gradient (HVPG).
- Measured with a Doppler using wedge hepatic venous pressure (balloon inflated) minus free pressure (balloon deflated).
- Values:
- 1-5 mm Hg: Normal.
- 6-10 mm Hg: Preclinical sinusoidal portal hypertension.
- ≥ 10 mm Hg: Clinically significant portal hypertension: Symptoms + formation of varices, increased risk of rupture of varices.
Porto-Systemic Shunts
- Portal hypertension causes decompression by draining into systemic circulation.
- Sites: Lower esophagus (gastric (coronary) vein and short gastric veins; gastric (coronary) vein or gastroepiploic vein).
- Results: Distal esophageal veins cause esophageal varices, and esophageal/paraesophageal veins also cause esophageal varices.
Sengstaken-Blakemore Tube
- Most commonly used tube for managing upper GI hemorrhage.
- Has 3 channels and 2 balloons: Gastric balloon for aspiration from stomach and esophageal balloon.
- Steps: Insert gastric balloon, inflate with 300 cc saline, achieve tamponade effect by inflating gastric balloon, arrest bleeding, inflate esophageal balloon, deflate every 12 hours to prevent esophageal necrosis.
- Disadvantages: The aspiration tube cannot aspirate from the esophagus.
Sclerotherapy
- Sclerosing agents: Sodium tetradecyl sulfate (most commonly used), Polidocanol, Ethanolamine Oleate, Sodium morrhuate.
- Avoid: Deep injection.
- Mechanism: Fibrosis.
- Complications: Perforation, chest pain.
Upper GI Hemorrhage Management
- If bleeding stops: Monitor for 24 hours for re-bleeding.
- If no re-bleeding: Discharge and oral propranolol prophylaxis.
- If bleeding continues/re-bleeding: Trial of endoscopy; if it fails, prepare for TIPSS. Correct deranged coagulation and use tubes for temporary bleeding control.
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Description
This quiz explores the essential aspects of biliopancreatic division (BPD) and duodenal switch (DS) surgeries, including their indications, complications, and surgical techniques. Understand the criteria for bariatric surgery among different populations and the impacts on obesity-related conditions such as diabetes and hypertension.
