Surgery Marrow Pg 131-140 (GIT)
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Surgery Marrow Pg 131-140 (GIT)

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Questions and Answers

What do the letters C and M in the Prague C & M Criteria stand for?

  • Extent of disease and Risk of cancer (correct)
  • Concentration and Measurement
  • Circumference and Mobility
  • Cancer and Mortality

    • A flat columnar mucosa is considered a finding during the examination phase.

    True

    What type of intervention is recommended if LGD is detected?

    MDT discussion and therapeutic intervention

    The protocol specifies a _____ biopsy every cm during the Seattle Biopsy Protocol.

    <p>4 quadrant</p> Signup and view all the answers

    Match the following terms with their correct definitions:

    <p>OGD = Esophagogastroduodenoscopy HGD = High-grade dysplasia BO = Barrett's esophagus MDT = Multidisciplinary team</p> Signup and view all the answers

    What is the primary purpose of fundoplication in gastrointestinal surgery?

    <p>To restore intra-abdominal esophagus length and prevent reflux</p> Signup and view all the answers

    The complete wrap fundoplication (Nissen's) involves a 270° wrap around the esophagus.

    <p>False</p> Signup and view all the answers

    Name one common complication associated with Nissen's fundoplication.

    <p>Gas bloat syndrome</p> Signup and view all the answers

    Collis gastroplasty is primarily indicated for __________ shortening.

    <p>esophageal</p> Signup and view all the answers

    Match the types of fundoplication with their descriptions:

    <p>Nissen's = 360° wrap around the esophagus Dor = 180° anterior wrap Toupet = 180°-270° posterior wrap Belsey mark = 270° anterior wrap</p> Signup and view all the answers

    Which of the following is NOT a protective factor against GERD?

    <p>Low LES pressure</p> Signup and view all the answers

    Obesity is considered a risk factor for GERD.

    <p>True</p> Signup and view all the answers

    What is the gold standard investigation for diagnosing GERD?

    <p>24 hr pH monitoring</p> Signup and view all the answers

    The most common clinical feature of GERD is __________.

    <p>heartburn</p> Signup and view all the answers

    Match the following treatments with their corresponding advice:

    <p>Weight reduction = Lifestyle change Avoid fried foods = Dietary modification Small, frequent meals = Eating pattern Dine before sleeping = Timing of meals</p> Signup and view all the answers

    Which of the following procedures is suitable for patients with minimal or no hiatus hernia?

    <p>LINX device</p> Signup and view all the answers

    Barrett's esophagus is characterized by columnar epithelium replacing squamous epithelium.

    <p>True</p> Signup and view all the answers

    What are the pathognomonic findings on biopsy for Barrett's esophagus?

    <p>Red velvety mucosa and goblet cells</p> Signup and view all the answers

    The type of Barrett's esophagus characterized by a length greater than 3 cm is called __________.

    <p>Long Segment</p> Signup and view all the answers

    Match the following identification methods to their corresponding findings:

    <p>Lugol's Iodine = Squamous epithelium Methylene Blue = Adenocarcinoma Histopathology = Barrett's Esophagus</p> Signup and view all the answers

    What is the common appearance of ulcers seen in CMV esophagitis?

    <p>Geographical/serpiginous ulcers</p> Signup and view all the answers

    Esophageal candidiasis is most commonly seen in immunocompetent patients.

    <p>False</p> Signup and view all the answers

    What is the peak age for eosinophilic esophagitis?

    <p>20-30 years</p> Signup and view all the answers

    The endoscopic appearance of eosinophilic esophagitis may include _____ mucosa.

    <p>crepe paper</p> Signup and view all the answers

    Match the type of esophageal infection with its characteristic feature:

    <p>Esophageal Candidiasis = Shaggy deposits CMV = Geographical/serpiginous ulcers Herpes Infection = Small ulcers with raised margins</p> Signup and view all the answers

    Which procedure has the highest risk of GERD as a complication?

    <p>Heller's myotomy</p> Signup and view all the answers

    Type 3 achalasia is best managed with Heller's myotomy.

    <p>False</p> Signup and view all the answers

    What is the primary indication for using botulinum toxin in achalasia management?

    <p>Elderly patients with co-morbidities</p> Signup and view all the answers

    Pneumatic dilation is most effective for patients who are _____ years old and older.

    <p>45</p> Signup and view all the answers

    Match the management type to its appropriate achalasia type:

    <p>Type 1 = Heller's myotomy Type 2 = Heller's + Pneumatic dilation Type 3 = POEM</p> Signup and view all the answers

    What is the earliest clinical feature of esophageal issues related to achalasia?

    <p>Regurgitation</p> Signup and view all the answers

    Nocturnal coughing is a classical feature of esophageal complications.

    <p>True</p> Signup and view all the answers

    What does the Chicago Classification of Achalasia specifically evaluate?

    <p>Disorders of Oesophageal Outflow</p> Signup and view all the answers

    The condition known as _____ pneumonia is the most common complication associated with esophageal disorders.

    <p>aspiration</p> Signup and view all the answers

    Match the parameters of the Achalasia-Eckardt Score with their corresponding points.

    <p>Weight loss = 0-3 Dysphagia = 0-3 Retrosternal pain = 0-3 Regurgitation = 0-3</p> Signup and view all the answers

    What is a common complication associated with Zenker's Diverticulum?

    <p>Aspiration pneumonia</p> Signup and view all the answers

    Halitosis is an uncommon symptom of Zenker's Diverticulum.

    <p>False</p> Signup and view all the answers

    What investigative choice is primarily used for diagnosing Zenker's Diverticulum?

    <p>Barium swallow</p> Signup and view all the answers

    Zenker's Diverticulum is primarily located on the _____ of midline at final position.

    <p>left</p> Signup and view all the answers

    Match the following management options for Zenker's Diverticulum with their descriptions:

    <p>Diverticulectomy = Surgical removal of the diverticulum Cricopharyngeal myotomy = Surgery to reduce recurrence Endoscopic diverticulopexy = Minimally invasive procedure to secure the diverticulum</p> Signup and view all the answers

    What is the main goal of treatment for eosinophilia in gastrointestinal surgery?

    <p>Decrease eosinophilia</p> Signup and view all the answers

    Obesity is NOT considered a risk factor for GERD.

    <p>False</p> Signup and view all the answers

    Name one common complication associated with surgical interventions in gastrointestinal procedures.

    <p>Dysphagia</p> Signup and view all the answers

    Barrett's esophagus typically involves the replacement of squamous epithelium with __________ epithelium.

    <p>columnar</p> Signup and view all the answers

    Match the following surgical procedures with their purpose:

    <p>Fundoplication = To treat GERD Collis gastroplasty = To lengthen the esophagus Nissen's fundoplication = To provide a complete wrap Bariatric surgery = To promote weight loss</p> Signup and view all the answers

    Which investigation is primarily confirmatory for Distal Esophageal Spasm (DES)?

    <p>Manometry</p> Signup and view all the answers

    Distal Esophageal Spasm is more common in males than in females.

    <p>False</p> Signup and view all the answers

    What is the appearance described in a barium swallow for Distal Esophageal Spasm?

    <p>Rosary bead/corkscrew appearance</p> Signup and view all the answers

    Achalasia and cancer are conditions that require ________ for work up.

    <p>endoscopy</p> Signup and view all the answers

    Match the type of esophageal diverticulum with its location:

    <p>Zenker’s = Upper esophageal Para-bronchial = Mid esophageal Epiphrenic = Lower esophageal Pulsion = Causes high pressure in diverticula</p> Signup and view all the answers

    What is an effective treatment for Distal Esophageal Spasm?

    <p>POEM</p> Signup and view all the answers

    Patients with reoccurring chest pain and normal cardiac enzymes may be experiencing DES.

    <p>True</p> Signup and view all the answers

    What is the less common type of esophageal motility disorder that has a high amplitude contraction?

    <p>Distal Esophageal Spasm</p> Signup and view all the answers

    Study Notes

    Prague C & M Criteria

    • Determines the extent of disease and risk of cancer in Barrett's esophagus
    • C: Circumferential extent (how much of the esophagus is affected)
    • M: Maximum extent (the length of the affected area)

    Seattle Biopsy Protocol

    • Suggests taking biopsies every centimeter in all 4 quadrants of the esophagus when investigating Barrett's esophagus

    Barrett's Esophagus

    • Specialized intestinal metaplasia of the esophagus
    • Caused by the replacement of squamous epithelium with columnar epithelium
    • Pathognomonic findings: red velvety mucosa and goblet cells on biopsy
    • Clinical features: similar to GERD, but less responsive to treatment, and an increased risk of adenocarcinoma
    • Types: Long Segment (>3 cm), Short Segment (< 3 cm), Cardia Metaplasia/Microscopic Barrett's (identified with chromoendoscopy i.e Lugol's iodine or methylene blue)

    Initial Examination for Barrett's Esophagus

    • Repeat OGD + biopsy every 3-5 years
    • If flat columnar mucosa is found, systematic cold biopsy is performed
    • Dysplasia diagnosis requires confirmation by two independent pathologists

    Management of Barrett's Esophagus based on biopsy

    • No Dysplasia:

    • OGD every 6 months until a consecutive evidence of non-dysplastic Barrett's esophagus is confirmed

    • LGD (Low-grade dysplasia)

    • MDT (Multidisciplinary team) discussion

    • Therapeutic intervention

    • HGD (High-grade dysplasia) or Cancer:

    • Surgery: Esophagectomy

    • Endoscopic RFA (radiofrequency ablation)

    Esophageal Infections

    • Esophageal Candidiasis:

      • Seen in immunocompromised patients
      • Commonly associated with oral thrush
      • Diagnosis: Endoscopy (shaggy deposits) and Barium swallow (worm-like ulcers)
      • Treatment: Antifungals

    • CMV (Cytomegalo Virus):

      • Seen after organ transplant
      • Commonly associated with Immunosuppressants and GVHD (Graft vs host disease)
      • Appearance: Geographical/serpiginous ulcers

    • Herpes Infection:

      • Associated with Herpes labialis
      • Appearance: Small ulcers & raised margins

    Feline Esophagus

    • GERD: Affects the upper 1/3 of the esophagus
    • Eosinophilic Esophagitis: Most commonly affects the lower 1/3
    • Clinical presentation: Chronic immune mediated disease with esophageal dysfunction
    • Eosinophilia and fibrosis is caused when food antigens trigger an immune response
    • Peak age: 20-30 years
    • Investigations: Endoscopy (crepe paper mucosa, furrows, rings) & biopsy (eosinophilia: >15-20 eosinophils/HPF)

    Gastroesophageal Reflux Disease (GERD)

    • Protective factors:

    • Intra-abdominal esophagus length (3–5 cm - most significant factor)

    • Diaphragmatic Crura

    • Angle of His

    • Mucosal fold arrangement (least contribution)

    • Pathogenesis:

    • Intra-abdominal esophagus length below 2 cm

    • Lower esophageal sphincter (LES) pressure below 6 mmHg (leading to GERD and increased TLOSR - Transient Lower Esophageal Sphincter Relaxation)

    • Risk factors: Obesity and Decreased H.pylori rates

    • Clinical Features:

    • Retrosternal burn (Heartburn) - most common

    • Water brash

    • Pharyngitis/Laryngitis

    • Dental caries

    • Chronic cough and wheezing

    Investigations for GERD

    • Gold Standard: 24 hr pH monitoring
    • Endoscopy: Indication: inconclusive endoscopy or planned intervention
    • pH probe: Inserted 5 cm proximal to GE junction. Stop PPI 5-10 days before for accuracy.
    • Demeester score: > 14.72 suggests GERD

    GERD Treatment

    • Lifestyle Changes:

      • Weight reduction
      • Avoid fried, fatty, spicy food, citrus, chocolate, mint
      • Eat small, frequent meals
      • Dine 2-3 hours before sleeping

    • Medications:

      • PPIs (Proton pump inhibitors)
      • Prokinetics
      • Antacids

    Surgical Management of GERD

    • Indications:

      • Failure of medical management
      • GERD complications
      • Associated with sliding hiatal hernia
      • Patient wishes to discontinue medical management

    • Surgeries:

      • Fundoplication
      • Collis Gastroplasty

    Fundoplication

    • Principles of Surgery:

    • Restore intra-abdominal esophagus length to ≥ 3 cm

    • Tighten diaphragmatic crura around the esophagus

    • Wrap fundus around the esophagus

    • Preserve the vagus nerve

    • Re-establish the angle of His

    • Types of Fundoplication:

    • Complete wrap (Nissen's): 360° - Most common complication: Gas bloat syndrome

    • Partial wrap: - Dor: 180° anterior wrap - Toupet: 180°-270° posterior - Belsey Mark: 270° anterior

    Collis Gastroplasty

    • Indication: Esophageal shortening

    Newer Modalities for GERD

    • Polymer injection around LES to tighten sphincter:
      • High recurrence, not preferred

    Esophageal Motility Disorders

    Achalasia

    • Pathophysiology:

    • Impaired relaxation of the LES, resulting in difficulty swallowing

    • Chicago Classification of Achalasia:

    • Type 1 (Classic Achalasia): 100% failed peristalsis without POP (Pan oesophageal pressurization)

    • Type 2: 100% failed peristalsis with POP in ≥ 20% swallows

    • Type 3: ≥ 20% swallows with premature spastic contractions, failed peristalsis, and POP may be present

    • Clinical Features:

    • Classic Triad: - Dysphagia (Initially liquids > solids) - Weight Loss - Regurgitation (Earliest Feature)

    • Other Clinical Features: - Heartburn - Nocturnal coughing - Post-prandial choking

    • Complications:

    • Aspiration pneumonia (most common)

    • Lung abscess

    • Investigations:

    • Manometry: 10C → ↑ IRP (Increased resting pressure), failure of LES relaxation

    • Endoscopy: Rule out cancer

    • Barium Swallow: To visualize the esophagus

    • Achalasia - Eckardt Score:

      • Scores weight loss, dysphagia, retrosternal pain, and regurgitation (0-3 points each)

    • Management:

    • Medications:

      • Botox: Inject botulinum toxin to relax the LES (Highest rate of recurrence, repeat administration can lead to fibrosis)
      • Calcium channel blockers (CCBs) & Nitrates: Primarily for symptomatic relief

    • Balloon (Pneumatic) dilation: - Deflated balloon inserted into the esophagus and inflated. Serial dilatations offer similar efficacy to surgical myotomy. - Best responders: Age > 45 years, Females, previously undilated esophagus, Type A achalasia. - Risk of perforation: Decreases with balloon < 30 mm

    • Surgical Treatments:

      • Heller's Myotomy: Cuts the LES muscle 6 cm proximal and 2-3 cm distal to the GE junction
      • POEM (Per Oral Endoscopic Myotomy): A type of NOTES (Natural orifice transluminal endoscopic surgery) procedure. Cuts the LES muscle through the mouth

    Distal Esophageal Spasm (DES)

    • Features:

    • 5x less common than achalasia

    • Females > males

    • Motor abnormality of the lower 2/3 of the esophageal body

    • Contractions: Repetitive, simultaneous, and high amplitude (↑ DCI)

    • Investigations:

    • ECG: Rule out angina

    • Barium Swallow: Rosary bead or corkscrew appearance

    • Manometry: Confirmatory

    • Treatment:

    • POEM: Very good response

    • CCB (Ca²⁺ channel blockers) / Nitrates

    Approach to Motility Disorders

    • Differentiating factors:

    • Female: With regurgitation, nocturnal cough, dysphagia, and weight loss.

    • Patient: With chest pain similar to angina, but normal cardiac enzymes.

    • Differentials:

    • Achalasia, Cancer: Endoscopy, Manometry, Barium swallow

    • DES, Angina: ECG, Manometry, Barium swallow

    Esophageal Diverticula

    • Types:

      • Zenker's (Upper Esophageal):

        • Causes:
          • Pulsion (increased pressure)
          • Tuberculosis (TB), Histoplasmosis
        • Appearance: False diverticulum (only mucosa)
        • Rx: Large/symptomatic: Diverticulectomy

      • Mid Esophageal (Para-bronchial):

        • Appearance: True diverticulum of esophagus (traction diverticula)

      • Lower Esophageal (Epiphrenic):

        • Causes: Pulsion, False diverticulum
        • Rx: Symptomatic: Surgery

    Zenker's Diverticulum (Crico-pharyngeal achalasia)

    • Associated Risks: Increased risk of squamous cell carcinoma
    • Pathophysiology: Outpouches through Killian's dehiscence created by discordant muscle contractions, increasing pressure.
    • Clinical Features:
      • Regurgitation (Earliest symptom)
      • Halitosis (Bad oral odor)
      • Dysphagia (Difficulty swallowing)
    • Complications:
      • Aspiration pneumonia (Most common)
      • Lung abscess
    • Investigation: Barium swallow
    • Management:
      • Diverticulectomy:
        • Large (>2 cm) & symptomatic cases
        • Linear stapler > LASER
      • Cricopharyngeal myotomy: Reduces recurrence
      • Endoscopic diverticulopexy with cricopharyngeal myotomy

    Abbreviations

    • BO: Barrett's esophagus
    • HGD: High-grade dysplasia
    • LGD: Low-grade dysplasia
    • MDT: Multidisciplinary team
    • OAC: Esophageal adenocarcinoma
    • OGD: Esophagogastroduodenoscopy

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    Description

    This quiz covers crucial aspects of Barrett's Esophagus, including the Prague Criteria for determining disease extent, the Seattle Biopsy Protocol, and the pathognomonic findings associated with the condition. Test your knowledge on the clinical features, types, and examination protocols related to this esophageal disease.

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