Gastrointestinal Surgery: Malrotation and Appendicitis

Gastrointestinal Surgery

• Malrotation: duodenojejunal junction is to the right of the spine instead of the left.
• Gross appendicitis: enlarged appendix and engorged blood vessels on it.

Acute Appendicitis

• Symptoms: pain (referred to periumbilical area) followed by nausea and vomiting, anorexia, and then pain migrates to the RLQ (constant and intense).
• Characteristics: high WBC, rebound tenderness, and periappendiceal fluid collection on ultrasound.
• Treatment: even if normal appendix is found upon exploration, it should be removed.

Appendiceal Abscess

• Treatment: percutaneous drainage, antibiotics, and elective surgery 6 weeks later.

Achalasia

• Manometry: failure of the LES to relax during swallowing, aperistalsis of the esophageal body.
• Symptoms: progressive dysphagia for both solids and liquids (worse for liquids), regurgitation.
• Treatment: upper endoscopy and balloon dilation of the LES, laparoscopic Heller's myotomy.
• Complications: aspiration pneumonia, weight loss, esophageal CA secondary to Barrett's esophagus from food stasis.

Barium Swallow

• Bird's beak sign and dilation of the proximal esophagus.

Diffuse Esophageal Spasm (DES) and Nut-Cracker Esophagus

• Manometry: intermittent contractions with high amplitudes.
• Symptoms: intermittent dysphagia for both solids and liquids, atypical chest pain that may mimic MI.
• Treatment: calcium channel blockers (diltiazem or nifidipine) and nitrates.
• Barium swallow: corkscrew appearance.
• DES: non-peristaltic contractions.
• Nut-Cracker: peristaltic contractions.

Schatzki Ring

• Location: usually at the squamo-columnar junction.
• Symptoms: intermittent dysphagia for solids only, no pain.
• Associated with: hiatal hernia.
• Diagnosis: barium swallow and endoscopy.
• Treatment: dilation by bougie tube or through scope hydrostatic balloon.
• Patients are placed on PPI after dilation.

Esophageal Webs

• Location: more proximal, usually in the hypopharynx.
• Symptoms: same as Schatzki ring.
• Example: Plummer-Vinson syndrome.
• Diagnosis: barium swallow and endoscopy.
• Treatment: dilation.

Plummer-Vinson Syndrome

• Characteristics: esophageal web, iron-deficiency anemia, dysphagia, spoon-shaped nails, and atrophic oral and tongue mucosa.
• Especially occurs in elderly women, 10% develop squamous cell carcinoma.
• May respond to treatment of IDA.

Esophageal Stricture

• Symptoms: constant and slowly progressive dysphagia for solids then liquids.
• Causes: long history of incomplete treated reflux, prolonged NG tube placement, lye ingestion.
• Diagnosis: barium swallow.
• Treatment: dilation.

Zenker's Diverticulum

• Location: outpouching of the upper esophagus (between the thyropharyngeus and cricopharyngeus muscles).
• Symptoms: halitosis, food regurgitation, dysphagia for solids only, posterior neck mass.
• Especially occurs in elderly.
• Diagnosis: barium swallow.
• Endoscopy and NG tube are contraindicated (risk of perforation).
• Treatment: surgical resection.

Mallory Weiss Tear Syndrome

• Characteristics: partial thickness lacerations at gastroesophageal junction.
• Symptoms: painful hematemesis preceded by vomiting, no dysphagia.
• Diagnosis: history and upper endoscopy.
• Treatment: resolves spontaneously.

Barrett's Esophagus

• Characteristic: change of cell type from esophageal squamous to specialized intestinal columnar (metaplasia).
• Causes: chronic GERD (most common), achalasia.
• Diagnosis: endoscopy.
• Treatment: PPI and follow up (if high grade dysplasia, do radiofrequency ablation or esophagectomy).
• Complication: increases the risk of adenocarcinoma.

Esophageal Varices

• Characteristics: dilated veins in the esophagus.