GIT Surgery Made Simple

1. Esophagus: Disorders and Management

Esophagus Anatomy: Length: 25 cm long, a muscular tube.

1. Infections and Esophagitis:

1. Candida Esophagitis:
   • History: Common in immunocompromised patients.
   • Symptoms: Painful swallowing, possible dysphagia.
   • Endoscopy Findings: White plaques adhering to the mucosa.
   • Cause: Candida albicans.
2. Cytomegalovirus (CMV) Esophagitis:
   • In Older or Immunocompromised Patients: More common in these individuals.
   • Diagnosis: Intracytoplasmic inclusion bodies in esophageal cells (diagnostic for CMV).
   • Treatment: Ganciclovir.
3. Herpes Simplex Virus (HSV) Esophagitis:
   • Treatment: Acyclovir.

2. Achalasia and Esophageal Spasm:

Symptoms:

• Dysphagia: Difficulty swallowing.
• Poor Appetite: Often associated with difficulty swallowing.
• Sensation of Early Fullness: Feeling full quickly while eating.
• Corkscrew-shaped Esophagus: Indicative of esophageal spasm.
• Bird Beak Appearance: Seen in achalasia cardia, where the lower esophageal sphincter does not relax properly, leading to a “bird beak” appearance on imaging.

Diagnosis:

• Manometry: Gold standard for diagnosing achalasia, which measures the pressure in the esophagus and lower esophageal sphincter.

Treatment for Achalasia:

1. Calcium Channel Blockers (CCB): To relax the smooth muscles of the esophagus.
2. Nitric Oxide: Can help in relaxing the lower esophageal sphincter.
3. Botox Injections: Used to relax the lower esophageal sphincter, providing symptom relief.
4. Definitive Treatment:
   • Heller Myotomy: Surgical procedure to cut the muscle at the lower esophageal sphincter, allowing food to pass more easily.

3. Barrett’s Esophagus

Intestinal Metaplasia:

• Stratified squamous epithelium changes to simple columnar epithelium.
• Can progress to adenocarcinoma.

Cancer Types:

• 1/3 of cases are adenocarcinoma.
• 2/3 of cases are squamous cell carcinoma.

4. Plummer-Vinson Syndrome

• Clinical Features:
  • Dysphagia.
  • Iron deficiency.
  • Esophageal web.

Bisphosphonates

• Use: Commonly used in rheumatology.
• Cause of Esophagitis: Can lead to esophagitis as a side effect.

2. Stomach

• Shape: J-shaped
• Function: Storage of food

Cell Types:

1. Parietal Cell:
   • Secretes HCl (Hydrochloric Acid).
   • Important for Vitamin B12 absorption.
2. Chief Cell:
   • Secretes Pepsinogen, which is converted into pepsin for protein digestion.

Types of Ulcers:

1. Burn Culling Ulcer:
   • Associated with burns and trauma.
2. ICP Raised Cushing Ulcer:
   • Seen in patients with increased intracranial pressure (ICP).
3. Gastric Ulcer:
   • Typically affects the left gastric artery.
4. Duodenal Ulcer:
   • Typically affects the gastroduodenal artery.

2. H. Pylori Treatment

• First-line treatment:
  • PPI (Proton Pump Inhibitor)
  • Clarithromycin
  • Amoxicillin or Flagyl

Diagnosis of H. Pylori Infection:

• Blood test
• Stool test
• Urea breath test

3. Gastric Ulcer and Complications:

• History of Rheumatoid Arthritis:
  • Long-term NSAID use can lead to gastric ulcer and epigastric pain.
  • Biopsy of the ulcer may be required to rule out gastric carcinoma.

4. Cancer Spread and Lymph Node Involvement:

• Virchow’s Node:
  • Left supraclavicular lymph node, often associated with gastric cancer.
• Sister Mary Joseph Nodule:
  • A palpable nodule in the umbilicus is often indicative of abdominal malignancy.
• Krukenberg Tumor:
  • Metastatic gastric cancer to the ovaries.

5. Irritable Bowel Syndrome (IBS)

Gender Distribution:

• Females > Males
• Commonly affects individuals aged 20-40 years.

Clinical Features:

• Abdominal bloating, often relieved after defecation.

Management:

• Diet Changes:
  • Increase intake of vegetables and fluids.
• Laxatives: Used for constipation-type IBS.

Feature	Crohn’s Disease	Ulcerative Colitis (UC)
Affected Area	Mouth to anus (except anus and rectum)	Rectum (extends proximally in continuous pattern)
Granuloma	Present	Absent
Submucosa	Affected (transmural involvement)	Not affected (only mucosa and submucosa)
Fistula	Common	Rare
Transmural Involvement	Present (affects all layers of the bowel wall)	Absent
Cobblestone Appearance	Present (due to deep ulcerations and inflammation)	Absent
Bleeding	Rare	Common (especially in active disease)
Skip Lesions	Present (intermittent areas of affected and unaffected bowel)	Absent
Abscess	May form due to transmural inflammation and fistula formation	Common (involved mucosal area)
Cancer Risk	Increased risk for small bowel and colon cancer	Increased risk for colon cancer
Diarrhea	Non-bloody	Bloody diarrhea (especially in active flare-ups)
Pattern of Inflammation	Discontinuous (patchy)	Continuous (starting from the rectum and extending proximally)

6. Carcinoid Tumor

A tumor that results in increased serotonin levels in the body.

Common Locations:

• Ileum
• Appendix

Clinical Features:

• Facial flushing: A common symptom due to serotonin release.
• Chronic diarrhea: Caused by serotonin’s effect on the gastrointestinal tract.
• Weight loss: Often seen in patients with carcinoid syndrome.

Diagnosis:

• 5-HIAA (5-Hydroxyindoleacetic acid) in urine
• CT Scan.

Treatment:

• Octreotide.
• Surgery.

Tricuspid Valve Involvement:

• Seen in IV drug abusers with carcinoid tumors. The increased serotonin can cause tricuspid valve fibrosis, leading to tricuspid regurgitation.

7. Carcinoid Syndrome

Clinical Presentation:

• Dementia
• Dermatitis
• Diarrhea

Biochemical Imbalance:

• Increased tryptophan (which is converted to serotonin).
• Increased serotonin levels.
• Decreased niacin (Vitamin B3) due to tryptophan being used for serotonin production, leading to niacin deficiency.

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8. Gastrointestinal Symptoms: Diarrhea and Abdominal Bloating

1. Lactose Intolerance:

• Cause: Inability to digest lactose, typically due to lactase deficiency.
• Symptoms: Diarrhea and bloating after consuming dairy products.
• Management:
  • Lactose-free diet.
  • Use of lactulose (sometimes as a laxative).
  • Avoidance of dairy products.

2. Celiac Disease:

• Cause: An autoimmune disorder triggered by wheat-containing foods, specifically gluten.
• Symptoms: Diarrhea, abdominal bloating, and malabsorption.
• Diagnostic Test: Anti-endomysial antibody test.
• Skin Manifestation: Dermatitis herpetiformis.
• Treatment:
  • Dapsone (used for managing dermatitis herpetiformis).
  • A gluten-free diet to manage the disease.
• Complication: Iron deficiency anemia due to malabsorption.

Check your NRE Step 1 result after completing the exam.