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CHAPTER 7 Upper gastrointestinal surgery
292
Small bowel tumours
Key facts
The small bowel is a rare location for tumours. Tumours may arise from:
• Mucosa small bowel—adenocarcinoma (<5% of all GI malignancies).
• Neuroendocrine tissue, e.g. carcinoid tumours.
• Connective tissue of the bowel wall, e.g. GIST, lipoma.
• Lymphoid tissue (lymphoma).
Adenocarcinoma of small bowel
• Forty per cent of all small bowel tumours.
• Commonest in the duodenojejunal junction and proximal jejunum;
least common in the mid- and distal ileum.
• Associations:
Familial adenomatous polyposis (third commonest location of •
adenocarcinoma after colorectum and duodenum).
Peutz–Jegher’s syndrome.•
Crohn’s disease.•
Untreated longstanding coeliac disease.•
Carcinoid tumours
• Twenty-fi ve per cent of all small bowel tumours.
• Commonest in the distal small bowel; may arise in the appendix or
Meckel’s diverticulum.
• Majority are benign (non-metastatic).
• May produce enteric hormones (e.g. 5-HT, kallikrein, substance P);
hormone effects only occur when the primary is able to secrete
hormones into the systemic circulation or when hepatitic metastases
secrete into the caval circulation (carcinoid syndrome; see b p. 293).
GIST (gastrointestinal stromal tumours)
• Ten per cent of small bowel tumours.
• Arise from the mesenchymal tissues of the bowel wall and mesentery
(smooth muscle cells, fi broblasts, lipocytes).
• Previously called variously leiomyo(sarc)oma, lipo(sarco)ma.
• Tumours of myenteric plexus tissues are a variant called GANT
(gastrointestinal autonomic nerve tumours).
Primary lymphoma
• Twenty per cent of small bowel tumours.
• Arise from the lymphoid tissue of the small bowel wall.
• Almost always non-Hodgkin’s; commonest are B-cell lymphomas
arising from the mucosa-associated lymphoid tissue (MALTomas).
Clinical features
• Adenocarcinoma of small bowel. Often presents late with metastases;
may present with small bowel obstruction, recurrent abdominal pain,
or recurrent/occult GI bleeding.
• Carcinoid tumours. Commonest presentation is incidental fi nding after
appendicectomy or Meckel’s diverticulectomy.
SMALL BOWEL TUMOURS
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• Carcinoid syndrome. Rare (typifi ed by fl ushing, tachycardia, colicky
abdominal pain, diarrhoea, wheezing).
• GIST. Often present with slow-growing abdominal mass, vague
abdominal pain; may present with occult GI bleeding due to tumour
ulceration.
• Primary lymphoma. Presents with malaise, abdominal pain, diarrhoea;
may present with acute perforation or small bowel obstruction.
Diagnosis and investigations
Common diagnostic tests for all are:
• CT chest and abdomen. Identifi es primary tumour, assesses extent of
involvement of other tissues, assesses possible metastatic disease.
• CT angiography. For assessment of particularly vascular tumours or
GISTs lying close to major visceral vessels to establish resectability.
• Small bowel contrast study. Rarely required for identifi cation of primary
tumours.
• Ileoscopy. May demonstrate proximal lesions presenting with occult,
recurrent upper GI bleeding.
Complications
• Bleeding. Common with adenocarcinoma and some GISTs.
• Obstruction. Especially adenocarcinoma, GISTs, GANTs, and lymphoma.
• Perforation. Commonest with lymphoma, especially shortly after
starting chemotherapy (due to bowel wall replacement by tumour);
also occurs with adenocarcinoma.
• Malabsorption. Often with lymphoma if widespread.
Treatment
Surgery
• Primary surgical resection with macroscopic clearance of tumour for
adenocarcinoma, carcinoid, GISTs, GANTs.
Potentially curative for non-metastatic disease.•
Palliative to prevent complications if disease is metastatic.•
• Surgical resection may be indicated for primary lymphoma prior to
chemotherapy if there is a high risk of perforation of primary.
• Surgical resection of metastases is uncommon.
Medical
• Chemotherapy. Lymphoma and metastatic adencarcinoma.
• Hepatic abalation/embolization. Used to treat carcinoid metastases to
treat symptoms of carcinoid syndrome.
• Imatinib (Glivec
®
) (anti-CD113). Treatment for GISTs that are positive
for c-Kit.
293
CHAPTER 7 Upper gastrointestinal surgery
294294
Acute haematemesis
Key facts
See Table 7.2 for predicting mortality of acute upper GI bleeding.
• Incidence 1 in 1000 adults per year in UK.
• Twenty per cent require intervention because of ongoing bleeding or
rebleeding.
• Haematemesis is vomiting of blood, usually due to bleeding proximal
to the duodenojejunal junction.
• Melaena is the passage of altered blood (dark purple, pitch black, or
‘tarry’, usually due to bleeding below the gastro-oesophageal junction.
Causes and features
• Peptic (gastric or duodenal) ulceration (benign, 50%). Fresh red blood
with clots, occasionally mixed with food.
• Oesophageal varices. Copious dark red venous blood with little mixing
with food; features of portal hypertension (e.g. caput medusa).
• Oesophageal ulceration. Small volumes of bright red blood/streaks
typical.
• Oesophageal trauma (‘Mallory–Weiss tear’). Small volumes of fresh
bright blood preceded by violent or prolonged vomiting or retching.
• Vascular malformations/lesions (e.g. ‘Dieu la Foy’).
• Gastric carcinoma, leiomyoma.
• Aortoenteric fi stula. Copious bright red blood (often rapidly fatal).
Associated or predisposing conditions
• Agents affecting mucosal health—NSAIDs, steroids, alcohol, major
trauma, or massive burns.
• Agents worsening risk of bleeding—anticoagulants.
Emergency management
Resuscitation
• Establish large calibre IV access; give crystalloid fl uid up to 1000mL if
tachycardic or hypotensive. Only use O –ve blood if the patient is in
extremis; otherwise wait for cross-matched blood if transfusion needed.
• Catheterize and place on a fl uid balance chart if hypotensive.
• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), cross-
match (at least 3U if haematemesis large), clotting.
• Always consider alerting HDU/ITU if very unwell.
• Monitor pulse rate, BP, and urine output (urinary catheter).
• Insertion of a Sengstaken–Blakemore gastro-oesophageal tube may be
a life-saving resuscitation manoeuvre.
Establish a diagnosis
• Urgent OGD is the investigation of choice (at least within 24h).
May require ongoing resuscitation with anaesthetist present.•
Allows diagnosis and biopsy if appropriate.•
May allow therapeutic interventions including adrenaline injection, •
heater probe coagulation, banding of varices, clipping vessel.
ACUTE HAEMATEMESIS
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• Angiography.
Occasionally suitable for active bleeding due to invasive •
intervention done in radiology department.
May allow selective embolization in some patients with recurrent •
bleeding.
Early treatment
• Give IV PPI (e.g. omeprazole 40mg IV); stop all NSAIDs.
• Blood transfusion if large volume haematemesis or drop in Hb.
• Ensure the appropriate surgical team knows of the patient in case
surgical intervention is required.
• Known or suspected liver disease—consider FFP to correct clotting.
• Surgery may be required if:
Massive haemorrhage requiring ongoing resuscitation.•
Failed initial endoscopic treatment with ongoing bleeding.•
Rebleeding not suitable for repeated endoscopic treatment.•
Defi nitive management
Varices (see b p. 322)
• Endoscopy coagulation or banding/interventional radiology/surgery.
• IV vasopressin or analogues.
Gastric/duodenal ulcer
• Endoscopic coagulation or injection; may be repeated if suitable ulcer.
• Surgery for failed primary management or rebleeding that is unsuitable
for attempted repeat endoscopic treatment.
• Surgical options—local excision of gastric ulcer or partial gastrectomy;
under-running of duodenal ulcer.
• H. pylori eradication (triple therapy).
Gastric carcinoma
• Endoscopic treatment often not effective.
• Partial or subtotal gastrectomy (often palliative, rarely curative).
Oesophageal trauma Oral antacids.
Aortoenteric fi stula Surgery if the patient survives beyond diagnosis.
295295
Table 7.2 Rockall score for predicting mortality of acute upper GI
bleeding*
Rockall score
0 1 2
Age (y) <60 60–79 >80
Shock None HR
Comorbidities None Cardiac Hepatorenal
* Percentage mortality for scores: 0, <1%; 1, 3%; 2, 6%; 3, 11%; 4, 25%; 5, 40%; 6, >80%.
>100bpm
Systolic BP
<100mmHg
disease
Carcinoma
CHAPTER 7 Upper gastrointestinal surgery
296296
Acute upper GI perforation
Causes and features
• Duodenal ulceration.
• Gastric ulceration (usually anterior prepyloric; less commonly anterior
body).
• Gastric carcinoma.
• Traumatic, e.g. fi sh bone perforation.
• Ischaemic (usually secondary to gastric volvulus).
Symptoms
• Acute onset upper abdominal pain. Severe, constant, worse with
breathing and moving; may radiate to back or shoulders.
• Prodrome of upper abdominal pain (in benign or malignant ulceration).
• Copious vomiting and upper abdominal distension suggest volvulus.
• Prodrome of weight loss, dyspepsia, and anorexia suggests carcinoma.
Signs
• Generalized peritonism common (‘board-like’ generalized rigidity with
marked guarding and tenderness).
• Localized upper abdominal peritonism may occur, especially
with previous surgery where adhesions may act to contain the
contamination.
• Mild fever, pallor, tachycardia, and hypotension (often profound due
to autonomic reaction); typically respond quickly to modest fl uid
resuscitation.
Emergency management
Resuscitation
• Establish large calibre IV access; give crystalloid fl uid up to 1000mL if
tachycardic or hypotensive.
• Catheterize and place on a fl uid balance chart.
• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), group
and save, clotting.
Establish a diagnosis
• Erect CXR (looking for free gas). If the CXR is non-diagnostic, a lateral
decubitus abdominal fi lm can be performed, although a CT is more
common.
• CT scan if diagnosis unclear on CXR; may demonstrate presence of
gastric carcinoma.
Early treatment
• Once the diagnosis of perforation is confi rmed on clinical or
radiological grounds, the treatment is surgical unless:
The patient declines.•
The patient is considered unlikely to survive and supportive care is •
deemed more appropriate.
• Conservative management. IV PPI, limited oral intake, active
physiotherapy—has a very limited role in management; it offers an
outcome similar to that of surgery only in cases where the perforation
ACUTE UPPER GI PERFORATION
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has sealed at the time of presentation, there is no haemodynamic
instability, and there are no signs of peritonism.
Defi nitive management
Duodenal ulcer
• Sutured closure with omental patch.
• Empirical oral triple therapy for H. pylori.
• Defi nitive surgery (partial gastrectomy, vagotomy, and drainage
procedure) should only be performed for recurrent perforation, failed
fully compliant medical therapy, recidivist non-compliant patient.
Gastric ulcer
• Sutured closure with omental patch if prepyloric.
• Local excision and sutured closure if body.
Gastric carcinoma Partial gastrectomy (usually palliative).
Traumatic Sutured closure.
Volvulus with ischaemia Usually subtotal gastrectomy.
297297
CHAPTER 7 Upper gastrointestinal surgery
298298
Acute appendicitis
Causes and features
2 Commonest cause of urgent abdominal surgery and the common provisional diagnosis of all emergency surgical admissions in the UK.
• Can affect any age, but uncommon under the age of 4 and over the age
of 80. Peak age of incidence is early teens to early twenties. Three types:
Mucosal.• Mildest form usually diagnosed by pathology reporting.
Phlegmonous.• Typifi ed by slow onset and relatively slow progression.
Necrotic.• Often due to acute bacterial infection with ischaemic
necrosis; leads to perforation unless treated by surgery.
Differential diagnosis
• Children.
Non-specifi c abdominal pain, including ‘mesenteric adenitis’.•
Meckel’s diverticulitis.•
Ovarian cyst/menstrual symptoms (peri-menarchal girls).•
• Adults.
Terminal ileal pathology• . Crohn’s, Meckel’s diverticulitis,
gastroenteritis.
Retroperitoneal pathology• . Pancreatitis, renal colic.
Ovarian pathology• . Ectopic pregnancy, cyst, infection, menstrual pain.
• Older adults.
Ileocaecal pathology• . Caecal diverticulitis, caecal tumours.
Colonic pathology• . Sigmoid diverticulitis.
Ovarian pathology• . Cysts, infection, tumours.
Clinical features
• Symptoms.
Malaise, anorexia, and fever.•
Diarrhoea common and may be mistaken for acute (gastro)•
enteritis.
Abdominal pain starts centrally and localizes to the right iliac fossa •
(RIF).
Abdominal pain caused by coughing and moving.•
• Signs.
Fever, tachycardia.•
Abdominal tenderness. Peritonism suggests perforation (local or •
generalized). Often maximal over ‘McBurney’s point’ (see opposite),
but only if appendix is in conventional anatomical position.
Palpation of left iliac fossa (LIF) causes pain worse in RIF (• Rovsing’s
sign).
• Investigations may be normal and none are diagnostic or exclusive (see
b p. 299).
Complications
• Perforation (localized or generalized).
• RIF ‘appendix’ mass (usually appendicitis with densely adherent caecum
and omentum, forming a ‘mass’).
• RIF abscess (usually 2* to perforated retrocaecal appendicitis).
• Pelvic abscess (usually 2* to perforated pelvic appendicitis).
ACUTE APPENDICITIS
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Emergency management
Resuscitation
• Establish IV access.
• Catheterize and place on a fl uid balance chart only if d BP or septic.
• Request FBC (Hb, WCC), U&E (Na, K), CRP (usually i WCC, CRP).
Establish a diagnosis
• The diagnosis is a clinical one in all but exceptional cases and
investigations are usually unnecessary.
• CT is appropriate in adults, especially over the age of 65 or if the
diagnosis is unclear since the differential diagnosis is much wider and
appendicitis relatively less likely above this age.
• CT is the best investigation in suspected appendix mass or abscess.
• Ultrasound scan (pelvic) is indicated in young women of childbearing
age if ovarian pathology is suspected.
• Laparoscopy is a useful surgical diagnostic manoeuvre, allowing
diagnosis of pelvic pathology, e.g. pelvic infl ammatory disease (PID)
without a major abdominal incision.
Early treatment Avoid giving IV antibiotics without a clear diagnosis.
Defi nitive management
2 Acute appendicitis
• Open or laparoscopic appendicectomy.
• IV antibiotics on induction; continued antibiotics only indicated for
perforation.
Appendix mass or appendix abscess
• IV antibiotics (e.g. cefuroxime 750mg tds + metronidazole 500mg tds).
• If symptoms settle, delayed (interval) appendicectomy after 6 weeks.
• If symptoms fail to settle, may need acute appendicectomy.
• Appendix abscess may be amenable to CT-guided drainage.
299299
Key revision points—anatomy of appendicectomy
• Commonly retrocaecal, but may be pelvic, retroileal, or retrocolic.
• Taenia coli of caecum converge at base of appendix and aid
location, especially in diffi cult locations.
• Small mesentery with sole blood supply from appendicular artery
(a terminal branch ileocolic) which may thrombose causing gangrene.
• Principles of appendicectomy are as follows:
Muscle splitting gridiron• incision centred at McBurney’s point.
Lapararoscopic approach• increasingly popular.
Appendix is carefully located and delivered into the wound.•
The mesentery of the appendix is divided and ligated.•
The appendix is clamped and tied at the base and excised.•
Some surgeons invaginate the stump using a purse-string in the •
wall of the caecum round the base of the appendix.
CHAPTER 7 Upper gastrointestinal surgery
300300
Acute peritonitis
Defi ned as acute infl ammation in the peritoneal cavity.
Causes
May be primary (rare) or secondary (common).
• Primary peritonitis. Typically streptococcal with probable portal of
entry via bloodstream rather than intra-abdominal organs.
• Commonest causes of secondary peritonitis are:
Acute perforated appendicitis • (see b p. 298)—commonest cause of
peritonitis especially in under 45s).
Acute perforated diverticular disease • (see b p. 404)—commonest
cause in elderly.
Upper GI perforation • (see b p. 296).
Perforated tumours (colonic or gastric).•
Perforated ischaemic bowel, e.g. due to adhesions.•
Acute pancreatitis (usually infl ammatory rather than infective).•
Peritoneal dialysis-related—often atypical or cutaneous organisms •
gaining entry via contaminated dialysate bags or catheter.
Post-surgical intervention, e.g. anastomotic leak, enteric injury.•
Clinical features
There are features common to all causes. Additional features suggestive of
an underlying cause should also be sought, particularly in the history.
Symptoms
• Anorexia and fever.
• Severe generalized abdominal pain radiating to shoulders and back.
• Abdominal pain worse with movement, coughing, sneezing.
Signs
• Fever, tachycardia.
• Generalized abdominal tenderness with guarding and rigidity.
• Differential maximal tenderness may indicate the possible underlying
cause.
• Gentle palpation may allow identifi cation of an underlying mass.
Emergency management
Resuscitation
• Establish large calibre IV access.
• Catheterize and place on a fl uid balance chart.
• Send blood for FBC (Hb, WCC), U&E (Na, K), CRP, amylase, group
and save.
• ABGs if shocked or ischaemic bowel/pancreatitis suspected.
Establish a diagnosis
Most causes of acute peritonitis require surgery to correct them, but surgery is contraindicated in most cases of acute pancreatitis.
Diagnostic investigations are indicated if the patient would otherwise be
a candidate for surgical intervention.
ACUTE PERITONITIS
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• Blood investigations may show neutrophilia, i CRP.
• Raised amylase may suggest pancreatitis.
• Abdominal CT scanning is the investigation of choice for diagnosis.
It should reliably exclude acute pancreatitis and often locate the
probable source of the pathology.
• Laparoscopy is occasionally useful in patients where a formal
laparotomy should be avoided if possible.
Early treatment
IV antibiotics are appropriate without a clear diagnosis, especially if surgery
is likely (e.g. metronidazole 500mg IV tds + cefuroxime 750mg IV tds).
Defi nitive management
Acute appendicitis See b p. 298.
Upper GI perforation See b p. 296.
Perforated diverticular disease
• IV antibiotics (e.g. cefuroxime 750mg tds + metronidazole 500mg tds).
• Surgical treatment involves resection of the affected segment.
Depending on the length of time from perforation, extent of the
contamination, and extent of infl ammation in the affected segment, the
bowel may be anastomosed (primary anastomosis) or the proximal
end brought out on to the abdominal wall as an end colostomy
(‘Hartmann’s type’ resection).
Perforated tumour Surgical resection is required even if palliative. Ends of
bowel may be re-anastomosed or exteriorized as stomas, depending on
the circumstances (degree of contamination, underlying pathology).
Primary peritonitis or continuous ambulatory peritoneal dialysis
(CAPD)-related peritonitis
• A diligent and systematic search is necessary to ensure there is no
occult source of perforation as a cause.
• Primary treatment is extensive lavage of all quadrants and treatment
with appropriate antibiotics (guided by culture results from peritoneal
fl uid).
301301
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