Dr.Ishara Maduka M.B.B.S. (Colombo)

Surgical conditions affecting upper GI tractOral cancerDysphagia and Oeasophageal cancerDyspepsia and GORDPeptic ulcerGastric carcinomaUpper GI bleeding

Oral cancersOral cancer is the commonest cancer in males in Sri

LankaAccounts for 2-4 % of all malignant tumours in the

western worldParticularly common in some parts of Asia where

betel chewing is common.Associated with other tumours of the aerodigestive

tractIn particular carcinoma of the :

LarynxBronchusOesophagus

85% are squamous cell carcinomas

Risk factors

Betel chewingSmokingAlcohol excessSyphilitic glossitisSideropenic dysphagia

What is a premalignant lesionA Premalignant lesions is a morphologically altered tissue that has a greater risk than normal tissue for a malignancy to occur.

What are the premalignant lesions in the oral cavityLeucoplakia

Erythroplakia

Chronic hyperplastic candidiasis

Leucoplakia Erythroplakia

Clinical features of oral cancerOral cancer produces symptoms earlyThis allows the potential for early diagnosis

and treatmentDiagnosis is usually clinicalCommonest sites with the mouth are

TongueFloor of the mouthGingiva and alveolar ridgeBuccal mucosaHard palate

Most tongue cancers occur on the lateral margin of the middle third of the tongue

Clinical features Contd…Tumours in the floor of the mouth often have

early bone involvementPresent as exophytic growths or ulcersPain is a late symptom

Investigation

Diagnosis can be confirmed by a biopsy under local anaesthetic

FNA of palpable nodes is useful to confirm lymphatic spread

CT is useful for assessing extent of nodal disease

ManagementResectionReconstructionRadiotherapyChemotherapy

Physiotherapists roleEstablish communication with the patientPreoperative assessmentPost operative careChest clearance exercisesShoulder and neck exercisesDonor flap site exerciseMobility

What’s meant by dyspahgia?Dysphagia means difficulty in swallowing.

Orynophagia means pain when swallowing.

Phagophobia means fear of swallowing.

What causes dysphagiaCauses can be divided anatomically into

mechanical and non mechanical causes

Mechanical causes Non mechanical causes

Oesophageal carcinoma

Achalasia cardia

Corrosive strictures Oesophageal spasms

Mediastinal tumours compressing oesophagus

Foreign bodies

Clinically categorized according to presentationProgressive dysphagia

Non progressive dysphagia

Oesophageal carcinoma

Achalsia cardia

Corrosive stricture

Foreign body

Mediastinal tumour compressing oesophagus

Oesophageal spasms

Oesophageal carcinoma2nd commonest cancer in males in Sri Lanka90% are squamous cell carcinomasOccur in the upper or middle third of the

oesophagus8% are adenocarcinomasOccur in the lower third of the oesophagusOverall 5 year survival is very poor and is at

best 20%

Risk factorsSquamous cell carcinoma

Alcohol / tobaccoDiet high in nitrosaminesTrace element deficiency - molybdenumVitamin deficiencies - vitamins A & CAchalasiaCoeliac DiseaseGenetic - TylosisHigh incidence in areas of Northern China and the

Caspian regionAdenocarcinoma

15% associated with Barrett's Oesophagus

Premalignant lesions in the oes.Barrett's oesophagus

Consists of columnar-lined distal oesophagusDue intestinal metaplasia of distal oesophageal mucosaCan progress to dysplasia and adenocarcinomaIts is an acquired condition due to gastro-oesophageal

refluxBile reflux appears to be an important aetiological

factor10% of patients with GORD develop Barrett's

oesophagusApproximately 1% of patients with Barrett's

oesophagus per year progress to carcinomaBarrett's oesophagus increase the risk of cancer by x30

Clinical features

Progressive dysphagia

Respiratory symptoms due to overspill or occasionally a trachea-oesophageal fistula

Weight loss

InvestigationsDiagnosis confirmed by:

Endoscopy plus biopsy / cytology

Barium swallow

TreatmentSurgicalResection and anastomosis

What is dyspepsiacharacterized by chronic or recurrent pain in

the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating. It can be accompanied by bloating, belching, nausea, or heartburn.

Conditions causing dyspepsiaGORD (gastro-oeasophageal reflux disease)Peptic ulcerCarcinoma of the stomachGall bladder stones

GORD (gastro-oeasophageal reflux disease)Occurs due to reflux of gastric contents in to

oesophagus causing symptoms of dyspepsia.

Risk factors – High fat diet, obesity, pregnancy, increased acid secretion, alcohol, smoking.

Treatment – Advice to remain seated after eating, reduced amount of fatty food, weight control, antacid drugs.

Peptic ulcer

Peptic ulcerOccur due to increased acid secretion by

parietal cells.

Risk factors – NSAIDS, H. Pylori infection

Sites of peptic ulcerationStomachDuodenum

SymptomsDyspeptic symptoms

Upper GI bleeding

Symptoms due to complications

ComplicationsGastric ulcer Duodenal ulcer

BleedingGastric carcinoma

Duodenal rupture

Gastric outlet obstruction

Duodenal stricture

Helicobacter pyloriH. pylori is gram-negative spiral

flagellated bacteriumProduces ureaseImportant in the aetiology of peptic ulcers

and gastric cancerFound in:

90% patients with duodenal ulceration70% patients with gastric ulceration60% patients with gastric cancer

Treatment of peptic ulcerAvoid NSAIDS as much as possible

Eradicate H. pylori by antibiotics and proton pump inhibitors.

Truncal vagotomy and highly selective vagotomy done in the past to reduce acid secretion

Gastrectomy in untreatable gastric carcinoma

Treat complications

Carcinoma of the stomachRisk factorsDiet low in Vitamin CBlood group APernicious anaemiaHypogammaglobulinaemiaPost gastrectomy

Precursor statesHelicobacter pylori infectionAtrophic gastritisIntestinal metaplasiaGastric dysplasiaGastric polyps

Clinical featuresDyspeptic symptoms

Upper GI bleeding

Loss of appetite

Wasting/ cachexia

ManagementSurgical – gastrectomyRadiotherapyChemotherapy

Gall bladder stonesGallstones are found in 12% men and 24%

womenPrevalence increases with advancing age10-20% become symptomatic

PathophysiologyThree types of stones are recognised

Cholesterol stones (15%)Mixed stones (80%)Pigment stones (5%)

Clinical presentation of gall stonesAcute cholecystitis

Biliary colic

Dyspepsia

Obstructive jaundice

Pancreatitis

Acute cholecystitis90% cases result from obstruction to the

cystic duct by a stoneIncreased pressure within the gallbladder

results in an acute inflammatory responseSecondary bacterial infections occurs in 20%

of cases of acute cholecystitisMost common organisms are E. coli,

Klebsiella and strep. faecalis

Clinical featuresConstant pain (usually greater than 12 hours

duration) in right upper quadrant

Fever, tachycardia

Tenderness in right upper quadrant

InvestigationsUltrasound scan

Serum bilirubin

Serum amylase

ManagementInitial management is usually conservativePatient is fasted, given intravenous fluids and

opiate analgesiaIntravenous antibiotics (e.g. second

generation cephalosporin) should be given to prevent secondary infection

80% patients improve with conservative treatment

Surgical treatment of choice is delayed cholecystectomy

CholecystectomyOpen or closed

Laparoscopic cholecystectomy is the gold standard

Questions?