Bedah_Digestif_Kuliah_ .pptx

Bedah Digestif Kuliah

1. BEDAH SALURAN PENCERNAAN SUB BAGIAN BEDAH DIGESTIF FK UNS / RSUD DR MOEWARDI SURAKARTA

2. A muscular tube, begins at the pharynx, travel through the thorax (post mediastinum), empties into the cardia of the stomach Superior 3 rd  striated muscle only Middle 3 rd  striated + smooth muscle Inferior 3 rd  smooth muscle only Two sphincters  UES (upper esofageal sphincter), LES (lower esofageal sphincter) ESOFAGUS

3. Dysphagia  difficulty swallowing, caused by obstruction Odynophagia  pain on swallowing, may / may not accompany dysphagia Types Mechanical (difficulty swallowing solids more than liquids) Foreign bodies Inflammation Strictures Neoplasm Extrinsic compression Neuromuscular (difficulty swallowing both solids and liquids) Tongue paralysis Lesions of cranial nerves IX and/or X Disorders of neuromuscular junction Disorders of esofageal smooth muscle Esofagus ------ dysphagia

4. Results of a primary or secondary derangement of the myenteric plexus 3 mechanisms : non peristaltic contractions, incomplete relaxation of the LES, increasing resting tone of the LES Signs & symptoms  dysphagia, regurgitation, severe halitosis Dx  Lateral upright CXR Barium swallow Esofageal motility study Esofagoscopy Treatment  Medical (drugs that relax the LES) : nitrates, ca channel blockers Surgical : Esofagomyotomy , Endoscopy dilatations ESOFAGUS ------ ACHALASIA

5. Spasm in the distal two thirds of the esofagus , caused by uncoordinated large amplitude contractions of smooth muscle Sings & symptoms : dysphagia, chest pain, no regurgitation Dx  Barium swallow (“corkscrew”, ripples & sacculations due to uncoordinated contractions) Esofageal manometry Esofagoscopy Treatment  Nitrates, Ca channel blockers Surgical treatment only in severe pain or dysphagia ESOFAGUS ------ DIFFUSE ESOFAGEAL SPASM

6. Result of portal hypertension, most commonly due to alcoholic cirrhosis Elevated portal system pressure  venous anastomosis become dilated secondary to retrograde flow from the portal to systemic circulations Most clinically sites : esofageal varices , caput medusae , hemorrhoids Signs & Symptoms : pailess , massieve hemorrhage, can progress to hypovolemic shock Treatment  Ceases spontaneously in 50% cases, Risk of rebleeding >> Medical (decreased portal blood flow)  vasopressin, octreotide , somatostatin , beta blocker Esofagus ------ esofageal varices

7. For ruptured varices  Volume replacement Nasogastric suction Endoscopic sclerotherapy Endoscopic band ligation Ballon tamponade TIPS ( transjugular intrahepatic portocaval shunt) Intraoperative placement of a portocaval shunt Liver transplant Esofagus ------ esofageal varices

8. Iatrogenic or pathologic trauma to the esofagus 50% mortality Etiology  Iatrogenic Boerhaave syndrome (full thickness tear) Mallory-Weiss syndrome (partial thickness tear) Foreign bodies ingestion Signs & Symptoms : severe – constant pain, dysphagia, dyspnea, subcutaneous emphysema, mediastinal emphysema Esofagus ------ esofageal perforation - rupture

9. Dx  CXR (left sided leural effusion, mediastinal / subcutaneous emphysema) Esofagogram – water soluble contrast Endoscopy, CT Scan, Thoracocentesis Treatments  Surgical repair of full thickness tears 90% of partial thickness tears resolve with NG decompression – gastric lavage Esofageal ------ esofageal perforation - rupture

10. 1-2% of all cancer related deaths 6 new cases per 100,000 population, mostly in over 50 y.o Males dominant (3 times more frequently than women) Risk factors : alcohol, tobacco, nitrate/nitrosamine diets, esofageal disorders (achalasia, chronic esofagitis , Plummer-Vinson syndrome) Signs & Symptoms : Gradual dysphagia Anorexia Weight loss, cachectic, supraclacicular lymphadenopathy Esofagus ------ esofageal carcinoma

11. Dx  Barium swallow CXR ( hilar lymphadenopathy) Endoscopy CT Scan of the thorax Treatment  < 40% will be candidates for curative surgery Radiation (temporary relief from obstruction) Endoscopic laser tx , endoscopic dilatation-stent placement Gastrostomy / Jejunostomy Esofagus ------ esofageal carcinoma

12. Outpouching of the esofageal mucosa that protudes through a defect in the tunica muscularis True diverticulum  involving all three layers False diverticulum  involving only the mucosa and sub mucosa Three types : Pharyngoesofageal ( Zenker’s ) pulsion , false diverticula Epiphrenic Mid esofageal  traction, true diverticula Esofagus ------ esofageal diverticula

13. Signs & Symptomps : dysphagia, halitosis, regurgitation, choking, aspiration (mostly found in Zenker’s ) Dx : Barium Swallow Treatment : Zenker’s  cervical esofagomyotomy + resection of diverticulum M id esofageal  Resection Epiphrenic  resection + esofagomyotomy via a left thoracotomy approach Esofagus ------ esofageal diverticula

14. Local, stenotic regions within the lumen of the esofagus , resulting from inflamation / neoplasm Risk factors : long standing GERD, radiation/infectious/corrosive esofagitis , post sclerotherapy Signs & Symptoms : progressive dysphagia Dx  Barium swallow Esofagoscopy (stricture must be evaluated for malignancy) Treatment  Endoscopy dilatation Surgery ( esofageal inter position) Esofagus ------ esofageal stricture

15. Consists of duodenal ulcers (DUs) and gastric ulcers (GUs) Pathophysiology Parietal cells  secrete HCl , bicarbonate  protective gastric mucous gel Parietal cells are stimulated by gastrin, the vagus nerve, histamine Gastrin release is stimulated by gastrin- realising peptide, inhibited by somatostatin Histamine reseptors  stimulate HCl secretion Gel thickness is increased by prostaglandin E (PGE), and reduced by steroid, NSAIDs Complication Bleeding Perforation Gastric outlet obstruction (GOO) GASTER ------ PEPTIC ULCER DISEASE (PUD)

16. Increased acid production Etiology : H. pylori, NSAIDs, steroid, Zolinger -Ellison syndrome Symptoms : Burning epigastric pain (with an empty stomach, relieved within 30 min by foods) Nighttime awakening when stomach empties Nausea, vomiting Diagnosis : Endoscopy + Biopsy Serology (Anti H. pylori IgG ) Urease breath test Serum gastrin level ( pahognomonic for ZE syndrome) Gaster ------ duodenal ulcer

17. Treatment (Medical) Discontinue NSAIDs, steroid, smoking PPI  90% cure rate after 4 weeks Eradication of H. pylori  PPI, claritromycin , amoxycillin /metronidazole H2 blockers  85-95% cure rate after 8 weeks Antacids Treatment (Surgical) Elective surgery  rare Surgery  when ulcer is refractrory to 12 weeks of medical treatment, hemorrhage, obstruction, perforation is present Procedure of choice  highly selective vagotomy Gaster ------ duodenal ulcer

18. Decreased protection against acid : normal or low acid production Causes : NSAIDs, steroids, H. pylori Classification Type I  ulcer in lesser curvature at incisura angularis Type II  simultaneous gastric and duodenal ulcer Type III  prepyloric ulcer Type IV  ulcer in gastric cardia Symptoms : Burning epigastric pain with anything in the stomach (pain is worst after food) Anorexia, weight loss Vomiting Gaster ------ gastric ulcer (GU)

19. Dx  Endoscopy + Biopsy (associated with gastric cancer) Treatment Medical options same as for DU Surgical options : Anthrectomy  type I, type II Highly selective vagotomy  type III Sub total gastrectomy  type IV Gaster ------ gastric ulcer (GU)

20. Highest incidence in > 60 y.o 95% of malignant gastric cancer Male predominance Leading cause of cancer related death in Japan Risk factors Familial adenomatous polyposis Chronic antrophic gastritis H. Pylori infection Pernicious anemia Diets (high in nitrares ) Cigarette smoking Gaster ------ malignant tumors – adenocarcinoma

21. Symptoms : Mostly asymptomatic Anorexia, weight loss, nausea, vomiting, dysphagia, melena, hematemesis Pain is constant, non radiating, exacerbated by food Dx : Upper GI Endoscopy Upper GI series (double contrast) Abdominal CT Scan Endoscopy US Gaster ------ malignant tumors adenocarcinoma

22. Treatment  Gastrectomy (depend on location) Chemotherapy (sometimes used palliatively ) Prognosis  depends on stage of disease, overall 5 years survival 5-15% Other types of malignant tumors  Gastric Lymphoma, Gastric Sarcoma Gaster ------ malignant tumors adenocarcinoma