Gastrointestinal Surgery

REFLUX

Also known as the gullet or food pipe, the oesophagus is a muscular tube that connects the mouth and throat with the stomach. A muscle known as the ‘lower oesophageal sphincter’ is responsible for contracting and relaxing to allow food to exit the oesophagus and enter the stomach. GORD (Gastro-Oesophageal Reflux Disease) is a condition that affects the lower oesophageal muscle; rendering it unable to close properly. When this happens, food from the stomach is able to go back up into the oesophagus.

When the contents from the stomach enter the oesophagus, a burning sensation may be felt in the chest cavity or up in the throat. This is called heartburn. It occurs because the stomach contains a lot of acid, which can be harmful to the lining of the oesophagus. Sometimes, you may be able to taste the fluid because it goes so far up the oesophagus (at the back of the throat). In cases like this, it is referred to as acid indigestion.

There are many persons who are affected by an occasional heartburn or acid indigestion, but it does not mean that they are suffering from GORD. It is only considered to be GORD when heartburn continually occurs more than twice in over a seven-day period. Unfortunately, GORD can be diagnosed in anyone regardless of age and gender and sadly, it can lead to additional health problems if left untreated.

Many symptoms of GORD are so common that self-diagnosis may be inaccurate. It is important to check with your physician if you begin to experience frequent heartburn or acid indigestion.

Your physician will be better at providing you with an accurate diagnosis and treatment.

Symptoms of GORD

The primary  symptoms of GORD are consistent feelings of heartburn and regurgitation of acid. Some sufferers experience GORD without  the feeling of heartburn. They may instead feel discomfort in their chest cavity, a hoarse feeling in their throat or difficulty swallowing. It is a similar sensation to having food caught in your throat. GORD can also cause a sufferer to develop a dry cough and possibly bad breath.

The most common symptoms of GORD are in fact so common that many sufferers are not even aware of their condition. It is important to seek the correct medical advice from the appropriate professional since self-diagnosis often leads to more harm than good when dealing with GORD.

Causes of GORD

  • Hiatal hernia – This occurs when the upper part of the stomach sits above the diaphragm
  • Alcohol
  • Obesity
  • Pregnancy
  • Smoking

Certain foods that relax the lower oesophageal sphincter, such as caffeine, can also be a factor.

Diagnoses of GORD

  • Your medical history
  • Response to Omeprazole
  • Barium radiograph – Ingested Barium uses xray technology to help spot abnormalities
  • Endoscopy


Treatment For GORD

Conservative treatment

  • Lifestyle modification
    • Reduce caffeine
    • Reduce alcohol
    • Extra bed ellevation
  • Medications including antacids etc.

Surgical treatment

Surgery should be considered when non-surgical lifestyle options are explored, and do not work.

Laparoscopic Fundoplication (+/- Hiatus Hernia Repair)

This type of surgical procedure is performed under general anaesthesia.

In order for this procedure to be performed, the patient has to be given general anaesthesia. It is a much more effective treatment than lifestyle changes and drugs. During the surgery, the upper part of the patient’s stomach is wrapped around the area of the oesophagus where the lower oesophageal sphincter muscles are located. This provides a kind of reinforcement or support for the muscles so they can regain their strength. Recently, they have modified this surgical procedure so a large abdominal incision is no longer necessary. This now lessens the recovery time and duration of stay in the hospital, which was typically 3-5 days. Currently, the hospital stay required is just overnight.

As the name suggests, the Laparoscopic Nissen Fundoplication is performed using a laparoscope. This specialised instrument allows the surgeon to have a clear view of what is inside the body so a safe and effective treatment can be provided. In a few cases, surgeons may not be able to perform small incisions and the traditional large incision will be made out of concern for the safety of the patient.

GALLSTONES

Gallstones tend to be around 3-4cm in size. They are hard lumps that tend to form in the gallbladder when there is an accumulation of bile salts and cholesterol deposits. Bile salts are substances produced by the liver and they are used to make bile (a chemical that helps to digest fats).

Types of gallstones and causes

  • Cholesterol stones
  • Pigment stones
  • Mixed stones – These are a combination of salts and cholesterol

Many people who have Gallstones will be diagnosed with Cholesterol Stones. About 80% of all Gallstone cases fall in this category. They are yellow-green in colour and as the name suggests, they are primarily made of cholesterol. Many Scientists and Health Professionals believe that these types of stones are formed when there is an elevated level of cholesterol present in bile. It may also result from a high content of bilirubin, an insufficient amount of bile salts or when the gallbladder does not drain itself as it should.

Pigment stones occur much less than Cholesterol Stones and their cause remains unknown. They are small and dark in colour and are more likely to form in patients who have medical conditions such as a biliary tract infection, cirrhosis and blood disorders that cause too much bilirubin to form (example- sickle cell anaemia). One thing that is certain about pigment stones is that they are composed of a lot of bilirubin.

Mixture stones, as the name indicates, This is a mixture of Cholesterol and Pigment Stones. To date, it is the most common type of Gallstone that is diagnosed in patients.

They include the following:

  • Gender – Women between the ages of 20 and 60 have double the chance of developing gallstones over their male counterparts.
  • Obesity – This is a significant risk-factor, particularly in women
  • Oestrogen – Excess oestrogen (from pregnancy, or from other means may be a factor),
  • Drugs to lower one’s cholesterol
  • Diabetes – Higher levels triglycerides can contribute to gallstones
  • Rapid weight loss – Loses weight too quickly can lead to gallstones as the liver secretes the extra cholesterol into bile

Symptoms

Some patients will not experience any symptoms that indicate the presence of a Gallstone. They are described as being asymptomatic and are called ‘silent stones’. For those who do experience symptoms, the symptoms may be very misleading as they can easily be confused with other conditions such as appendicitis, heart attack, ulcers, IBS, pancreatitis and a few others. It is therefore very important that patients refrain from self-diagnosis and visit their physician. Most times, the symptoms of Gallstones will occur during the night or after consuming foods with a lot of fat content. Some of these symptoms are:

Those who experience symptoms may do so during the night. This is more likely if a fatty meal has been eaten for dinner. Symptoms include.

  • Abdominal bloating
  • Recurring intolerance of fatty foods
  • Steady pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours
  • Pain in the back between the shoulder blades
  • Pain the right shoulder
  • Nausea or vomiting
  • Indigestion & belching

Diagnoses

An ultrasound produces comprehensive results due to its sensitivity. Other tests include:

  • CT Scan
  • ERCP: The patient swallows an endoscope–a long, flexible, lighted tube connected to a computer and TV monitor.  This tube is navigated to the lower digestive system where a dye is injected that will stain the biliary ducts temporarily. This is used to locate and remove stones in the ducts
  • Blood tests are used to highlight infection, jaundice or any other obstructions.

Cause of illness

Bile-duct blockage and infection caused by stones in the biliary tract can be a life-threatening illness. With prompt diagnosis and treatment, the outcome is usually very good.
Complications

If a duct is blocked or becomes infected, the situation is serious and urgent medical attention is required as this can be fatal. Treatment significantly improves the patient’s chances of survival. Other conditions may result from gallstones. These are.

  • Cirrhosis of the Liver
  • Cholangitis of the bile ducts

Treatment

The most common treatment for gallstones that exhibit symptoms such as those above is to remove them surgically. The most frequently used procedure is a laparoscopic cholecystectomy. During this surgical procedure, the surgeon will make a few, small incisions in the patient’s abdomen and then insert the laparoscope.

This instrument is a long tube with a camera attached. It is connected to a monitor that provides a clear view of where the camera is going. Once it reaches the area of concern, the surgeon can use the necessary tools to excise the gallbladder from other structures. In some cases, another procedure known as ERCP (Endoscopic Retrograde Cholangiopancreatography) may be done to remove gallstones in bile duct prior to the laparoscopic cholecystectomy.

HERNIA

 

The term hernia refers to any weakness or defect in the walls of the abdomen. They tend to develop at specific areas that have a natural tendency of being weak, for example, the belly button (umbilicus), the groin or where surgical incisions were made. Hernias may be diagnosed at birth or they can develop over a period of time. In some cases, the Hernia may be large enough so the patient can see a lump or bulge. This lump or bulge may contain abdominal contents such as the bowels, which have protruded because of the size of the Hernia.

Hernias develop at certain sites which have a natural tendency to be weak; the groin, umbilicus (belly button), and previous surgical incisions.

Signs and Symptoms

  • Lump in the groin area when standing/straining & disappears when reclining
  • Pain at the site of the lump, especially when lifting a heavy object
  • Swelling of the scrotum
  • Excruciating abdominal pain (if you have strangulation)
  • Nausea, vomiting, loss of appetite & pain (if intestinal obstruction occurs)

Cause of hernia

Hernias usually get larger after they begin to form. In many cases, they even end up causing a lot of discomfort. The situation may even become fatal if the hernia is obstructed or it loses its supply of blood because a loop of bowel is stuck in the area. Consequently, it is usually recommended that hernias should be corrected quickly unless there are factors that make the surgery too risky.

Treatment

Hernia repair (Surgery)

Typically, a very simple process corrects hernias surgically. The process involves making an incision in the wall of the abdomen until the weak area is found. Sutures are used as the means of repairing the weakness in the abdominal wall in addition to some other material that can provide extra support. The incision is then closed as the surgery is complete.

Recently, laparoscopic methods have been used to carry out the surgery. This process is much less invasive and is more suitable for hernias that recur.

OESOPHAGEAL CANCER

Cancers occur because there is an excess in the number of a particular cell. This abnormal growth and cell division is often fatal if untreated. Oesophageal Cancer is cancer of the oesophagus where the old cells of the oesophagus are not replaced as they normally would. Instead, the cells divide too fast and a mass or tumour forms. Sometimes the tumour is referred to as being benign because it does not invade the tissues or organs that surround it. On the other hand, the tumour can spread rapidly to other tissues and organs where it classified as malignant or cancerous.

Initially, a malignant tumour may not be very invasive. However, it may undergo a process called angiogenesis where the tumour develops its own blood vessels. Following this process, it will begin to grow much further and invade other areas of the body.

The term used to describe the process by which cancer cells break away from their original location, travel and get large at other areas of the body is metastasis. This is when cancer becomes especially dangerous and fatal. Screening for cancer may be able to prevent some of these occurrences especially if diagnosed at an early stage.

Oesophageal Cancer

Oesophageal cancer (also called cancer of the oesophagus) is a malignant tumour that grows in the lining of the oesophagus. The oesophagus (the gullet) is the tube that carries food from the mouth down into the stomach using a series of muscular movements.

Types of oesophageal cancer

Oesophageal Cancer is also called Cancer of the Oesophagus and there are two types of this cancer that are commonly diagnosed- squamous cell carcinoma and adenocarcinoma. Only 10% of patients with Oesophageal Cancer will not be diagnosed with one of those types of cancer. If the cancer cells develop in the upper region of the oesophagus, it is termed squamous cell carcinoma. The name behind this cancer is simple. The cells in that region of the oesophagus are called squamous (scaly) cells. If the cancer originates in the lower region of the oesophagus, it is called adenocarcinoma. This type of cancer tends to occur mostly in people who have a medical condition known as Barrett’s Disease.

 

INFLAMMATION

Infections and Inflammations

At any point in time, a parasite or microorganism may invade the body. When they gain entry and begin to multiply, an infection occurs. Once there is an infection, the body’s immune system will take the necessary steps to get rid of the infection. In response to the infection, inflammation may develop. In simple terms, inflammations are reactions involving the blood vessels and the nearby tissues in response to an injury or abnormal situation that is caused by a chemical, physical or biologic agent. Some people may use the terms infection and inflammation interchangeably because of their vast similarities.

APPENDICITIS

Appendicitis is the medical term for inflammation in the appendix. The appendix is a small ‘pouch-like’ organ that is found on the right side of the lower abdomen. It has virtually no function in adults and may be considered as an unnecessary organ. This is why its removal has no impact on the normal functioning of the body. Appendicitis can affect anyone at any age but most known cases affect people between the ages of 8 and 25 years old. In fact, appendicitis may be the culprit behind many cases of stomach pain that require emergency surgery.

Causes

On most occasions when appendicitis occurs, the cause is unknown. In other cases, it happens because small pieces of stool (faecaliths) are stuck in the appendix. In all cases, however, the opening that connects the appendix to the colon is blocked

Symptoms

One of the first signs of Appendicitis that you may experience is a pain in your abdomen. The pain is usually located in the centre of the abdomen or it may be just a general feeling of discomfort in the area. More often than not, the pain may begin close to the belly button then radiate downwards and to the right. The pain may not be consistently present but it usually gets more intense if you move. Other symptoms include:

  • Nausea
  • Vomiting
  • Constipation
  • Diarrhoea
  • Inability to pass gas
  • Low fever that begins after other symptoms
  • Abdominal swelling
  • Anorexia (loss of appetite)

Diagnoses

There are several ways that Appendicitis can be diagnosed. Generally, doctors use a CT scan or ultrasound to check if the appendix is inflamed. Other diseases can cause the same symptoms as Appendicitis so surgery is usually not performed until the diagnosis is certain. Some other commonly used methods for diagnosis are:

  • The doctor takes a medical history from the patient and checks their temperature
  • Blood and urine tests are performed to look for infection
  • The doctor examines the patient by pressing on the lower right part of the abdomen and sometimes by inserting a finger in the anus (back passage) in order to exclude other causes of pain
  • Women are often given a vaginal examination

PANCREATITIS

Pancreatitis

This is the inflammation of the pancreas; a gland that is responsible for producing a digestive enzyme that breaks down proteins, fats and carbohydrates. These enzymes are passed into the small intestine through the pancreatic duct and are an important facet of our digestive process. The pancreas also produces the hormones Glucagon and Insulin which are passed into the bloodstream and aid the body in converting the glucose it absorbs from food into energy.

This condition occurs when the digestive enzymes within the pancreas activate before reaching the small intestine. The result is that these enzymes begin “digesting” the pancreas which causes internal bleeding and swelling. An attack such as this might last for 48-hours.

Types Of Pancreatitis

    • Acute: This type of pancreatitis occurs suddenly lasting for short periods of time before resolving itself. Typically, this type of condition is caused by gallstones or excessive alcohol consumption
    • Chronic: This type of pancreatitis is far more destructive. The enzymes destroy all the surrounding tissues and the pancreas itself. This condition does not resolve itself and is typically caused by prolonged alcohol consumption. An elevated level of blood-iron may also be a factor. Chronic pancreatitis can also be triggered by an acute attack that has damaged the pancreatic ducts.

Either form of pancreatitis can cause severe health complications such as internal bleeding and damage to tissues. Pseudocysts may occur and may lead to infection. Should the enzymes enter the blood, the lungs, kidneys, heart or other vital organs might be compromised.

Generally, acute pancreatitis is very painful and will require a visit to the emergency room. It is relatively easy to diagnose through a routine examination of the abdominal area. The condition can be confirmed via a blood test, CT Scan or Ultrasound. The nature of the cause of the condition will dictate the course of action recommended.

Complications

Complications arising from pancreatitis include low blood pressure, failure of the kidneys, adult respiratory distress syndrome, heart failure, pancreatal cysts, fluid accumulation in the abdomen cavity and diabetes.

Treatment options

Treatment depends on the causes and severity of the condition, but may include:

Acute pancreatitis

  • Hospital care is required for all forms of pancreatitis
  • Intensive care may be required for severe cases of acute pancreatitis
  • Intravenous fluids  and fasting will be necessary until the inflammation settles down
  • An Endoscopy will be required so your doctor can physically see your pancreas
  • Surgery may be required to remove gallstones – even the gallbladder. Damaged parts of the pancreas might require surgical removal.
  • Lifestyle changes such as eliminating alcohol from one’s diet.

Chronic pancreatitis

  • Significantly lowering the fatty intake in one’s diet
  • Supplementing the digestive process by taking pancreatic tablets with meals
  • Eliminating alcohol from your diet
  • Insulin injections
  • Analgesics for pain

HEPATITIS

Hepatitis” translated to “inflammation of the liver”. Liver disease can be caused by alcohol or drug abuse, infection or chemicals.

Acute symptoms of viral hepatitis include the following; (several of these may be present.) A yellow-complexion to the face, known as jaundice, nausea, fever, lethargy, headaches, pale stool samples and dark urine. Hepatitis A, B and C are the most common variants of this disease.

Hepatitis A

This viral disease directly affects the liver’s ability to function. It is contracted via direct contact with contaminated items that have been handled by an individual infected with Hepatitis A. This can include objects, drinks or food.

Hepatitis B

This viral infection causes the liver to become inflamed. Severe illness and even death can be the outcome of Hepatitis B if symptoms go untreated. It is typically transmitted through unsafe sex or through the use of contaminated needles. You can be inoculated against this form of Hepatitis, but an infected mother can transmit the illness to her child while in the womb. Cirrhosis, or scarring, of the liver, may occur, even if the sufferer is unaware they are a carrier of the disease. It is possible to recover from Hepatitis B.

Hepatitis C

This type of Hepatitis is a blood-borne and is often transmitted through the sharing of needles. There is no vaccine to prevent Hepatitis C and no known cure for it.

COLESCYSTITIS

 

An acute condition in which the gall bladder becomes inflamed and swollen because the flow of bile into the duodenum is blocked by Gallstones; the result is biliary colic – intense pain in the upper right abdomen or between shoulders, Indigestion, especially after fatty food, and nausea with or without vomiting. Untreated, the condition can lead to jaundice and occasionally, if gall bladder bursts, to peritonitis. If the site of pain is as described above, and pain persists for more than 3 hours, consult your doctor.

Causes

    • Gallstones
    • Ischemia (decrease blood supply to gallbladder)
    • Secondary Infections

Symptoms

  • Epigastric and/or right upper quadrant pain
    • Often starts after a large fatty meal
    • Sudden, steady pain in the middle or right upper abdomen
    • Vomiting
    • Fever

Diagnoses

    • Medical History
    • Clinical examination
    • Abdominal X-ray
    • Ultrasound

Cause of illness

If untreated cholecystitis may lead to

    • Gangrene in the gallbladder may occur. This is a severe infection with the destruction of tissue. Diabetics and the elderly are at highest risk.
    • Cholangitis – an infection that occurs in common bile duct outside the gallbladder

Treatment

    • Bowel rest (no food or drink)
    • Intravenous fluid/feeding
    • Antibiotics to combat Infections. I.V. antibiotics may be used
    • Pain medications
    • Laparoscopic Cholecystectomy, Surgical removal of the gallbladder 2-3 days after cholecystitis for most patients

What you should do?

Go to the Hospital emergency or call the local emergency number if you have symptoms that may indicate peritonitis, as it is a medical emergency.

OESOPHAGITIS

Alternative names: Indigestion and Heartburn

The term ‘indigestion’ is a layman’s term and is used to cover the symptoms of a few different medical conditions. Medical conditions that are often described as ‘indigestion’ and which have ‘indigestion’ as a symptom are:

  • Heartburn (gastro-oesophageal reflux)
  • Ulcers
  • Non-ulcer dyspepsia (when you have symptoms of an ulcer but no sign of ulcer on investigation)
  • Food intolerance, e.g. lactose intolerance
  • Bloating and flatulence
  • Aerophagia (swallowing excessive amounts of air)

Many people with indigestion suffer in silence, sometimes for years, receiving little or no medical treatment apart from over-the-counter antacids. While these are very effective in medicating heartburn, there are now many more medications available, which can provide perfect symptomatic relief.

There is also a greater awareness that acid reflux which causes the heartburn may damage the lining of the oesophagus and increase the potential for serious health problems due to the process of chronic inflammation. It is becoming increasingly important to treat your symptom of heartburn less casually and discuss the prospects for treatment with your doctor.

PERITONITIS

Peritonitis is an inflammation of the peritoneum, which is the membrane that lines the wall of the abdomen and covers the abdominal organs.

Causes, incidence, and risk factors

Types of peritonitis include:

  • Spontaneous Peritonitis – an infection that occurs as a complication of ascites (a collection of fluid in the peritoneal cavity), which is usually related to liver or kidney failure
  • Secondary Peritonitis – caused by another condition, most commonly the spread of an infection from the digestive organs or bowels
  • Dialysis associated Peritonitis – this is an acute or chronic inflammation (irritation and swelling) of the peritoneum (lining of the abdominal cavity) that occurs in people receiving peritoneal dialysis

Intra-abdominal abscess (abdominal abscess). This condition involves a collection of pus in the abdomen and may cause peritonitis. Before peritonitis develops, it can still cause symptoms that are similar or identical to peritonitis.

An intra-abdominal abscess may arise following:

  • Localisation of peritonitis
  • Gastrointestinal perforation
  • Anastomotic leak
  • Haematogenous (bloodstream) spread
  • They develop in sites of gravitational drainage
  • Pelvis
  • Subhepatic spaces
  • Subphrenic spaces
  • Paracolic gutters

Symptoms

  • Nausea
  • Vomiting
  • Abdominal pain, which increases on movement
  • Abdominal tenderness
  • Abdominal distension
  • Fever
  • Low urine output
  • Point tenderness
  • Thirst
  • Fluid in the abdomen
  • Constipation
  • Inability to pass faeces/gas
  • Signs of shock in extreme cases

Diagnoses

  • Physical examination and medical history
  • Blood tests including blood culture and X-rays or CT scans may be ordered
  • Peritoneal fluid analysis( paracentesis) & culture

Treatment

The cause must be identified and treated promptly.

Treatment typically involves fluid infusion to control shock, surgery to drain the peritoneal cavity and repair the cause, and antibiotics to deal with the infection. In cases associated with peritoneal dialysis, antibiotics may be infused through the dialysis catheter, but if the infection is severe, the catheter itself must often be removed.

Treatment typically involves surgery and antibiotics. In cases associated with peritoneal dialysis, antibiotics may be infused through the dialysis catheter, but if the infection is severe, the catheter itself must often be removed.

Course of illness

The outcome is often good with treatment but can be poor without treatment. Sometimes the outcome is poor even with prompt and adequate treatment.

Complications

Peritonitis can be life-threatening and cause a number of different complications, depending on the type.
Complications may include:

  • Peritonitis stops the movement of bowel contents (peristalsis), which can block the bowel (paralytic ileus).
  • Septic shock – Fluid from the blood accumulates in the abdominal cavity and the loss of fluid from the circulation may also cause shock.
  • Abscess
  • Intraperitoneal adhesions

What you should do?

Go to the Hospital emergency or call the local emergency number (such as 000, for Australia) if you have symptoms that may indicate peritonitis, as it is a medical emergency.