Hyposplenism/Splenectomy
Definition & DDx
Causes hyposplenism
- Splenectomy
- Sickl-cell
- Coeliac disease/dermatitis Causes hypersplenism
herpetiformis - Infectious mononucleosis
- Graves’ disease - Non-Hodgkin’s lymphoma
- SLE - Acute myeloid leukaemia
- Amyloid
Anatomy & Risks
Indications
- Trauma
- Spontaneous rupture
o EBV
- Hypersplenism
o Hereditary spherocytosis/elliptocytosis/etc.
- Malignancy
o Lymphoma/leukaemia
- Splenic cysts/hydatid cysts/splenic abscesses
Symptoms & Complications
Complications
- Haemorrhage
- Pancreatic fistula (from iatrogenic damage)
- Thrombocytosis
o Prophylactic aspirin
- Encapsulated bacterial infection
o Strep. Pneumoniae, H. influenzae, N/ meningitidis
Investigations
Post-op changes
- Rise in platelets
- Howell-Jolly bodies/Pappenheimer bodies/siderocytes
o On blood film
Treatment/Management & Side effects
Vaccination – done 2wks pre-op
- Hib, meningitisAC
- Annual flu
- Pneumococcal every 5yrs
Abx prophylaxis
- PenV
- Normally continued 2yrs post-op
- Can be much longer
,Oesophageal Cancer
Definition & DDx
DDx
- GORD
- Achalasia
o Dysphagia for solids and liquids from the start
o Regurgitation of undigested food
o Chest pain
- Peptic stricture
- Zenker diverticulum
o Halitosis
o Aspiration pneumonia
o Regurgitation of undigested food
- Neurological conditions
o MND
o Myasthenia gravis
- Oesophagitis
o Candidiasis
o May be underlying immunosuppression e.g., HIV
Anatomy & Risks
Adenocarcinoma - lower 1/3rd near gastric Squamous cell cancer – upper 2/3rds
junction oesophagus
- GORD - Smoking
- Barrett’s - Alcohol
- Smoking - Achalasia
- Obesity - Plummer-Vinson syndrome
- Diets rich in nitrosamines
Symptoms & Complications
- Dysphagia (progressive)
- Anorexia/weight loss 2ww endoscopy
- Vomiting - Dysphagia
- Odynophagia - ≥55yo + weight loss plus any of:
- Hoarseness (local invasion of o Upper abdo pain
recurrent laryngeal nerve) o Reflux
- Melaena o Dyspepsia
- Cough
Investigations Treatment/Management & Side effects
- UGI endoscopy - Operable disease by surgical
- Barium swallow – irregular resection
narrowing o Challenge = anastomotic
- Endoscopic ultrasound for regional leak
staging o Intrathoracic anastomosis
o Useful for resection leading to mediastinitis
decision - Adjuvant chemotherapy
- CT TAP for initial staging
,Gastric Cancer
Definition & DDx
Cancer of older people with male predominance
Anatomy & Risks
- H. pylori
o Triggers inflammation of mucosa
o Leading to atrophy and intestinal metaplasia
- Atrophic gastritis
- Diet
o Salt / nitrates (smoked foods)
- Smoking
- Blood group A
- High alcohol intake (>6 units/day)
- Adenomatous polyps
Symptoms & Complications
- Abdo pain
o Typically vague, epigastric pain
o May present as dyspepsia
- Weight loss/anorexia
- N&V
- Dysphagia
o Particularly if proximal stomach
- In lymphatic spread
o L supraclavicular LN
o Periumbilical nodule
- Melaena/haematemesis rare
Investigations
- OGD with biopsy 2ww
o Signet ring cells seen
o Higher numbers = worse prognosis
- Staging CT
Treatment/Management & Side effects
Surgical depending on extent and side
- Endoscopic mucosal resection
- Partial/total gastrectomy
Chemotherapy
, Pancreatic Cancer
Definition & DDx
Malignant neoplasm – most commonly adenocarcinoma of the head
Anatomy & Risks
- Increasing age
- Smoking
- Diabetes
- Chronic pancreatitis
o Alcohol not an independent risk factor
- Hereditary non-polyposis colorectal carcinoma
- MEN
- BRCA2
- KRAS gene mutation
- FHx
- Obesity
Symptoms & Complications
- Painless jaundice
o Pale stool (loss of exocrine function)
o Dark urine, pruritus
o Cholestatic LFTs
- Abdominal masses
o Hepatomegaly (mets)
o Gallbladder – unlikely to be gallstones if painless jaundice present
▪ ‘Courvoisier’s sign’
o Epigastric mass (least common)
- Non-specific
o Anorexia/weight loss
o Epigastric pain
- Atypical back pain
- Loss of endocrine function (DM)
Investigations
2ww = s≥40 with jaundice
Other:
- USS
- HR CT = gold standard
o May show ‘double duct’ sign
o Presence of simultaneous dilatation of common bile and pancreatic ducts
Treatment/Management & Side effects
- <20% suitable for surgery at diagnosis
o No evidence of SMA or coeliac artery involvement
o No distant metastases
- ERCP with stenting for palliation
Definition & DDx
Causes hyposplenism
- Splenectomy
- Sickl-cell
- Coeliac disease/dermatitis Causes hypersplenism
herpetiformis - Infectious mononucleosis
- Graves’ disease - Non-Hodgkin’s lymphoma
- SLE - Acute myeloid leukaemia
- Amyloid
Anatomy & Risks
Indications
- Trauma
- Spontaneous rupture
o EBV
- Hypersplenism
o Hereditary spherocytosis/elliptocytosis/etc.
- Malignancy
o Lymphoma/leukaemia
- Splenic cysts/hydatid cysts/splenic abscesses
Symptoms & Complications
Complications
- Haemorrhage
- Pancreatic fistula (from iatrogenic damage)
- Thrombocytosis
o Prophylactic aspirin
- Encapsulated bacterial infection
o Strep. Pneumoniae, H. influenzae, N/ meningitidis
Investigations
Post-op changes
- Rise in platelets
- Howell-Jolly bodies/Pappenheimer bodies/siderocytes
o On blood film
Treatment/Management & Side effects
Vaccination – done 2wks pre-op
- Hib, meningitisAC
- Annual flu
- Pneumococcal every 5yrs
Abx prophylaxis
- PenV
- Normally continued 2yrs post-op
- Can be much longer
,Oesophageal Cancer
Definition & DDx
DDx
- GORD
- Achalasia
o Dysphagia for solids and liquids from the start
o Regurgitation of undigested food
o Chest pain
- Peptic stricture
- Zenker diverticulum
o Halitosis
o Aspiration pneumonia
o Regurgitation of undigested food
- Neurological conditions
o MND
o Myasthenia gravis
- Oesophagitis
o Candidiasis
o May be underlying immunosuppression e.g., HIV
Anatomy & Risks
Adenocarcinoma - lower 1/3rd near gastric Squamous cell cancer – upper 2/3rds
junction oesophagus
- GORD - Smoking
- Barrett’s - Alcohol
- Smoking - Achalasia
- Obesity - Plummer-Vinson syndrome
- Diets rich in nitrosamines
Symptoms & Complications
- Dysphagia (progressive)
- Anorexia/weight loss 2ww endoscopy
- Vomiting - Dysphagia
- Odynophagia - ≥55yo + weight loss plus any of:
- Hoarseness (local invasion of o Upper abdo pain
recurrent laryngeal nerve) o Reflux
- Melaena o Dyspepsia
- Cough
Investigations Treatment/Management & Side effects
- UGI endoscopy - Operable disease by surgical
- Barium swallow – irregular resection
narrowing o Challenge = anastomotic
- Endoscopic ultrasound for regional leak
staging o Intrathoracic anastomosis
o Useful for resection leading to mediastinitis
decision - Adjuvant chemotherapy
- CT TAP for initial staging
,Gastric Cancer
Definition & DDx
Cancer of older people with male predominance
Anatomy & Risks
- H. pylori
o Triggers inflammation of mucosa
o Leading to atrophy and intestinal metaplasia
- Atrophic gastritis
- Diet
o Salt / nitrates (smoked foods)
- Smoking
- Blood group A
- High alcohol intake (>6 units/day)
- Adenomatous polyps
Symptoms & Complications
- Abdo pain
o Typically vague, epigastric pain
o May present as dyspepsia
- Weight loss/anorexia
- N&V
- Dysphagia
o Particularly if proximal stomach
- In lymphatic spread
o L supraclavicular LN
o Periumbilical nodule
- Melaena/haematemesis rare
Investigations
- OGD with biopsy 2ww
o Signet ring cells seen
o Higher numbers = worse prognosis
- Staging CT
Treatment/Management & Side effects
Surgical depending on extent and side
- Endoscopic mucosal resection
- Partial/total gastrectomy
Chemotherapy
, Pancreatic Cancer
Definition & DDx
Malignant neoplasm – most commonly adenocarcinoma of the head
Anatomy & Risks
- Increasing age
- Smoking
- Diabetes
- Chronic pancreatitis
o Alcohol not an independent risk factor
- Hereditary non-polyposis colorectal carcinoma
- MEN
- BRCA2
- KRAS gene mutation
- FHx
- Obesity
Symptoms & Complications
- Painless jaundice
o Pale stool (loss of exocrine function)
o Dark urine, pruritus
o Cholestatic LFTs
- Abdominal masses
o Hepatomegaly (mets)
o Gallbladder – unlikely to be gallstones if painless jaundice present
▪ ‘Courvoisier’s sign’
o Epigastric mass (least common)
- Non-specific
o Anorexia/weight loss
o Epigastric pain
- Atypical back pain
- Loss of endocrine function (DM)
Investigations
2ww = s≥40 with jaundice
Other:
- USS
- HR CT = gold standard
o May show ‘double duct’ sign
o Presence of simultaneous dilatation of common bile and pancreatic ducts
Treatment/Management & Side effects
- <20% suitable for surgery at diagnosis
o No evidence of SMA or coeliac artery involvement
o No distant metastases
- ERCP with stenting for palliation
