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SU28.5-9 | Upper Gastrointestinal Surgery — PBL Case

CLINICAL SETTING

You are the surgical firm in an upper GI unit. In one clinic and ward round you meet three patients across the age spectrum, each with a problem of the upper gastrointestinal tract. Discuss each trigger as a group, in order, applying the applied anatomy and physiology of the oesophagus and stomach to reach a diagnosis and a plan. Reveal each trigger only after discussing the previous one.

Trigger 1: The young woman who cannot swallow solids or liquids

A 33-year-old teacher describes two years of difficulty swallowing that, unusually, affects both solids and liquids equally and has done so from the very beginning. She regurgitates undigested food at night, sometimes waking with a cough, but her weight is stable. A barium swallow shows a smoothly tapering 'bird-beak' narrowing at the lower oesophagus with a dilated body above it.

DISCUSSION POINTS

  • How does the pattern 'solids and liquids together from the outset, stable weight' point you toward a motility disorder rather than malignancy?
  • What is the diagnosis, what is the underlying defect, and which investigation confirms it?
  • What are the principles of treatment that address the non-relaxing lower oesophageal sphincter?
Click to reveal Trigger 2: The hungry baby who keeps vomiting (discuss previous trigger first!)

Trigger 2: The hungry baby who keeps vomiting

A 4-week-old first-born boy is brought in by anxious parents. For ten days he has vomited forcefully — the milk shoots across the room — immediately after feeds. The vomit is never green, and despite vomiting he is always hungry and eager to feed again, but he has stopped gaining weight and looks a little dry. During a test feed you see a wave moving across the upper abdomen and feel a firm, olive-sized lump under the right costal margin.

DISCUSSION POINTS

  • What is the diagnosis, and how do 'non-bilious projectile vomiting' and 'still hungry' distinguish it from other causes of infant vomiting?
  • What electrolyte and acid-base disturbance do you expect, and why does it develop?
  • Why is this a MEDICAL emergency before it is a surgical one, and what must be done before the Ramstedt pyloromyotomy?
Click to reveal Trigger 3: The older man with epigastric pain and a hard node (discuss previous trigger first!)

Trigger 3: The older man with epigastric pain and a hard node

A 61-year-old man has had months of epigastric pain, early satiety and a 7 kg weight loss. He has noticed his clothes are loose. On examination he is pale, with a hard, irregular mass in the epigastrium and a firm, enlarged node in the left supraclavicular fossa. Endoscopy shows a malignant-looking gastric ulcer; biopsy reports signet-ring cells.

DISCUSSION POINTS

  • Which examination findings indicate advanced/metastatic gastric carcinoma, and what are the eponyms (Virchow's node, Troisier's sign)?
  • Why is it taught to 'finish the abdominal examination outside the abdomen', and which extra-abdominal sites do you examine and why?
  • What do signet-ring cells and 'linitis plastica' signify, and how does staging shape whether treatment is curative or palliative?

Group Task Assignments

  • Build a comparison chart of the causes of dysphagia, separating motility disorders (achalasia) from mechanical/malignant causes, with the key history, investigation and treatment of each.
  • Map the sites of gastric carcinoma spread to the examination findings (Virchow's node, Sister Mary Joseph nodule, rectal shelf, Krukenberg tumour) and explain the route of spread for each.
  • Write a step-by-step pre-operative resuscitation plan for an infant with hypertrophic pyloric stenosis, stating the target electrolytes and why surgery waits.

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [SU28.5] What are the applied anatomy and physiology of the oesophagus (constrictions, divisions, sphincters) and how do they explain the patterns of oesophageal disease?
  2. [SU28.6] How do the clinical features, investigation and management of achalasia differ from those of oesophageal carcinoma, and how does tumour site relate to histological type?
  3. [SU28.8] How do infantile hypertrophic pyloric stenosis, peptic ulcer disease and carcinoma stomach differ in aetiology, presentation, investigation and principles of management?
  4. [SU28.9] What is the disciplined technique for examining a patient with a stomach disorder, including the extra-abdominal sites that reveal metastatic spread?