Q: Make an exam oriented notes crisp and important points asked in exam with BULLETS and TABLE format from the given source A: Here are crisp, exam-oriented notes from all the provided sources: --- 📋 EXAM NOTES: OESOPHAGUS, INTESTINAL OBSTRUCTION & PRURITUS ANI --- 🔴 REFLUX OESOPHAGITIS GORD Key Definitions - Gastro-oesophageal reflux = regurgitation of gastric contents into oesophagus - Normal reflux: gastric juice enters oesophagus only 20 min/day erect posture, waking hours - Pathological reflux: occurs when stomach is not distended - GORD = caused by loss of LOS Lower Oesophageal Sphincter competence Mechanism of LOS Competence - Governed by: i Basal LOS pressure, ii Overall LOS length, iii Length exposed to intra-abdominal pressure - TLOSRs Transient LOS Relaxations = main cause of physiological reflux; increased TLOSRs = early GORD - Key researchers: Dent TLOSRs & DeMeester LOS competence Causes of GORD Aetiology Cause Details ------ Sliding hiatus hernia Variable association; reflux oesophagitis in 40-50% referred to hospital Systemic collagen diseases Scleroderma = most common; loss of LOS tone + peristalsis Impaired gastric outlet emptying Increases reflux Post-surgical Resection of GOJ, cardioplasties, badly-performed myotomy for achalasia Obesity Increasing incidence in last few years H. pylori reduction Paradoxically may increase GORD incidence Symptoms 3 Groups - HIGH YIELD Symptom Details ------ Pain Retrosternal "heartburn"; worsens on stooping/lying; radiates to arms; mimics angina pectoris Dysphagia Mild to complete; due to muscle spasm, oedema, fibrosis, stricture Haemorrhage Usually occult chronic anaemia; overt = deep peptic ulcer Other Flatulent dyspepsia, respiratory symptoms aspiration pneumonia, lung abscess, bronchiectasis Grading of Oesophagitis Oesophagoscopy - EXAM FAVOURITE Grade Finding ------ I Reddening of mucosa, no ulceration II Ulcerations in oesophageal mucosa III Stiffening of oesophageal wall IV Frank stricture - prevents passage of oesophagoscope into stomach - Barrett's oesophagus: columnar epithelium 3 cm above GOJ = metaplasia, precursor of adenocarcinoma of distal oesophagus Diagnosis - Barium swallow + upper oesophageal radiograph - first investigation; only 50% show reflux - Acid reflux test - most informative - Oesophagoscopy - always indicated; grades damage Complications of GORD 8 - MEMORIZE 1. Bleeding 2. Shortening of oesophagus 3. Stricture of oesophagus 4. Barrett's oesophagus 5. Oesophageal ulcer penetration/perforation 6. Respiratory aspiration 7. Schatzki's ring contraction ring of lower oesophagus 8. Adenocarcinoma Treatment Medical 6 months trial minimum: - Head end of bed elevated on 6-inch blocks - No eating just before bedtime - Avoid stooping - Avoid smoking, alcohol, tea, coffee - Antacids 1 hr after meals + at bedtime; PPIs omeprazole, lansoprazole, pantoprazole - most effective - Metoclopramide - increase peristalsis and gastric emptying - Reduce weight; small meals; avoid tight garments - AVOID: Muscle relaxants, Anticholinergics, Tranquilizers Surgical Indications: 1. Symptoms not controlled by vigorous medical therapy 2. Symptoms recur soon after stopping medical treatment 3. Intractable oesophagitis 4. Ulceration or stricture 5. High-grade dysphagia or metaplasia to columnar epithelium - Operation: Nissen Fundoplication anti-reflux operation - restores intra-abdominal segment of oesophagus, maintains tube-like structure of distal oesophagus --- 🔵 ACHALASIA OF THE OESOPHAGUS Key Facts HIGH YIELD - Discovered 1674 by Thomas Willis; properly described 1915 by Hurst - Term 'achalasia' = Greek for "failure of relaxation" - Pathology: Absent/incomplete relaxation of LOS + absent peristalsis in body of oesophagus - Histology: Reduction of ganglion cells with chronic inflammation Auerbach's plexus - Neurogenic basis = main cause - 30% cases: degeneration/absence of ganglion cells not found = extraoesophageal cause - Pseudoachalasia = due to carcinoma of cardia/cancers outside oesophagus - Important fact: Increased incidence of carcinoma of oesophagus in achalasia patients squamous cell type, arises in middle-third Difference: Achalasia vs Hirschsprung's Feature Achalasia Hirschsprung's --------- Ganglia absent Yes dilated oesophagus has few ganglion cells In constricted segment aganglionosis Dilated segment Has few ganglion cells Has normal ganglion cells proximal to constriction Clinical Features 3 MAIN - TRIAD a Dysphagia - obstruction at low retrosternal area; starts with cold warm foods; liquids pass more easily; solids increasingly difficult b Regurgitation - very characteristic; at night when recumbent; no sour taste distinguishes from GORD c Weight loss - patient fails to take food - Pain - not usual; retrosternal occasionally in early cases; may radiate to interscapular/arm area Diagnosis Investigation Finding ------ Barium meal X-ray Oesophagogram Bird-beak / rat-tail tapering at oesophago-gastric junction; megaoesophagus Oesophageal manometry BEST Pressure in body atmospheric; LOS fails to relax after swallowing; no co-ordinated peristalsis; intraluminal LOS pressure increased at rest Mecholyl test 8-10 mg methacholine IV → marked elevation of intra-oesophageal pressure + simultaneous contractions supersensitivity to cholinergic agents Oesophagoscopy Assess retention oesophagitis; exclude carcinoma; mucosa looks oedematous + reddish-purple vs GORD - whitish, fibrotic, superficially ulcerated - Straight X-ray: Bilateral air-fluid levels; little/no fundal gas in stomach Treatment Method Details ------ Medical Calcium channel blockers nifedipine - sublingual; Botulinum toxin injection into LOS temporary Mechanical Dilatation Balloon dilatation 30-40 mm diameter; inserted over guide wire; ruptures circular muscle fibres; complication = perforation 0.5%; cure rate 65-85% Oesophagomyotomy Heller's operation - GOLD STANDARD Longitudinal incision on anterior wall of oesophagus 7-10 cm; performed only on anterior wall; submucosa exposed; add anti-reflux procedure Nissen Laparoscopic Heller's Myotomy Now 90% success; currently most used - Treatment of choice: Oesophagomyotomy surgery - Hydrostatic dilatation can cure 65% - tried first in some centres - 3% treated by myotomy develop GORD - add prophylactic anti-reflux procedure --- 🟢 CAUSES OF DYSPHAGIA Definition - Dysphagia = difficulty in swallowing - Odynophagia = painful swallowing - Types: Functional neurological or Physical pressure/foreign body Classification Table Location In the Lumen In the Wall Outside the Wall ------------ Mouth - Tonsillitis, quinsy, tongue carcinoma, soft palate paralysis - Pharynx Foreign body coin, tooth Pharyngitis, malignancy, hysterical spasm, Paterson-Kelly syndrome, CNS diseases CVA, Parkinson's, MS, ALS, muscular diseases, myasthenia gravis, cricopharyngeal spasm Retropharyngeal abscess, enlarged cervical LN, malignant thyroid Oesophagus Foreign body impaction a Benign stricture - reflux, corrosives, TB, scleroderma, radiotherapy; b Spasm - Paterson-Kelly, achalasia, webs/rings; c Diverticulum & cyst; d Neoplasms mainly malignant; e Nervous disorders - bulbar palsy, post-vagotomy; f Crohn's Malignant/large thyroid, retrosternal goitre, pharyngeal diverticulum, aortic aneurysm, mediastinal growth, dysphagia lusoria, epiphrenic diverticulum --- 🟡 INTESTINAL OBSTRUCTION Types Type Feature ------ Mechanical Pathological interference with progression; blood supply may be intact Paralytic ileus Peristalsis lost due to muscle paralysis Simple mechanical Obstruction present but blood supply intact Strangulated Mesenteric vessels occluded + mechanical obstruction; DANGEROUS - operate without delay Closed loop Both limbs of loop obstructed; no progression nor regurgitation Aetiology A. Mechanical Obstruction: - In the lumen: Meconium, bezoars trichobezoar/phytobezoar, gallstones, polyps, intussusception, barium, worms - Bowel wall lesions: - Congenital: Atresia, stenosis, Megacolon Hirschsprung's, Meckel's diverticulum, imperforate anus - Traumatic - Inflammatory: Crohn's, ulcerative colitis rare, diverticulitis rare - Neoplastic: tumours - Miscellaneous: radiation, iatrogenic stricture, potassium-induced stricture - Extrinsic: - Adhesive band = LEADING cause of small intestinal obstruction - External hernia = second most common inguinal, femoral, umbilical, incisional - Volvulus - Haematomas, neoplasms, annular pancreas, abnormal vessels B. Paralytic Ileus: - Abdominal: intestinal distension, peritonitis, retroperitoneal lesions - Systemic: electrolyte imbalance hypokalaemia, toxaemias Pathology Points HIGH YIELD - Bowel above obstruction: vigorous peristalsis for 2-6 days → then flaccid and paralysed - Bowel below obstruction: normal peristalsis initially → becomes immobile, contracted, pale - Distension: fluid + gas accumulate proximal to obstruction - Fluid/electrolyte: Various digestive juices = 8000 ml/day saliva 1500, gastric 2500, bile+pancreatic 1000, intestinal juice 3000 Intestinal Gas Composition Gas % ------ Nitrogen 70% Oxygen 12% CO2 8% Organic gases H2S, ammonia, amines, hydrogen 10% - Swallowed air = most important source of gas in intestinal distension - Bacterial proliferation occurs rapidly in small bowel obstruction - bacteria probably play no role in simple mechanical SBO but critical in strangulation Clinical Features 4 Cardinal Symptoms HIGH YIELD: 1. Abdominal pain - crampy, colicky; synchronous with hyperperistalsis; 4-5 min intervals proximal vs 15-20 min intervals distal SBO; continuous severe pain without quiescent period = strangulation 2. Vomiting - early reflex; site dependent - high = frequent, copious; low SBO = less frequent; faeculent vomiting = large bowel obstruction / distal SBO; in colon obstruction, reflex vomiting absent if ileocaecal valve competent 3. Constipation failure to pass flatus/faeces - becomes evident only after bowel distal to obstruction evacuated; may be 1-2 natural actions after onset; NO constipation in Richter's hernia, mesenteric vascular occlusion, intestinal obstruction with pelvic abscess 4. Abdominal distension - less in high SBO; visible peristalsis + borborygmi; Metallic bowel sounds on auscultation HIGH pitched Physical Examination Points Finding Significance ------ Tachycardia + hypotension Severe dehydration/peritonitis Visible peristalsis Early stage, long-standing Rigidity at obstruction site Strangulation Rebound tenderness Peritonitis, strangulation High-pitched metallic bowel sounds Simple mechanical obstruction Absent bowel sounds Strangulation Tenderness on light percussion Strangulation All hernial orifices must be inspected Critical - may be cause of obstruction --- 🟣 PRURITUS ANI Definition - Intractable itching around the anus Surgical Causes 9 1. Prolapsing haemorrhoid 2. Anal fissure 3. Fistula-in-ano 4. Ectropion 5. Condyloma acuminata 6. Colloid carcinoma of rectum 7. Carcinoma of anal canal 8. Basal cell carcinoma of anal canal 9. Malignant melanoma of anal canal Other Non-surgical Causes - Dermatitis, Diabetes mellitus, Jaundice, Diarrhoea, Leukorrhoea, Parasitic thread worms - especially children, Monilial infection, Allergy, Psychoneurosis, Idiopathic largest group Treatment - Treat underlying cause - Idiopathic: hygienic measures keep anus clean and dry - Hydrocortisone 0.5% - applied locally temporary relief - Topical fungicides - Straping buttocks apart = keeps perianal region dry idiopathic --- ⭐ HIGH-YIELD EXAM MNEMONICS & QUICK FACTS Topic Exam Fact ------ GORD grading I=redness, II=ulceration, III=stiffening, IV=stricture Barrett's oesophagus Columnar epithelium 3 cm above GOJ; precursor of adenocarcinoma Achalasia X-ray "Bird-beak" / "Rat-tail" at GOJ Best investigation for achalasia Oesophageal manometry Achalasia surgery Heller's oesophagomyotomy anterior wall only Leading cause of SBO Adhesive bands 2nd most common cause of SBO External hernia Strangulation sign Continuous pain without quiescent period Faeculent vomiting Large bowel obstruction / distal SBO Gas composition in obstruction N2 70%, O2 12%, CO2 8% Pruritus ani largest group Idiopathic Anti-reflux operation Nissen fundoplication PPIs used in GORD Omeprazole, lansoprazole, pantoprazole Achalasia carcinoma type Squamous cell middle-third of oesophagus Mecholyl test Methacholine 8-10 mg IV for achalasia diagnosis
