Surgical

Gastroenterology

Toar JM Lalisang
Digestive division Department of Surgery
Medical School
University of Indonesia
Objective :
The student have an overview about SGI

Have Knowledge about common cases in

SGI which needed surgery management

Knowledge on General rules /indications for

Surgery

Knowledge General rules for operative

procedure and reconstruction
 Overlap between medical and
Introduction
surgery fields interest
Highest incidence Ca GI tract,
1/4 of all Ca
Team Approach
Multidiscipline approach
Aims for the best of the
patients
Fields area

Upper GI
HPB
Lower GI ( Colon
& Rectum)
Peri Anal & Anal
Canal.
 Disease pathology
Inflammations
Malignancy
Obstruction :
Adhesion

Mechanic
Hernia

Volvulus

Intussusceptions
 Indication for Surgery
Massive infection, severe
intervention
contamination
Massive bleeding
Obstruction
Intra abdominal Tumor
Abdominal penetrating wounds
Anatomy disruption ,bowel
perforation
Physiology impairment : fistula
Operative Procedure

Abdominal Toilet
Contamination control
Excision & Resection
Gut continuity
Main GI Symptoms &
Dysphagia
Vomiting
Sign Pain /Colicky
Obstructions
Abdominal distention
Hematemesis,
Melena &
Hematochezia (GI Bleeding)
Diarrhea
Mass
Jaundice
PAIN
Pain Characteristic
 GI Bleeding

H E M AT O S C H E Z I A

Hematemesis Melena
4 9

Abdominal wall sector/Quadrant

 ESOPHAGEAL

Esophagus
Dysphagia
Hematemesis
Melena

Diseases
Achalasia
Malignancy Adeno&
Squemous Ca
Traumatic
Varicose vein ec CH
Esophagotomy
Gastric transposition

Definition
Achlasia :
Failure of the LES
to relax in Malignancy:
response to
swallowing Mid eso : Squamous
Incoordinate Ca
between
esophagus and
LES relaxation Distal eso : Adeno Ca
GERD :
Gastroesophageal
reflux disorders
Incompetent LES
 Resection & Anastomosis
Surgery Correction
Achalasia grade III-IV
Heller Procedure (Myotomy)

Esophageal Ca Wide resection and

gastric or colon
Transposition

GERD Anti reflux Nissen

fundoplication

Esophageal Varicose
ec CH SB tube
Hemathemesis Transaction
melena
 SB-tube

SENGSTAKEN-BLAKEMORE tube
 Gastric/Stomach

Vomiting Peptic Ulcer

Hematemesis Malignancy
Melena
Pain
Dyspepsi
 Peptic Ulcer
Definition
Ulcer :
defect at mucosa membrane due to local tissue
disruption

Local defect or excavation at organ / tissue surface

due to sloughing of necrotic tissue on an inflammatory
process.
Peptic Ulcer : Ulcer in the mucosa and sub mucosa of the GI
system caused by peptic enz and acid

Common location : pre pyloric and Duodenal part I

Peptic Ulcer
Etiology

Aggressor Defense

Acid Mucosa HCO3-

Pepsin PH
Bile reflux Splanich circulation
NSAID/Ulcerogenic Cytoprotection

1982 Helycobacter Pylorii.

Peptic Ulcer Complication

Stricture and Gastric outlet

obstruction

Bleeding

Perforation

Malignancy ?

Refractor pain
Surgery Intervention
The indication became narrower

Perforation

Massive bleeding /Surgical bleeding

Gastric outlet obstruction

Intractable pain.
Malignan
cy
Medical Vagotomy : Acid
inhibition by
medicamentus

Surgical Vagotomy

Truncal Vagotomy
TV
Selective Vagotomy
SV
High selective
Vagotomy HSV
For Bleeding : Haemostatic suture
 Gastric cancer
Symptoms not clear / insidious in early
states

Symptoms ++ means advance for surgery

Operative on an early state better survival

Early gastric Ca EGC mucosectomy

State I&II Resection and Lymphadenectomy

desection (D 2, D 3 )
 Small Bowel

Invagination
Thypoid
Jejunum Obstruction/Ileus perforation
Peritonitis Thypoid bleeding
Ileum Pain/Colic Volvulus
Appendix Hernia
Acute Appendicitis
 Ileus/ obstruction
Mechanical
Abdominal distention
Vomiting Bowel sound Increase
Functional
No bowel passage
Bowel sound
Decrease

Simple
no pain

Strangulated
colicky & Pain
increasing
Ileus / Bowel
Obstruction
Surgical Intervention

Strangulation

Respiratory distress

Abdominal Compartment
Syndrome
 Intussuception
Ileus syndrom
Strangulated pain
Hematochezia
Recurrent abdominal mass
Babies more than 6 months
Causes Polyps &Lymph
node Management
Enema Pressure

Operative
Rectal Exam : pseudoportio
Manual milking
Resection &
ABD US
Anastomosis
Complication Non viable
bowel
 Abdominal Hernia.
Protrusion of
abdominal content
in a sac through a
weak area of the
abdominal wall
or intra abdominal
organ.

Complication:
Non Viable of the
content
Abdominal Wall Weak area
 Classification
External
Internal
Epigastric Ext
Hernia Para esophageal
Diaphragm
Umbilical Ext
Hernia
Obturator
Groin :
Inguinal Lat &
Med
Femoral
Acquire & Congenital
 Epigastric

Umbilical

Groin

Inguinal H above inguinal lig.

Femoral H below inguinal lig.

 Inguinal

Femoral
External Abdominal Hernia
the conditions

Reducible
Incarcerated
Irreducible

Strangulated:
Emergency
Operation
 Treatment
Reduced the content & Support the weak
area

Operative reconstruction:
Inguinal Hernia
Bassini Mayo repaired: Umbilical H
Mc Vay
Shouldice
Tension Free Repaired
Mesh

Laparoscopic
 Acute appendicitis
Pain start in the umbilical region and fixed to
RLQ
Vomiting, dyspepsia, followed by fever.

RLQ : Sign local peritonitis

Tenderness, Muscle regarding ect .

Rectal Exam :
Tenderness at 9-12 a clock direction
Rectal Temp. > 1.5 Axillar Temp.

Lab : WBC increase shift to left.

Treatment : Emergency Appendexectomy
Differential Diagnosis

Ectopic pregnancy
Right Ureter stone Made a good history taking

Strangulated And Physical Examination

Ovarial cyst
Collitis It is a Clinical Diagnosis

Ileitis
Meckel Diverticel
PID
Complication
Peri appendix mass
Abscess
Perforation
Sepsis
Jaundice , hepatitis
 Perforated Thypoid
Symptoms and sign for Thypoid

Abdominal pain after 2-3 weeks fever

Sign: General peritonitis
Lab : Tyhpoid
Plain Abd x rays : intra abdominal
free air
compare to peptic ulcer perforation )

Treatment : Operative Intra abdominal toilet and

sewing the perforation/control the perforation
 Colon Ca
Early symptoms and sign not clear
Diarrhea, Hematoschezia,
Weight lost,
Chronic obstruction
Right Colon presented with Palpable Mass
Left Colon presented with Obstruction
 Ca Colon
Diagnosis + Staging
Colon in loop
Colonoscopy + biopsy
Tumor marker : CEA.
US : Lymph node + Liver assessment

Treatment : Curative or palliative

Right Hemicolectomy
Left hemicolectomy
Sigmoidectomy
Transfersecolectomy

Combine treatment : Surgery +Chemotheraphy

 Rectal Ca

Anal bleeding
Change bowel
habit / passing
stools
Rectal
Examination : is
mandatory
Scope ; Biopsy
 Treatment
Total mesorectal excision
Reconstruction :
End colostomy
Low anterior anastomosis
Anal Spinchter preserving
Combined: Radiation, Surgery,
Chemotherapy
Sandwich treatment
 SAVE OUR ANAL CANAL

Anal cushion must be preserved as long as we can

 HAEMORRHOIDS
Diagnosis :
Hemorrhoid /Piles : Protrusion of anal cushion
Rubber band ligation
 Fissure

Fissure

Painful during passing stools

Fresh anal bleeding

Treatment : Pain killer

Anal dilatation
Lateral spinctherotomy
Perianal fistulae
Severe multiple peri anal fistula
HPB : Hepato Pancreatico Biliary System
Objective

To know common disease in

HPB which the treatment of
choise are surgery intervention.
Clinical presentation base on
the pathophysiologicalways.
Normal vascular anatomy of the liver

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Liver
Mass : Solid & Cyst

Cyst : Parasitic & non parasitic

Solid : Malignant & Benign

Infection:
Abscess:
Pyogenic
Amebic Malignancy :
Primary :
HHC
Secundary :
Metastasis
Colorectal
Ca
Breast Ca
 Amebic

Pyogenic Amebic

Pyogenik
Sign & Symptyoms
Fever / Chills
R Abd. Q Pain to shoulder
Inter Costae tenderness
Liver enlargement
Lab : WBC shift to the
left
Serology

USG
CT-Scan
Pyogenic abscesses

Fever + Pain + Jaundice

Onset gradual / insidious

Mesenteric Vein / Portal
Iatrogenic / Endoscopic procedure

Pus yellowish
X-Ray
Amebic abscesses

High fever
Acute onset
Diarrhoea
Hematogenic
Pus Anchovy paste / chocolate
Burgundy
Abscess Management

Drainage : US Guided
Laparotomy

Antibiotic :

Metronidazole : Amebic
Cephalosporin : Pyogenic
Abscess Complication
Perforation
General
Peritonitis
Sepsis
Lung Amebic
Brain amebic
Hepatoma
(Hepato Cellular
Carcinoma)
(HCC)
Diagnosis

Underlying liver disease

Tumor Marker
Ultra Sonography
CT scan
Angiography
Ultrasound examination of the liver
Contrast-enhanced CT scan

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 Hepatocellular carcinoma marked
by a small area
 Management
Resectable HCC: Liver resection

TAE TA Chemotherapy

Radio Frequency Ablation (RFA)

Radiation
Resected specimen of cirrhotic
liver

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 Biliary System
Infection :
Acute : Cholecystitis &
Cholangitis
Stones :
Gall Stones
Gall bladder stones
Malignancy :
Gall bladder Ca
Cholangio Ca
Gallbladder filling and bile flow during fasting

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Gall Stones / Cholelithiasis
Stones in the biliary tract
Intra hepatic

Extra hepatic :
Common Hepatic duct
CBD
GB stones
Diagnosis of stone disease by ultrasound
Gall Bladder stones / Cholecystolithiasis

Bilier Colic
Pain radiating to the scapula
4F
 Biliary Colic

COLIC : Acute abdominal pain

intermittent visceral pain with fluctuations
corresponding to smooth muscle peristalsis.

Biliary Colic :
Colic due to passage of gallstones.
 Biliary Colic :

70%-80% main complain for

symptomatic gallstones

Visceral pain of tonic spasm due to

transient obstruction of Cystic
duct.

Different with the pain due to

Acute Cholecystitis.
CHARACTERISTICS OF
CHOLESTEROL GALLSTONES
Gallstone:
Gallbladder
Intra & Extra
Hepatic duct Stones
Stones in Biliary tract
Management
Removed all Stones
Minimal invasive :
Endoscopic

Laparoscopy
Conventional
CBD Stone
 Once ports in place, abdomen is briefly
inspected
Complication

Infection
Cholestasis
Malignant
Complication

Acute Cholecistitis

Gall Bladder empyema

Perforation Bile peritonitis

Gallstone ileus.

Treatment
Surgical intervention
Acute cholecystitis
Constant pain
RUABDQudrant
Murphy sign ++
WBC increase

Management
Antibiotic
Limited oral intake
LCC within 48
Hours
Acute Cholangitis

Charcot`s Triad:

Biliary Colic

Jaundice

Spiking fever& Chills /

BC. Management

Pain treatment (Non Narcotics)

Limitation biliary activity

Treatment underlying disease.

 Definisi
Cholestasis : Failure of bile flow to
reach duodenum.
Obtructive Jaundice : not used due to
in many instances no mechanical block.
Extra hepatic Cholestasis = Obstructive
Jaundice
Funcsional
Lab
Pathologic
Clinical .
Classification

Extra Hepatic & Intra Hepatic

Acute or Chronic

Complete
Intermittent
Chronic
Segmental
 Cholestasis
Prolonged cause Biliary cirrhosis
Impairment Liver Function
Impairment Kidney Function
Coagulation
liver Blood Flow: Reduced in Chronic
Obst
Increase in Acute
obst.
Extra hepatic Cholestasis
Obstructive Jaundice
Mechanical :

Stones
Tumor
Parasite
Stricture
Extra Hepatic
Cholestasis
Progressive Jaundice
Intermittent Jaundice
Greenish in color quality
Itching
Dark Urine
Colicky pain : due to stones
Painless due Peri Ampullary Tumor
Melena
Extra Hepatic
Cholestasis
Physical Examination :
Icteric Sclera and mucosa
Many superficial scrap wound
Courvoisier Law +++
No stigmata/sign cirrhosis
found
Courvoisier Law

Obstructive Jaundice::
with distended/palpable Gall
Bladder cause due to neoplasm

Not palpable/not distended is

due to stones
Extra Hepatic
Cholestasis
Laboratory finding
Increase Alkaline phosphate
Increase Y GT
Increase Conjugated Bilirubine
Increase Cholesterol
 Treatment
Extra hepatic cholestasis
Treat the Etiology

Release /Decompression
Pancreas
Infections:
Acute Pancreatitis
Chronic Pancreatitis

Malignancy :
Pancreas` Head Ca
( ductal Adeno Ca)

Pseudo Cyst Pancreas.

acute pancreatitis
Pathogenesis

Autodigestion : enzyme
activation within pancreas
ETIOLOGIES
Clinical presentation

Severe Nausea/vomiting
abdominal pain
Fever
Abdominal distention
Clinical Spectrum of
Pancreatitis

Mild, self limiting (80-90%)

Necrotizing or hemorrhagic (10-20%)
: retroperitoneal burn CO, SVR,
HR , hypovolemia, O2 consumption
Complication(s) of severe
pancreatitis
Diagnosis of acute pancreatitis

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Computed tomography: severe acute
pancreatitis

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Scan of pancreas indicating gas bubbles
within pancreas

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Pathology of necrotizing pancreatitis

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Fat necrosis

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PROGNOSTIC INDICATORS OF
SEVERITY
PRINCIPLES OF TREATMENT OF
ACUTE PANCREATITIS

Surgery Intervention at Necrotic and haemorragic states

Infected Cyste
 PANCREATIC CANCER
WHAT IS THE
DIRECTION

TOAR JM LALISANG
Digestive division department of surgery
Cipto Mangunkusumo hospital Jakarta
Medical school University of Indonesia
05/18/17 127
Introduction:
Pancreatic
Cancer
Resection is the only hope for prolong survival.
If Diagnose early can be treated but rarely cure.

80 % Unresectable, 20 % localized.

90 % Ca of the exocrime, in ductal adeno ca type.

Location mostly at the head

65 % located in Pancreas head

05/18/17 128
05/18/17 130
05/18/17 131
 Diagnosis: Pancreatic cancer

Recognizing symptoms

Investigation

Staging/Resectability

05/18/17 132
Diagnosis: Pancreatic
cancer
Recognizing symptoms:

Painless Jaundice
Epigastric pain
Body weight lost
Anorexia
New onset of DM
Fatigue
Steatorrhoe
 Diagnosis : Pancreatic
Px.cancer
: Jaundice,
Courvoisiers Law(+)

Imaging : USG, CT scan

MRI

ERCP/MRCP

Ca 19-9 >>100
IMAGING
IMAGING
Diagnostic
Algorithm

/resectable

Curative/Palliative
Pancreatic Management :

Removable Unremovable Metastatic

PD/PPPD Double Stent

Surgery bypass/Stent
TP + D

Radiotherapy -- -- --

Chemotherapy adjuvant better QL --

Birgid Gudjonsson
John Hopskin
 Pancreaticoduodenal resection

Pancreas MV

PV IVC
Classic Whipple
The end

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