Conditions

Gallstones

Bile is produced by the liver to act as the detergent of the gastrointestinal tract. Stones form when the levels of the various substances in bile inside the gallbladder are out of balance.

Gallstones can cause a variety of symptoms and complications.

• Biliary colic is a transient pain after eating, especially rich or fatty foods.
• Cholecystitis is a pain that is persistent and usually requires hospitalisation. It occurs when a stone becomes stuck in the outlet of the gallbladder.
• Cholangitis is an infection in the bile duct which is usually caused by gallstones passing out of the gallbladder and then getting stuck in the duct system (choledocholithiasis). It is characterised by fevers and jaundice.
• Pancreatitis is an inflammatory condition of the pancreas that is most commonly caused by gallstones.

All of these conditions are managed by surgery with removal of the gallbladder, known as Cholecystectomy. When stones have escaped into the bile duct [choledocholithiasis] an ERCP may also be required.

Hiatus Hernia

This is a condition in which the opening in the diaphragm where the oesophagus passes through, the oesophageal hiatus, stretches and allows the stomach or other organs to slip through. These hernias can be categorised into four types:

• Type 1: Sliding type. The hiatus stretches, and the upper part of the stomach slides up along with the junction between the oesophagus and the stomach.
• Type 2: Rolling type. Also known as “paraoesophageal hernia”. The junction between the oesophagus and the stomach remains where it belongs below the diaphragm, but the very top of the stomach, the fundus, rolls up through the stretched hiatus.
• Type 3: Mixed type. A combination of types 1 and 2.
• Type 4: Organs other than the upper stomach have slipped through the stretched hiatus. Examples include, the entire stomach, part of the liver or part of the colon.

95% are Type 1 and can often be managed with medications alone. Large hiatus hernias can cause reflux, cardiac (heart) symptoms and respiratory (lung) symptoms. These larger hernias often require repair and this is done with key-hole (laparoscopic) Hiatus Hernia Surgery, usually combined with a Fundoplication (see Gastro-Oesophageal Reflux section).

Gastro-Oesophageal Reflux Disease (GORD)

Gastro-Oesophageal Reflux Disease, also known as GORD or simply ‘Reflux’ is a common condition in Australia. It is a condition where stomach acid and other gastric juices, sometimes along with undigested food, flows backwards, the wrong way from the stomach up the oesophagus (food-pipe or gullet). It is caused by a failure of one or more of the several natural mechanisms that prevent reflux at the lower end of the oesophagus where it joins the stomach.

Patients suffering from reflux often report symptoms such as heartburn, waterbrash, indigestion or even regurgitation of gastric juices or partially digested food. This often occurs more in bed at night or after a large meal. Sometimes GORD can cause other problems including respiratory problems and irritation of the oesophagus leading to Barrett’s Oesophagus.

Most cases of GORD can be managed with medications alone, however in some circumstances, surgery is required, and, in these situations, it is generally very effective. The operation performed is a Laparoscopic (keyhole) Fundoplication. Hiatus Hernia can also lead to reflux and can also be managed with a surgical procedure to fix the hernia and the reflux simultaneously.

Gastric Cancer

Gastric Cancer is uncommon in Australia but is more common in places such as Japan and Korea. The biggest risk factor in Australia is infection with Helicobacter pylori which is the bacteria that has been shown to cause stomach ulcers. The most common type of gastric cancer is ‘adenocarcinoma’ which makes up about 95% of cases. The remaining 5% of cases are made up from a variety of other types.

The symptoms of gastric cancer tend to be fairly vague and the diagnosis is made with a Gastroscopy (telescope test with a camera passed down the gullet) and a biopsy.

The definitive treatment for gastric cancer is surgery, however chemotherapy may play a role in treatment before, after or instead of an operation.

Gastrectomy is the removal of all or part of the cancer-affected stomach along with the lymph nodes where cancer tends to spread to first. The digestive system is then reconstructed by bringing the small intestine up to the remaining oesophagus or upper stomach so that food can pass through the digestive tract.

Liver Cancer

The most common true cancer of the liver is hepatocellular carcinoma, or HCC. This cancer is related to cirrhosis which may be caused by excessive alcohol, Non-Alcoholic Steato-Hepatitis (NASH) or Hepatitis C infection.

In addition to HCC is colorectal cancer which has spread to the liver. This is not a true liver cancer, but represents a large proportion of cancers for which liver surgery is performed in Australia.

In addition to cancer, there are a wide variety of benign conditions that may be detected on imaging performed for other regions and be mistaken for cancer.

The diagnosis of liver cancers is based on a specialised CT or MRI scan of the liver and only occasionally with a biopsy. Once the diagnosis is made, there are a variety of treatment options available. Surgery with Liver Resection is the gold standard treatment, and when appropriate can be performed by either laparoscopy (keyhole surgery) or open approaches.

Liver transplant is a treatment option available for some people with liver cancer who meet certain criteria.

Pancreatic Cancer and other Pancreatic Lesions

Pancreatic cancer represents the 11th most common cancer in Australia and the 6th most common cause of cancer-related death. There are some known risk factors for pancreatic cancer such as family history, smoking and alcohol, but no clearly identified cause. The most common type of pancreatic cancer is Pancreatic Ductal Adenocarcinoma (PDAC) which makes up for 85% of cases. The remaining 15% of cases are a variety of other subtypes of cancers.

Pancreatic cancer can present in a number of different ways with vague symptoms, pain, jaundice or even diabetes. The diagnosis is generally made by using specialised CT or MRI scans of the pancreas as well as a biopsy which may be performed by Endoscopic Ultrasound (EUS) or Endoscopic Retrograde Cholangio-Pancreatography (ERCP).

The mainstay of treatment for pancreatic cancer is surgery. Pancreatic Surgery has several different forms, the most common is a pancreaticoduodenectomy (Whipple procedure) and the main alternatives are a distal pancreatectomy, or total pancreatectomy.

Prior to surgery, the surgeon will usually discuss the treatment with a group of cancer specialists in the multi-disciplinary team to discuss the role of chemotherapy in the treatment of any individual patient. Chemotherapy may play a role prior to, after or both before and after surgery, with the approach tailored to the individual.

Achalasia

Achalasia is a benign condition of the oesophagus that causes difficulty swallowing. It is caused by a problem with the nerves and muscles of the oesophagus that leads to failure of the lower end of the oesophagus to relax with swallowing. This failure prevents the normal passage of food through the lower oesophagus and causes symptoms of dysphagia (difficulty swallowing) or heartburn symptoms similar to reflux. The symptoms usually progress slowly with time and have often been present for years before the sufferer decides to see a doctor for it.

Treatment aims at improving swallowing by decreasing the pressure, or tension, in the lower oesophageal sphincter. This can be achieved by injection of a chemical to relax the muscle, by stretching the muscle fibres (dilation) or by cutting the muscle fibres (myotomy) through either keyhole surgery (Heller’s Myotomy) or a procedure known as Per-Oral Endoscopic Myotomy (POEM).

None of these treatments fix the underlying problem with the nerves but aim to improve the symptoms which are bothering the individual.

Acute Appendicitis

Acute appendicitis is one of the most common diseases requiring surgery seen in patients admitted through the Emergency Department. Approximately 7% of people will be affected by this problem, and although it is most common in teenagers, it is seen in people of any age, from little babies though to people in their 90’s.

The appendix is a small worm shaped extension of the first part of the large bowel (colon). Acute appendicitis begins when the appendix becomes blocked at its opening to the bowel, and then the contents of the appendix start to fester, and the worm-shaped organ begins to swell. Eventually, the pressure inside the appendix builds up and the ability of the tiny blood vessels to supply the tissue with oxygen from the blood is compromised and the appendix can become gangrenous. If this occurs then the appendix will eventually perforate, or burst, and this will make the sufferer even more sick.

Typical symptoms of appendicitis come on over 6-24 hours but are sometimes a little faster or slower. Symptoms tend to include generalised abdominal pain which localises to the right bottom corner of the abdomen, loss of appetite, fevers, loose bowels and feeling generally unwell. Children often report that the pain is worst with sudden movement such as going over bumps in the car.

The only proven treatment for appendicitis is surgery, which is typically performed by laparoscopic (keyhole surgery) Appendicectomy, although a traditional open operation is sometimes better in small children. There is some evidence that, in certain circumstances, appendicitis can be managed with antibiotics alone, however, there are reasonably high early and delayed failure rates, and identifying which patient may get better with antibiotics remains a challenge. The standard of care in Australia remains surgery and these patients tend to do well without any long-term complications of their surgery. Most people go home the day after their operation.

Abdominal Wall Hernia

A hernia is a defect, or hole, in the abdominal wall that allow some of the contents of the abdominal cavity to bulge out. Hernias can occur in the groin (inguinal hernia), just below the groin (femoral hernia), at the navel (umbilical hernia) above the navel (epigastric hernia) or at a previous scar after abdominal surgery (incisional hernia).

Sometimes the hernia is harmless and causes no symptoms, however, depending on the size and location of the hernia, there is a chance that it could become symptomatic in a number of ways. Some people notice pain when the hernia bulges out and particularly notice that this occurs with strenuous activity or exercise. If a hernia becomes stuck out it can become very painful and strangulated if the blood supply to the tissue bulging out gets restricted by the ring of the hole. Strangulation is an emergency. If bowel becomes stuck in a hernia it can cause a bowel obstruction.

There are a variety of options for Hernia Repair, and the best technique to use, and in fact whether or not they should be fixed at all, depends on their size, location and symptoms. Once symptomatic, almost all hernias should be fixed. Surgery is the only way to fix a hernia definitively, with there being no long-term evidence to support any devices or trusses that have been promoted to help prevent the complications of hernia compared to surgical repair. Surgical options include laparoscopic (keyhole) and open approaches and the use of mesh or not. As a general rule, if a hernia needs to be fixed, it is better to fix it after it is symptomatic, but before it becomes acutely problematic in an emergency.

Pilonidal Disease

Pilonidal disease, which often manifests as pilonidal sinus or pilonidal abscess, is a common problem characterised by a tender area of inflammation in the natal cleft, also known as the gluteal cleft.

The exact cause of this condition is unclear, but it essentially reflects a condition of ingrown and infected hair follicles that collect under the skin and cause either long term chronic inflammation and mild pain, or acute infection with moderate to severe pain. These collections can either swell up and become very painful or discharge purulent fluid. 

Classically, patients with this problem are older teenagers or young adults, and it is more common in men than women. A number of risk factors have been identified, but it can occur in patients without any risk factors to explain its occurrence.

It almost always presents as an emergency, and some patients have recurrent disease that may be managed electively. Pilonidal surgery involves either releasing the infection acutely, or removal of the whole area of inflamed tissue more definitively. This isn’t always required.

Acute Pancreatitis

Acute pancreatitis is an inflammation of the pancreas triggered by the activation of pancreatic digestive enzymes in the tissue of the pancreas instead of in the bowel where they are designed to work to digest food.

There are many causes of pancreatitis, but the two most common by far are gallstones and alcohol consumption. When it is related to gallstones, it is often the first sign that gallstones are present, but equally it can occur in people who have had gallstones for many years. When alcohol triggers pancreatitis, it is classically after a heavy binge but has been known to occur after even very small amounts of drinking.

The symptoms of pancreatitis are severe abdominal pain that goes through to the mid-back. The severity of the illness ranges from very mild through to life-threatening, and it is difficult to predict where any particular attack will be on that spectrum.

In general terms, the treatment of pancreatitis involves supporting the patient whilst they feel unwell with interventions like pain relief and intravenous fluids in hospital and allowing the pancreas to heal on its own. Once recovered, the next step is to aim to prevent further attacks by treating the underlying cause. This will mean a cholecystectomy to remove the gall bladder if gallstones are the cause or recommending abstinence from alcohol when it has been the trigger.

When pancreatitis is particularly severe it can cause a wide variety of complications, and these can require numerous different interventions. The worst cases of pancreatitis can be fatal or require hospitalisation for many months. Thankfully, these situations are rare.