What does primary mean in terms of cancer?
Arising directly from cells in an organ
What does Secondary/metastasis mean in terms of cancer?
Spread from another organ, directly or by other means
What types of cells are present in the GI tract?
Epithelial cells (squamous, glandular), neuroendocrine cells (enterochromatin cells, interstitial cells of Cajal), connective tissue (smooth muscle, adipose tissue)
What Cancers arise from cells in the GIT?
Epithelial: squamous cell carcinoma, adenocarcinoma Neuroendocrine: carcinoid tumours, gastrointestinal stromal tumours Connective tissue: leiomyoma/leiomyosarcoma, lipomas
What is dysphagia?
What would you like to know if a patient comes in with dysphagia (63 yo, F)?
What does she find difficult to swallow How long Vomiting Other symptoms - WEIGHT LOSS!! Risk factors (reflux, overweight, smoking, alcohol)
What are the 3 sections of the Oesophagus?
Cervical oesophagus, middle oesophagus and lower oesophagus
What are the 2 main types of oesophageal cancer?
Adenocarcinoma and squamous cell carcinoma
What is Adenocarcinoma?
From metaplastic columnar epithelium, occurring in lower 1/3 of oesophagus, related to acid reflux and mainly in developed world
What is Squamous cell carcinoma?
From normal oesophageal squamous epithelium, upper 2/3, acetaldehyde pathway, occurs more less developed world
What are some diagnostic tests to check for oesophageal cancer?
Endoscopy, OGD, gastroscopy
How does the oesophagus progress from reflux to cancer?
Chronic exposure to acid, injury, ongoing inflammation, cytokines drive Oesophagitis > Barrett's oesophagus > Dysplasia > carcinoma
What is a type of metaplasia?
Barrett's oesophagus - replacement of squamous cell mucosa with columnar mucosa
What is the risk of cancer from Barrett's?
0.12% per year, BUT Dysplasia can increase the risk to 30% when high grade Dysplasia occurs
From Barrett's oesophagus what happens?
BO can go to low grade Dysplasia/high grade Dysplasia/straight to adenocarcinoma or can go in between each option
What to do with patient with low grade Dysplasia?
Reassure, start her on anti-acid medication, start surveillance and maybe begin on aspirin
What are the possible surveillance guidelines?
4 biopsies every 1 cm segment BO: no Dysplasia - every 3-5yrs Low grade dysplasia - every 6 months until no dysplasia, high grade dysplasia - Flat (RFA) or nodular (endoscopic mucosal resection then HALO)
What are the risk factors for bowel cancer?
Family history, specific inherited condition (FAP, HNPCC, Lynch syndrome), uncontrolled Ulcerative Colitis, age, previous polyps
How is Adenocarcinoma formed?
Normal epithelium, hyperproliferative epithelium, small adenoma, large adenoma, colon carcinoma
What are polyps made from?
Small adenoma - benign but have potential to become cancer
What is the pathology of colorectal cancer?
Not a single gene process, sequence of genetic errors, and not simple Mendelian inheritance
What are the symptoms of colorectal cancer?
Asymptomatic (incidental anaemia), change in bowel habit (diarrhoea/constipation), blood in stool (bright red is rectum and not very worrying; dark red/black is higher up and is very worrying), acute intestinal obstruction
What are some symptoms NOT to do with colorectal cancer?
Rectal bleeding with anal symptoms (itch, soreness, external lump, prolapse), change in bowel habit to harder/less frequent stool, abdominal pain in the absence of obstruction
What are some advantages and disadvantages of abdominal X Rays?
Adv: cheap, easy, quick Disadvantage: not that useful, sensitivity of obstruction 77%, specificity for obstruction 50%
What are some advantages and disadvantages of CT scan?
Adv: Quick easy, see large lesions Disadvantage: May miss smaller lesions, no tissue, no therapy
What are some advantages and disadvantages of Barium enema?
Adv: reasonable specificity/sensitivity Disadvantage: time intensive, technically demanding, unacceptable to patients
What are some advantages and disadvantages of Colonoscopy?
Adv: safe, relatively quick, high sensitivity, able to obtain tissue Disadvantage: 2 days of iatrogenic diarrhoea, small risk perforation, risk of dehydration
What are some advantages and disadvantages of CT virtual colonoscopy?
Adv: quick, easy, reduced bowel prep, more tolerable, as good as colonoscopy for lesions >6mm Disadvantage: unable to obtain tissue, unable to remove lesions
What are signs of Pancreatic cancer?
Silent killer, non-specific symptoms
What is the Pancreatic Virchow's triad?
Pain 70%, anorexia 10%, weight loss 10%
What are the Early symptoms of pancreatic cancer?
Abdominal pain, depression, glucose intolerance
What are the late symptoms of pancreatic cancer?
Weight loss, jaundice, ascites (massive build up of fluid in peritoneum), obstructed gall bladder
How do you treat pancreatic cancer?
Outcome is poor; removal of whole pancreas, gall bladder and on pancreatic enzymes 5yr survival rate 2%
What are some risk factors for pancreatic cancer?
Smoking, drinking, obesity, family (rare conditions = MEN)
What are the types of diseases that have abdominal pain as a symptom?
Gastroesophageal reflux disease, ulcer, cholecystitis, colon perforation, ntestinal obstruction, diverticulitis, pelvic inflammatory disease, pancreatitis, colon cancer, appendicitis
How do we approach pain?
History, examination, investigation
What do you want to know about pain?
SOCRATES: site, onset, character, radiation, associated symptoms, timing, exacerbating/relieving factors, severity
What are some characteristics of GI pain?
Initially poorly located, onset usually over hours, usually more of a dull ache, may have associated GI symptoms
What are the sections of the GI system?
Foregut (oesophagus to duodenum), midgut (duodenum to mid transverse colon), hind gut (transverse colon to anal canal), retro peritoneal organs (kidney, pancreas), diaphragm (liver, gallbladder, duodenum)
What are the sites of pain associated with embryological site of pain?
Foregut: epigastrium Midgut: umbilical region Hindgut: suprapubic Retroperitoneal: back pain Diaphragm: shoulder tip pain
Which of the 9 regions does each of the following cause pain? Oesophagus, Stomach, small bowel, large bowel, appendix, hepatic pain, biliary pain, pancreatitis
Oesophagus - epigastric Stomach - left hyperchondriac Small bowel - umbilical Large bowel - umbilical and suprapubic Appendix - right inguinal Hepatic pain - right hyperchondriac Biliary pain - right hyperchondriac Pancreatitis - epigastric
What is peritonitis pain?
Sharp, very severe, located initially then becomes more generalised, worse on movement, guarding, rebound tenderness
What are colicky pain?
Muscular contractions of a hollow tube in an attempt to relieve an obstruction by forcing content out - may be accompanied with vomiting and sweating
In which hollow tubes may colicky pain occur?
Ureter, urethra, colon, bile ducts, pancreatic ducts
What are some non GI causes of abdominal pain and where is the pain located?
Renal pain - flank to groin Bladder - suprapubic Pneumonia - upper quadrant Heart attack - epigastric Pelvic inflammatory disease - lower abdomen Musculoskeletal - anywhere
What are some pancreatitis symptoms?
Variable presentation, abdominal pain localised to epigastrum and radiating to the back, Nausea and Vomiting common, patient acutely unwell and in shock, may have organ failure, may have evidence of jaundice/cholangitis, potentially very unwell
What are the types of tests?
Simple, blood tests, complex blood tests, simple imaging, cross sectional imaging, invasive test
What are some simple diagnostic tests?
Blood pressure, pulse, urine dipstick
What are some blood tests for abdominal pain?
Full blood count, urea and electrolytes, inflammation markers, liver function test, clotting, calcium, glucose
What are some complex blood tests for abdominal pain?
Amylase, lipase, triglycerides
What are the types of imaging that can be done?
Chest x Ray, abdominal x Ray, ultrasound, CT scan, MRCP
What is an invasive test to diagnose abdominal pain?
What are the common causes of pancreatitis?
GETSMASHED - gallstones*, ethanol*, trauma, steroids, mumps, autoimmune, Scorpion venom, hyperlipidaemia/hypercalcaemia, ERCP, drugs (NSAID, furosemide, sulphonamides, azathioprine)
What are some systemic complications of pancreatitis?
Hypovolaemia, hypoxia, hypocalcaemia, hyperglycaemia, DIC, multiple organ failure
Why is cancer important?
Common and serious
What is cancer?
A disease caused by an uncontrolled division of abnormal cells in part of body
What are the mutations to cause adenocarcinoma?
5 mutations in stages: APC mutation, COX-2 over expression, K-raw mutation, p53 mutation, loss of 18q
What are some diagnostic tests to check for bowel cancer?
Abdominal x ray, Plain CT, colonoscopy, barium enema, CT virtual colonoscopy
What is a virtual CT colonoscopy?
Modified bowel prep, tag stool using bismuth, computer aided subtraction to create images
What are some common causes of abdominal pain in each of the 9 regions?
What are some localised complications of acute pancreatitis?
Pancreatic neurosis, fluid collections (pseudocysts), splenic vein thrombosis/pseudoaneurysm, chronic pancreatitis
What are some common types of abdominal pain diseases (img)?