GI Surgery - Cancer and Surgery Flashcards by Guy Kirkpatrick

Overview of GI cancer

Oesophageal (+Barrett's)
Stomach cancer
Pancreatic cancer
Liver cancer
Cholangiocarcinoma
Colorectal cancer

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A 74 ♂ presents to his GP with a 3mo history of weight loss, fatigue and loose stools. His maternal grandmother was diagnosed with bowel cancer in her 60s. O/E, you discover bright red blood PR.

What tumour marker is associated with your feared diagnoses?

Pancreatic cancer
Oesophageal cancer
Left-sided colorectal cancer
Hepatocellular carcinoma
Barrett’s oesophagus
Cholangiocarcinoma
α-fetoprotein
CA19-9
CEA
Stomach cancer

CEA

Carcinoembryonic antigen
Colorectal cancer tumour marker

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A 60♀ presents complaining of vague abdominal pain and a feeling of nausea for the past 4mo. She denies any vomiting. On further questioning you find she has lost a significant amount of weight over the past 6mo or so, largely unintentionally. O/E, you discover a firm, rubbery lump in the left, supraclavicular fossa.

What is the most likely Dx?

Pancreatic cancer
Oesophageal cancer
Left-sided colorectal cancer
Hepatocellular carcinoma
Barrett’s oesophagus
Cholangiocarcinoma
α-fetoprotein
CA19-9
CEA
Stomach cancer

Stomach Cancer

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A 45 ♂ with a background of IBD presents complaining of pruritus. He denies any further symptoms, but on direct questioning remarks that his stools have perhaps been slightly more pale of late. Physical examination is largely unremarkable, aside from a mild jaundice noted in his sclera. You order a series of investigations, which reveal a negative CA19-9.

What is the most likely diagnosis?

Pancreatic cancer
Oesophageal cancer
Left-sided colorectal cancer
Hepatocellular carcinoma
Barrett’s oesophagus
Cholangiocarcinoma
α-fetoprotein
CA19-9
CEA
Stomach cancer

Cholangiocarcinoma

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An obese 56♂ with a PMH of chronic GORD presents complaining of a
worsening, burning pain in his chest, and of feeling a lump in his throat when eating. He describes himself as a ‘non-smoker’, having given up yesterday evening following a 40+yr history of smoking 30 a day.

What is the most likely diagnosis?

Pancreatic cancer
Oesophageal cancer
Left-sided colorectal cancer
Hepatocellular carcinoma
Barrett’s oesophagus
Cholangiocarcinoma
α-fetoprotein
CA19-9
CEA
Stomach cancer

Oesophageal Cancer

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A 56 ♀ presents with a 2 week history of increasing jaundice and pruritis. Direct questioning reveals that over the past few months she has lost about 10kg in weight. An ultrasound scan shows dilated bile ducts but no evidence of gallstones.

What is the most likely diagnosis?

Pancreatic cancer
Oesophageal cancer
Left-sided colorectal cancer
Hepatocellular carcinoma
Barrett’s oesophagus
Cholangiocarcinoma
α-fetoprotein
CA19-9
CEA
Stomach cancer

Pancreatic cancer

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Types of Oesophageal Cancer

Adenocarcinoma (commonest)

Squamous cell

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Oesophageal Adenocarcinoma

Location, RF, Barrett’s?

Lower Third of Oesophagus
RF: Smoking, Obesity
Does arise from Barrett’s

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Oesophageal Squamous cell cancer

Location, RF, Barrett’s

Middle third of oesophagus
RF: Smoking, Alcohol
Doesn’t arise from Barrett’s

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Chronic Presentation of Oesophageal Cancer

Progressive dysphagia, solids –> liquids
Chest pain (burning)
Wt loss

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Oesophageal Cancer Ix

Dx: OGD
Staging: CT

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Barrett’s Oesophagus

Definition, Cause, Complications

“Columnar lined oesophagus [CLO]”
Metaplasia of the oesophagus, replacing normal squamous epithelium with columnar epithelium.

Caused by acid reflux (GORD)

Complications: Increased risk of adenocarcinoma of the oesophagus

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Stomach Cancer Risk Factors

Smoking, H. Pylori infection, Chronic gastritis

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Stomach Cancer Presentation

Epigastric Pain
Nausea
Vomiting +/- blood
Anorexia, Dysphagia
Wt Loss

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Commonest Type of Stomach Cancer

Adenocarcinoma

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Stomach Cancer O/E

Virchow’s Node/ Troisier’s sign: Lymphadenopathy in left supraclavicular fossa
Sister Mary Joesph node: Metastatic nodule on umbilicus
Palpable epigastric mass

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Stomach Cancer Ix

OGD

Biopsy

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Courvoisier’s Law

Painless jaundice + Palpable Gallbladder is unlikely to be due to gallstone’s

(Likely malignancy of gallbladder or pancreas)

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Pancreatic Cancer RF

Smoking
Increased BMI
Chronic pancreatitis
Diabetes

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Pancreatic Cancer Genetics

K-ras mutation (95%)

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Pancreatic Cancer Presentation

Painless jaundice

Obstructive jaundice picture - pale stools/dark urine

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Pancreatic Cancer O/E

Courvoisier’s Law

Painless jaundice/palpable gallbladder

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Pancreatic Cancer Commonest type

Study These Flashcards

Ductal carcinoma

Pancreatic Cancer Commonest location

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Head > Body > Tail > Diffuse

Pancreatic Cancer Tumour marker

Ca 19-9

Pancreatic Cancer Ix

LFTs : Raised ALP USS: Dilated biliary tree +/- pancreatic mass Biopsy

Commonest cause of liver cancer

Metastasis

Liver Cancer RF

``` Cirrhosis: Infection - Viral hepatitis Inflammation - PSC, PBC Metabolic - NASH [Non-alcoholic steatohepatitis] Toxins - Alcohol, Drugs ```

Liver Cancer Presentation

Constitutional symptoms: FLAWS +/- Ascites +/- Abdo pain

Liver Cancer Commonest Type

1. Secondary - Metastasis | 2. Primary - Hepatocellular carcinoma

Liver Cancer Tumour marker

α-fetoprotein

Liver cancer Ix

USS | Biopsy

Cholangiocarcinoma | RF, Presentation, O/E

NB Presentation is similar to pancreatic cancer RF: Primary sclerosing cholangitis (UC) Presentation: Obstructive jaundice picture; Constitutional symptoms O/E: ? Courvoisier's law

Colorectal cancer | RF, Commonest Type, Tumour marker, Ix

RF: Age FHx Diet (Meat in diet; Fat in diet; Low fibre) Commonest: Adenocarcinoma TM: CEA Ix: FBC - Microcytic anaemia Colonoscopy + Biopsy

Colorectal cancer Presentation

R sided: Iron deficiency anaemia +/- Dark blood mixed in with stool +/- RIF mass ``` L sided (Commonest): Change in bowel habits Rectal bleeding Bright red blood coating stool +/-mucus ``` Rectal: +Tenesmus + Worm like stool Anal: Pain +/- Pruritis ani +/- Mass

Duke's Staging System

Used for colorectal cancers A/B1/B2/C1/C2/D A - Limited to mucosa B1 - Extending into muscularis propria; No lymph node involvement B2 - Transmural invasion; No lymph node involvement C1 - Extending into muscularis propria; + Lymph node involvement C2 - Transmural invasion; + Lymph node involvement D - Distant metastasis

Progressions before colorectal cancer

Familial adenomatous polyposis [FAP] | Hereditary non-polyposis colorectal cancer [HNPCC]

FAP | Inheritance, Genetics, Characteristics, Lifetime risk of CRC without treatment

Autosomal dominant Gene: APC Characteristics: >1,000 polyps Risk: 100%

HNPCC | Inheritance, Genetics, Characteristics, Lifetime risk of CRC without treatment

``` AKA lynch syndrome Autosomal dominant Genes: Mismatch repair genes Characteristics: Multiple CRCs and extra-colonic cancers Risk: 60% ```

A trauma Pt is rushed to AandE following a stab wound to the abdomen. On initial assessment, the Pt is septic, and it quickly becomes clear that the wound has perforated his bowel. Which is the most appropriate procedure to perform? ``` Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz ```

Hartmann's

A patient is known to have symptomatic Familial Adenomatous Polyposis, and is recommended surgery due to avoid his otherwise inevitable progression to colorectal cancer. Which is the most appropriate procedure to perform? ``` Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz ```

Proctocolectomy

A ♀ swimsuit model requires and appendectomy. She is however refusing to sign the consent form as she is concerned about the cosmetic implications. Which is the most appropriate procedure to perform? ``` Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz ```

Lanz

A Pt with Crohn’s disease has undergone a right hemicolostomy. The surgeon is, however, concerned about the integrity of the anastamosis in the short-term, given the status of the Pt. Which is the most appropriate procedure to perform? ``` Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz ```

Loop ileostomy

Catherine Middleton, Duchess of Cambridge has been admitted to the Lindo Wing at St Mary’s, as she will imminently give birth to a future heir to the throne. She has requested a C-section. BUT – as the surgeon scrubs in, he momentarily forgets which surgical procedure he should perform. He turn’s to the 3rd year Imperial medical student who is assisting and asks: Which is the most appropriate procedure to perform? ``` Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz ```

Pfannestiel

Hemicolectomy | Description and Indications

Removal of either the right or the left side of the bowel Indications R: Crohn's Disease involving terminal ileum; Right sided CRC L: Left sided CRC; Diverticular disease

Hartmann's Procedure | Description and Indications

Emergency procedure: Resection of the recto-sigmoid colon Formation of an end colostomy stoma ``` Indications: Obstruction Perforation Abscess Trauma ```

"Reversal of Hartmann's" | Description and Indications

Anastomosis of bowel and removal of stoma If pt well enough - 3 months after Hartmann's

Proctocolectomy | Description and Indications

Removal of the entire colon and rectum. Results in either: Ileo-anal pouch anastomosis ("J pouch") End ileostomy ``` Indications: UC Crohn's FAP Pts with > 1 bowel cancer ```

Ileo-anal pouch anastomosis (J Pouch)

Formation of a new rectum - the pouch - out of loops of small bowel following proctocolectomy

Abdominoperineal resection | Description and Indications

Removal of the entire rectum and anus. Formation of an end colostomy. Indications: Lower rectal cancer Anal cancer

Anterior resection of rectum - Lower anterior resection | Description and Indications

Removal of part or all of the rectum. Anastomosis of free ends. Indications: Upper rectal cancer Diverticular disease

Scars - Indications ``` Kocher’s =Right subcostal Mercedes-Benz Midline laparotomy Loin McBurney’s =Gridiron Lanz Rutherford-Morrison = Hockey-Stick Pfannestiel Inguinal ```

Kocher’s =Right subcostal Open cholecystectomy Mercedes-Benz Liver transplant Midline laparotomy Numerous Major GI/abdo surgery Loin Nephrectomy McBurney’s =Gridiron Appendicectomy Lanz Appendicectomy (+ improved cosmetic outcome) Rutherford-Morrison = Hockey-Stick Renal transplant Pfannestiel Gynaecological procedure Eg C-Section Inguinal Hernia repair Vascular access

Stoma

A conduit between the skin and a hollow viscus to divert faeces or urine outside the body to where it can be collected in a bag.

Ileostomy | Bowel, Appearance, Location, Faeces

Small bowel Spouted (sticking out) RIF Green, Liquid

Colostomy | Bowel, Appearance, Location, Faeces

Large bowel Flush LIF Formed

Loop ileostomy/colostomy

Temporary procedure: A loop of bowel is brought to the surface and half divided, allowing faecal matter to drain into a stoma bag without reaching the distal bowel. It is then later reversed once the distal anastamosis has recovered.

GI Surgery - Cancer and Surgery Flashcards

(56 cards)