Session 11

Question 1

1. How common is bowel cancers in male and females?
2. Most common type of bowel cancer?
3. Symptoms for bowel cancer?
4. Common in?
5. Risk factors?

Answer 1

1. 3rd most common in both
2. Adenocarcinoma (mucinous, signet ring)
3. Meleana (dark sticky feaces),

Palpatable lump on right side,

change in bowel habit (frequency, consistency, abdominal discomfort)

weight loss,

straining

5. Elderly <70
6. UC, Chrons, FH, diabetes, acromegaly, obese, smoking alcohol, Polyposis syndromes-FAP

Question 2

1. How do cancers of the oesophagus differ to cancers below the oesophagus?
2. Risk factors of oesophageal cancer
3. Dysphasia red flags
4. Signs and symptoms of oesophageal carcinoma
5. Where do you get pain in Chron’s and UC?
6. Diagnosis

Answer 2

1. Generally

Stratified squamous epithelium in the oesophagus -> squamous cell carcinomas

Lower third can develop adenocarcinoma -> Barrett’s

Everywhere else in GI tract columnar epithelium -> adenocarcinomas

2. Obesity, smoking, alcohol, Barrett’s ( no everyone with Barrett’s has GORD), age, diet,

achalasia - valve between stomach and oesophagus does not relax

3. Anaemia

Loss of weight (unintentional)

Anorexia

Recent onset of progressive symptoms

Masses/Malaena

4. -dysphagia (sticking, burning)
   - persistent indigestion or heartburn (cardiac sphincter)
   - weight loss
   - pain in your throat or behind your breastbone (epigastric)
   - cough

- haemetemesis ( vomiting up blood)

5. Image
6. Barium swallow, endoscopy, CT for spread

Question 3

Epigastric pain: Red flags

Causes of the Red flags

Answer 3

• Malaena
• Haematemesis

Question 4

Stomach cancer (16th most common)

1. Causes/ risk factors
2. Signs and symptoms
3. Location, type of cancer
4. Prognosis
5. Diagnosis

Answer 4

1. Diets (high salt), smoking, H.PYLORI, obese, FH, radiotherapy for other cancers
2. Indigestion can be pain or discomfort in your upper abdomen (dyspepsia) or burning pain behind the breastbone (heartburn). Dyspepsia and heartburn may occur together or on their own. Symptoms usually appear soon after eating or drinking.
   - similar pain to peptic ulcer
   - 50% have a palpable mass!
3. Typically in the cardia or antrum

◦ Adenocarcinomas

General note: Chronic inflammation puts you at higher risk of malignancy

4. ◦ 10% 5 year survival

◦ 50% after ‘curative’ surgery

5. Upper endoscopy, stool urine sample?

Question 5

Other cancers that can occur in the stomach…

Answer 5

Gastric lymphoma

◦ MALT tissue

◦ Similar presentation to gastric carcinoma

◦ Most associated with H. pylori

◦ Prognosis much better than gastric cancer

Gastrointestinal stromal tumours (GISTs)

◦ Sarcomas (not epithelial)

◦ Tend to be an incidental finding on endoscopy

Question 6

1. State the primary types and secondary types of liver cancer
2. For the primary type of liver cancer, state risk factors
3. Jaundice: Red flags
4. signs/ symtoms

Answer 6

1. Hepatocellular carcinoma (HCC)
2. M>W, Hep B/C, haemochromatosis, alcohol, lupus etc
3. Hepatomegaly (Irregular border)
   Ascites
   Painless
   Unintentional weight loss
4. weight loss

jaundice -> itching

feeling sick

Ascites

loss of appetite or feeling full after eating small amounts

pain in your abdomen or your right shoulder

a lump in the right side of your abdomen

Question 7

1. Tests for liver cancer
2. Cancers that often cause secondary liver cancer

Answer 7

1. BLOODS:

alanine aminotransferase (ALT)

aspartate aminotransferase (AST)

alkaline phosphatase (ALP)

gamma-glutamyl transferase (Gamma GT)

billirubin

a fetoprotein (tumour marker)

albumin

ULTRASOUND:

CT SCAN:

2. bowel cancer

breast cancer

pancreas

cancer of the stomach and oesophagus (gullet)

lung cancer

melanoma

neuroendocrine tumours.

Question 8

Pancreatic cancer

1. Types
2. Risk factors?
3. Presentation:
4. Diagnosis

Answer 8

1. Most common exocrine -> 80% ductal adenocarcinoma (cells lining duct)
2. Smoking

drinking (chronic pancreatitis)

radiotherapy

3. Epigastric -> back

◦ Head: Painless jaundice – Courvoisier’s law

◦ Body/tail: Symptoms more vague

4. Bloods: glucose?enzymes? Insulin/glucagon?

CT scan:

POOR PROGNOSIS

Question 9

1. Lower GI obstruction symptoms
2. Obstruction: Differential diagnosis
   a. Benign

b. Malignancy
3. Symptoms
4. PR bleeding: Red flags

Answer 9

1. Abdominal distension , Abdominal pain , Constipation, Nausea & vomiting, Weight loss
   - Change in bowel habit, - per rectal bleeding
   2a. - Diverticular disease
   - Volvulus
   - Hernias
   b. - Adenocarcinoma large colon
   - Small bowel cancer
2. Per rectum bleeding -> Fresh bright red bleeding, Melena, Anal pain, Tenesmus
3. Iron deficient anaemia

Unexplained weight loss

Age dependant

Change in bowel habit

Question 10

Per Rectum Bleeding: Differential Diagnosis

Answer 10

Benign

- Haemorrhoids

• Anal fissures
• Infective gastroenteritis
• Inflammatory bowel disease
• Diverticular disease

Malignancy

• Adenocarcinoma large colon
• Small bowel cancer

Question 11

1. Change in bowel habit: Symptoms

Answer 11

1. Change in frequency

Change in consistency

Bloating

Abdominal discomfort

Question 12

Change in bowel habit: Differential diagnosis

Answer 12

Benign

• Thyroid disorder
• Inflammatory bowel disease
• Medication related
• Irritable bowel
• Coeliac disease

Malignancy

• Adenocarcinoma of large bowel
• Small bowel cancer

Question 14

How to differentiate whether it is right or left colon cancer

Answer 14

Question 15

Small bowel cancer RARE!!

Name five different types:

Answer 15

• Stromal
• Lymphoma
• Adenocarcinoma
• Sarcoma
• Carcinoid tumours

Risk factors: IBD, coeliac disease, FAP, diet

Symptoms include: weight loss, abdominal pain, blood in stools

Question 16

What is Dukes staging?

Answer 16

Colorectal carcinoma

Dukes’ A: Invasion into but not through the bowel,

Dukes’ B: Invasion through the bowel wall,

Dukes’ C: Involvement of lymph nodes,

Dukes’ D: Distant metastases

Question 17

Tests to diagnose colon adenocarcinoma

Answer 17

• Flexible sigmoidoscopy
• colonoscopy

(- CT colonogrpahy

• barium enema)

Bloods:

CEA: Carcinoembryonic antigen (CEA)

Question 18

Answer 18

Question 19

1. Methods of imaging the GI tract include:
2. An abdominal x-ray is still useful in determining?
3. How to locate small bowel on a x-ray?
4. Large bowel on x-ray?
5. What is this x ray showing?

Answer 19

1. plain x-rays, contrasts studies (AXR/CXR), ultrasound, cross sectional imaging & angiography
2. bowel obstruction and flare ups of IBD
3. • central position
     - have lines ‘valvulae conniventes’ - cross the entire bowel wall
4. • peripheral position
     - incomplete lines ‘haustra’ across the bowel wall
     - Faeces can be visible (slow transit time)
     - T colon and hang down to pelvis
     - S colon can loop and be long

small bowel

Question 20

Compare and contrast the appearance of small and large bowel on an abdominal radiograph and describe the classical images of bowel obstruction LO

1. Small bowel diameter greater than? Indicates obstruction
2. Large bowel greater than ? on an abdominal x-ray can indicate obstruction
3. What is this image showing?

Answer 20

1. 3cm
2. 6cm (9cm for the caecum)
3. Small bowel obstruction

Question 21

1. What is this image showing?
2. Presentation
3. Causes?
4. How do you know this is a small bowel obstruction?

Answer 21

1. Small bowel obstruction (80% of obstructions,
2. • Vomiting (early)
     - Distension (mild)
     - Absolute constipation (late)
     - Colicky pain
3. Extrinsic (outside of the gut wall)

• Adhesions e.g. from
• Previous surgery
• Malignancy
• Hernia

Intrinsic (within the gut wall)

Paralytic ileus – common postoperatively

Intra-luminal (within the lumen)

• Inflammation - Malignancy - Intestinal ischaemia
  4. — centrally dilated bowel loops >3cm

- Valvulae conniventes visible – mucosal folds of the small intestine

• Air fluid level if x-ray taken erect
• CT scan is more sensitive than X-rays and identifies the cause of obstruction in most cases

Question 22

1. What is this x-ray showing?
2. Causes?
3. Presentation

Answer 22

1. Large bowel obstruction (20%) - Check image
2. Colorectal Cancer (particularly sigmoid)

Strictures (narrowing) – IBD, diverticulitis (outpouching in the large instestine?)

Sigmoid Volvulus

Hernias (protrusion of viscera out of its containing cavity) – femoral/inguinal

Faecal impaction – common in elderly

immobile bulk of feces that can develop in the rectum as a result of chronic constipation

3. • Vomiting (late, faeculant)
     - Distension (significant -> hyper resonant)
     - Pain
     - Absolute constipation
     - Peritonism + Sepsis

(tinkling before)

Question 23

Large vs small bowel obstruction

Answer 23

Large - pain, vomitting late

small - colicky pain , vomitting early

Question 24

1. What is this image showing? Define it.
2. State how you know

Answer 24

1. Sigmoid volvulus (more common than ceacal)

Twisting around mesentery

Enclosed bowel loop -> Dilates -> Perforation & Ischaemia

2. ‘coffee bean’ on abdominal x-ray

LIF pointing towards the RUQ

Question 25

1. What is this image showing? 2. What causes it? 3. Features of x-ray 4. What is toxic megacolon 5. Complication?

Answer 25

1. Toxic megacolon 2. **- Ulcerative collitis** **- collitis (inflammation of the inner lining of the colon -\> infection, IBD,)** 3. - Colonic dilatation (can develop toxicity withought dilatation) - Oedema - Pseudopolyps 4. acute toxic colitis with dilatation of the colon (Inflammation in the colon causes gas to become trapped, resulting in the colon becoming enlarged & swollen) 5. colon can rupture (split) and cause sepsis

Question 26

1. What is this image showing? What are the features that brought you to this diagnosis? 2. Cause/associated with?

Answer 26

1. Lead Pipe Colon - **Featureless** colon - **Loss of haustra** 2. Chronic ulcerative colitis

Question 27

1. What is this x-ray showing 2. What is the imaging of choice? 3. Causes of pneumoperitoneum 4. How do they take CXR

Answer 27

**1. pneumoperitoneum** in the right subdiaphragmatic region 2. **CXR** is the initial imaging of choice, subtle signs can be seen on AXR. Most people will have a **CT**. 3. - May look sick, but may look surprisingly well! - Abdominal pain - Nausea and vomiting - Altered bowel habit - Fevers - Haemodynamically unstable - Rigid abdomen - Absent bowel sounds 4. **Erect chest x-ray** **CT** imaging is more sensitive & you can identify the location of the problem at the same time using this imaging modality and therefore plan treatment.

Question 28

Why request an AXR! LO

Answer 28

Acute abdominal pain - debatable Small or large bowel obstruction Acute exacerbation of IBD Renal colic?? (CT now first line investigation)

Question 30

1. The solid organs are the ? 2. The hollow organs are the? 3. How do we identify hollow organs?

Answer 30

1. liver, spleen, kidneys, adrenals, pancreas, ovaries & uterus 2. stomach, small intestines, colon, gallbladder, bile ducts, fallopian tubes, ureters and urinary bladder 3. Contrast e.g. barium & water soluble contrast (typically using iodine) - Swallow - Meal - Follow through - **Contrast Enema (contrast medium is inserted rectally. This study enables the colon to be visualized)**

Question 31

Use of ultrasound in GI?

Answer 31

- Gallstones - Liver and portal vein, even the Appendix

Question 32

Ultrasound vs CT vs ultrasound

Answer 32

Abdominal ultrasound is a cheap and portable method for imaging the abdomen, but it is very user dependant. Abdominal ultrasound is commonly used to visualise the biliary tree (for gallstones and dilated bile ducts).

Question 33

What is this AXR showing?

Answer 33

AAA

Question 34

What is the importance of angiography in GI?

Answer 34

GI angiography For both bleeding and ischaemia, being able to visualise the Blood supply to the GI tract is very useful. This is done by injecting a radio-opaque contrast agent intravenously and then using various modalities to capture the images. Here you can see the Aorta with the Coeliac trunk and the Superior Mesenteric arteries (and branches) very obviously shown. The Inferior Mesenteric artery & its branches are harder to see Abdominal CT produces high resolution images of the abdomen (and can be further augmented with contrast) but at the cost of high dose radiation. Individual images from a CT scan can be reformatted and combined to produce a 3D representation of the scanned anatomy. Eg a virtual colonoscopy. Abdominal MRI gives detailed and high contrast images of the abdomen without using any radiation. It is however a very time consuming process. It can also be used with contrast to enhance images.