Week Ten - Case One

Question 1

what is the second most common cancer worldwide

Answer 1

gastric adenocarcinoma

Question 2

what is the male to female ratio of gastric adenocarcinoma

Answer 2

2:!

Question 3

what is the cause of gastric adenocarcinoma thought to be

Answer 3

the combination of genetic factors and nitrates in the diet, with increased risk on smokers and those with h pylori infection

Question 4

what is diagnosis usually a combination of

Answer 4

usually a combination of an endoscopy and CT +/- USS

Question 5

what is staging of gastric adenocarcinoma done using

Answer 5

the TNM scale

Question 6

what are gastric tumours almost always

Answer 6

almost always an adenocarcinoma of the mucous secreting cells of gastric pits. the most common mutation is that of tumour suppressor gene p53

Question 7

what is the 5 year syrivival rate of stomach cancer

Answer 7

about 10%

Question 8

what are the two other types of tumours that affect the stomach

Answer 8

Gastric lymphoma (MALT) – accounts for 1-2% of gastric carcinomas.
H pylori is again a large precipitating factor. Presentation often similar to gastric adenina carcinoma and thus may be difficult to differentiate from GORD or gastric ulcer

Oesophageal carcinoma – almost always occurs in the presence of Barrett’s oesophagus, and is basically just an adenocarcinoma of the new columnar epithelium – i.e. it is similar historically to gastric carcinoma. Likely to present with dysphagia

Question 9

what sort of diets can predispose you to gastric adenocarcinoma

Answer 9

smoked fish, pickled foods, salt and nitrates

Question 10

what foods have a beneficial benefit

Answer 10

fresh fruit and vegetables, particular those containing vitamin C and A

Question 11

what is thought to be responsible for 60-70% of gastric adenocarcinoma s

Answer 11

h pylori

you are at greater risk of you get the infection when you are young, and if you are one of the people who goes hypocholorohydric when they get it

H pylori will often cause inflammation, leading to gastritis, leading to gastric atrophy, which leads to gastric carcinoma

Question 12

what are the other risks for developing gastric adenocarcinoma

Answer 12

Smoking
Gastric polyps
FAP (familial adenomatous polyposis)
Genetic factors – e.g. HDC-1 mutations
Resection of the stomach

Question 13

what are the symptoms of gastric adenocarcinoma

Answer 13

History of recent dyspepsia.(50%) This pain will be very similar to that of peptic ulcer disease, and can often be relieved by antacids.
Loss of appetite / anorexia (35%)
Bloating / fullness
Weight loss (72%)
Vomiting/nausea (40%)
Iron-deficiency anaemia due to occult bleeding
Dysphagia (22%)
Melaena (20%)
Mass (17%)
Haematemesis is unusual

Question 14

what are the red flag symptoms

Answer 14

patients of any age, with dyspepsia, AND
- chronic GI bleeding
- dysphagia
- progressive wright loss
- iron deficiency anaemia
- perisitent vomtiing
- epigastric mass
- suspicious barium meal result

OR

patients > 55
- with sudden onset dyspepsia

Question 15

what are the tests done to confirm gastric adenocarcinoma

Answer 15

essentially all you need to do is a gastroscopy and routine FBC, and LFTs

Question 16

what is the most common genetic factor for gastric adenocarcinoma

Answer 16

loss of the TSG p53 which occurs in about 70% of gastric cancersw

Question 17

where are early gastric cancers confined to

Answer 17

the mucosa and the submucosa, whilst more advanced cancers can penetrate the muscular proproria, and may become ulcerating

Question 18

what is the prognosis for early gastric cancer

Answer 18

90%

Question 19

how can the cancers be described

Answer 19

as either intestinal or diffuse

intestinal ones have histology representative of internal epithelium, whilst diffuse ones arise form normal gastric mucosa

Question 20

who do diffuse cancers tend to occur in

Answer 20

younger patients

Question 21

what is the pattern of the disease

Answer 21

initially there will be chronic gastritis leading to atrophy, then onto metaplasia, and premalignant dysplasia, finally ending up at malignancy

Question 22

where can gastric cancer spread lymphatic ally to

Answer 22

the Virchow’s node, and can spread via venous blood to the liver and ovaries

Question 23

what are Krukenburg tumours

Answer 23

spread of cancer via the venous blood to the liver and ovaries

Question 24

what will a CT show

Answer 24

liver metastasis, but not lymph node involvement. will also show gastric wall thickening

Question 25

what will an endoscopic ultrasound show

Answer 25

how far the tumour has progressed through the gastric wall and lymph node involvement

Question 26

what is the other way to stage gastric tumours apart from TNM

Answer 26

UICC score

Question 27

what is the best form of treatment

Answer 27

surgery is the best form of treatment

Question 28

what does this surgery involve

Answer 28

a partial or total resection of the stomach, and removal of varying amounts of surrounding lymph nodes

Question 29

what are the only treatments available for those who surgery is not available to

Answer 29

only palliative care, pain relief and counselling are available

Question 30

what are the early complications of surgery

Answer 30

usually respiratory, cardiac and wound complications leakage at the point of anastomosis, particularly if it was a total gastrectomy, and the oesophagus is joint straight onto the jejunum fluid collection and accesses around areas of lymph node dissection acute pancreatitis if lymph nodes form this region have been removed nasogastric drainage if the jejunum doesn't drain well after the operation

Question 31

what are the features of late complications of surgery usually

Answer 31

these are normally due to physiological changes in the upper GI tract. most of these will appear within a few months of surgery, but then disappear within a year

Question 32

what are the actual late complications of surgery

Answer 32

Reflux gastritis due to loss of the pyloris and reflux of biliary contents into the stomach. Most patients who have surgery will have endoscopic evidence of gastritis, but only a small percentage will have significant symptoms. Dumping – is a term used to refer to many symptoms that are attributed to rapid gastric emptying. These symptoms include: Fullness Pain Nausea Diarrhoea Vomiting Vasomotor symptoms – i.e. the symptoms affecting the level of dilatation of the blood vessels. These are due to rapid fluid shifts into the bowel lumen, and are similar to the symptoms of hypovolaemia. Hypovolaemia is a decreased blood volume. Late dumping – this is due to an insulin surge soon after a meal followed by reactive hypoglycaemia. Dumping is treated by controlling the diet. Patient’s should eat lots of small meals, keep dry food and liquids separate, and avoid simple sugars. The symptoms of dumping will lessen over time. Weight loss – Patients who have a total gastrectomy will lose about 10% of their body weight, whilst those who have a partial gastrectomy will only lose about 5%. This is due to a combination of factors, including, symptoms of dumping, change in diet, gastritis, and possibly due to continuing cancer progression. Anaemia – very common as a result of loss of intrinsic factor due to the fact you have removed the parietal cells in the stomach! Another factor will also be that iron remains in its insoluble ferric form, as there may not be enough acid to convert it to ferrous. After a total gastrectomy, patients have to have vitamin B12 injections. Increased risk of osteoporosis and osteomalacia – it is not entirely clear why this is the case, but it is possibly to do with reduced calcium / vitamin D absorption

Question 33

what is one of the most common indications for palliative care

Answer 33

gastric outlet obstruction from a stenosing distal gastric cancer, but there are many others

Question 34

what is the median life expectancy for somebody just diagnosed with incurable gastric cancer

Answer 34

4-6 months it is very important that a palliative plan is put in place as soon as possible after diagnosis

Question 35

what percentage of all gastric neoplasms does gastric lymphoma account for

Answer 35

2-5%

Question 36

where do gastric lymphomas occur

Answer 36

in the mucosa associated lymphoid tissue (MALT) this type of tissue appears in the stomach as a result of chronic inflammation, which is thought to be a result of h pylori infection

Question 37

is MALT tissue normally present in the stomach

Answer 37

NO

Question 38

the lymphomas are normally ? cell derived?

Answer 38

normally B cell derived although T cell ones do sometimes occur

Question 39

how can these gastric lymphomas be classified

Answer 39

as high or low grade low grade tumours are treated with H pylori eradication treatment, and this'll also result in healing of the tumour in 70-100% of cases high grade tumours are treated with chemoradiotherapy

Question 40

what is Murphy's sign

Answer 40

this is pain in the right upper quadrant from local peritoneum from acute cholecysitits

Question 41

what is a paraumbilical hernia

Answer 41

a paraumbilical hernia should present with a lump around the umbilicus. there may be skin changes over this lump if there are incarcerated contents within the hernia

Question 42

what is Cullens sign

Answer 42

this is periumbilical ecchymosis

Question 43

what is Caput Medusae

Answer 43

these are periumbilical varies that branch out from the umbilicus that occurs with portal hypertension from liver cirrhosis

Question 44

what is Rovsing's sign

Answer 44

this is pain felt in the right iliac fossa on palpation in the left iliac fossa from local peritoneum from acute appendicitis

Question 45

what is Grey-Turner's sign

Answer 45

ecchymosis in either flank

Question 46

what do Cullen's and Grey-Turner's sign both indicate

Answer 46

internal haemorrhage which can present in acute pancreatitis, splenic rupture or perforatied peptic ulcer disease when these signs result from acute haemorrhagic pancreatitis, this can indicate severe disease and higher mortality

Question 47

what is acute pancreatitis

Answer 47

is an inflammation of the pancreas caused by an activation of pancreatic enzymes and autodigestion it can often cause a SIRS which in turn can cause organ failure such as AKI, and respiratory failure

Question 48

how is acute pancreatitis diagnosed

Answer 48

a diagnosis requires at least 2 of the following 3 features; - abdominal pain - serum lipase/amylase levels greater than 3 times the upper limit of normal - radiological evidence of pancreatitis

Question 49

what is more sensitive, lipase or amylase

Answer 49

lipase Amylase rises rapidly within 2 hours of the onset of acute pancreatitis, and peaks between 12 and 72 hours. It is then excreted rapidly by the kidneys, with levels returning to normal as soon as 3 days. Lipase, however, peaks at 24 hours and can remain elevated for between 8 and 14 days as it is reabsorbed by the renal tubules back into the circulation. This biochemical profile makes lipase a much better clinical test for acute pancreatitis.

Question 50

what is the description of mild acute pancreatitis

Answer 50

no organ failure or local/systemic complications

Question 51

what is the description of moderate severe acute pancreatitis

Answer 51

transient organ failure such as AKI, resolving within 48 hours may have local complication

Question 52

what is the description of severe acute pancreatitis

Answer 52

persistent organ failure or multi organ failure

Question 53

what are the two types of acute pancreatitis

Answer 53

interstitial oedematous pancreatitis and necrotising pancreatitis

Question 54

what is the most common type of pancreatitis

Answer 54

interstitial oedematous pancreatitis pancreatic parenchyma is inflamed or oedematous

Question 55

what does interstitial oedematous pancreatitis lead to

Answer 55

acute peripancreatic fluid collection (APFC) occurs within 4 weeks, the fluid is extra pancreatic in location if not resolved within 4 weeks, it may organise and become a pseudocyst

Question 56

what is a pseudocyst

Answer 56

a homogenous fluid filled collection with a cyst wall can compress on surrounding structures, such as the stomach

Question 57

what is necrotising pancreatitis

Answer 57

necrosis of the pancreatic parenchyma and or peripancreatic tissue may become infected

Question 58

what does necrotising pancreatitis lead to

Answer 58

acute necrotic collection (ANC) occurs within 4 weeks. the fluid is intra or extra pancreatic in location inhomogeneous collection of fluid and solid components no wall

Question 59

what is walled off necrosis (WON)

Answer 59

occurs after 4 weeks of onset of pain

Question 60

what are the causes for acute pancreatitis

Answer 60

ERCP alcohol gallstone disease autoimmune diswase family history idiopathic high serum triglyceride levels

Question 61

what criteria is used to diagnose acute pancreatitis

Answer 61

Atlanta criteria

Question 62

what does the Atlanta criteria state

Answer 62

that the patent should have two of the following to diagnose acute pancreatitis ; 1. epigastric pain 2. raised lipase/amylase 3. radiological evidence of acute pancreatitis

Question 63

once diagnosis has been established, what is the next most appropriate investigation in patients pathway of acre

Answer 63

ultrasound of the abdomen Investigations should focus firstly on establishing the diagnosis. If the diagnosis at admission is at all unclear, then a CT scan would be warranted to rule out any other pathology. A CT for acute pancreatitis within the first week correlates very poorly with clinical severity, as is its sensitivity for diagnosing necrotising pancreatitis within the first few days. CT imaging is most useful 5-7 days after hospital admission, as this is the timeframe for when local complications may develop. An US Abdo is therefore the next appropriate investigation for the patient. Although he has a clear risk factor (i.e., high alcohol intake), gallstone disease accounts for over 50% of acute pancreatitis cases and needs to be ruled out as a cause. An US is the investigation of choice for this.

Question 65

w