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Year 3 > Week Ten - Case Three > Flashcards

Week Ten - Case Three Flashcards

1
Q

what is the criteria for a direct access upper GI endoscopy?

A

1.3 Referral guidance for Endoscopy links to NICE guidelines on suspected cancer: recognition and referral (1.2.7. endoscopy for people with dysphagia or aged > 55 with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia).

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2
Q

what is the most common histological type of gastric cancer

A

adenocarcinomas

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3
Q

what is it called when an adenocarcinoma spreads primarily through the musculature of the stomach wall

A

the thickening is called linitis plastica

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4
Q

what is the 5 year survival for stage 4 cancer

A

less than 1%

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5
Q

what are the risk factors for gastric adenocarcinoma

A

Age (75 years and over)
Male (2:1 – 12:1)
H.pylori infection
Familial adenomatous polyposis (FAP)
Ethnicity (Black, Hispanic and Asian)
Smoking and alcohol
Diet
Obesity – more so in men

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6
Q

what are the 5 investigations carried out for suspected gastric adenocarcinomas

A
  1. upper GI endoscopy
  2. minimum of 6 biopsies
  3. initial staging CT t,a,p
  4. discussion at MDT
  5. staging laparoscopy
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7
Q

what is a peptic ulcer

A

a break in the mucosal lining of the stomach (gastric ulcer) or duodenum. (duodenal ulcer)

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8
Q

where does the disruption usually extend into

A

the submucosa or the muscularis propria

usually more than 5mm in diameter

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9
Q

what are the risk factors for peptic ulcer disease

A

alcohol
smoking
blood group O
naproxen
h pylori

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10
Q

what kind of pain is typical of peptic ulcer pain

A

epigastric pain that is constant, radiates into the back usually when hungry

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11
Q

what are the typical symptoms of peptic ulcer disease

A

epigastric pain, early satiety, reflux symptoms, and nausea

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12
Q

what is the relationship between H pylori and stomach acid

A

h pylori is protected from stomach acid as it uses its flagella to migrate into the mucous lining from the stomach wall to bind to epithelial cells. it also produces urease to neutralise stomach acid into CO2 and ammonia

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13
Q

can patients with h pylori be asymptomatic

A

yes

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14
Q

how its H pylori transmitted

A

can be transmitted by the oral to oral route, or faecal oral route

h pylori has been isolated from saliva and faeces in infected people

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15
Q

what can an ulcer lead to if untreated

A

can erode through the entire stomach wall leading to perforation If untreated

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16
Q

how do patients present with a perforation

A

a rigid abdomen which is indicative of generalised peritonitis secondary to florid bowel contents in the peritoneal cavity. there is usually a sudden onset of epigastric pain before becoming more generalised in nature

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17
Q

what is the A and E management of a patient with perforation

A

NBM
antibiotics
general surgery team
analgesia
antiemetics
VTE prophylaxis
fluid balance

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18
Q

what are the most common postoperative complications from a laparotomy

A

intra-abdominal collection
LRT infection
urinary tract infection
ongoing leak form the site of the perforation
DVT
postoperative ileus

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19
Q

what do peptic ulcers involve

A

ulceration of the mucosa of the stomach or the proximal duodenum

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20
Q

what type of ulcer is the most common

A

duodenal ulcers are the most common

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21
Q

what are the risk factors for peptic ulcers

A

helicobacter pylori
NSAIDs

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22
Q

what are the key risk factors that increase stomach acid

A

stress
alcohol
caffeine
smoking
spicy foods

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23
Q

what is the risk of bleeding from a peptic ulcer increased with the use of

A

NSAIDs
aspirin
DOACs
steroids
SRRI antidepressants

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24
Q

how do peptic ulcers present

A

Epigastric discomfort or pain
Nausea and vomiting
Dyspepsia

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25
Q

what are the signs of upper GI bleeding

A

Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in haemoglobin on a full blood count

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26
Q

what can chronic microscopic bleeding lead to

A

iron deficiency anaemia, with low haemoglobin, low mean cell volume and low ferritin

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27
Q

what typically worsens the pain of gastric ulcers

A

eating

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28
Q

what typically improves the pain associated with duodenal ulcers

A

the pain of duodenal ulcers tends to improve immediately after eating, followed by pain 2-3 hours later.

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29
Q

in MCQ’s, how do we differentiate between gastric and peptic, apart from the pain

A

patients with gastric ulcers tend to lose weight due to fear of pain on eating, whereas with duodenal ulcers, the weight is stable or increases

30
Q

what are the 3 core aspects of treating peptic ulcers

A

stopping NSAIDs
treating h pylori infections
PPIs

31
Q

what may be performed at 4-8 weeks to ensure the ulcer heals

A

repeat endoscopy

32
Q

what are the three complications of peptic ulcers

A

bleeding
perforation
scarring and strictures

33
Q

what does perforation result in

A

acute abdominal pain and peritonitis, requiring urgent surgical repair, which is usually done laparoscopically

34
Q

what can scarring and strictures lead to

A

narrowing of the exit of the stomach, causing difficulty emptying the stomach contents

35
Q

how does gastric outlet obstruction present

A

with early fullness after eating, swell as upper abdominal discomfort, abdominal distention and vomiting, particularly after eating

36
Q

how is gastric outlet obstruction treated

A

with balloon dilatation during an endoscopy or surgery

37
Q

what are the vast majority of pancreatic cancers

A

adenocarcinomas and occur in the head of the pancreas as opposed to the body or tail

38
Q

what can the tumour result in

A

jaundice

once the tumour in the head of the pancreas grows large enough, it can compress the bile ducts, resulting in obstructive jaundice

39
Q

where does pancreatic cancer spread and what is the average survival

A

pancreatic cancers tend to spread and metastasis early, particularly to the liver, then to the peritoneum, lungs and bones.

the average survival when diagnosed with advanced disease is around 6 months

40
Q

what is the survival rate when it is caught early

A

When caught early, the cancer is isolated to the pancreas and surgery is possible, the 5-year survival is still around 25% or less.

41
Q

what is the key presenting features that should make you immediately consider pancreatic cancer and what is the key differential

A

painless obstructive jaundice is the key presenting features and the key differential is cholangiocarcinoma

42
Q

what does painless obstructive jaundice present with

A

presents with:
Yellow skin and sclera
Pale stools
Dark urine
Generalised itching

43
Q

what are the other vague presenting features for pancreatic cancer

A

Non-specific upper abdominal or back pain

Unintentional weight loss

Palpable mass in the epigastric region

Change in bowel habit

Nausea or vomiting

New-onset diabetes or worsening of type 2 diabetes

44
Q

in relation to diabetes, what can be a sign of pancreatic cancer

A

a new onset of diabetes, or a rapid worsening of glycemic control type 2 diabetes

45
Q

what are the NICE guidelines for referring suspected pancreatic cancer

A
  • over 40 with jaundice - referred on a 2 week wait referral
  • over 60 with weight loss plus an additional symptom - referred for a direct accesss CT abdomen
46
Q

what are the additional symptoms for those over 60

A

Diarrhoea
Back pain
Abdominal pain
Nausea
Vomiting
Constipation
New-onset diabetes

47
Q

what is the only scenario where GPs can refer directly for a CT scan

A

suspected pancreatic cancer

Whenever guidelines and clinical practice have notable exceptions like this it is worth taking note of, as these make good facts for examiners to test your knowledge on.

48
Q

what is Courvoisier’s Law

A

states that a palpable gallbladder along with jaundice is unlikely to be gallstones

the cause is usually cholangiocarcinoma or pancreatic cancer

49
Q

what does Trousseau’s sign of malignancy refer to

A

refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma

50
Q

what is thrombophlebitis

A

where blood vessels become inflamed with an associated blood clot (thrombus) in that area. migratory refers to the thrombophlebitis recurring in different location over time

51
Q

what is diagnosis of pancreatic cancer usually based on

A

imaging (CT scan) plus histology from the biopsy

52
Q

what does a staging CT scan involve

A

Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers.

53
Q

what is the tumour marker that may be raised in pancreatic cancer

A

CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in pancreatic cancer. It is also raised in cholangiocarcinoma and a number of other malignant and non-malignant conditions.

54
Q

what may be used to access the biliary system in detail to assess the obstruction

A

Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction.

55
Q

what can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour

A

Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.

56
Q

what are the four types of surgery used in the management of pancreatic cancer

A

Total pancreatectomy

Distal pancreatectomy

Pylorus-preserving
pancreaticoduodenectomy (PPPD) (modified Whipple procedure)

Radical pancreaticoduodenectomy (Whipple procedure)

57
Q

what is a Whipple procedure

A

A Whipple procedure (pancreaticoduodenectomy) is a surgical operation to remove a tumour of the head of the pancreas that has not spread. A Whipple procedure is a massive operation so patients need to be in good baseline health. It involves the removal of the:

Head of the pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes

58
Q

what is a modified Whipple procedure

A

involves leaving the pylorus in place. it is also known as a pylorus-preserving pancreaticoduodenectomy (PPPD)

59
Q

what is cholangiocarcinoma

A

a type of cancer that originates in the bile ducts. the majority are adenocarcinomas

60
Q

where may cholangiocarcinoma affect

A

the bile ducts in the liver (intrahepatic ducts) or outside the liver (extrahepatic ducts).

61
Q

where is the most common site of cholangiocarcinoma

A

in the perihilar region, where the right and left hepatic duct have joined to become the common hepatic duct, just after leaving the liver

62
Q

what are the key risk factors for cholangiocarcinoma

A

primary sclerosing cholangitis

liver flukes (a parasitic infection)

63
Q

patients with ulcerative colitis are at risk of developing what

A

primary sclerosing cholagitis

64
Q

what is the presentation of cholangiocarcinoma

A

obstructive jaundice is the key presenting feature to remember.

65
Q

what is obstructive jaundice also associated with

A

pale stools
dark urine
generalised itching

66
Q

what are the other non-specific signs and symptoms of cholangiocarcinoma

A

Unexplained weight loss
Right upper quadrant pain
Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder)
Hepatomegaly

67
Q

how to differentiate between causes of painless jaundice in your exams

A

pancreatic cancer is more common than cholangiocarcinoma, so therefore this is the likely answer in your exams

68
Q

what is diagnosis based on

A

imaging (CT scan) and histology from a biopsy

69
Q

what tumour marker is raised in cholangiocarcinoma

A

CA 19-9

it is also raised in pancreatic cancer

70
Q

what is the management of cholangiocarcinoma

A

curative surgery may be possible however, palliative treatment involves
Stents inserted to relieve the biliary obstruction
Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
Palliative chemotherapy
Palliative radiotherapy
End of life care with symptom control

71
Q
A

Year 3 (63 decks)

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