24- Upper GIT Explains 2 Flashcards
What are the main risk factors for pancreatic adenocarcinoma?
Smoking, diabetes, adenoma, familial adenomatous polyposis
In which part of the pancreas does adenocarcinoma mainly occur?
Head of the pancreas (70%)
How does pancreatic adenocarcinoma spread?
It spreads locally and metastasizes to the liver
Why is it important to differentiate carcinoma of the pancreas from other periampullary tumors?
Pancreatic carcinoma has a worse prognosis compared to other periampullary tumors
What are the clinical features of pancreatic adenocarcinoma?
Weight loss, painless jaundice, epigastric discomfort (late feature due to invasion of the coeliac plexus), pancreatitis, Trousseau’s sign (migratory superficial thrombophlebitis)
What imaging studies are used to investigate pancreatic adenocarcinoma?
Ultrasonography (may miss small lesions), CT scanning (pancreatic protocol), PET/CT (for operable disease), ERCP/MRI (bile duct assessment), staging laparoscopy (to exclude peritoneal disease)
How can jaundice in pancreatic adenocarcinoma be managed?
ERCP and stent placement for palliation
What is the management approach for adenocarcinoma in the head of the pancreas?
Whipple’s resection (with the possibility of dumping syndrome and ulcers). Pylorus preservation and SMA/SMV resection are newer techniques.
What is the management approach for adenocarcinoma in the body and tail of the pancreas?
Distal pancreatectomy, with a poor prognosis
What is the usual treatment for resectable pancreatic adenocarcinoma?
Adjuvant chemotherapy
What procedure may be necessary for duodenal obstruction caused by pancreatic adenocarcinoma?
Surgical bypass
What are some extrinsic causes of dysphagia?
Mediastinal masses and cervical spondylosis
What are some examples of intrinsic causes of dysphagia?
Tumours, strictures, oesophageal web, and Schatzki rings
What is an example of an oesophageal wall cause of dysphagia?
Achalasia
Which neurological conditions can cause dysphagia?
CVA (cerebrovascular accident), Parkinson’s disease, multiple sclerosis, brainstem pathology, and myasthenia gravis
What is the recommended investigation for all patients with dysphagia?
Upper GI endoscopy, unless there are compelling reasons not to perform it
How can motility disorders be best appreciated in dysphagia patients?
Fluoroscopic swallowing studies
What blood test should be performed in patients with dysphagia?
Full blood count
What additional studies may be required to evaluate conditions like achalasia and GERD in dysphagia patients being considered for fundoplication surgery?
Ambulatory esophageal pH and manometry studies
What causes benign prostatic hyperplasia (BPH)?
An increase in the epithelial and stromal cell numbers in the peri-urethral zone of the prostate
How common is BPH in men over 80 years old?
90% of men aged over 80 will have at least microscopic evidence of BPH
What are the common lower urinary tract symptoms associated with BPH?
Poor flow, nocturia, hesitancy, incomplete and double voiding, terminal dribbling, urgency, incontinence
What are the medical therapy options for BPH?
Alpha blockers and 5 α reductase inhibitors
What examinations and tests are done to investigate BPH?
Digital rectal examination (to assess prostatic size and morphology), urine dipstick (for infections and haematuria), uroflowmetry (to assess flow rate and exclude BOO), bladder pressure studies (for detrusor failure, in atypical symptoms or prior to redo surgery), bladder scanning (to measure residual volumes), ultrasound (if high pressure chronic retention)
What lifestyle changes can help manage mild BPH symptoms?
Stopping smoking and altering fluid intake
How do alpha blockers work in BPH?
They work quickly on receptor zones located at the bladder neck
What are the potential side effects of alpha blockers?
Well-documented cardiovascular side effects
What is the role of 5 α reductase inhibitors in preventing acute urinary retention?
They may help prevent acute urinary retention
How do 5 α reductase inhibitors work in BPH?
They work on testosterone metabolizing enzymes and have a slower onset of action
What is the surgical therapy of choice for severe BPH symptoms or if medical therapy fails?
Transurethral resection of the prostate (TURP)
What alternative surgical procedures may be considered for small prostates?
More tailored bladder neck incision procedures
What potential complication may occur following surgical therapy for BPH?
Retrograde ejaculation
How has the change in irrigation solutions helped minimize complications during TURP?
It has minimized the TURP syndrome of electrolyte disturbances
What is the most common cause of biliary disease in patients with HIV?
Sclerosing cholangitis due to infections like CMV, Cryptosporidium, and Microsporidia
What can cause pancreatitis in the context of HIV infection?
Anti-retroviral treatment, especially didanosine, or opportunistic infections like CMV
Why do treatments differ for SCC’s and adenocarcinomas of the oesophagus?
Due to positive outcomes observed with radical chemoradiotherapy for localised SCC’s, obviating the need for surgery
What are the surgical options for oesophageal cancer treatment?
Endoscopic mucosal resection (for early localised adenocarcinoma of the distal oesophagus), transhiatal oesophagectomy (commonly used for junctional tumors), Ivor Lewis oesophagectomy (two stage approach for middle and distal tumors), McKeown oesophagectomy (three field approach, useful for proximal tumors)
Who should be considered for surgery in oesophageal cancer treatment?
Only patients whose staging investigations are negative for metastatic disease
Is neoadjuvant radiotherapy alone routinely performed prior to resection?
No, it confers little benefit and is not routinely performed
What is associated with a survival advantage in oesophageal cancer treatment?
Preoperative chemotherapy (OE02 trial) and perioperative chemotherapy in junctional tumors
Is postoperative chemotherapy generally recommended following oesophageal resections?
No, it is not generally recommended outside of clinical trials
What strategies are used for palliation in non-operable oesophageal cancer?
Combination chemotherapy to improve quality of life and survival, trastuzumab for HER2 positive tumors, oesophageal intubation with self-expanding metal stents for occluding tumors >2cm from the cricopharyngeus, covered metal stents for malignant fistulas, laser therapy and argon plasma coagulation for tumor overgrowth and bleeding
Are photodynamic therapy and ethanol injections routinely used in oesophageal cancer treatment?
No, they confer little benefit and should not be routinely used
What can cause haematuria due to trauma?
Injury to the renal tract, commonly due to blunt injury, but can also be caused by penetrating injuries. Ureter trauma is rare and usually iatrogenic. Bladder trauma can occur due to road traffic accidents or pelvic fractures.
What infection should be remembered as a cause of haematuria?
Tuberculosis
Which malignancies can cause haematuria?
Renal cell carcinoma (may present with paraneoplastic syndromes), urothelial malignancies (transitional cell carcinoma, painless haematuria), squamous cell carcinoma and adenocarcinoma (rare bladder tumors), prostate cancer, and penile cancers (squamous cell carcinoma)
What renal disease can cause haematuria?
Glomerulonephritis
What are some structural abnormalities that can cause haematuria?
Benign prostatic hyperplasia (BPH) due to hypervascularity of the prostate gland, cystic renal lesions (e.g., polycystic kidney disease), vascular malformations, and renal vein thrombosis due to renal cell carcinoma
What coagulopathy can cause bleeding of underlying lesions?
Coagulopathy
Which drugs can cause haematuria?
Aminoglycosides, chemotherapy (causing tubular necrosis or interstitial nephritis), penicillin, sulphonamides, NSAIDs (causing interstitial nephritis), and anticoagulants
What non-pathological cause of haematuria should be considered?
Exercise-induced haematuria
Which gynaecological condition can cause haematuria?
Endometriosis, presenting with flank pain, dysuria, and cyclical haematuria
What iatrogenic factors can cause haematuria?
Catheterisation and radiotherapy (causing cystitis, severe haemorrhage, and bladder necrosis)
What can cause pseudohaematuria?
Consumption of beetroot
What are penile fractures?
Rare urological trauma involving a fracture in the proximal part of the penile shaft, often involving the urethra.
What is the typical history given by patients with penile fractures?
A snapping sensation followed by immediate pain, usually occurring during vigorous intercourse.
What can be observed during examination of a penile fracture?
Tense haematoma and blood at the meatus if the urethra is injured.
What is the recommended management for penile fractures?
Surgical intervention, specifically a circumferential incision made immediately inferior to the glans.
What is done during the surgical procedure for penile fractures?
The skin and superficial tissues are stripped back, and the penile shaft is inspected. Injuries are usually sutured, and the urethra is repaired over a catheter.
What is tuberous sclerosis (TS)?
A genetic condition with autosomal dominant inheritance.
What are the cutaneous features of TS?
Depigmented ‘ash-leaf’ spots that fluoresce under UV light, roughened patches of skin over the lumbar spine (Shagreen patches), adenoma sebaceum (butterfly distribution over the nose), fibromata beneath nails (subungual fibromata), and café-au-lait spots (less commonly seen).
What are the neurological features of TS?
Developmental delay, epilepsy (infantile spasms or partial), and intellectual impairment.
What other features can be seen in TS?
Retinal hamartomas (dense white areas on the retina), rhabdomyomas of the heart, gliomatous changes in brain lesions, and polycystic kidneys with renal angiomyolipomas.
What is the prevalence of café-au-lait spots in TS?
Café-au-lait spots are less commonly associated with TS, but a 1998 study found them in 28% of patients.
In which country is gastric cancer most common?
Japan
Do Japanese migrants retain their increased risk of gastric cancer?
Yes, although the risk decreases in subsequent generations
Is gastric cancer more common in men or women?
Men
What are some risk factors for gastric cancer?
Smoking, consumption of smoked or preserved foods
What is the proposed progression of gastric cancer?
From intestinal metaplasia to atrophic gastritis and subsequent dysplasia, leading to cancer
What is the favored staging system for gastric cancer?
TNM
What is the risk of lymph node involvement in early cancers confined to submucosa?
20% incidence of lymph node metastasis
How are tumours of the gastro-oesophageal junction classified?
As Type 1 (associated with Barrett’s esophagus), Type 2 (arising from cardiac type epithelium or with intestinal metaplasia), and Type 3 (subcardial cancers that spread across the junction)
Which groups require close endoscopic monitoring for gastric cancer?
Those with intestinal metaplasia of columnar type, atrophic gastritis, and low to medium grade dysplasia. Also, patients who have previously undergone resections for benign peptic ulcer disease (except highly selective vagotomy).
Which patients with dyspepsia should be referred for endoscopy?
Patients of any age with dyspepsia and any of the following: worsening dyspepsia, chronic gastrointestinal bleeding, dysphagia (Barrett’s esophagus or unexplained), unexplained abdominal pain or weight loss, weight loss with vomiting, iron deficiency anemia, upper abdominal mass, or atrophic gastritis. Also, patients aged over 55 years with unexplained or persistent dyspepsia.
What is the routine first-line staging investigation for gastric cancer?
CT scanning of the chest, abdomen, and pelvis
What is the purpose of laparoscopy in gastric cancer staging?
To identify occult peritoneal disease
Which imaging modality is particularly useful for junctional tumors?
PET CT
What surgical treatment options are available for gastric cancer?
Subtotal gastrectomy for proximally sited disease greater than 5-10cm from the OG (esophagogastric) junction, total gastrectomy if the tumor is <5cm from the OG junction, and esophagogastrectomy for type 2 junctional tumors extending into the esophagus. Endoscopic submucosal resection may be considered for early gastric cancer confined to the mucosa or submucosa.
Should lymphadenectomy be performed in gastric cancer?
Yes, a lymphadenectomy should be performed. A D2 lymphadenectomy is widely advocated by the Japanese, although the survival advantages of extended lymphadenectomy are debated.
Do most patients with gastric cancer receive chemotherapy?
Yes, most patients will receive chemotherapy either before or after surgery (pre or postoperatively).
What is the 5-year survival rate for all RO resections?
54
What is the 5-year survival rate for early gastric cancer?
91%
What is the 5-year survival rate for stage 1 gastric cancer?
87%
What is the 5-year survival rate for stage 2 gastric cancer?
65%
What is the 5-year survival rate for stage 3 gastric cancer?
18%
What is the first step in the procedure after making the incision?
Perform a thorough laparotomy to identify any occult disease
What is the operative procedure for gastric cancer involving total gastrectomy?
Total gastrectomy, lymphadenectomy, and Roux-en-Y anastomosis
What type of anesthesia is used for the procedure?
General anesthesia
What is the purpose of prophylactic intravenous antibiotics?
To prevent infection
What type of incision is made for the procedure?
Rooftop incision
How is the left lobe of the liver mobilized during the procedure?
It is mobilized off the diaphragm and covered with a large pack
What structures are mobilized during the dissection?
The omentum, short gastric vessels, and pylorus
At what distance is the pylorus divided using a linear cutter stapling device?
At least 2cm distally
What is the next step after dividing the pylorus?
Continue the dissection into the lesser sac, taking the lesser omentum and left gastric artery flush at its origin
What should be done with the lymph nodes during the procedure?
They should be removed en bloc with the specimen where possible
How is the oesphago jejunal anastomosis constructed?
The distal oesophagus is divided, and the oesophagus is anastomosed to the jejunum, followed by the creation of the Roux-en-Y reconstruction distally
What should be done at the end of the procedure before closing the abdomen and skin?
Wash out the abdomen, insert drains (usually at the anastomosis and duodenal stump), and help the anaesthetist insert the nasogastric tube
When can enteral feeding commence after the surgery?
It may commence on the first post-operative day, but most surgeons will keep patients on free NG drainage for several days and keep them nil by mouth
What is the normal process of gastric emptying?
Gastric emptying is a co-ordinated process involving contractions of the stomach, relaxation of the pylorus, and digestion.
What surgical procedures were often needed to address delayed gastric emptying after vagotomy?
Pyloroplasty and gastro-jejunostomy were often performed to disrupt or bypass the pylorus.
What are the effects of vagotomy on gastric emptying?
Vagotomy, a surgery to the vagus nerves, reduces gastric acid production but can cause delayed gastric emptying.
Why is a gastro-jejunostomy usually necessary following gastric surgery?
Gastro-jejunostomy is needed to provide an alternative route for gastric emptying after gastric surgery.
How does a gastro-jejunostomy affect gastric emptying?
A gastro-jejunostomy disrupts the coordinated emptying of the stomach, resulting in rapid entry of carbohydrate-rich loads into the proximal small bowel.
What are the short-term consequences of rapid emptying into the small bowel after a gastro-jejunostomy?
Rapid emptying can cause significant fluid shifts into the small bowel, leading to increased gut transit times.
What is the potential hormonal effect of rapid emptying after a gastro-jejunostomy?
Rapid emptying can stimulate increased insulin release, which may lead to rebound hypoglycemia and the symptoms of late dumping syndrome.
Which nerves are responsible for erection and ejaculation?
Autonomic sympathetic nerves (T11-L2) and parasympathetic nerves (S2-4)
What is the role of sympathetic discharge in penile ejaculation and detumescence?
Sympathetic discharge causes ejaculation and detumescence.
What is the role of parasympathetic discharge in penile erection?
Parasympathetic discharge causes erection.
Which muscles are innervated by somatic nerves during penile erection?
Ischiocavernosus and bulbocavernosus muscles
What triggers the flow of arterial blood into the penile sinusoidal spaces?
Autonomic discharge to the penis triggers the veno-occlusive mechanism, leading to the flow of arterial blood.
How does increased inflow of arterial blood affect venous return during erection?
Increased inflow compresses the subtunical venous plexus, reducing venous return.
What is priapism?
Prolonged, unwanted erection lasting more than 4 hours without sexual desire.
What happens during the detumescence phase of penile erection?
Arteriolar constriction reduces arterial inflow, allowing venous return to normalize.
What are the common causes of low flow priapism?
Veno-occlusion, often associated with high intracavernosal pressures.
What are the two types of priapism?
Low flow priapism and high flow priapism
What are the common causes of high flow priapism?
Unregulated arterial blood flow
What is the typical presentation of high flow priapism?
Semi-rigid, painless erection
Which condition is recurrent priapism commonly seen in?
Sickle cell disease, often of the high flow type
What are some possible causes of priapism?
Intracavernosal drug therapies, blood disorders, neurogenic disorders, trauma to the penis resulting in arterio-venous malformations
How can the type of priapism be determined?
Blood sampling from the cavernosa can help determine if it is a high flow or low flow type
What can happen if low flow priapism is not treated promptly?
Delayed therapy may result in erectile dysfunction.
What is the management for priapism?
Ice packs, cold showers, aspiration of blood from corpora or intracavernosal alpha adrenergic agonists for low flow priapism
What is schistosomiasis?
Schistosomiasis, also known as bilharzia, is a parasitic flatworm infection.
What are the recognized types of schistosomiasis?
Schistosoma mansoni and Schistosoma intercalatum cause intestinal schistosomiasis, while Schistosoma haematobium causes urinary schistosomiasis.
What are the features of Schistosoma haematobium infection?
Schistosoma haematobium infection typically presents as “swimmer’s itch” in individuals who have recently returned from Africa. It is also a risk factor for squamous cell bladder cancer.
What are the common symptoms of Schistosoma haematobium infection?
Haematuria (blood in urine) and bladder calcification are common symptoms.
What is the management approach for schistosomiasis?
The management involves a single oral dose of praziquantel.
What is cryptorchidism?
Cryptorchidism is a condition where a testis fails to descend into the scrotum by three months of age.
What is the incidence of cryptorchidism by three months of age?
By three months of age, the incidence of cryptorchidism falls to 1-2%.
What is the cause of maldescent in most cases of cryptorchidism?
The cause of maldescent is usually unknown.
What is the incidence of undescended testis at birth?
Up to 5% of boys may have an undescended testis at birth.
What are some congenital defects that may be associated with cryptorchidism?
Congenital defects such as patent processus vaginalis, abnormal epididymis, cerebral palsy, mental retardation, Wilms tumor, and abdominal wall defects (e.g., gastroschisis, prune belly syndrome) may be associated with cryptorchidism.
When is surgery indicated for retractile testes?
Surgery is indicated if the testis rapidly returns into the inguinal canal when released by the examining clinician.
What are the differential diagnoses for cryptorchidism?
Differential diagnoses include retractile testes and intersex conditions in cases of absent bilateral testes.
What are the reasons for correcting cryptorchidism?
The reasons for correction include reducing the risk of infertility, examining the testes for testicular cancer, avoiding testicular torsion, and improving cosmetic appearance.
What is the increased risk associated with males having undescended testes?
Males with undescended testes are 40 times more likely to develop testicular cancer (seminoma) than males without undescended testes.
What is the recommended treatment for cryptorchidism?
Orchidopexy, performed at 6-18 months of age, is the recommended treatment. The procedure involves exploring the inguinal area, mobilizing the testis, and implanting it into a dartos pouch.
What is the recommended approach for individuals presenting with late-stage cryptorchidism?
In untreated individuals presenting after the age of 2 years, orchidectomy (removal of the testis) may be preferable to salvaging a non-functioning testis with an increased risk of malignancy.
How should an intra-abdominal testis be evaluated and mobilized?
An intra-abdominal testis should be evaluated laparoscopically and then mobilized. The approach may be a single-stage or two-stage procedure depending on the exact location.
What are the potential post gastrectomy syndromes?
Post gastrectomy syndromes may vary depending on whether a total or partial gastrectomy is performed.
Which reconstruction method generally provides the best functional outcomes?
A Roux en Y reconstruction generally gives the best functional outcomes.
How can gastric emptying be improved following a distal gastrectomy with gastrojejunostomy reconstruction?
Gastric emptying is generally better if the jejunal limbs are tunneled in the retrocolic plane.
What are the post gastrectomy syndromes that may occur?
Post gastrectomy syndromes that may occur include small capacity (early satiety), dumping syndrome, bile gastritis, afferent loop syndrome, efferent loop syndrome, anemia (B12 deficiency), and metabolic bone disease.
What are insulinomas?
Insulinomas are tumors that produce insulin in the pancreatic β cells.
What is the incidence of insulinomas?
The incidence of insulinomas is approximately 1 per 1,000,000 per year.
What percentage of insulinoma lesions are benign?
Approximately 90% of insulinoma lesions are benign.
What percentage of insulinomas are associated with MEN type 1?
Between 5 and 10% of insulinomas are associated with MEN type 1.
What is the typical size of most insulinomas?
Most insulinomas are less than 2cm in size.
What tests are performed to diagnose insulinoma?
When neuroglycopenic symptoms occur, blood is taken for serum insulin levels, serum glucose, C-peptide, and proinsulin concentrations. The plasma insulin concentration is typically >10 micro U/ml in patients with insulinoma.
What percentage of patients with MEN 1 will develop pancreatic islet cell tumors?
Approximately 75% of patients with MEN 1 will develop pancreatic islet cell tumors.
What are the typical features of insulinoma?
Typical features of insulinoma include symptomatic hypoglycemia during fasting, concomitant blood glucose of less than 3mmol/L, and relief of hypoglycemia with glucose use.
What imaging methods are used for tumor localization in insulinoma?
Imaging methods such as ultrasound (25% accuracy), endoscopic ultrasound (75% accuracy), CT scanning (pancreatic protocol=40% accuracy), and MRI (nearly 100% accuracy for malignant insulinomas) are used for tumor localization.
What is the recommended treatment for insulinoma?
Since the majority of insulinomas are benign, blind segmental resection of the pancreas (e.g., Whipple procedure) is not justified. However, for malignant lesions, it may be considered acceptable. Intraoperative ultrasonography is used to identify the lesion, and the perioperative use of octreotide reduces pancreatic drainage but does not decrease overall complications.
