3. GI: Clinical Medicine Flashcards by J L

GI Disorders – General Principles

General impact is often ____
Frequently misdiagnosed, untreated or undertreated
U.S.
70 million with GI disorders
> 105 million physician visits annually
Significant morbidity, mortality and decreased QoL• Are you following with your PCP for your condition?
• Population of US: 350M
○ 1 out of ____ people have a GI disorder = frequent
• Must have good reason to provide a study; insurance won’t normally pay for these procedures
• GI conditions lead to higher chance of developing ____

underestimated
5
cancer

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GERD – Epidemiology

Impairment of the esophageal sphincter allows for ____ of stomach contents
Acid, Bile, Food
US Adults complaining of “____”
40% monthly
20% weekly
7% daily
No ____ predilection; ____ > females
US / Western Europe > Asia / Africa
Hispanic-Americans > Caucasian-Americans > Asian-Americans• Tendency to develop as one gets older
• Lifestyle has an impact in developing GERD
○ Stress
○ Work lifestyle
• Some populations have higher chance of developing GERD

backflow
heartburn
age
males

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GERD - pathophysiology

• \_\_\_\_ of esophageal tube > area doesn't close off > acid/stomach contents goes back up; and \_\_\_\_ of the ES which allows it to go further into the esophageal tube

herniation

relaxation

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GERD – Clinical Presentation

____
Burning retrosternal discomfort starting in the ____ or ____ and moving upwards toward the neck
Acidic taste in mouth
____ pain
Asymptomatic
Extraesophageal manifestations
____
Odynophagia
____
Sore throat
____
Cough

	• Acidic taste
		○ Orofacial pain conditions > LP > acidic taste in mouth, or taste is altered
			§ Reflux or disease-related?
			§ If have reflux disease/mucosal disease > get reflux disorder managed to minimize component to just minimize component to oral symptoms
	• Extraesophageal
		○ These are quite common
		○ Dysphagia
			§ Problem with swallowing
		○ Odynophagia
			§ Painful swallowing
		○ Globus
			§ Lump in throat
		○ Sore throat
		○ Laryngitis
		○ Cough

heartburn
epigastrium
lower chest
gastric
dysphagia
globus
laryngitis

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GERD

Exacerbating factors
____
Citrus fruits
____ / tomato-based foods • High fat foods
____
Alcohol
Eating before ____
Risk factors
Advancing ____
Males
____
Stress
____
Cigarette smoking• Citrus and spicy/tomato foods will exacerbate any case of LP or oral lichenoid lesions as well
○ Overlap in lifestyle modifications in LP and reflux > will benefit both the oral and reflux disease
• Eating before bed
○ Need ____ hours between time you eat and lay flat for bed
• Stress = chronic disease
○ Many impacts on body
§ Not only psychologically, but also physically
□ ____ - stress, anxiety and depression is higher in this population

chocolate
spicy
caffeine
bed

age
obesity
pregnancy

3
TMD

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GERD – Diagnostic Evaluation

No standard ____ for diagnosis of GERD
Clinical symptomatology
____
____
- / - ____
Identification of exacerbating factors
Assessment of risk factors
Reflux disease questionnaire
R/O other conditions that mimic symptoms of GERD
Role of diagnostic testing• Dysphagia may or may not be there

criterion
heartburn
regurgitation
dysphagia

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RDQ

• Help give \_\_\_\_ to whether a patient will have reflux disorder
• Symptoms over past 7 days
	○ 0 day = always there
• Symptoms
	○ Heartburn
		§ For 4-7 days = 3
	○ Regurgitation
		§ The longer it's there, the higher the score
		§ If pain is ever present = \_\_\_\_
	○ Nausea is the same as \_\_\_\_; ever there = highest (3)

pain

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GERD - Complications

____
Inflammation of esophageal lining
Narrowing of the esophagus due to ____
Esophageal ulcers
Barrett esophagitis
Pre-____ change
____• Long-term complications that need to be monitored
• Narrowing or stricturing of the esophagus
○ ____ has a similar phenotype
§ Immune-mediated blistering disorder > ulcers, and when heal > leave scar tissue > narrowing of the esophagus
• Barrett esophagitis
○ Pre-malignant change seen that can lead to esophageal adenocarcinoma

esophagitis
scarring
malignant
esophageal adenocarcinoma

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GERD - Management

Treatment Goals
• Symptom ____
• Healing of ____ esophagitis
• ____ and management of GERD-related complications
• Maintenance of ____ and symptom remission

relief
erosive
prevention
mucosal

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Lifestyle Modifications
• ____ reduction
• ____ the head of the bed
• Avoid spicy food, coffee and carbonated beverages • Avoid ____ and drinking alcohol
• Do not lie flat after a meal for up to ____ hours
• Avoid heavy, fatty meals
• Avoid ____-fitting garments

* Mechanical modification > elevating head of the bed
* Patients with globus > increased awareness of their symptoms > don't wear tight-fitting garments

weight
elevate
smoking
3
tight

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GERD - Prognosis

• Anti-reflux ____
• Post surgical
____
• High ____ of GERD symptoms

GERD
• Symptoms typically ____ within weeks of treatment
• Considered a ____ disease
• ____ treatment
• Lifelong monitoring for Barret esophagus / cancer

surgery
complications
recurrence
resolve
chronic
lifelong

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PUD - Epidemiology

Erosion – ____ to the muscularis mucosae
Ulcer – ____ the muscularis mucosae
U.S.
Lifetime prevalence is 10%
4.5 million individuals affected
____ ulcers > gastric ulcers (4:1)
____ = females

superficial
penetrates
duodenal
males

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PUD - Pathophysiology

• Normal
	○ Gastric \_\_\_\_
	○ Peptic enzymes
	○ And defensive forces

• Injury > most common > \_\_\_\_infection
	○ Use aspirin frequently
	○ \_\_\_\_
	○ Hyperacidity of gastric secretions

• Impaired defenses
	○ \_\_\_\_
	○ Delayed gastric emptying
• Peptic ulceration develops

acidity
H pylori
cigarettes
ischemia

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PUD - Clinical Presentation
• \_\_\_\_ / vomiting
• Abdominal pressure / fullness • \_\_\_\_ tenderness
• Hematemesis
• \_\_\_\_

Diagnostic test of choice
____• Hematemesis
○ ____ blood
• Melena
○ ____ in stool

nausea
epigastric
melena
EGD
vomiting
blood

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Endoscopic findings and risk for future bleeding

	• Prevalence of ulcers
		○ \_\_\_\_
			§ Most common peptic ulcer
			§ Risk of further bleeding is minimal
		○ \_\_\_\_
			§ Low prevalence
			§ High risk of further bleeding
			§ Could have BV loss, can have cardiovascular problems

LOOK AT THE SCALE!

clean base

active bleeding

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ACHIEVING HEMOSTASIS

Epinephrine sclerotherapy
Bicap electrocautery
Use of hemoclips

	• Cauterize lesions
	• Sclerotherapy
		○ \_\_\_\_ is injected; BV are \_\_\_\_ and bleeding stops
	• Electrocaudery
		○ \_\_\_\_ open vessels to coagulate
	• Thermocaudery
		○ Heat up tip, and touch tissue and \_\_\_\_ the area
		○ More \_\_\_\_ way to stop bleeding ulcer
	• Historic way: \_\_\_\_
		○ Titanium clips

saline
contracted
fry
coagulate
common
clips

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PUD – Diagnostic Evaluation

Tests for H. pylori
• Invasive (EGD with biopsy)
- ____ (histology)
- ____ (culture)

• Non-invasive

____ (anemia)
____(UBT)
____ antigen

	• H. pylori one of more common ways of developing
	• Outcomes of H pylori
		○ Most into \_\_\_\_
		○ Intestinal \_\_\_\_
		○ Gastric/duo \_\_\_\_
		○ Gastric \_\_\_\_ or MALT lymphoma

biopsy
biopsy

serology
urea breath test
stool

asymptomatic
metaplasia
ulcer
cancer

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PUD - Management

Lifestyle ____ (avoid alcohol, tobacco)
Discontinue ASA or NSAIDs
____ eradication therapy
Anti-secretory therapy
Surgery reserved for cases refractory to ____ therapy or for complications
Repeat ____ after 10-12 weeks to confirm healing of ulcers• Discontinue ASA/NSAIDs > impact in oral care > common drugs that people take for dental pain
○ Maybe ____ or acetaminophen

changes
H. pylori
medical
EGD
tylenol

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Inflammatory Bowel Disease (IBD)

Term for two idiopathic diseases of the GI tract: • Ulcerative colitis (UC)
mucosal disease limited to ____ and ____
Crohn’s disease (CD)
____ process, may produce patchy ulcerations at any point from mouth to anus, most commonly involves the ____• Initial presentation may be in the oral cavity
• UC is more limited in its distribution
○ Oral lesions can be suggestive of both UC and CD

large intestine
rectum
transmural
terminal ileum

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IBD

	• Clinically UC and CD are different
	• CD
		○ \_\_\_\_ in GI tract and oral cavity
		○ \_\_\_\_ wall of GI tract
	• UC
		○ No cobblertoning > \_\_\_\_ are present
		○ Mucosa form \_\_\_\_ > not true polyps

cobblestoning
thickening
ulcers
pseudopolyps

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IBD - Epidemiology

U.S.
1.4 million individuals affected
UC = ____ (250 cases of each / 100,000) • Highest rate in ____
____ = female
____ age distribution
Most diagnosed between 15 – 25 years • Second peak between 55 – 65 years

CD
caucasians
male
bimodal

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IBD - Pathophysiology

• Unknown, but likely ____

Genetic susceptibility genes identified
NOD2/ ____ gene
IL-23 receptor gene
____ superfamily
TLR-4 gene
Immunologic stimulation
Activation of ____, B-cells, ____
No specific enteric ____ associated with inducing the pro-inflammatory responses in IBD

multifactorial
CARD15
TNF
T-cells
immunoglobulins
microbe

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IBD – Clinical Presentation

Ulcerative colitis
• Mild – moderate ____
• Rectal bleeding
• ____ pain

Advanced disease→
Development of ____ symptoms

Crohn’s disease
• Chronic \_\_\_\_
• Perianal disease (fissures/fistulae)
• Abdominal \_\_\_\_
• Constitutional symptoms 
• \_\_\_\_ loss
• Unexplained fever
• \_\_\_\_

* Present similarly, but minor differences
* UC has more episodic forms of diarrhea, whereas CD has chronic
* Peranal disease is different from rectal bleeding
* CD you see constitutional symptoms earlier than in an UC

diarrhea
abdominal

constitutional
diarrhea
pain
weight
fatigue

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IBD - Extra-intestinal manifestations

• \_\_\_\_
	○ Similar to other immune mediated processes
• Kidneys
• \_\_\_\_
	○ Stomatitis - non-specific inflammation of oral cavity
• Liver
• \_\_\_\_
• Biliary tract
• \_\_\_\_
• If many sites > not well-controlled and needs to be treated

eyes
mouth
joints
skin

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Skin Pyoderma gangrenosum Erythema nodosum • Pyoderma gangrenosum ○ Large skin infections that are difficult to treat in terms of ____ and wound-healing • Erytherma nodusom ○ Looks like EM > not ____ like that, but it's present on the skin

antibiotics | bulls-eyes

IBD – Diagnostic Evaluation • Clinical symptomatology * Laboratory studies * Complete blood count * Abnormal ____, Hct, ____ indices - ____ * Elevated WBC - ____ * Iron / B12 deficiency – ____ * Antibody testing * Anti-Saccharomyces cerevisiae antibodies (ASCA) * perinuclear anti-neutrophil cytoplasmic antibody (pANCA) * ASCA (+) and pANCA (-) = c/w ____ * ASCA (-) and pANCA (+) = c/w ____ • Colonoscopy / Sigmoidoscopy • Higher prevalence of ____ in those with CD > if antibodies in blood serum > suggestive of Chron's ○ ASCA + and pANCA - = CD ○ ASCA - and pANCA + = UC

``` Hgb RBC anemia infection malabsorption ``` CD UC yeast

Macroscopic appearances: UC Diffuse mucosal ____, granular mucosa with loss of normal ____ markings ____ * Ulcerated lining of the GI tract * Diffuse mucosal friability * Granular mucosa with loss of normal hasutral markings * Toxic enlargement of lower GI tract > toxic ____ * Pseudopolyps

friability haustral pseudopolyps megacolon

Macroscopic appearances: CD ____ Deep, long ____, serpiginous ulcers * Looks different * Cobblestoning * Long fissures * Oral condition with serpiginous > immune mediated mucosal disease > ____

cobblestoning fissures pemphigus vulgaris

IBD - Medical Management * Goals of therapy in IBD * Induction and maintenance of remission • Standard approach ○ Antibiotics and ____ used first ○ As go up in pyramid > more potent medications > ____/corticosteroids § Higher risk for ____ § Delicate balance between benefit and risk • Lastly, may undergo surgery; or the use of biologic agents > ____ is most commonly used for PV

salicylates immunomodulators side effects ritixumab

IBD - Medical treatments • 5-ASA drugs - oral (____, mesalamine) - topical (____, rowasa) • Steroids - topical (____, cortenemas) - oral (____, budesonide) - IV (____, hydrocortisone) • Antibiotics (for CD) - ____, ciprofloxacin * Immunomodulators - ____, azathioprine * Other immunosuppressants - ____ - cyclosporine • Biologics - ____ (Remicade ®) - adalumimab (Humira ®) - ____ (Cimzia ®) - golimumab (Simponi ®) • Side effects ○ Most common - ____ of mouth ○ Drug reactions > look like aphtous ulcers/lichenoid reactions • Methyletrexate > ____ suppression ○ Low platelet counts > emergency when removing teeth

``` sulfasalazine canasa cortifoam prednisone solumedrol ``` ``` metronidazole 6MP methotrexate infliximab certolizumab dryness ``` bone marrow

IBD – Surgical Therapy • UC: 30 - 40% of patients - Indications: ____, perforation, stricture, toxic ____ without responding to 48-72 hrs of therapy - ____ or carcinoma • CD: 70 - 80% of patients - Indications: ____, abscesses, stricturing type disease, chronic ____ dependency - ____ or carcinoma

``` hemorrhage megacolon dysplasia fistulae steroid dysplasia ```

PC - Epidemiology * Colonic inflammation associated with ____ use * ____ is causative agent * Most common ____ infection of GI tract * 50 cases / 100,000 annually * No ____ predilection * Common populations affected: * ____ * Hospitals / Nursing homes * ____ • Treat MRONJ > put on antibiotics for an extended period of time • Immunosuppressed ○ ____ positive ○ Long-term ____ • ____ dentist > spend time in nursing homes > will see more patients that are at higher risk for PC

``` antibiotic clostridium dificile nosocomial gender elderly immunosuppressed HIV CS geriatric ```

PC - Pathophysiology ``` • C. dificile • Gram (____), ____-forming ____ rod ---• Sand, soil, feces • Colonizes gut in 2-3% of ____ adults ---• Up to 50% of ____ persons ``` * Risk of disease increases with prolonged ____ use * Altered microflora of gut→C. dificile overgrowth→ enzymes / toxins→alterations in gut lining→formation of ____ • Pseudomembranes > presents as bloody ____

``` + spore anaerobic asymptomatic elderly antibiotic pseudomembranes ```

Antibiotics associated with PC * ____ antibiotics > parenteral antibiotics * ____ * Amoxicillin * ____ * Third generation cephalosporins * ____ (Suprax®) * Cefdinir (Omincef®) * Trimethoprim / sulfonamides * ____ * Fluoroquinolones * ____ (Levaquin®) • ____ antibiotics have a higher risk of developing PC than parenteral antibiotics • Amoxicillin > primary antibiotic for antibiotic ____ for cardiac patients • Third generation cephalosporins ○ More commonly seen ____ setting ○ Undergoing surgery > given for general prophylaxis ○ Salivary gland infections > better resolution with ____ antibiotics better than amoxicillin • Bactrim ○ Used for patients with different infectious diseases ○ Low t cell and CD4 counts ○ Prevent respiratory infections • Levofloxacin ○ Used for ____ ○ A lot of oral surgeons to help manage infections related to ____ ○ Effective for MRONJ

``` oral clindamycin ampicillin cefixime bactrim levofloxacin oral prophylaxis inpatient cephalosporin ``` UTI osteoradionecrosis

PC – Clinical Presentation * Diarrhea * Early – ____ and loose • Late – ____ * Abdominal pain * ____ * Temporal relationship with: * Receiving antibiotics in the past ____ days * After ____ hours of hospitalization * Late is thick and mucosy appearance * Can backtrack and temporally relate to antibiotic starting around that time > it's the antibiotic involved

watery bloody 60 72

PC – Diagnostic Evaluation * Clinical symptomatology * Association with ____ use / hospitalization * Stool sample * Evidence of ____ or toxins * CBC * Elevated ____ * Colonoscopy / sigmoidoscopy * Evidence of yellow – white ____ * Inflammation * Want to get people out of hospital ____ > longer you're exposed to bacteria that you're not normally exposed to > increases risk of developing nosocomial infection * Normal WBC count > 4500-____

``` antibiotic c. dificile WBCs pseudomembranes ASAP 11000 ```

PC - Management * Goal is eradication of ____ * Treatment based on severity of disease * Mild disease (no fever, no abdominal pain) * ____ of causative antibiotic * Moderate disease (moderate diarrhea >10 days) * ____ or vancomycin * Severe disease (severe diarrhea) * IV ____ * Life-threatening * ____ occurs in up to 25% of cases

``` c. dificile cessation metronidazole vancomycin relapse ```

Celiac disease - Epidemiology * Overall, condition is ____ * Highest prevalence in USA / Western Europe * U.S. * 1% of population affected * No ____ predilection * ____ > males

underdiagnosed age females

Celiac disease – Pathophysiology • etiology • Genetic predisposition • ____ haplotype on chromosome 6 • Environmental factors * Gliadin (protein class) is a component of gluten * ____ * ____ * ____ * Triggers inflammatory reaction in gut * Destruction of ____ * Production of ____ mediators • Strong ____ component to developing ○ Not everyone gets screened - not part of the ____ testing • Gliadin triggers inflam reaciton in the GI system

``` HLA-DQ2 wheat rye barley intestinal villi inflammatory genetic standard ```

Celiac disease - clinical presentation ``` • Challenging • Many manifestations ○ Intestinal § ____ intolerance, nutritional deficiencies ○ Extraintestinal may present § ____ □ Would have to dig a lot deeper § ____ herpetiformis § ____ signs § Neurologic § ____ § Reproductive § Oral findings ```

``` lactose anemia dermatitis hepatobilliary bone ```

Celiac disease – Diagnostic Evaluation * Family history * Clinical symptomatology * Serology * Detections of ____ (tissue transglutaminase) antibodies * Assess for IgA ____ * ____ testing NOT routinely performed * EGD assessment * Histopathologic evidence of ____ * Response to a ____-free diet * Non-celiac gluten sensitivity (NCGS) • Family history ○ Genetic predisposition • Diffuse clinical symptomatology • Most common lab test > detections of IgA tTG • First thing recommended > go on a gluten-free diet ○ Only management strategy for Celiac ○ No impact on QoL • NCGS ○ Patients who report celiac-like symptoms that respond to gluten-free diet ○ No ____ of antibodies, no wheat allergies; but other symptoms improve ○ Aphthous stomatitis > will take themselves off gluten and it will improve

``` IgA tTG deficienc genetic villous atrophy gluten serologic ```

Celiac disease – Management • Avoid barley, rye, wheat • Can lead to a ____ lifestyle • Patients may still have symptoms on gluten-free diet > like CS, etc. ○ May need long-term ____ to treat

restrictive | immunosuppresion

Eating Disorders • Anorexia • Individuals who intentionally ____ themselves when they are already underweight • Intense fear of being “____” * Bulimia * Consume large amounts of food episodically * “____” * Prevent weight gain by expulsion of food * “____” * Unable to perceive physical appearance correctly * Purging can be done by ____, laxatives, and/or ____ * ____ syndrome > found in patients with eating disorders

starve fat ``` binging purging vomiting diuretics body dismorphic syndrome ```

EDs - Epidemiology * Adolescent females * 5% prevalence * Higher prevalence in ____ societies * Anorexia * 14 – 18 years of age * 0.3% - 0.7% prevalence * Bulimia * Late ____ – early twenties • 1.7% - 2.5% prevalence

industrialized | teens

EDs – Clinical Considerations * ____ disorders with physical complications * Distorted ____ image * Preoccupation with ____ weight * Rule out systemic etiologies for clinical symptoms * Laboratory ____ * Psychiatric evaluation * Multidisciplinary therapy * ____ / relapse * Mortality * Starvation, suicide, ____ imbalance * ____ therapy is most effective but common recovery/relapse * Patients can go into ____ arrest and seizures because of electrolyte imbalance

``` psychitric body losing evaluation recovery electrolyte multidisciplinary cardiac ```

Gardner’s Syndrome * Multiple ____ (pre-malignant) * Mutation in ____ gene * Extra-intestinal manifestations * ____ * Multiple impacted supernumerary teeth * ____ tumors * Thyroid carcinoma * Hypertrophy of ____ pigmented epithelium * Lifelong ____ * Increased risk of ____ cancer

``` intestinal polyps APC osteomas CT/soft tissue retinal surveillance colorectal ```

Plummer – Vinson Syndrome • Dysphagia secondary to esophageal strictures • ____ sensation • Caucasian ____ in 4th – 7th decades * Etiopathogenesis unknown * Association with ____-deficiency anemia * Clinical symptomatology * Cutaneous findings of ____-tinted and dry skin • Spoon-shaped fingernails (____) * Multiple oral ____ * Lifelong surveillance * Increased risk of ____ GI cancers • Choking sensation ○ Cough > instruments in the mouth > dangerous to patient and operator • Yellow-tinted and dry skin > may seen in perioral/cutaneous skin

``` choking females iron yellow koilonychia manifestations upper ```

Peutz – Jeghers Syndrome • Intestinal ____ (____) • Mucocutaneous pigmentation • Mutation in ____ gene * Clinical symptomatology * ____ – pain, bleeding * ____ – pigmentation of face / oral cavity * Lifelong surveillance * Increased risk of ____ / Lung / Breast / Prostate cancers

polyposis STK11/LKB1 GI cutaneous GI

Cowden’s Syndrome * Facial ____ (benign neoplasms) * Acral keratoses * GI ____ (benign) * Neoplasms * ____ * Thyroid * Oral manifestations * Mutation in ____ tumor suppressor gene * Cutaneous marker of internal malignancies * Lifelong surveillance * Increased risk of ____ / thyroid / endometrial cancers • Multiple hamartoma syndrome ○ Hamartoma = alteration of tissue derived from ____, mesenchymal and ____ origin ○ A lot of features of this syndrome • Acral keratoses > thickening of ____ surfaces • Can develop all three types of cancers

trichelemmomas polyps ``` breast PTEN breast ectodermal endodermal ``` cutaneous

GI Neoplasia * 2.7 million deaths globally * 145,000 deaths in the U.S. * Typically are ____ malignancies * Risk factors / presentations are ____-specific * Multimodal therapy – ____ / chemotherapy / ____ * Increased morbidity due to: * Intestinal or biliary ____ * Impaired ____ * End stage of disease * Debilitating therapies

``` epithelial site surgery radiation obstruction nutrition ```

Esophageal Cancer ``` U.S. Statistics • 16,980 cases; 15, 590 deaths • ____ > females • ____ > whites • Typically presents in 6th decade and older • 5 year survival is <10% ``` * Upper esophagus – ____ * Distal esophagus – ____ (____ of cases)

``` males blacks SCC adenocarcinoma majority ```

Esophageal cancer Clinical features * ____ * Weight loss * Chronic ____ * Laryngeal nerve palsy Diagnosis • Endoscopy • Visualization of ____ / mucosal irregularities • Biopsy for ____ confirmation • Imaging • ____ with contrast ____ scan

``` dysphagia GERD masses histopathologic CT PET ```

Esophageal cancer ``` Treatment • Stage I (early) • ____ resection • Stage II / III (locally advanced disease) • ____ / chemotherapy / ____ • Stage IV (advanced) • ____ chemotherapy ``` ``` Prognosis • Stage I • 70% survival rate • Stage II • 40% survival rate • Stage III • 30% survival rate • Stage IV • 5% survival rate ``` • Better if detected earlier

surgical surgery radiation combination

Gastric Cancer U.S. Statistics • 24,590 new cases; 10,720 deaths • Overall ____ in incidence and mortality in U.S. • ____ > female (2:1) • Typically presents in 6th and 7th decades • 5 year survival is <15% * ____ in 85% of cases * ____ in 15% of cases • Decline is due to not using food preservatives that harbor carcinogenics > once ____ became common gastric cancer decreased

decline male adenocarcinoma lymphoma refrigeration

Gastric cancer ``` Clinical features • ____ pain • Early satiety • ____ loss • Dysphagia • ____ / vomiting • Acute / chronic GI bleeding ``` ``` Diagnosis • ____ • Biopsy • ____ evaluation • Metastatic disease ``` • Eat little food but you're very full > tumor is taking up space in the stomach > early satiety

``` epigastric weight nausea EGD CT ```

Gastric cancer ``` Treatment • ____ • Chemotherapy • ____ • Palliation ``` ``` Prognosis • Stage I • 65% survival rate • Stage II • 40% survival rate • Stage III • 15% survival rate • Stage IV • 5% survival rate ```

surgery | radiation

Colorectal Cancer U.S. Statistics • 132,700 new cases; 49, 700 deaths • Accounts for 10% of cancer-related deaths in U.S. • Incidence increases ____ >50 years of age • ____ = females * ____ most common cancer in the U.S. * Adenocarcinomas arising from ____ * Most common type of GI/neoplastic syndrome you'll come across in dental career > most prevalent type of GI cancer * Recommendation have identified younger patients developing colorectal cancer > starting to screen at ____ now

``` dramatically males third adenomatous polyps 45 ```

Colorectal Cancer – Risk Factors * Family history * ____ disease * Familial polyposis syndromes * ____ * Coronary artery disease * ____-fat, ____-fiber diet * Smoking * Alcohol • ____ is the best key to figure out what disease the patient is at risk for ○ Patient is screened at earlier age; more frequent colonoscopies • Cannot modify family history; but ____ the others that you can

inflammatory bowel hypercholesterolemia high low family history control

Colorectal cancer Clinical features • Early cases are ____ • ID via ____ * Advancing disease * ____ * Altered bowel habits * Abdominal ____ * Weight loss * Bowel ____ / perforation ``` Diagnosis • ____ • Endoscopy • ____ • Fecal occult blood testing ``` * ____ is considered the gold standard * Visualization * Biopsy * Polyp removal • Hematochezia is different from melena ○ ____ blood > lower end of GI tract (from the ____) ○ Melena is dark • Emergency > bowel obstruction and perforation

``` asymptomatic screning hematochezia pain obstruction ``` screening imaging colonscopy bright red anus

Colorectal cancer • Age has dropped from 50 to ____ y/o

Colorectal cancer ``` Treatment • Local disease • ____ • Adjuvant radiotherapy • Adjuvant ____ ``` * Metastatic disease * ____ * Anti-____ receptor antibodies Prognosis • Local disease • 5-year survival rate ranges from 50% - ____% * Metastatic disease * Median overall survival time approximately ____ years • Earlier detected > the better prognosis

surgery chemo chemo EGF 95 2

Anal Cancer U.S. Statistics • 7,270 new cases; 1,010 deaths • ____ > males • Increased prevalence in ____+ individuals * Human papillomavirus (HPV) etiology * 95% of ____ cancers caused by HPV • Majority caused by HPV-____ * Consistent with ____ • 16 and 18 are the players in oropharyngeal cancer

``` females HIV anal 16 SCC ```

``` HPV vaccines • Available in the US: gardisil-9 ○ Covers ____ serotypes of HPV ○ Prevent ____ cancers ○ Some protective effective of developing ____ cancer ```

9 STD oroesophageal

* Not just adolescents, will include 27 to ____ y/o * To decrease risk of STDs * Only one state where dentists can give a vaccine - it's only flu vaccine

Anal cancer Clinical features - localized symptoms - -- ____ - -- bleeding - -- ____ - -- mass-like sensation ``` Diagnosis • Physical ____ findings • Biopsy • ____ scan • Evaluate for metastatic spread ```

pain pruritus examination CT

Anal cancer Treatment Very small lesion • Complete ____ Lesion <3cm • ____ + ____ Lesion >3cm • ____ therapy Prognosis Very small lesion • ____ Lesion <3cm • ____% cure rate Lesion >3cm • ____

excision chemo radiation multimodal curative 80 variable