Block 32 Week 4 Flashcards
1
Q
false high blood glucose
A
It is the glycerine in the newspapers, glossy magazines and hairspray that causes the false highs. Basically anything that shines may contain the sugar glycerine – hand cream, moisturisers etc.
2
Q
false low blood glucose?
A
Wet hands and perspiration can dilute samples and give false low results – take care with patients who have a high temperature.
3
Q
over-estimation of cap blood glucose to do w Txs?
A
IV Ascorbic Acid (vitamin C), used in cancer therapy or chronic alcoholism (Pabrinex), causes over estimation of CBG
4
Q
what else can falsely cause low blood glucose levels?
A
High triglyceridelevels cause falsely lowblood glucosevalues as they tend to take up volume in the sample reducing theglucoselevels.
5
Q
what can cause sample dilution when taking cbg?
A
Squeezing the patients finger releases interstitial fluid, which dilutes the sample and generates false lows.
6
Q
when should cbg not be taken?
A
- peripherally shut down patients
- venous blood sample required
7
Q
peripheral circ shutdown occurs bc:
A
· severe dehydration (e.g. due to diabetic ketoacidosis)
· hypotension
· shock
· hyperosmolar hyperglycaemic state (known previously as H.O.N.K.)
· decompensated heart failure
8
Q
meds that interfere w cbg?
A
- medications that can interfere with blood glucose readings eg. statins, corticosteroids, beta blockers and thiazide diuretics.
9
Q
acute, chronic and acute on chronic abdo pain?
A
- acute: no previous history, sudden
- chronic: recurrent pain
- acute on chronic: sudden onset, had similar pain recently or before
10
Q
acute onset abd = emergency
A
- volvulus - a twist
- ischaemia
- perforation
- obstruction
- bleeding - ruptured AAA
11
Q
colic pain?
A
- colic = obstruction. muscular contractions
- e.g. bowel colic, biliary colic, ureteric colic, in labour
- comes and goes, frequency
12
Q
itis pain?
A
- itis = inflammatory
- cholecystitis, gastritis, pancreatitis
- persistent pain
13
Q
colic and then later itis?
A
- colic and then later itis - biliary colic, later cholecystitis/ pancreatitis
14
Q
pain that is initially in the epigastrium and then moves to the RUQ?
A
cholecystitis
15
Q
pain that starts in epi and moves to back?
A
pancreatitis
16
Q
periumbilical pain that moves to RIF?
A
appendicitis
17
Q
pain that is periumbilical and moves lower?
A
meckles diverticulitis
18
Q
pain that starts lower and moves to LIF?
A
diverticulitis
19
Q
epigastric pain that moves to RIF and upper?
A
perforated duodenal ulcer
20
Q
visceral pain?
A
- non specific
- poorly localised
- not affected by movement
21
Q
parietal pain?
A
- localised
- peitonitic
- worse by movement
22
Q
factors assoc w abd pain caused by a GI pathology?
A
- vomiting, bowel changes, bleeding, weight loss, fever
23
Q
factors associated with abdo pain associated w gynae pathology?
A
- PV bleeding, dysmenorrhoea
24
Q
factors associated with abdo pain caused by urology pathology?
A
- fever, freq, UTI, bleeding
25
features associated w abdo pain caused by a vascular pathology?
* dizziness, sweaty, palpitations
26
cholecystitis radiation?
shoulder tip pain
27
ureteric colic pain radiation?
pain from loin to groin
28
herpes zoster pain radiation?
back to front
29
extraperitoneal pain can be caused by ?
e.g. by warfarin which allows them to bleed
30
diff pain causes
31
abdo pain history?
PMH`
* e.g. prev surgery, recurrent pain, trauma
FH
* cancers, IBD
DHx
* laxatives, recreational drugs
SH
* smoking alcohol
32
SOCRATES
33
riglers sign?
* If there is free intra-abdominal gas adjacent to a gas-filled loop of bowel then both sides of the bowel wall are well-defined. This is known as 'Rigler's sign'.
* - PERFORATION
34
investigation for abdo pain?
* erect CXR
* Abdominal X ray
35
management of abdo pain?
* resus, analgesia, +/- antibiotics
* VTE prophylaxis
* ABG
* NGT/ urinary catheter
36
cholecystitis -> panc?
* RUQ pain - cholecystitis
* then epigastric pain that radiates to the back, dark urine pale stools, vomiting -> stone moved into CBD - pancreatitis
37
Small bowel obstruction
38
4 signs of obstruction?
colicky, vomiting, no bowel movement, distension
39
causes of SBO?
- appendix removal
- surgery
- hernias
40
why does vomiting occur late in LBO?
* Ileocecal valve holding back the contents -> no vomiting
41
Perforated ulcer scan
42
tachycardia and anemia in young adults?
suspect bleed
43
glandular fever?
check for this if theyre fainting spontaneously
44
intussuception?
* right abd - caecum
* the doughnut sign - intussuception
* intussuception - bowel within a bowel
45
what can cause mid abd pain?
* small bowel
* large bowel to splenic flexure
* right IF pain
* midline hernias
* inguinal and femoral hernias
46
surgical outpatient clinic?
* further investigations
* explanation and information leaflets
* waiting list for surgery
* consent
47
consent?
* verbal
* written - surgery e.g.
* informed consent
48
when is consent not required?
* emergency treatment to save their life when the patient is incapacitated
* additonal emergency procedure needed to be done during an operation
- risks to public health
49
what makes consent valid
* patient needs to have capacity
* needs to understand the procedure and complications
* allowed time to think and weigh up risks and benefits
* not being forced to give consent
50
pre-op assessment?
* may be seen by pre-op nurse/ doc
* go through meds and RFs
* anaesthetist review
* pre-op Ix - bloods, imaging, MRSA/ C diff
51
blood transfusion/ clotting factors?
* for patients who have a high risk of bleeding
* for patients who have bled
* procedures that may potentially bleed
52
WHO surgical safety checklist?
* WHO surgical safety checklist - improves safety of surgical procedures by brining thw heol team together to perform key safety checks during perioperative care, prior to induction of anaesthesia, prior to skin incision and before the team leaves the operating room
* debriefing - what has gone well and what can be improved - identifies human factors
53
why can malabs occur w CD?
* malabs w CD bc small bowel can be affected
54
IBD is mostly diagnosed in which age gr?
20-30s
55
what increases risk of iBD?
appendicectomy
56
what can malabs from CD lead to?
osteoporosis and anemia - osteoporosis from malabs and steroids used in Tx
57
what can worsen IBD?
oral preperations of iron
58
microscopic colitis?
* inbetween
* bowel normal on colonoscpy but histological changes present
59
microscopic colitis symptoms?
persistent watery diarrhoea without blood is the most common symptom
60
CD?
* mouth ulcers
* fistulas, strictures
* peri-anal comps
61
IBD in children?
* weight loss, lethargy, anorexia, FTT
* only half have diarrhoea
62
calprotectin can also be raised w?
* raised w NSAIDs and infection
63
first line for a UC flare up?
mesalazine
64
crohns flare up first line?
steroids, enteral feeding
65
Celiac?
steatorhoea, diarhoea, bloating, abd pain
66
celiac screen?
tTG
67
noctural diarrhoea is more suggestive of?
IBD
68
CRC contributes ? of all cancer cases?
13%
69
Order of cancers in terms of prevalence?
lung, breast, prostate, CRC
70
CRC incidence and death rates?
incidence increasing but death rates falling
71
aetiology of CRC?
* most arise from adenomatous polyps - adenoma carcinoma sequence
72
genetic mutations in CRC?
APC, K-ras, DCC, p53
73
Herediary causes of CRC?
HNPCC and FAP
74
majority of cases of CRC occur?
spontaneously
75
RF for CRC?
* obesity
* red meat
* processed meat
* alc
* smoking
* animal fat
* long standing IBD
76
Protective factors for CRC?
* regular exercise
* dietary fibre
* non starchy vegetables
* calcium, garlic
77
Sites of CRC?
* rectum
* sigmoid colon
* right colon
78
Spread of CRC - direct invasion...
of adjacent organs e.g. bladder, small bowel
79
spread of CRC - nodes
* lymphatic drainage to adjacent lymph nodes
80
CRC spread - haematogenous to
distant organs e.g. liver, lungs
81
other ways CRC spreads?
* haematogenous to distant organs e.g. liver, lungs
* trans-coelomic e.g. peritoneum, ovaries
82
how soon do patients referred for cancer need to be seen?
within 14 days and need to commence Tx within 62 days
83
left sided cancer symptoms?
* change in bowel habits - frequency, consistency
* bleeding PR
* abd pain
84
right sided CRC symptoms?
* iron deficiency anemia due to chronic occult bleeding
* abd pain - late symptom
85
investigations for CRC?
* colonoscopy
* CT colonography (virual colonoscopy) - but can't take biopsy
* conventional CT - doesn't require full prep
86
Screening for CRC?
* 60-74 yrs
* FOB testing kit every 2 years
* positive patients offered a colonoscopy
87
Staging =
measure of spread
88
pre-op staging?
* all patients need to have a CT, chest, abdomen, pelvis to assess primary tumour and look for distant mets
* serum carcinoembryonic antigen (CEA) - raised suggested metastatoc disease
89
MR rectum?
to assess extent of spread through the rectal wall and mesorectal nodes for rectal cancers
90
TNM?
* T = extent of spread
* Node = nodal involvement
* M = distant mets
91
Curative Tx for CRC?
* surgery
* w chemo
* rectal cancers only: radiotherapy
92
Surgery for CRC?
* curative Tx of CRC almost always involves surgical resection - often laparoscopically
* resection of the segment of the colon/ rectum containing the tumour plus blood supply and draining lymph nodes
93
what do all CRC surgery patients require?
* all patients need prophylactic ab and VTE prophylaxis (e.g. LMWH)
94
Duke's staging
* Duke C = lymph node involvement
* TNM used now
95
chemotherapy?
* usually given post-op in higher risk patients e.g. nodes involved, vascular invasion, poorly diff, young patients
* commence within 6-8 weeks of surgery
* sometimes given as a neo-adjuvant pre-op to downstage tumour to allow surgical resection
96
enhanced recovery
97
radiotherapy?
* used to treat rectal cancr but non colon cancer due to moving target and risk of damage to the small bowel
* usually given pre-op (NA) as tissues are more radiosensitive, anatomy is preserved and small bowel is out of the pelvis
98
non surgical treatment of CRC?
* some early rectal cancers may be dealt w by TEMS
* local excision of a rectal cancer can be supplemented by radiotherapy
99
Secondary surgery?
* surgery can be done even if they have metastatic disease
* liver and lung mets can be resected
* locally recurrent rectal cancer and localised intra-abd recurrence can be resected
100
CRC emergency treatment?
* approx 20% present acutely usually due to obstruction
* distended and tender caecum -> acutal or imminent perforation considered
101
what is the alt to surgery for left sided obstruction?
* self expanding metal stent inserted endoscopically is the alt to surgery for left sided obstruction
102
palliative tx?
* usually due to inoperable mets but sometimes bc patient isn't fit enough
* options: resection, defunctioning stoma or bypass procedure
103
MDT?
* every hosp must have an MDT team for each cancer type
* meets every week
* aims to ensure a co-ordinated and consistent approach to diagnosis and treatment of patients
104
Peer review =
process by which MDT is assessed according to set of national measures, occurs on an annual basis
105
CRC MDT core members?
* CRC surgeons
* radiologist
* histopathologists
* oncologists
* specialist nurses
106
Post op surveillance?
* aim is to identify recurrent disease earlier, allowing further curative tx
* consists of regular serum CEA, and chest abdo pelvis CT
* patients followed up for 5 years bc it usually recurs within 2-3yrs
107
Mx of infective diarrhoea?
* fluid replacement - oral or IV
* public health management
108
constipation - aetiology?
* dietary
* functional
* metabolic
* neuropathy
* medication
* structural
* anal outlet
109
management of constipation?
* correct cause
* laxatives
* colonic irrigation
* surgery in severe cases only
110
CD features?
* all layers of gut
* small and LI
* discontinous
* in most patients affects small bowel and colon
111
CD granulomas?
* Discrete non caseating granulomas
112
mucosal appearance of CD?
cobblestone
113
other features of CD?
* Fat creeping on mesentery
* Skip lesions
* Fistulation
114
Ethnic groups which have a higher risk of iBD?
Caucasian and jews
115
CD - intestinal complications?
* Small bowel obstruction
* Perianal fistulas and fissure
* Bowel fistulas
* Bowel perforation
* Gastrointestinal blood loss
* Malignant neoplasm
116
CD - EIM?
* Arthritis
* Ankylosing spondylitis
* Iritis
* Aphthous ulcers
* Erythema nodosa
* Nephrolithiasis
117
ulcerative colitis?
* Inflammation confined to mucosa
* crypt abcesses
* mucosal ulceration
* pseudopolyps
118
UC complications?
* Bleeding
* Toxic megacolon
* Colonic perforation
* Risk of colon cancer
119
IBD Ix?
* Clinical history & examination
* FBC/BCP/CRP/stool culture
* Rigid sigmoidoscopy (biopsy)
* Colonoscopy (biopsy) / Barium enema
* Small bowel enema
* CT scanning
120
UC - surgery Ix?
Failed medical management
Toxic megacolon
Perforation
Dysplasia
121
CD - surgery Ix?
Obstruction
Fistulation
Perforation
Defunctioning
122
IBS affects who more?
* female predominance 2:1
123
What is IBS?
* Disorder of increased intestinal motility with heightened visceral sensitivity
* No biochemical or structural test
* DIAGNOSIS OF EXCLUSION
124
symptoms of IBS - bowel movements?
* fewer than 3 bowl movements a week
* more than 3 bowel motions per day
125
other IBS symptoms?
* Hard or lumpy stools
* Loose or watery stools
* Straining during bowel movement
* Urgency
* Passing mucus
* Abdominal bloating and swelling
126
Tx of IBS?
* Bulking agents
* Smooth muscle relaxants
* Loperamide
* 5HT receptor antagonists
127
3 phases of malabs?
* luminal
* mucosal
* postabsorptive
128
Malabs history?
* Diarrhoea
* Steatorrhoea
* Weight loss
* Abdominal distension & flatulence
* Oedema
* Anaemia
* Bleeding
* Bone disorders
129
Celiac disease?
* Hyper sensitivity to gluten
* Immune reaction induced by ingested gluten
* Reaction causes damage to small intestine (villous atrophy)
130
Treatment of celiac disease?
gluten free diet
131
CF of right colon cancer?
* Anaemia (iron deficiency)
* Midgut colic
* Diarrhoea
* Abdominal bloating
132
CFs of left colon cancer?
* Constipation
* Dark red rectal bleeding
* Passing mucus
* Tenesmus
133
Diverticular disease complications?
* pericolic abscess
* pelvis abcess
* purulent peritonitis
* feculent peritonitis
134
Mx of diverticular disease?
* HFD
* resection (with anastomisis)
135
FAP - clues to early diagnosis?
* These abnormalities may include bumps or lumps on the bones of the legs, arms, skull, and jaw;
* cysts of the skin;
* teeth that do not erupt when they should;
* and freckle-like spots on the inside lining of the eyes.
136
what helps reduce risk of CRC in ppl w Lynch syndrome?
daily aspirin for > 2 yrs
137
diarrhoea investigations
138
infective diarrhoea causes
139
constipation investigations
140
O-G cancer incidencr?
* incidence is rising faster than any other solid organ maligancy in the uk
141
O-G cancer symptoms?
* IDA - GOJ which typically bleed at a low level
* weight loss
* dysphagia
* dyspepsia
* mets e.g. RUQ pain
* aspiration, fistulas etc
* hoarnessness - LN compression or recurrent LN
142
Dyspepsia?
* indigestion
* epigastric pain/ discomfort/ burning
* heartburn or acid reflux
* bloating or fullness post prandial
* nausea and or vomiting
143
Functional dyspepsia?
symptoms in a patient without structural or biochemical disease process
144
red flag symptoms for dyspepsia?
* weight loss
* overt GI bleeding
145
Pancreatic cancer symptoms?
* diarrhoea
* abd pain radiating to back
* constipation
* new onset diabetes
* weight loss & over 60
146
Other symptoms of pancreatic cancer?
* nausea
* vomiting
147
dyspepsia summary
148
criteria for CRC referral
149
oesophageal and gastric cancer?
* upper abd mass
* dysphagia in any age
* over 50 and upper abd pain, reflux and dyspepsia
150
GB cancer?
* Upper abd mass consistent w enlarged GB
151
Dyspepsia flowchart
152
Liver cancer
* upper abd mass w enlarged liver
153
investigations for UGI symptoms
154
common causes of dyspepsia?
* functional dyspepsia
* GORD
* PUD
* GALLSTONES
155
referral critera
156
Dysphagia?
* subjective difficulty swallowing
157
odynophagia?
painful swallowing
158
globus sensation
* globus sensation = non painful sensation of a lump, foreign body, food bolus in the phayrngeal or cervical area (proximal)
159
globus?
* Globus = a functional oesophageal disorder characterised by globussensation in the absence of underlying structural pathology, GORD or major oesophageal dysmotility disorder
160
key history of dysphagia?
* Progressive dysphagia?
* Solid/Liquids/Both
* Chronic GORD symptoms
* Weight loss
* Anaemia
* Hematemesis
* Respiratory symptoms
161
dysphagia with solids alone?
suggests a mechanical problem
162
dysphagia with solids and liquids?
motor disorder
163
oropharyngeal dysphagia?
* Oropharyngeal dysphagia: difficulty initating a swallow associated w coughing, choking or nasal regurgitation
164
oesophageal dysphagia?
* oesophageal dysphagia - sensation of food getting stuck in the oesophagus (seconds after initating a swallow) - more concerning
165
MDT?
* Communication between diagnostic, primary, secondary & tertiary care
* Improve outcomes and compliance with guidelines
* Enter patients into high quality research projects
* Holistic approach to patients and their cancer
166
Adenocarcinomas?
* Most common in developed world
* Distal 1/3 oesophagus
* BO
167
risk factors of adenocarcinomas?
* Risk: GORD, Obesity, EtOH
* Commonly arises from metaplastic epithelium in the distal oesophagus – Barrett’s O which progresses to dysplasia and invasive carcinomas
168
Squamous cell carcinoma (oesophageal cancer)
* More common in the developing world
* Middle and upper 1/3 oesophagus
169
risks of SCC?
smoking, alcohol
170
diagnosis of dysphagia - orophrayngeal?
171
diagnosis of dysphagia - esopheageal dysphagia?
172
staging for oesophageal cancer?
* first line OGD and CT TAP
* PET for distant mets for those eligible for curative therapy
173
other methods for staging O cancer?
* endoscopic ultrasound for accurate staging
* bronchoscopy - involevement of bronchus is sig
174
why do O cancer often need to be downstaged?
* most present at advanced non curable stage so we aim to downstage the tumour w chemo and radio
175
Upper oesophgeal cancer?
cervical oesophagus from UOS to lower border of azygos vein
176
middle oesophageal cancer?
lower border of azygos vein to lower border of inferior pulmonary vein
177
lower oesophageal cancer?
lower border of inferior pulmonary vein to stomach, including gastroesophageal junction
178
resectable vs operable?
* resectable = surgically possible to resect
* operable - patient fit and willing to undergo surgery
179
Z line?
* Z line defines transition from pale white epithelium of oesophagus to pink columnar epithelium of the stomach
180
Siewert tumours?
- junctional tumours in the oesophagus
* for a siewert 1 or 2 tumour -> oesophagogastrectomy - doesn't require thoracic incision
* siwert 3 -> total gastrectomy
181
which stage are siwert tumours most commonly seen at?
T3 - generally present w dysphagia
182
Adenocarcinomas - curatuve management?
* neoadjvant chemo and chemoradiotherapy
* surgical resection
* adjuvant chemo or radio
183
SCC curative management?
* radical chemoradiotherapy
* but can have surgical resection too
* t4 and metastatic disease not resectable
184
palliative management of O cancer?
* chemo
* radio - local control of tumours e.g. dysphagia and bleeding
* stenting - improving oral intake
185
emerging concepts for O cancer?
* endosponge - screening for Barrett's
* advanced endoscopy for early diagnosis
* genetics and tumour biology
* immunotherapy
186
gastric cancer gene ?
* consider familal gastric cancer
* CDH1 or e-cadherin
187
non metastatic gastric cancer management?
- early stage = endoscopic resection
- > T2 tumour -> gastrectomy
- mets - chemo palliation
188
acute panc?
* acute inflammatory process of the pancreas
* usually accompanied by and pain and elevated serum pancreatic enzymes
189
signs and symptoms of acute panc?
* abd pain - epigastrium and can go to left or right UQ
* nausea and vomiting
* low grade fever
* tachycardia and hypotension
* mild jaundice
190
causes of panc - top 3?
* gallstones most common
* microlithiasia - small stones 2nd most common
* alcoholism - 3rd most common
191
other causes of pancreatitis - trauma?
* Trauma e.g. iatrogenic - ERCP (for gallstones)/Sphincter of Oddi Dysfunction
192
causes of panc - infection?
* Infection- viral, bacterial, and parasitic infectious causes may lead to pancreatitis with mumps and Coxsackie B viruses being the most common.
193
other causes of panc?
* Hypercalcemia - metabolic causes
* post-op, pancreatic cancers, pancreas divisium - 2 ducts drain into minor ampulla
194
gallstones and pancreatitis?
* half of all cases of acute pancreatitis
* older women
195
drugs causing pancreatitis?
* Azathioprine
* Asacol
* Estrogens
* Isoniazid
* 6-mercaptopurine
* Thiazide diuretics
* trimethoprim
* valproic acid
* tetracycline
196
Bloods for panc?
* Hyperglycemia
* Hypocalcemia
* hypertrigylceridemia
197
LFTs in panc?
inc AST, inc ALT, inc AlkPhos, inc Bilirubin
198
serum amylase inc with panc?
2-3x elevation
199
gallstone panc results?
* ALT or ALP 3x upper limit of normal + elevated amylase is highly sensitive for gallstone pancreatitis
200
scoring of panc?
- glasgow scoring
* 3 or above means that its severe -> need cont monitoring
* meeting one of the criteria give a score of 1
201
gastric cancer investigations
202
advanced metastatic gastric cancer
203
Radiology for panc?
* ultrasound - best (looks for gallstones - cause) and CT
* MRI - MRCP for stones in the bile duct
204
what is very sensitive for detection of gallstones, bile duct stones and bile duct dilatation?
US
205
What is the best diagnostic test for acute panc?
* CT is the best diagnostic test for the diagnosis of acute pancreatitis. Contrast-enhanced CT is good for diagnosis of pancreatic necrosis.
206
Tx for acute panc?
* analgesia
* IV fluids - close input/output monitoring required
* oxygen if needed
* anti-emetics for vomiting
207
nutrition for panc?
* pancreatitis is catabolic state
* enteral nutrition
208
complications of panc?
* Pancreatic Necrosis
* Pancreatic Abscess
* Haemorrhagic Pancreatitis
* Pancreatic Pseudocysts
* Diabetes - bc the pancreas secretes glucagon and insulin
209
pancreatic necrosis?
* most imp comp - CT is good for this
* When there is frequent attack of acute pancreatitis, then some of the pancreatic tissues might die.
* medically referred as Acute Necrotising Pancreatitis.
210
pancreatic pseudocysts?
* when the pancreatic juice leaks, the fluid accumulates
* can form cyst like pockets on the pancreas
* In general, the pseudocysts appears after 4-6 weeks of acute pancreatitis attack.
211
signs of panc?
- Cullens
- Grey turner
212
Cullens sign?
* superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus.
* This sign takes 24–48 hours to appear and can predict acute pancreatitis
* predictor of high mortality
213
grey turner sign?
* sign of retroperitoneal haemorrhage
* to bruising of the flanks, the part of the body between the last rib and the top of the hip.
* The bruising appears as a blue discoloration,and is a sign of retroperitoneal hemorrhage, or bleeding behind the peritoneum, which is a lining of the abdominal cavity.
214
how long does grey turner sign take to appear?
24–48 hours to develop, and can predict a severe attack of acute pancreatitis.
215
chronic panc?
* repeated severe abd pain which often starts after eating
* related to alcohol intake
216
chronic panc pain?
* pain usually develops in the middle or left side of abdomen and can radiate to back
* It's been described as a burning or shooting pain that comes and goes, but may last for several hours or days.
* often no trigger for pain
217
as chronic panc progresses...
* As the condition progresses, the painful episodes may become more frequent and severe.
* Eventually, a constant dull pain can develop, between episodes of severe pain.
218
5 yr survival for pancreatic cancer?
3%
219
cholangiocarcinoma?
cancer of bile duct
220
extrahepatic cholangiocarcinomas =
occur after the cystic duct inserts into CBD
221
Pres of HPB cancers?
* new onset DM
* jaundice - 20% malignancy in over 40s
* weight loss
* abd/ back pain
* nausea and vomiting
* change in BH - e.g. steathorrhea from lack pancreatic enzymes
222
mets from HPB cancer?
lung, liver, LNs
223
biliary system
224
cancer incidence graph
breast > prostate > lung > bowel
225
types of jaundice table
226
tests for pancreatic cancer?
* CT
* Tumour markers CA19.9
227
exocrine pancreatic cancer?
* 95% pancreatic cancer exocrine –>80% ductal adenocarcinoma
228
endocrine pancreatic cancer?
* 5% pancreatic cancers endocrine pNET (Insulinoma, Gastrinomas, VIPomas)
229
pancreatic cancer - >80% of cases in
over 60s
230
RFs for panc cancer?
- smoking
- chronic panc
- obesity
- FH
- DM
231
genetics relating to pancreatic cancer?
- BRCA2
- HNPCC
232
where does pancreatic cancer usually occur?
head - Whipples
233
oncogene in 90% of pancreatic cancers?
* KRAS oncogene in 90%
* TP53 or SMAD4
234
majority of pancreatic cancers are?
adenocarcinomas
235
courvoisier sign?
palpable gallbladder in patient with painless jaundice (presumed malignancy as stone disease is very unlikely)
236
obstructive jaundice features?
* dark urine
* pale stools
* steatorrhea
* ALP> ALT
* high GGT
237
dark urine w jaundice
* dark urine is caused by high levels of conjugated bilirubin as its water soluble - renal excretion -> dark urine
* not urobilinogen bc small amounts of this are in the GI tract so small amounts reabs
238
tests results for post hepatic jaundice?
* conjugated bilirubin inc
* urine urobilinogen decreases
* ALT/AST normal/ mild inc
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what inc in hepatic vs obstructive jaundice?
* ALT/ AST more raised in hepatic jaundice
* ALP/GGT - inc in obstructive jaundice
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pre-hepatic jaundice?
* excessive amount of bilirubin due to hemolysis
* elevated unconjugated bilirubin in serum
241
what cause spre-hepatic jaundice?
* transfusion reactions, sickle cell anemia, thalassemia
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test results for pre-hepatic jaundice?
* normal urine and stool, no pruitis, elevated bilirubin
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hepatic jaundice?
* impaired cellular uptake, defective conjugation or abn secretion of bilirubin by the liver cell
* both conjugated and unconjugated bilirubin may be elevated in serum
244
causes of hepatic jaundice?
* hepatitis, cancer, cirrhosis, drugs
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test results for hepatic jaundice?
* dark urine and normal stool, no pruritus
246
post hepatic jaundice?
* impaired excretion due to the mechanical obstruction to bile flow
* elevated conjugated bilirubin in serum
247
Causes of post hepatic jaundice?
* gallstones, tumours blocking outflow of bile into intestines
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test results for post hepatic jaundice?
* dark urine, pale stools and pruitis
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imaging for <40 jaundice?
USS - stones, biliary dilatation
250
imaging for > 40 jaundice which is painless?
CT r/o malignancy
251
> 40 jaundice w pain?
USS
252
Adjunct imaging for jaundice?
* Stone – MRCP +/- ERCP
* Cancer – Staging CT/ERCP/EUS/Liver MRI/PET-CT
253
staging of PC?
* CT pancreas (triple phase) and thorax
* enodsopic US + biopsy
254
PC - MRCP and ERCP?
* MRCP to assess strictures
* ERCP for strictures and therapeutic intervention stent
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CBD and PD dilatation (double duct dilatation) with jaundice =
HPB cancer
256
gold standard for staging PC?
* triple phase CT pancreas and thorax is the gold standard
* MRCP for assessing strictures
257
PC staging - EUS and PT?
* EUS for vascular assessment
* PET for distant mets
258
GORD?
* dyspepsia patients with predominant symptoms of reflux
* reflux is physiological - TLESRs
259
determining if someone has mucosal damage (erosive) from GORD:
* Grade C or D oesophagitis
* peptic stricture - recurrent bouts of inflammation that heal w fibrosis which narrows the lumen
* Barrets oesophagus - squamous -> redder columnar epithelium cells
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symptoms of GORD?
* heartburn, regurg are typical
* atypical: chest pain
* dysphagia
* odynophagia
* water brash
* globus
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Extra-oesophageal symptoms of GORD?
cough, laryngeal - hoarseness, wheeze, dentition
262
if GORD Tx fails...
* OGD if treatment fails, rebound, med issues
263
barium swallow?
for hiatal hernias and emptying of stomach (for surgery)
264
impedence monitoring for GORD?
* pH monitored in O and they get a button to press when they have synptoms
* number and duration of efflux episodes, if its postural etc
* helpful for testing when theyre on a PPI or if its not acid reflux
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? for motility disorders of the oesophagus?
* mannometry for motility disorders
* paticularly achalasia
266
PUD?
* Defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall
* 70% asymptomatic
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symptoms of PUD?
* Dyspepsia (epi pain)
* DU - pain 2-3hrs post meal or overnight (circadian acid secretion absence food/ chyme)
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Gastric ulcer pain?
* GU - pain provoked by food
269
complications of ulcers?
* haemorrhage
* perforation
* GOO/ stricture
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which type of ulcer is more common?
* DU 4x more common than GU
* DU are more common in men and tend to present in younger patients
271
90% of ulcers are from?
H pylori or NSAIDs
272
Dyspepsia rome IV criteria
273
GU vs DU?
274
PUD pathogenesis
275
rare causes of ulcers?
* stress
* lymphoma
* CD
- zollinger elison syndrome
- ischeaemic - espec smokers
- MEN1
276
Zollinger elison syndrome?
gastrin secreting tumour of the duodenum or pancreas which results in increased stimulation of acid secreting cells
277
MEN-1?
characterized by tumors of the parathyroids, pancreatic islet cells, and the anterior pituitary
278
Drugs that can lead to ulcers?
cocains or OTC meds
279
H pylori - urease?
* protects from Hcl
* generates ammonia which damages the mucosa
280
H pylori testing?
* stool antigen test - screening and confirmation of eradiation
* histology
- rapid urease test
- urea breath test
281
rapid urease test?
reduced accuracy in patients w active GI bleeding
282
urea breath test?
ab and PPIs can increase false negative results
283
maintenance antisecretory therapy?
* require NSAIDs/ aspirin
* over 50 and have co-morbities
* rebound symptoms on cessation of Tx
* recurrent ulcers - >2 per year
* H pylori or NSAID negative ulcers
284
Tx of functional dyspepsia?
* test and treat H pylori
* PPI +/- H receptor antagonist
* SSRI/SNRI/5-HT antagonist
* low fodmap diet, CBT
285
gallstones prev?
10%
286
Complicated gallstones?
* acute cholecystitis
* empyema
* perforation
* cholangitis
* pancreatitis
* Mirrizi syndrome
287
typical biliary colic?
* intense pain in RUQ/ epigastrium
* radiates to back or right scapula
* intermittent
* post prandial (fatty) or nocturnal
288
onset of biliary colic?
* onset 30mins to hrs post meal
* lasts at least 30mins - sev hours
289
biliary colic assoc symptoms ?
* associated w sweating, nausea and vomiting
* not relieved by movement, bowel opening of flatulence
290
atypical biliary colic?
* bloating
* flatulence
* epigastric burning
* nausea/vom alone
* fullness
291
functional biliary disorders?
* subset of disorders in patients without gallstones that can present w dyspeptic symptoms
* functional GB disorder
* sphincter of Oddi dysfunction
292
meds that can cause GORD?
* calcium antagonists
* nitrates
* theophyllines
* bisphosphonates
* corticosteroids
* NSAIDs
293
Treatment of GORD?
full dose PPI
294
What should not be given w barretts oesophagus?
* don't offer aspirin to prevent progression to oesophageal dysplasia and cancer
295
oesophageal cancer ref criteria?
296
crc cancer ref criteria?
297
pancreatic cancer ref criteria?
298
stomach cancer ref criteria?
299
what do patients complain of w dyspepsia?
* symptoms: nausea, vomiting, pain or distension
* patients likely to complain of indigestion
300
common causes of dyspepsia?
* Non-ulcer dyspepsia
* GORD (gastro-oesophageal reflux disease)
* Peptic ulcer disease
* Rarely gastric cancer
301
Which cells secrete acid?
* Parietal cells secrete acid into the stomach via H+/K+-ATPase
302
stimulants of Hcl secretion?
* Acetylcholine from parasympathetic fibres
* Gastrin, hormone released from G-cells into the bloodstream
303
How can gastrin and ACh act on parietal cells?
- directly on parietal cells
- indirectly via paracrine cells which release histamine which acts on pareietal cells to stimulate the pump
304
mucus production
* Forms a physical barrier over surface of stomach and consists of a gel rich in HCO3 (bicarbonate)
* This bicarbonate helps neutralise the acid creating a pH gradient
* Prostaglandins are synthesized by gastric mucosa + protect the mucosa by stimulating secretion of mucus/bicarbonate
305
PPIs?
* Act directly on H/K-ATPase responsible for pumping H+ out of parietal cell (which would then go on to form HCL)
* It irreversibly inhibits the enzyme, therefore acid secretion only resumes on synthesis of new enzymes
306
PPIs examples?
Omeprazole, Lansoprazole + Pantoprazole
307
histamine 2 receptor antagonists?
* Block the action of histamine from paracrine cells acting via receptors on parietal cells which has an inhibiting effect on the H/K-ATPase channel
308
example of H2 receptor antagonist?
Cimetidine + Ranitidine
309
antacids?
* Raise luminal pH of stomach
* Can cause an acid rebound
310
when are antacids given?
* Usually given between meals +at bedtime
* Normally contain aluminium/magnesium compounds
311
alginates?
* Increase the viscosity of stomach contents + protect the oesophageal mucosa from reflux
* Include Peptac +Gaviscon
312
GORD CFs?
* Cough
* Nocturnal asthma
* heartburn - aggrevated by bending/ lying down
313
RF for PUD?
* H.pylori
* NSAIDs, Aspirins, Steroids, Bisphosphonates
* Smoking
* Gastrinomas
* Genetic factors
314
Classic descriptions of PUD vs DU?
* Gastric ulcer – pain soon after meals – not relieved by eating
* Duodenal ulcer – pain 2-3 hrs after meal, relieved by eating and my wake patient up at night
315
H pylori?
* Linked with gastritis, peptic ulceration, gastric cancer + gastric lymphoma
* Usually acquired in childhood with transmission likely via oral-oral or faecal-oral
* More common in lower socioeconomic staus
316
Lifestyle advice for uninvestigated dyspepsia?
* Healthy eating
* Weight reduction
* Smoking cessation
* Avoid known precipitants – alcohol, coffee, chocolate, fatty foods
* Raising head of the bed
* Early main meal before going to bed
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