coeliac disease and bowel cancer

Question 1

what are some issues that stop you absorbing properly

Answer 1

• pernicious anaemia
• coeliac disease
• Crohn’s disease
• infections
• tumours
  ( coeliac and Crohn’s disease affect the small bowel which is where you absorb nutrients so you become malnourished)

Question 2

what is coeliac disease

Answer 2

• a sensitivity to alpha- gladden component of gluten = gluten isn’t the problem, only a part of it

Question 3

what is the prevalence of coeliac disease

Answer 3

• 1 in 2000 in western societies
• 1 in 500 in western Ireland
• true prevalence is 1 in 300 = some have gluten sensitivity but don’t know as don’t show any clinical symptoms

Question 4

what foods is gluten in

Answer 4

• wheat = durum, semolina, flour, pasta, cous-cous
• barley = beer, malt, baked goods
• spelt = wheat-free products
• rye = breads
• kamut = cereals, breads
• oats = ok but are usually contaminated in the factory with gluten grains

Question 5

what is the aetiology of coeliac disease

Answer 5

• genetic DQw2
• different component is absorbed, alpha part causes reactive issues which causes damage to epithelial cells in bowel which causes inflammation an t lymphocytes activated which then removes villi from cells so reduces surface area
• villous atrophy

Question 6

what is another name for coeliac disease

Answer 6

• gluten sensitive enteropathy

Question 7

where does villous atrophy occur

Answer 7

• subtotal villous atrophy of the jejunum

- upper jejunal mucosal immunopathology = 5 stages

Question 8

what are the 5 stages of upper jejunal mucosal immunopathology

Answer 8

• stage 0 = pre infiltrative
• stage 1 = infiltrative
• stage 2 = infiltrative hyperplastic
• stage 3 = flat destructive
• stage 4 = atrophic hypo plastic
• stage 3 and 4 means you can still absorb normal stuff but slower

Question 9

what happens if you remove gluten in coeliac disease

Answer 9

• process will reverse

Question 10

what are the effects of jejunal atrophy varies

Answer 10

• clinical 30-40%= growth failure, oral ulceration
• subclinical = no effects, have disease but no problem form it, but issue os that they are malnourished from malabsorption but are unaware
• can develop at any age
• if patient keeps eating gluten as they are unaware then they can develop bowel lymphoma

Question 11

classic symptoms of coeliac disease

Answer 11

• most patients have none at all
• weight loss
• lassitude = lack of energy
• weakness
• abdominal pain/swelling
• diarrhoea
• aphthae/glossitis = ulcers
• steatorrhoea = excrete abnormal amounts of fat in stool)
• dysphagia

Question 12

what are the 4 main things patients have malabsorption of with coeliac disease

Answer 12

• iron = from bleed
• folate = not in diet
• vitamin B12 = pernicious anaemia
• fat

Question 13

what are the investigations of coeliac disease

Answer 13

• jejunal biopsy = either capsule or endoscope, most important test
• foecal fat
• haematinics
• autoantibodies = mostly look for antibodies in the blood associated with disease, serum transglutaminase, anti-gliadin/anti-endomyseal

Question 14

how is the autoantibodies test very sensitive but not very specific

Answer 14

• will always tell you everyone who has it but will tell some people who don’t have it, they do
• gives false positives

Question 15

what are the areas of small bowel

Answer 15

• duodenum
• jejunum
• ileum

Question 16

what are the benefits of a gluten free diet

Answer 16

• reversal of jejunal atrophy
• improved well being = will feel better
• reduced risk of lymphoma
• no one knows if it means you are gluten sensitive for life

Question 17

what is dermatitis herpetiformis

Answer 17

• coeliac disease is associated with this
• is an oral disease
• granular IgA is deposited on the skin and mucosa
• get blisters on skin = shoulder and back mainly
• caused by gluten = from a reaction of gluten

Question 18

how is coeliac disease diagnosed

Answer 18

• want to know patients history of mouth ulcers and how they have changed
• all aphthae patients are screened by haemitinic assays to detect deficiency = blood tests, folate or combined ferritin and folate deficiency suggests malabsorption

Question 19

what used to be the biggest killer in Scotland

Answer 19

• bowel cancer

- there was a genetic tendency to form bowel cancers

Question 20

is bowel cancer easily treated

Answer 20

• yes, if found early

- need to catch tumour before it becomes malignant

Question 21

what is colonic carcinoma

Answer 21

• second most common malignancy in the western world
• Europe and USA are 10 x more common that Africa = largely due to diet
• there is now bowel cancer screening programmes in UK = when you turn 50 you are invited to take a test

Question 22

what are the symptoms of bowel cancer

Answer 22

• often none until disease is advanced then you notice
• anaemia
• rectal blood loss

Question 23

what is screening for colonic cancer

Answer 23

• FOB
• barium enema
• endoscopy
• CT/MRI scan
• carcinoembrionic antigen (CEA)
• all adults over 50 in UK give FOB sample by post = 5 year repeat if negative, endoscopy if positive

Question 24

what is the aetiology of bowel cancer

Answer 24

• most carcinomas arise in polyps = may be pedunculate or flat, most will bleed due to irritation and trauma, most take 5 years to progress to malignancy
• if polyps found on endoscopy, screening interval reduced
• polyps form in bowel from mixture of gland mucosal tissue = if removed within 5 years then chance of cancer is low, bowel cancer starts with polyps then progresses

Question 25

how are polyps detected and removed

Answer 25

• check FOB for red blood cells in bowel cancer screening
• use and instrument called diatherm unit to remove them = conducts electricity to heat up loop to cut through polyp to remove
• if have +ve FOB then get removal

Question 26

what factors can increase or decrease risk of bowel cancer

Answer 26

• diet
• smoking increases risk
• alcohol has no effect
• exercise reduces risk
• genetics = p53 in 75%
• ulcerative colitis
• intestinal polyps

Question 27

what foods in diet can increase of decrease risk of bowel cancer

Answer 27

• important but has not been conclusively proven
• fibre = decreases risk
• fat = increases risk
• meat = increases risk
• veg = decreases risk

Question 28

what is intestinal polyposis

Answer 28

• risk of carcinoma
• small intestine = low risk (Petuz-jehgers syndrome)
• large intestine = high risk (Gardiners Syndrome, Cowden’s syndrome)

Question 29

what is the survival of bowel cancer

Answer 29

• if graded well differentiated = 80% chance of 5 year survival
• if graded moderately differentiated = 60% chance of 5 year survival
• if graded poorly differentiated = 25% chance of 5 year survival
• survival depends on what stage you find lesion

Question 30

what classification is used for bowel cancer

Answer 30

• Duke’s classification

- 4 stages of classification on development of polyps

Question 31

what are the chances of 5 year survival depending on where polyps are

Answer 31

• submucosal = 80%
• muscularis = 65%
• lymph nodes = 45%
• liver = 5%

Question 32

how is survival nowadays for bowel cancer

Answer 32

• have good 5 year survival

- survival is improving but there is no cure

Question 33

what is the treatment for bowel cancer

Answer 33

• surgery = to remove lesion
• hepatic metastases
• radiotherapy
• chemotherapy = if have spread