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Gastrointestinal - Level 2 Flashcards

1
Q

Definition of malnutrition?

A

o Nutrient deficient state of protein, energy or micronutrients

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2
Q

Definition and symptoms of Kwashikor?

A 
o	Inadequate protein intake
o	Moon facies, swollen abdomen (pot belly)
o	Hepatomegaly
o	Pitting oedema
o	Dry, dark skin which splits
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3
Q

Definition and symptoms of marasmus?

A 
o	Inadequate energy and protein intake
o	Loss of weight and reduction in muscle mass
o	Thin, atrophic skin
o	Alopecia, brittle hair
o	Lanugo hair
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4
Q

Symptoms and management of iodine deficiency?

A

 Symptoms - Goitre, hypothyroidism, growth restriction

 Management - Iodine supplements, seafood

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5
Q

Symptoms and management of vitamin A deficiency?

A

 Symptoms - Night blindness, oval Bitot’s spots, cloudy corneas, immune dysfunction, increased illnesses
 Management – dark green leafy vegetables, animal products, vitamin Asupplements

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6
Q

Symptoms and management of vitamin C deficiency?

A

 Symptoms – listlessness, anorexia, bleeding gums, gingivitis, loose teeth, halitosis, muscle pain
 Management – increase vitamin C, supplements (Ascorbic Acid PO)

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7
Q

Symptoms and management of Vitamin B1 (thiamine) deficiency?

A

 Symptoms – beri beri – heart failure with oedema, neuropathy
 Management – Thiamine urgently

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8
Q

Symptoms of vitamin B2 (riboflavin) deficiency?

A

 Symptoms – angular stomatitis, cheilitis

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9
Q

Symptoms of Vitamin B6 (pyridoxine) deficiency?

A

 Symptoms – polyneuropathy

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10
Q

Symptoms of Vitamin E deficiency?

A

 Symptoms – haemolysis, neurological deficit

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11
Q

Symptoms of Vitamin K deficiency?

A

 Symptoms – bleeding disorders

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12
Q

Symptoms and management nicotinic acid deficiency?

A

 Symptoms – Pellegra – diarrhoea, dementia, dermatitis (Casal’s necklace)
 Rx – Nicotinamide PO

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13
Q

Risk factors for malnutrition?

A 
o	Young age
o	Neglect
o	Poverty 
o	Living alone
o	Severe learning difficulties or mental health problems
o	Gastric surgery
o	Malabsorption ~(CF, Crohn’s disease, Coeliac disease, chronic pancreatitis)
o	Stroke
o	Cancer
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14
Q

Symptoms of malnutrition?

A
  • BMI <18.5
  • Increasing fatigue
  • Non-healing wounds
  • Slowed growth
  • Reduced muscle mass
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15
Q

Definition of dyspepsia?

A
  • Dyspepsia – upper abdominal pain, heartburn, acid reflux, nausea and/or vomiting, typically >4 weeks
    o Most common cause of dyspepsia – GORD, PUD, functional dyspepsia, upper GI malignancy
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16
Q

Pathology of GORD?

A

 Reflux of gastric contents (acid, bile and pepsin) into oesophagus causing heartburn
 Due to transient relaxation (reduced tone) of LOS, increased intra-abdominal pressure, delayed gastric emptying and impaired oesophageal clearance of acid

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17
Q

Epidemiology of dyspepsia?

A
  • Dyspepsia occurs in 40% each year
    o At endoscopy 40% have GORD
  • Higher prevalence in Northern Europe
  • Increases with age and more common in women
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18
Q

Risk factors of GORD?

A 
o	Stress/Anxiety
o	Smoking
o	Alcohol
o	Foods – coffee, chocolate, fatty foods
o	Obesity
o	Drugs – alpha-blockers, anticholinergics, benzodiazepines, BB, bisphosphonates, CCB, corticosteroids, NSAIDs, nitrates, theophylline, TCA
o	Pregnancy
o	Hiatus hernia
o	FHx
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19
Q

Causes of dyspepsia?

A

o Oesophagitis

o Endoscopy-negative

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20
Q

Risk factors for Barrett’s oesophagus?

A

o Male, long duration/severe of GORD, previous oesophagitis/hiatus hernia/ulcers

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21
Q

Symptoms of GORD?

A

Heartburn
 Burning epigastric/retrosternal pain
 Worse on bending, lying down, with hot drinks, alcohol
 Relieved by antacids

Regurgitation

Belching

Odynophagia (pain on swallowing)

Increased salivation (waterbrash)

Nocturnal cough/asthma

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22
Q

Atypical symptoms of GORD?

A

hoarseness, cough, asthma, dental erosions

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23
Q

Investigations to perform in dyspepsia?

A

o FBC (low Hb, raised platelets)

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24
Q

Referral to endoscopy within 2-weeks under what criteria?

A

 With dysphagia or

 Aged 55 and over with weight loss and any of the following:
• Upper abdominal pain
• Reflux
• Dyspepsia

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25
Q

Referral to endoscopy non-urgently under what criteria?

A

 Treatment-resistant dyspepsia or

 Upper abdominal pain with low haemoglobin levels or

	Raised platelet count with any of the following:
•	Nausea
•	Vomiting
•	Weight loss
•	Reflux
•	Dyspepsia
•	Upper abdominal pain, or
	Nausea or vomiting with any of the following:
•	Weight loss
•	Reflux
•	Dyspepsia
•	Upper abdominal pain
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26
Q

Management of dyspepsia with unknown cause - lifestyle advice?

A

Lose weight, avoid triggers (coffee, chocolate, tomatoes, fatty/spicy foods)

Eat smaller meals, eat in evening 3-4 hours before going to bed

Stop smoking

Reduce alcohol

Sleep with head of bed raised

Antacids - OTC

Review medications

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27
Q

Management of dyspepsia with unknown cause -if persistent symptoms?

A

o If persistent symptoms – FBC (check for anaemia or high platelets)

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28
Q

Management of dyspepsia with unknown cause - initial drug treatment?

A

 PPI for 1 month

• Lansoprazole 30mg, Omeprazole 20-40mg, esomeprazole 20mg

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29
Q

Management of dyspepsia with unknown cause - initial testing and eradication?

A

 H.pylori test – if positive then eradication therapy
• Carbon-13 urea breath test or stool antigen test (no PPI in last 2w, no Abx in last 4w)
• Eradication 7-days triple therapy - Omeprazole 20mg BD/Lansoprazole 30mg BD, amoxicillin 1g BD + clarithromycin 500mg BD (or metronidazole 400mg BDS)
 If persists then switch

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30
Q

Management of dyspepsia with unknown cause - recurrent/refractory symptoms?

A

 H2-receptor antagonists
 Re-test H.pylori only if – poor compliance, NSAIDs indicated, FHx of gastric malignancy, severe symptoms or patient request

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31
Q

Management of dyspepsia with unknown cause - when to refer to endoscopy?

A

 Refractory or recurrent symptoms

 Treatment with 2nd line H.pylori unsuccessful

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32
Q

Management of endoscopically proven GORD - lifestyle measures?

A

 Lose weight, avoid triggers (coffee, chocolate, tomatoes, fatty/spicy foods)
 Eat smaller meals, eat in evening 3-4 hours before going to bed
 Stop smoking
 Reduce alcohol
 Sleep with head of bed raised

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33
Q

Management of endoscopically proven GORD -if proven GORD?

A

 PPI for 4-8 weeks
• Lansoprazole 30mg, omeprazole 20-40mg, esomeprazole 20mg, pantoprazole 40mg, rabeprazole 20mg

 If symptoms recur:
• Offer PPI at lowest dose possible to control symptoms
• H2RA therapy if inadequate response to PPIs

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34
Q

Management of endoscopically proven GORD - if proven severe oesophagitis?

A

 PPI for 8 weeks
• If treatment fails – switch to another PPI
• Maintenance treatment – Full-dose PPI long-term

 If symptoms recur:
• Further 1 month PPI course
• Double dose of PPI
• H2RA therapy if inadequate response to PPIs

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35
Q

Management of endoscopically proven GORD - when to consider endoscopy?

A

o Consider endoscopy to diagnose Barrett’s oesophagus if long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia

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36
Q

Referral to GI or upper GI surgeon - when?

A
  • Refractory, persistent or unexplained
  • Controlled on PPI but does not want to continue or PPI not tolerated
  • RF of Barrett’s oesophagus – upper GI endoscopy
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37
Q

Referral to GI or upper GI surgeon - specialist investigations?

A
  • Oesophageal manometry
  • Ambulatory 24-hour oesophageal pH monitoring (exclude achalasia, hypomotility)
  • Barium swallow (exclude structural disorders – hiatus hernia, achalasia)
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38
Q

Referral to GI or upper GI surgeon - specialist management?

A

• Laparoscopic Nissen fundoplication
o Confirmed diagnosis of acid reflux and adequate symptom control but does not want to continue on long-term PPI or cannot tolerate PPI
• Endoscopic radiofrequency ablation
• Laparoscopic insertion of magnetic bead band
• Endoscopic infection of bulking agent

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39
Q

Complications of GORD?

A 
o	Oesophageal ulcers/haemorrhages/strictures
o	Anaemia
o	Aspiration pneumonia
o	Barrett’s oesophagus
o	Dental erosions, gingivitis, halitosis
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40
Q

What is Barrett’s oesophagus?

A

 Columnar metaplasia of distal oesophagus, malignant potential and risk of adenocarcinoma
 Endoscopy surveillance needed

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41
Q

Prognosis of GORD?

A

o Recurrence is 80%
o 10-15% of people with GORD symptoms will develop Barrett’s oesophagus, of these 1-10% will develop oesophageal adenocarcinoma over 10-20 years

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42
Q

Risk factors for GORD in children?

A

o Fluid diet, horizontal stature and short intra-abdominal length of oesophagus
o Cerebral palsy
o Preterm infants
o Following surgery for oesophageal atresia or diaphragmatic hernia

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43
Q

Symptoms of GORD in children?

A
  • Recurrent regurgitation/vomiting - Possetting
  • May contain some blood
  • Increased salivations
  • Chronic cough
  • Normal weight and otherwise well
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44
Q

when to investigated GORD in children?

A

o Upper GI contrast with Hx of bile stained vomiting or Hx of GORD
o Specialist assessment for endoscopy with biopsies if:
 Haematemesis, melaena, dysphagia, no improvement after 1 year old, faltering growth, distress, feeding aversion, iron-deficiency anaemia
o Oesophageal pH study – recurrent aspiration pneumonia, unexplained apnoea/seizure-like events/upper airway inflammation, frequent otitis media

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45
Q

Management of GORD in infants?

A
  • Position at 30o head-up prone position after feeds
  • Dietary: Thickened milk feeds (Carobel), small frequent meals, avoid food before sleep, avoid fatty foods, caffeine, citrus juices, alcohol, smoking

• Drugs:
 1-2 weeks Gaviscon added to feeds (antacid and alginate forms viscous layer)
 4 week trial H2 receptor antagonists (ranitidine) or PPI (omeprazole)
- If unexplained feeding difficulty, distressed, faltering growth

• Surgery if failed medical therapy
 Upper GI endoscopy
 Fundoplication – fundus of stomach wrapped around intra-abdominal oesophagus

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46
Q

Management of GORD in children?

A

• Lifestyle management

• Drugs
 Consider if regurgitation + feeding difficulty/distressed/faltering growth
 4-week PPI/H2 – persistent heartburn
- If not resolving – endoscopy

• Enteral Feeding
 If faltering growth and no other explanation

• Surgery
 Endoscopy and biopsies prior to surgery
 Fundoplication if intractable, medical therapy unsuccessful

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47
Q

Complications of GORD in children?

A
  • Failure to thrive
  • Oesophagitis – haematemesis and iron deficiency anaemia
  • Recurrent pulmonary aspiration – pneumonia, wheeze
  • Dystonic neck posturing (Sandifer syndrome – extension and lateral turning of head)
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48
Q

Pathology of oesophageal carcinoma?

A

o SCC – usually middle 1/3, incidence decreasing, men 2:1

o Adenocarcinoma – arises from Barrett’s oesophagus, lower 1/3 of oesophagus

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49
Q

Types of oesophageal carcinoma?

A 
o	Adenocarcinoma – most common
	Smoking
	Obesity
	GORD
	Barrett’s oesophagus
	Radiotherapy for breast cancer

o	SCC – high in China/Japan
	Smoking
	High salt diet
	Achalasia
	Coeliac disease
	Very hot food
	Plummer Vinson syndrome
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50
Q

Symptoms of oesophageal carcinoma?

A 
o	Progressive dysphagia (initially solids then liquids)
o	Weight loss
o	Retrosternal chest pain
o	Hoarseness
o	Cough (if upper 1/3)
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51
Q

When to offer urgent 2-week upper GI endoscopy of oesophageal carcinoma?

A
  • Offer urgent upper GI endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people:
    o with dysphagia or
    o aged 55 and over with weight loss and any of the following:
     upper abdominal pain
     reflux
     dyspepsia
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52
Q

When to offer non-urgent upper GI endoscopy of oesophageal carcinoma?

A

o Treatment-resistant dyspepsia or

o Upper abdominal pain with low haemoglobin levels or

o	Raised platelet count with any of the following:
	Nausea
	Vomiting
	Weight loss
	Reflux
	Dyspepsia
	Upper abdominal pain, or
o	Nausea or vomiting with any of the following:
	Weight loss
	Reflux
	Dyspepsia
	Upper abdominal pain
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53
Q

Staging tests of oesophageal carcinoma?

A

o PET-CT whole body
o TNM staging
o Her2 testing in metastatic oesophageal adenocarcinoma

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54
Q

Management of oesophageal carcinoma - radical treatment?

A

 Radical oesophagectomy
o T1N0 (Endoscopic mucosal resection or oesophagectomy)
• +/- lymph node dissection

 Neoadjuvant chemradiotherapy

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55
Q

Management of oesophageal carcinoma - follow up?

A

o Give advice on symptoms of recurrence and advise to contact MDT if symptoms present

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56
Q

Management of oesophageal carcinoma - palliative management - if non-metastatic but not fit for surgery?

A

 Chemoradiotherapy

 OR chemo + stenting, palliative radio

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57
Q

Management of oesophageal carcinoma - palliative management - if locally advanced or metastatic?

A

 Palliative Chemotherapy (trastuzumab + cisplatin + 5-FU)
 If outflow obstruction:
• Palliative surgery
• Stenting
o Self-expanding if needed to help with dysphagia
• Radiotherapy

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58
Q

Definition of hiatus hernia?

A
  • Protrusion of intra-abdominal contents through enlarged oesophageal hiatus of diaphragm
  • Most commonly contains portion of stomach
  • Displacement of GOJ above diaphragm reduces LOS pressure and predispose to GORD
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59
Q

Types of hiatus hernia?

A

o Sliding (Type 1) (80%) – protrusion of GOJ followed by body of stomach above diaphragm

o Type 2 (20%) – Pure para-oesophageal hernia/rolling hernia – herniation of fundus or body with GOJ below

o Type 3 – mixed

o Type 4 – Giant – any type of hernia with herniation of organs

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60
Q

Epidemiology of hiatus hernia?

A
  • Many people asymptomatic

- 95% Type 1

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61
Q

Risk factors of hiatus hernia?

A

o Obesity
o Previous gastro-oesophageal procedure
o Elevated intra-abdominal pressure – pregnancy, ascites
o Age

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62
Q

Symptoms of hiatus hernia?

A 
o	Heartburn
	Typically, after meals, on bending/lying down
	Retrosternal burning sensation
o	Regurgitation
	Sour/metallic taste in mouth, particularly when lying flat
o	Dysphagia
o	Nausea &amp; vomiting
o	Hiccups
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63
Q

Investigations of hiatus hernia?

A 
-	CXR
o	Soft tissue opacity
o	Retrocardial air-fluid level diagnostic of para-oesophageal hiatus hernia
-	Barium studies
-	Endoscopy
-	Oesophageal manometry
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64
Q

Management of hiatus hernia - general measures?

A

o Avoid factors which increase intra-abdominal pressure
o Elevate bed to relieve nocturnal symptoms
o Weight loss
o Small meals and avoid eating just before bed
o Avoid food trigger for GORD – alcohol, acidic foods

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65
Q

Management of hiatus hernia - drug therapy?

A

o If symptomatic GORD

 PPIs - omeprazole

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66
Q

Management of hiatus hernia - surgical management - when to offer?

A

 Drug or general measures failed
 Complications of reflux
 Symptomatic para-oesophageal hernia

67
Q

Management of hiatus hernia - surgical management - what?

A

o Laparoscopic fundoplication (can be open)
 Nissen’s – complete wrapping of fundus around oesophagus or modified – partial
 Gastropexy can be used

68
Q

Prognosis of hiatus hernia?

A

o If sliding – most symptoms relieved by medical treatment

69
Q

Complications of hiatus hernia?

A

o Bloating
o Volvulus
o Obstruction
o Recurrence of hernia post-repair

70
Q

Pathology of peptic ulcer disease?

A

o Breakdown of epithelial cells to muscularis mucosa

o Acid breaks down wall

71
Q

Epidemiology of peptic ulcer disease?

A
  • Duodenal 4x more common
  • Men 4:1 Women
  • Elderly more susceptible
  • Developing countries due to H.pylori
72
Q

Aetiology of peptic ulcer disease?

A 
o	H.pylori (80-90%)
o	NSAIDs and aspirin (gastric)
o	Smoking
o	Alcohol
o	Zollinger-Ellison Syndrome
o	Duodenal reflux
o	Crohn’s
73
Q

Symptoms of gastric peptic ulcer disease?

A

 Epigastric pain (burning)
 Worse at meal times, relieved by antacids
 Weight loss and nausea common

74
Q

Symptoms of duodenal peptic ulcer disease?

A

 Epigastric pain (burning)
 Worse when hungry or at night – relieved by eating/milk
 Nausea, flatulence common
 Relieved by antacids

75
Q

Red flag symptoms of gastric malignancy?

A 
o	Anaemia (iron def)
o	Loss of weight
o	Anorexia
o	Recent onset/Progressing
o	Melaena/Haematemesis
o	Swallowing difficulties
76
Q

Management of peptic ulcer disease- lifestyle advice?

A

o Weight loss
o Avoid trigger foods – coffee, chocolate, tomatoes, fatty or spicy foods
o Eat smaller meals and eat evening meals 3-4 hours before going to bed
o Stop smoking
o Reduce alcohol
o Raising head of bed

77
Q

Management of peptic ulcer disease- medication review?

A

o Stop NSAIDs

o Reduce or stop – aspirin, bisphosphonates, corticosteroids, potassium supplements, SSRIs

78
Q

Management of peptic ulcer disease- when to refer to endoscopy within 2 weeks?

A 
	With dysphagia or
	Aged 55 and over with weight loss and any of the following:
•	Upper abdominal pain
•	Reflux
•	Dyspepsia
79
Q

Management of peptic ulcer disease- when to refer to endoscopy non-urgently?

A

 Treatment-resistant dyspepsia or

 Upper abdominal pain with low haemoglobin levels or

	Raised platelet count with any of the following:
•	Nausea
•	Vomiting
•	Weight loss
•	Reflux
•	Dyspepsia
•	Upper abdominal pain, or
	Nausea or vomiting with any of the following:
•	Weight loss
•	Reflux
•	Dyspepsia
•	Upper abdominal pain
80
Q

Management of proven peptic ulcer disease- initial testing?

A

Test for H.pylori infection (if not known)
 Initial detection – Carbon-13 urea breath test or stool antigen test
 Ensure no PPI in past 2 weeks, or antibiotics in last 4 week

81
Q

Management of proven peptic ulcer disease- if person positive for H.pylori with PU?

A

Associated with NSAID use – full-dose PPI therapy for 8 weeks, then eradication therapy after completion of PPI therapy
• PPI = lansoprazole 30mg, omeprazole 20-40mg, esomeprazole 20mg, pantoprazole 40mg, rabeprazole 20mg
• Eradication 7 day = PPI BD + amoxicillin 1g BD + clarithromycin 500mg BD (or metronidazole 400mg BD)

Not associated with NSAID use – eradication therapy
• Eradication 7 day = PPI BD + amoxicillin 1g BD + clarithromycin 500mg BD (or metronidazole 400mg BD)

82
Q

Management of proven peptic ulcer disease- if person negative for H.pylori with PU?

A

Full-dose PPI therapy for 4-8 weeks

• PPI = lansoprazole 30mg, omeprazole 20-40mg, esomeprazole 20mg, pantoprazole 40mg, rabeprazole 20mg

83
Q

Management of proven peptic ulcer disease- follow up?

A

o Repeat endoscopy 6-8 weeks after starting eradication therapy

o H.pylori retesting 6-8 weeks after starting eradication, with carbon-13 urea breath test
 If H.pylori positive – offer second line eradication
• 2nd line eradication = offer PPI, amoxicillin and the other drug not given

o If healed – offer PPI if needed, reduce dose of NSAIDs, switch aspirin
 Lowest dose effective with PPI and consider PRN prescription

84
Q

Management of proven peptic ulcer disease- review in primary care?

A

o Annual review

85
Q

Management of proven peptic ulcer disease- when to refer to GI?

A

o Refractory or recurrent symptoms despite optimal management
o Treatment with 2nd line eradication unsuccessful
o Limited antibiotics options
o Proven gastric ulcer has not healed on repeat endoscopy
o Zollinger-Ellison syndrome

86
Q

Complications of Peptic ulcer disease?

A

o Haemorrhage
o Perforation
o Gastric outlet obstruction
o Gastric malignancy

87
Q

Prognosis of peptic ulcer disease?

A

o Mortality rate 6-8%
o 1 in 10 with bleeding ulcer will die
o 1 in 4 with perforated ulcer will die

88
Q

Causes of bowel perforation - chemical, infection & ischaemia?

A

Chemical
 Peptic ulcer disease
 Foreign Body (battery)

Infection
 Diverticulitis
 Cholecystitis
 Meckel’s diverticulum

Ischaemia
 Mesenteric ischaemia
 Cancer
 Obstruction

89
Q

Causes of bowel perforation - colitis, iatrogenic and direct rupture?

A

Colitis
 Toxic megacolon (C.diff/UC)

Iatrogenic
 Surgery, endoscopy
 Trauma

Direct rupture
 Excessive vomiting leading to oesophageal perforation (Boerhaave syndrome)

90
Q

Symptoms of bowel perforation?

A

o Severely painful sudden event
o Sudden localised epigastric pain spread to remainder of abdomen
 Worse on coughing or moving and may radiate to shoulder tip
o Vomiting, lethargy

91
Q

Signs of bowel perforation?

A

o Patient lies still, may writhe in agony

o Absent bowel sounds, generalised peritonitis and fever

92
Q

Investigations in bowel perforation?

A

AXR
o Rigler’s sign (both sides of bowel seen, due to free abdominal air

Erect CXR (free gas under diaphragm)
o	Contrast CT scan when CXR not definitive
Bloods
o	FBC (raised WCC), U&amp;Es, LFTs, CRP, glucose, amylase, clotting, Ca, Group and save

Pregnancy test if woman

Urinalysis

ECG/Troponin

93
Q

Initial management of bowel perforation?

A

o Oxygen
o IV analgesia (morphine) and antiemetic (IV metoclopramide 10mg)
o IV fluid resuscitation (0.9% saline)
o NBM and NG tube
o IV Abx (co-amoxiclav 1.2g TDS and metronidazole 500mg TDS and stat gent if septic)
o Refer to surgeon

94
Q

Surgical management of bowel perforation?

A

o Laparotomy and repair:
 Peptic ulcer – omental patch
 Perforated diverticulae – Hartmann’s procedure

95
Q

Conservative management of bowel perforation?

A

o If mild disease and only localised peritonitis on CT or elderly patients

96
Q

Most common location and type of gastric cancer?

A
  • Most commonly found in antrum

- Mostly adenocarcinoma

97
Q

Types of gastric cancer?

A
  • Type 1 (intestinal)
    o Localised ulcerated lesions with rolled edges, distal stomach
  • Type 2 (diffuse)
    o Extensive submucosal spread, mostly cardia
98
Q

Spread of gastric cancer?

A
  • Spread via local, lymph, blood, transecoelomic
99
Q

Other tumour types of gastric cancer?

A

o GIST – stromal or mesenchymal tumours in stomach or proximal SI
 Have malignant potential
 Usually asymptomatic and incidental finding
• Can ulcerate and bleeding
o MALToma – B-cell lymphomas

100
Q

What are the types of gastric polyps?

A

o Asymptomatic, usually removed endoscopically
o Hyperplastic – most common, <2cm and not malignant
o Adenomatous – solitary in antrum, rare, premalignant
o Cystic Gland – microcysts lined by chief/parietal cells, fundus and body

101
Q

Epidemiology of gastric cancer?

A
  • 4th most common cancer
  • More common in Japan, China, Eastern Europe
  • Men 2:1 Women
102
Q

Aetiology of gastric cancer?

A 
o	H.pylori
o	Chronic Gastritis
o	Smoking
o	Diet (low in fruit &amp; veg, high in salted &amp; smoked foods)
o	Pernicious anaemia
o	FHx
o	Nitrosamines
103
Q

Symptoms of gastric cancer?

A 
o	Epigastric pain
	Like peptic ulcer
	Relieved by food/antacids
o	Loss of appetite
o	Weight loss
o	Vomiting
o	Dysphagia
104
Q

Signs of gastric cancer?

A 
o	Anaemia
o	Palpable Virchows node
o	Mass in epigastrium
o	Hepatomegaly, ascites – metastases
o	Acanthosis Nigricans
o	Dermatomyositis
105
Q

Management of gastric cancer - when to refer on 2-week pathway?

A

APPOINTMENT
Upper abdominal mass consistent with stomach cancer

UPPER GI ENDOSCOPY
	with dysphagia or
	aged 55 and over with weight loss and any of the following:
•	upper abdominal pain
•	reflux
•	dyspepsia.
106
Q

Management of gastric cancer - when to refer non-urgently?

A

 Haematemesis OR

	People aged 55 or over with:
•	Treatment-resistant dyspepsia or
•	Upper abdominal pain with low haemoglobin levels or
•	Raised platelet count with any of the following:
o	nausea
o	vomiting
o	weight loss
o	reflux
o	dyspepsia
o	Upper abdominal pain, or
•	Nausea or vomiting with any of the following:
o	weight loss
o	reflux
o	dyspepsia
o	upper abdominal pain
107
Q

Management of gastric cancer - secondary care investigations?

A

o Endoscopy and biopsies taken
o CT
 TNM staging
o Staging laparoscopy if potentially curable
o EUS to determine depth if help
o PET scan if metastatic disease suspected
o Her2 testing in metastatic gastric adenocarcinoma

108
Q

Management of gastric cancer - radical treatment?

A

Nutritional assessment by specialist dietician

Gastrectomy (radical surgical resection)
 Neo-adjuvant chemotherapy
 D2 lymph node dissection

109
Q

Management of gastric cancer - palliative treatment?

A

Specialist cancer-specific dietician

Palliative Chemotherapy (trastuzumab (HER2 positive) + cisplatin + 5-FU)

If outflow obstruction:
 Palliative surgery
 Stenting - Self-expanding if needed to help with dysphagia
 Radiotherapy

110
Q

Prognosis of gastric cancer?

A

o 5-year survival 20%

o Surgery improves survival

111
Q

Most common pancreatic cancer?

A
  • Mostly ductal adenocarcinoma, metastasise early and present late
112
Q

Epidemiology of pancreatic cancer?

A
  • 5th most common cause of cancer death in UK
  • Men < Women
  • Incidence increases with age
113
Q

Types of pancreatic cancer?

A

Adenocarcinomas (96%)
 Head 60%, Body 25%, tail 15%

Others – ampullary tumour, pancreatic islet cells (insulinoma, gastrinoma, glucagonoma, somatostatinoma)

114
Q

Aetiology of pancreatic cancer?

A 
o	Smoking
o	Petrol
o	Obesity
o	High fat/Red meat diet
o	Alcohol
o	Diabetes
o	Chronic pancreatitis
115
Q

Symptoms pancreatic cancer - if head or ampulla?

A 
o	Painless obstructive jaundice
o	Blocks CBD
o	Weight loss
o	Distended gall bladder
o	May be mass palpable
116
Q

Symptoms pancreatic cancer - if body or tail?

A

o Abdominal pain – back, dull
 Relieved by sitting forwards
o Weight loss
o Anorexia

117
Q

Signs of pancreatic cancer?

A 
o	Jaundice
o	Palpable gallbladder
o	Epigastric mass
o	Hepatomegaly
o	Splenomegaly
o	Ascites
118
Q

Bloods in pancreatic cancer?

A

o Cholestatic jaundice (rise in ALP and GGT)

o Ca19-9 raised

119
Q

When to offer surveillance for pancreatic cancer?

A

o hereditary pancreatitis and a PRSS1 mutation
o BRCA1, BRCA2, PALB2, or CDKN2A (p16) mutations, and one or more first-degree relatives with pancreatic cancer
o Peutz-Jeghers syndrome

120
Q

Referral for 2-week appointment in pancreatic cancer?

A

Aged >40 and jaundice

121
Q

Consider direct access CT scan within 2 weeks in pancreatic cancer?

A 
Consider an urgent direct access CT scan within 2 weeks, or an urgent ultrasound scan if CT is not available, if aged >60 with weight loss and any of the following:
o	diarrhoea
o	back pain
o	abdominal pain
o	nausea
o	vomiting
o	constipation
o	new-onset diabetes
122
Q

Secondary care diagnosis of pancreatic cancer?

A

o Pancreatic protocol CT scan (chest, abdomen, pelvis)

o If unclear – PET/CT or EUS tissue sampling (FNA)

123
Q

Staging of pancreatic cancer?

A

o If localised disease and having treatment – PET/CT

o MRI if liver metastases suspected

124
Q

Management of pancreatic cancer - general measures?

A

o Nutrition
 Enteric-coated pancreatin if unresectable or after resection of cancer

o Pain Management
 Opiates
 If uncontrolled, opioid adverse effects: EUS-guided percutaneous neurolytic coeliac plexus block

o Biliary Obstruction
 Offer resectional surgery if possible
 If unresectable – endoscopically placed self-expanding metal stent

125
Q

Management of pancreatic cancer - resectable disease?

A

 Surgical excision (pancreaticoduodenectomy – Whipple’s) + lymphadenectomy

126
Q

Management of pancreatic cancer - locally advanced?

A

 Chemotherapy

 Chemoradiotherapy

127
Q

Management of pancreatic cancer - metastatic cancer?

A

 Chemotherapy
• FOLFIRINOX
• Gemcitabine
 Stent insertion

128
Q

Prognosis of pancreatic cancer?

A

o Mean survival 6 months

129
Q

Definition of coeliac disease?

A
  • T-cell mediated autoimmune disease of small bowel which glutens/prolamin (in wheat, barley, rye, oats) intolerance causes villous atrophy and malnutrition
  • Gliadin toxic part which leads to villous atrophy, crypt hyperplasia and increased intraepithelial lymphocytes
  • Mucosa improves when gluten removed
  • Called gluten-sensitive enteropathy
130
Q

Epidemiology of coeliac disease?

A
  • Incidence increasing with 1 in 300 people
  • Peaks in infancy, 50-60 but can occur at any age
  • Women 2>1 Male
131
Q

Risk factors of coeliac disease?

A 
o	Genetic
	HLA DQ2/8
o	Familial
o	Autoimmune Disease
	DM1, Thyroid disease, Addison’s
132
Q

Symptoms of coeliac disease?

A 
o	Diarrhoea
o	Weight loss
o	Abdominal pain
o	Bloating
o	Nausea, vomiting
o	Foul-smelling stools
o	Steatorrhea
o	Malaise/Fatigue
133
Q

Signs of coeliac disease?

A

o Anaemia (iron or B12)
o Aphthous mouth ulcers
o Angular stomatitis
o Dermatitis herpatiformis

134
Q

When to offer serological testing in coeliac disease?

A

o Persistent unexplained abdominal or GI symptoms
o Faltering growth
o Prolonged fatigue
o Unexpected weight loss
o Severe or persistent mouth ulcers
o Unexplained iron, vitamin B12 or folate deficiency
o T1DM
o Autoimmune thyroid disease at diagnosis
o IBS
o 1st degree relatives with coeliac disease

135
Q

what serological testing to perform in suspected coeliac disease?

A

Before testing, confirm patient eaten gluten at least 2x/day for last 6 weeks

Antibodies
 IgA tTGA (tissue transglutamase)
• IgA EMA (endomysial) – 2nd line if IgA tTG weakly positive
 Total IgA

Bloods
 FBC
• Decreased Hb, ferritin, B12

136
Q

When to refer patient suspected of coeliac disease?

A

Refer anyone with positive serological test result to GI specialist (or negative test but clinical suspicion) for:
o Duodenal Endoscopy & Biopsy
 Villous atrophy, Increased WBC, Crypt hyperplasia
 Reverses upon cessation of gluten

137
Q

Management of coeliac disease - annual review?

A

o Adherence to gluten-free diet
o Measure BMI
o Risk of osteoporosis
o Consider FBC, coeliac screen, TFT, LFT, Vit D/B12, U&Es

138
Q

Management of coeliac disease - management?

A

Lifelong gluten-free diet - IMPORTANT
o Avoid food based on wheat, barley and rye
 Bread, flour, cakes, pastries, biscuits
 Foods-contained gluten (sausages, ready meals, soups, sauces)
o Read food labels to check products suitable
o Can prescribe gluten-free biscuits, flour, bread, pasta
o Provide information – Coeliac UK

139
Q

Management of coeliac disease - supplements?

A

o High-dose folic acid for women who are pregnant

o If deficient, folic acid, calcium, Vit D

140
Q

Management of coeliac disease - Vaccines?

A
  • Pneumococcal vaccine if hyposplenic
141
Q

Management of coeliac disease - if refractory disease?

A
  • If refractory coeliac disease – refer to specialist centre for treatment with prednisolone
142
Q

Complications of coeliac disease?

A 
o	Anaemia
o	Lactose-intolerance
o	T-Cell lymphoma
o	Malignancy
o	Osteoporosis
143
Q

Pathology of acute pancreatitis?

A

o Inappropriate activation of trysinogen into trypsin by lysosomal enzymes (cathepsin)
o Activation leads to further activation and inflammation, oedema and necrosis
o Damage causes by TNF-a and IL-1
o Neutrophil recruitment and inflammatory process leads to capillary permeability, ARDS, DIC, renal failure

144
Q

Definitions of acute pancreatitis?

A

o Mild – Absence of complications or organ dysfunction
o Moderate – Local complications and organ dysfunction resolved <48 hours
o Severe – Persistent organ dysfunction often leading to necrosis and abscess/cysts

145
Q

Epidemiology of acute pancreatitis?

A
  • Increasing incidence

- 20% mortality, 80% mild

146
Q

Causes of acute pancreatitis?

A 
o	Idiopathic
o	Gallstones
o	Ethanol
o	Trauma
o	Steroids
o	Mumps
o	Autoimmune
o	Scorpion bites
o	Hypercalcaemia, hyperlipidaemia
o	ERCP
o	Drugs – Oestrogens, azathioprin
147
Q

Symptoms of acute pancreatitis?

A

o Severe, constant epigastric pain radiating to centre of back
 Relieved by sitting forward
o Nausea and vomit in

148
Q

Signs of acute pancreatitis?

A

o Epigastric tenderness, guarding, rigidity
o Tachycardia, fever, jaundice, shock, ileus
o Cullen’s signs – periumbilical bruising
o Grey Turner’s signs – flank bruising, retroperitoneal haemorrhage

149
Q

Investigations of acute pancreatitis?

A

Check blood glucose and SpO2

Bloods
o FBC (raised WCC), CRP, U&E, LFTs, Ca, glucose
o Lipase – grossly raised >5x upper limit
o Coagulation screen
o Lactate if unwell
o ABG

Imaging
o CXR
o Contrast spiral CT scan to identify necrosis
o ECG

150
Q

Management of acute pancreatitis - severity assessment?

A 
	Glasgow modified criteria for severity
	3 or more detected within 48h suggests severe disease and prompts transfer to ITU/HDU
•	PaO2 (<8kPa)
•	Age (>55)
•	Neutrophilia (>15x109/L)
•	Ca (<2mmol/L)
•	Renal function (Urea >16mmol/L)
•	Enzymes (LDH>600iu/L, AST>200iu/L)
•	Albumin (<32g/L)
•	Sugar (glucose>10mmol/L)
151
Q

Management of acute pancreatitis - initial management?

A

 O2
 IV access and IV fluids
 IV analgesia (pethidine) and antiemetic (cyclizine 50mg)
 IV Abx (Tazocin 4.5g IV)
 NG if vomiting
 If able to take oral intake, encourage - Enteral nutrition if moderate/severe acute pancreatitis
 Urinary catheter and monitor UO
 Consider insertion of central venous line
 Contact HDU/ICU
 May need endoscopic surgical debridement

152
Q

Complications of acute pancreatitis?

A

o Early complications
 Shock, ARDS, Renal failure, DIC, Sepsis, hypocalcaemia, high glucose

o Late Complications
 Pancreatic necrosis, pseudocyst, abscesses, bleeding, thrombosis, fistulae

153
Q

Pathology of peritonitis?

Definition of peritonitis - primary?

A

o Omentum attempts to confine area by wrapping around infection
o Adjacent bowel and fibrinous adhesions involved
o If fails, generalised peritonitis occurs

o Primary = inflammation occurs in peritoneum itself rather than as a result of pathology arising in another organ (SBP)

154
Q

Definition of peritonitis -secondary?

A

o Secondary = Pathological process adjacent to peritoneum causes inflammation (perforated viscus)

155
Q

Definition of peritonitis - localised?

A

o Localised = inflammation in limited area, such as adjacent to inflamed appendix/diverticulum

156
Q

Definition of peritonitis - generalised?

A

o Generalised = Widespread inflammation

157
Q

Definition of peritonitis - intra-abdominal sepsis?

A

o Intra-abdominal sepsis = intra-abdominal infection and encompasses localised and generalised peritonitis

158
Q

Aetiology of peritonitis?

A

Upper GI
- Malignancy, trauma, perforated peptic ulcer, iatrogenic (endoscopy)

Lower GI - Ischaemic bowel, diverticulitis, hernia, obstruction, IBD, appendicitis, trauma

Biliary - Cholecystitis, pancreatitis, endocarditis, malignancy

GU - PID, malignancy

159
Q

Symptoms of peritonitis?

A 
o	Abdominal pain
	Poorly, localised initially
	Worsening and more localised when infection spreads
o	Anorexia
o	Nausea and vomiting
160
Q

Signs of peritonitis?

A

o Prostration (lying down stretched out)
o Shock – hypotension, fever, hypothermia, tachycardia
o Lying still
o Tenderness (+/- rebound/percussion pain)
o Board-like abdominal rigidity
o Guarding
o No bowel sounds

161
Q

Investigations to perform in peritonitis?

A

Bloods
o FBC, U&E, LFT, CRP, amylase and lipase, clotting, Ca
o Cultures
o Crossmatch/Group and Save

ABG

ECG + troponin if cardiac suspected

Urinalysis + PREGNANCY TEST

162
Q

Imaging to perform in peritonitis?

A

o Erect CXR
o AXR
o USS
o CT scan if no delay

163
Q

Initial management of peritonitis?

A

Bed Rest + NBM

Treat Shock
 IV 0.9% NaCl 500ml bolus

NG Tube if severe vomiting, signs of obstruction or unwell and risk of aspiration

Antibiotics
 IV co-amoxiclav + metronidazole

Analgesia
 Morphine + Ondansetron/cyclizine

Urgent surgical/gynaecological review

164
Q

Further management of peritonitis?

A
  • Laparoscopy/Laparotomy

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