Gastrointestinal - Level 2 Flashcards
1
Q
Definition of malnutrition?
A
o Nutrient deficient state of protein, energy or micronutrients
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
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
4
Q
Symptoms and management of iodine deficiency?
A
Symptoms - Goitre, hypothyroidism, growth restriction
Management - Iodine supplements, seafood
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
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)
7
Q
Symptoms and management of Vitamin B1 (thiamine) deficiency?
A
Symptoms – beri beri – heart failure with oedema, neuropathy
Management – Thiamine urgently
8
Q
Symptoms of vitamin B2 (riboflavin) deficiency?
A
Symptoms – angular stomatitis, cheilitis
9
Q
Symptoms of Vitamin B6 (pyridoxine) deficiency?
A
Symptoms – polyneuropathy
10
Q
Symptoms of Vitamin E deficiency?
A
Symptoms – haemolysis, neurological deficit
11
Q
Symptoms of Vitamin K deficiency?
A
Symptoms – bleeding disorders
12
Q
Symptoms and management nicotinic acid deficiency?
A
Symptoms – Pellegra – diarrhoea, dementia, dermatitis (Casal’s necklace)
Rx – Nicotinamide PO
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
14
Q
Symptoms of malnutrition?
A
- BMI <18.5
- Increasing fatigue
- Non-healing wounds
- Slowed growth
- Reduced muscle mass
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
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
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
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
19
Q
Causes of dyspepsia?
A
o Oesophagitis
o Endoscopy-negative
20
Q
Risk factors for Barrett’s oesophagus?
A
o Male, long duration/severe of GORD, previous oesophagitis/hiatus hernia/ulcers
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
22
Q
Atypical symptoms of GORD?
A
hoarseness, cough, asthma, dental erosions
23
Q
Investigations to perform in dyspepsia?
A
o FBC (low Hb, raised platelets)
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
25
Referral to endoscopy non-urgently under what criteria?
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
```
26
Management of dyspepsia with unknown cause - lifestyle advice?
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
27
Management of dyspepsia with unknown cause -if persistent symptoms?
o If persistent symptoms – FBC (check for anaemia or high platelets)
28
Management of dyspepsia with unknown cause - initial drug treatment?
PPI for 1 month
| • Lansoprazole 30mg, Omeprazole 20-40mg, esomeprazole 20mg
29
Management of dyspepsia with unknown cause - initial testing and eradication?
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
30
Management of dyspepsia with unknown cause - recurrent/refractory symptoms?
H2-receptor antagonists
Re-test H.pylori only if – poor compliance, NSAIDs indicated, FHx of gastric malignancy, severe symptoms or patient request
31
Management of dyspepsia with unknown cause - when to refer to endoscopy?
Refractory or recurrent symptoms
| Treatment with 2nd line H.pylori unsuccessful
32
Management of endoscopically proven GORD - lifestyle measures?
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
33
Management of endoscopically proven GORD -if proven GORD?
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
34
Management of endoscopically proven GORD - if proven severe oesophagitis?
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
35
Management of endoscopically proven GORD - when to consider endoscopy?
o Consider endoscopy to diagnose Barrett’s oesophagus if long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia
36
Referral to GI or upper GI surgeon - when?
* 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
37
Referral to GI or upper GI surgeon - specialist investigations?
* Oesophageal manometry
* Ambulatory 24-hour oesophageal pH monitoring (exclude achalasia, hypomotility)
* Barium swallow (exclude structural disorders – hiatus hernia, achalasia)
38
Referral to GI or upper GI surgeon - specialist management?
• 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
39
Complications of GORD?
```
o Oesophageal ulcers/haemorrhages/strictures
o Anaemia
o Aspiration pneumonia
o Barrett’s oesophagus
o Dental erosions, gingivitis, halitosis
```
40
What is Barrett's oesophagus?
Columnar metaplasia of distal oesophagus, malignant potential and risk of adenocarcinoma
Endoscopy surveillance needed
41
Prognosis of GORD?
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
42
Risk factors for GORD in children?
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
43
Symptoms of GORD in children?
- Recurrent regurgitation/vomiting - Possetting
- May contain some blood
- Increased salivations
- Chronic cough
- Normal weight and otherwise well
44
when to investigated GORD in children?
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
45
Management of GORD in infants?
* 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
46
Management of GORD in children?
• 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
47
Complications of GORD in children?
- 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)
48
Pathology of oesophageal carcinoma?
o SCC – usually middle 1/3, incidence decreasing, men 2:1
| o Adenocarcinoma – arises from Barrett’s oesophagus, lower 1/3 of oesophagus
49
Types of oesophageal carcinoma?
```
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
```
50
Symptoms of oesophageal carcinoma?
```
o Progressive dysphagia (initially solids then liquids)
o Weight loss
o Retrosternal chest pain
o Hoarseness
o Cough (if upper 1/3)
```
51
When to offer urgent 2-week upper GI endoscopy of oesophageal carcinoma?
- 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
52
When to offer non-urgent upper GI endoscopy of oesophageal carcinoma?
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
```
53
Staging tests of oesophageal carcinoma?
o PET-CT whole body
o TNM staging
o Her2 testing in metastatic oesophageal adenocarcinoma
54
Management of oesophageal carcinoma - radical treatment?
Radical oesophagectomy
o T1N0 (Endoscopic mucosal resection or oesophagectomy)
• +/- lymph node dissection
Neoadjuvant chemradiotherapy
55
Management of oesophageal carcinoma - follow up?
o Give advice on symptoms of recurrence and advise to contact MDT if symptoms present
56
Management of oesophageal carcinoma - palliative management - if non-metastatic but not fit for surgery?
Chemoradiotherapy
| OR chemo + stenting, palliative radio
57
Management of oesophageal carcinoma - palliative management - if locally advanced or metastatic?
Palliative Chemotherapy (trastuzumab + cisplatin + 5-FU)
If outflow obstruction:
• Palliative surgery
• Stenting
o Self-expanding if needed to help with dysphagia
• Radiotherapy
58
Definition of hiatus hernia?
- 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
59
Types of hiatus hernia?
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
60
Epidemiology of hiatus hernia?
- Many people asymptomatic
| - 95% Type 1
61
Risk factors of hiatus hernia?
o Obesity
o Previous gastro-oesophageal procedure
o Elevated intra-abdominal pressure – pregnancy, ascites
o Age
62
Symptoms of hiatus hernia?
```
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 & vomiting
o Hiccups
```
63
Investigations of hiatus hernia?
```
- CXR
o Soft tissue opacity
o Retrocardial air-fluid level diagnostic of para-oesophageal hiatus hernia
- Barium studies
- Endoscopy
- Oesophageal manometry
```
64
Management of hiatus hernia - general measures?
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
65
Management of hiatus hernia - drug therapy?
o If symptomatic GORD
| PPIs - omeprazole
66
Management of hiatus hernia - surgical management - when to offer?
Drug or general measures failed
Complications of reflux
Symptomatic para-oesophageal hernia
67
Management of hiatus hernia - surgical management - what?
o Laparoscopic fundoplication (can be open)
Nissen’s – complete wrapping of fundus around oesophagus or modified – partial
Gastropexy can be used
68
Prognosis of hiatus hernia?
o If sliding – most symptoms relieved by medical treatment
69
Complications of hiatus hernia?
o Bloating
o Volvulus
o Obstruction
o Recurrence of hernia post-repair
70
Pathology of peptic ulcer disease?
o Breakdown of epithelial cells to muscularis mucosa
| o Acid breaks down wall
71
Epidemiology of peptic ulcer disease?
- Duodenal 4x more common
- Men 4:1 Women
- Elderly more susceptible
- Developing countries due to H.pylori
72
Aetiology of peptic ulcer disease?
```
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
Symptoms of gastric peptic ulcer disease?
Epigastric pain (burning)
Worse at meal times, relieved by antacids
Weight loss and nausea common
74
Symptoms of duodenal peptic ulcer disease?
Epigastric pain (burning)
Worse when hungry or at night – relieved by eating/milk
Nausea, flatulence common
Relieved by antacids
75
Red flag symptoms of gastric malignancy?
```
o Anaemia (iron def)
o Loss of weight
o Anorexia
o Recent onset/Progressing
o Melaena/Haematemesis
o Swallowing difficulties
```
76
Management of peptic ulcer disease- lifestyle advice?
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
Management of peptic ulcer disease- medication review?
o Stop NSAIDs
| o Reduce or stop – aspirin, bisphosphonates, corticosteroids, potassium supplements, SSRIs
78
Management of peptic ulcer disease- when to refer to endoscopy within 2 weeks?
```
With dysphagia or
Aged 55 and over with weight loss and any of the following:
• Upper abdominal pain
• Reflux
• Dyspepsia
```
79
Management of peptic ulcer disease- when to refer to endoscopy non-urgently?
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
Management of proven peptic ulcer disease- initial testing?
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
Management of proven peptic ulcer disease- if person positive for H.pylori with PU?
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
Management of proven peptic ulcer disease- if person negative for H.pylori with PU?
Full-dose PPI therapy for 4-8 weeks
• PPI = lansoprazole 30mg, omeprazole 20-40mg, esomeprazole 20mg, pantoprazole 40mg, rabeprazole 20mg
83
Management of proven peptic ulcer disease- follow up?
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
Management of proven peptic ulcer disease- review in primary care?
o Annual review
85
Management of proven peptic ulcer disease- when to refer to GI?
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
Complications of Peptic ulcer disease?
o Haemorrhage
o Perforation
o Gastric outlet obstruction
o Gastric malignancy
87
Prognosis of peptic ulcer disease?
o Mortality rate 6-8%
o 1 in 10 with bleeding ulcer will die
o 1 in 4 with perforated ulcer will die
88
Causes of bowel perforation - chemical, infection & ischaemia?
Chemical
Peptic ulcer disease
Foreign Body (battery)
Infection
Diverticulitis
Cholecystitis
Meckel’s diverticulum
Ischaemia
Mesenteric ischaemia
Cancer
Obstruction
89
Causes of bowel perforation - colitis, iatrogenic and direct rupture?
Colitis
Toxic megacolon (C.diff/UC)
Iatrogenic
Surgery, endoscopy
Trauma
Direct rupture
Excessive vomiting leading to oesophageal perforation (Boerhaave syndrome)
90
Symptoms of bowel perforation?
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
Signs of bowel perforation?
o Patient lies still, may writhe in agony
| o Absent bowel sounds, generalised peritonitis and fever
92
Investigations in bowel perforation?
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&Es, LFTs, CRP, glucose, amylase, clotting, Ca, Group and save
```
Pregnancy test if woman
Urinalysis
ECG/Troponin
93
Initial management of bowel perforation?
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
Surgical management of bowel perforation?
o Laparotomy and repair:
Peptic ulcer – omental patch
Perforated diverticulae – Hartmann’s procedure
95
Conservative management of bowel perforation?
o If mild disease and only localised peritonitis on CT or elderly patients
96
Most common location and type of gastric cancer?
- Most commonly found in antrum
| - Mostly adenocarcinoma
97
Types of gastric cancer?
- Type 1 (intestinal)
o Localised ulcerated lesions with rolled edges, distal stomach
- Type 2 (diffuse)
o Extensive submucosal spread, mostly cardia
98
Spread of gastric cancer?
- Spread via local, lymph, blood, transecoelomic
99
Other tumour types of gastric cancer?
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
What are the types of gastric polyps?
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
Epidemiology of gastric cancer?
- 4th most common cancer
- More common in Japan, China, Eastern Europe
- Men 2:1 Women
102
Aetiology of gastric cancer?
```
o H.pylori
o Chronic Gastritis
o Smoking
o Diet (low in fruit & veg, high in salted & smoked foods)
o Pernicious anaemia
o FHx
o Nitrosamines
```
103
Symptoms of gastric cancer?
```
o Epigastric pain
Like peptic ulcer
Relieved by food/antacids
o Loss of appetite
o Weight loss
o Vomiting
o Dysphagia
```
104
Signs of gastric cancer?
```
o Anaemia
o Palpable Virchows node
o Mass in epigastrium
o Hepatomegaly, ascites – metastases
o Acanthosis Nigricans
o Dermatomyositis
```
105
Management of gastric cancer - when to refer on 2-week pathway?
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
Management of gastric cancer - when to refer non-urgently?
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
Management of gastric cancer - secondary care investigations?
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
Management of gastric cancer - radical treatment?
Nutritional assessment by specialist dietician
Gastrectomy (radical surgical resection)
Neo-adjuvant chemotherapy
D2 lymph node dissection
109
Management of gastric cancer - palliative treatment?
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
Prognosis of gastric cancer?
o 5-year survival 20%
| o Surgery improves survival
111
Most common pancreatic cancer?
- Mostly ductal adenocarcinoma, metastasise early and present late
112
Epidemiology of pancreatic cancer?
- 5th most common cause of cancer death in UK
- Men < Women
- Incidence increases with age
113
Types of pancreatic cancer?
Adenocarcinomas (96%)
Head 60%, Body 25%, tail 15%
Others – ampullary tumour, pancreatic islet cells (insulinoma, gastrinoma, glucagonoma, somatostatinoma)
114
Aetiology of pancreatic cancer?
```
o Smoking
o Petrol
o Obesity
o High fat/Red meat diet
o Alcohol
o Diabetes
o Chronic pancreatitis
```
115
Symptoms pancreatic cancer - if head or ampulla?
```
o Painless obstructive jaundice
o Blocks CBD
o Weight loss
o Distended gall bladder
o May be mass palpable
```
116
Symptoms pancreatic cancer - if body or tail?
o Abdominal pain – back, dull
Relieved by sitting forwards
o Weight loss
o Anorexia
117
Signs of pancreatic cancer?
```
o Jaundice
o Palpable gallbladder
o Epigastric mass
o Hepatomegaly
o Splenomegaly
o Ascites
```
118
Bloods in pancreatic cancer?
o Cholestatic jaundice (rise in ALP and GGT)
| o Ca19-9 raised
119
When to offer surveillance for pancreatic cancer?
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
Referral for 2-week appointment in pancreatic cancer?
Aged >40 and jaundice
121
Consider direct access CT scan within 2 weeks in pancreatic cancer?
```
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
Secondary care diagnosis of pancreatic cancer?
o Pancreatic protocol CT scan (chest, abdomen, pelvis)
| o If unclear – PET/CT or EUS tissue sampling (FNA)
123
Staging of pancreatic cancer?
o If localised disease and having treatment – PET/CT
| o MRI if liver metastases suspected
124
Management of pancreatic cancer - general measures?
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
Management of pancreatic cancer - resectable disease?
Surgical excision (pancreaticoduodenectomy – Whipple’s) + lymphadenectomy
126
Management of pancreatic cancer - locally advanced?
Chemotherapy
| Chemoradiotherapy
127
Management of pancreatic cancer - metastatic cancer?
Chemotherapy
• FOLFIRINOX
• Gemcitabine
Stent insertion
128
Prognosis of pancreatic cancer?
o Mean survival 6 months
129
Definition of coeliac disease?
- 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
Epidemiology of coeliac disease?
- Incidence increasing with 1 in 300 people
- Peaks in infancy, 50-60 but can occur at any age
- Women 2>1 Male
131
Risk factors of coeliac disease?
```
o Genetic
HLA DQ2/8
o Familial
o Autoimmune Disease
DM1, Thyroid disease, Addison’s
```
132
Symptoms of coeliac disease?
```
o Diarrhoea
o Weight loss
o Abdominal pain
o Bloating
o Nausea, vomiting
o Foul-smelling stools
o Steatorrhea
o Malaise/Fatigue
```
133
Signs of coeliac disease?
o Anaemia (iron or B12)
o Aphthous mouth ulcers
o Angular stomatitis
o Dermatitis herpatiformis
134
When to offer serological testing in coeliac disease?
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
what serological testing to perform in suspected coeliac disease?
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
When to refer patient suspected of coeliac disease?
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
Management of coeliac disease - annual review?
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
Management of coeliac disease - management?
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
Management of coeliac disease - supplements?
o High-dose folic acid for women who are pregnant
| o If deficient, folic acid, calcium, Vit D
140
Management of coeliac disease - Vaccines?
- Pneumococcal vaccine if hyposplenic
141
Management of coeliac disease - if refractory disease?
- If refractory coeliac disease – refer to specialist centre for treatment with prednisolone
142
Complications of coeliac disease?
```
o Anaemia
o Lactose-intolerance
o T-Cell lymphoma
o Malignancy
o Osteoporosis
```
143
Pathology of acute pancreatitis?
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
Definitions of acute pancreatitis?
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
Epidemiology of acute pancreatitis?
- Increasing incidence
| - 20% mortality, 80% mild
146
Causes of acute pancreatitis?
```
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
Symptoms of acute pancreatitis?
o Severe, constant epigastric pain radiating to centre of back
Relieved by sitting forward
o Nausea and vomit in
148
Signs of acute pancreatitis?
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
Investigations of acute pancreatitis?
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
Management of acute pancreatitis - severity assessment?
```
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
Management of acute pancreatitis - initial management?
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
Complications of acute pancreatitis?
o Early complications
Shock, ARDS, Renal failure, DIC, Sepsis, hypocalcaemia, high glucose
o Late Complications
Pancreatic necrosis, pseudocyst, abscesses, bleeding, thrombosis, fistulae
153
Pathology of peritonitis?
| Definition of peritonitis - primary?
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
Definition of peritonitis -secondary?
o Secondary = Pathological process adjacent to peritoneum causes inflammation (perforated viscus)
155
Definition of peritonitis - localised?
o Localised = inflammation in limited area, such as adjacent to inflamed appendix/diverticulum
156
Definition of peritonitis - generalised?
o Generalised = Widespread inflammation
157
Definition of peritonitis - intra-abdominal sepsis?
o Intra-abdominal sepsis = intra-abdominal infection and encompasses localised and generalised peritonitis
158
Aetiology of peritonitis?
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
Symptoms of peritonitis?
```
o Abdominal pain
Poorly, localised initially
Worsening and more localised when infection spreads
o Anorexia
o Nausea and vomiting
```
160
Signs of peritonitis?
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
Investigations to perform in peritonitis?
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
Imaging to perform in peritonitis?
o Erect CXR
o AXR
o USS
o CT scan if no delay
163
Initial management of peritonitis?
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
Further management of peritonitis?
- Laparoscopy/Laparotomy
