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GI Flashcards

1
Q

Describe Duke Staging for colorectal cancer

A

A - 95% 5 year survival, limited to mucosa
B - 75% 5 year survival, through bowel lining and into submucosa (not lymph nodes)
C - 35% 5 year survival, involvement of lymph nodes
D - 25% 5 year survival, metastatic! :( distant organs affected

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2
Q

Cause of colorectal cancer

A

Most due to random mutations

But some due to known mutations e.g.
Familial adenomatous polyposis (FAP)
Tumour suppressor gene, causes polyps to form which can develop into tumours

Hereditary non-polyposis colorectal cancer (HNPCC) (Lynch Syndrome)

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3
Q

Types of polyps in colorectal cancer

A

Adenomatous (APC mutation, cells appear normal)
& Serrated (mutations in DNA repair gene, saw-tooth appearance)

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4
Q

Where does colorectal cancer metastasise to mostly?

A

Liver and lungs

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5
Q

Key presentation of colorectal cancer

A

Depends on the region affected
but the closer cancer to outside, more visible blood and mucus there will be

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6
Q

Presentation of ascending colon carcinoma

A

Asymptomatic first for ages
Iron def anaemia bc of bleeding
Weight loss
Abd pain
May present w/ mass

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7
Q

Presentation of descending and sigmoid colon carcinoma

A

Change in bowel habits
Blood/mucus in stool
Alternating constipation and diarrhoea
Thinner stools

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8
Q

Presentation of rectal carcinoma

A

Rectal bleeding and mucus
If cancer grows, thinner stools and tensmus

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9
Q

Emergency of colorectal cancer! - Complete obstruction

A

Absolute constipation
Colicky abd pain
Abd distention
Vomiting (faeculent)

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10
Q

Ix Colorectal cancer

A

Stool test
DRE!

GS : COLONOSCOPY + BIOPSY
if can’t, 2nd line :
double contrast barium enema
in ELDERLY use CT colonoscopy

CT TAP for staging!
CEA (Carcinoembryonic antigen) - not specific enough ∴ useful for follow up/screening

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11
Q

Epidemiology of Colorectal cancer

A

M > F
> 60 years
More in common in Western countries
4th most cancer common in world

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12
Q

Where is Colorectal cancer mostly found?

A

Rectum! Sigmoid colon

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13
Q

RF Colorectal cancer

A

IBD
Obesity
DM
Smoking
Alcohol

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14
Q

Red flags for GI cancer

A

ALARMS

Anaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Masses, Melaena or haematemesis
Swallowing difficulty!

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15
Q

Pathophysiology of Colorectal cancer

A

Normal epithelium -> Adenoma -> Colorectal adenocarcinoma

Nearly all are adenocarcinomas

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16
Q

4 cardinal signs of obstruction

A
  1. Absolute constipation
  2. Colicky abdominal pain
  3. Abdominal distention
  4. Vomiting (faeculent)
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17
Q

Bowel cancer screening test

A

Faecal Immunochemical test (FIT)
60 - 74 years, every 2 years

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18
Q

Tx Colorectal cancer

A

Surgical resection
Radiotherapy
Chemotherapy

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19
Q

When would you refer for suspected colorectal cancer?

A

40+ with abdominal pain and unexplained weight loss
50+ w/ unexplained rectal bleeding
60+ w/ change in bowel habit or IDA

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20
Q

Name the types of open surgery done to treat colorectal cancer and when each type would be used

A

Right sided - right hemicolectomy
Transverse colon - extended right hemicolectomy
Left sided - L hemicolectomy
Sigmoid - sigmoid colectomy
Low sigmoid, high rectal - Anterior resection

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21
Q

Name the two types of gastric cancer

A

Intestinal & Diffuse

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22
Q

What are the difference between the cells of intestinal and diffuse gastric cancer?

A

Intestinal -
Well formed, differentiated cells, tubular

Diffuse -
Poorly cohesive, undifferentiated cells, signet ring cells

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23
Q

Which areas of the stomach are usually involved in intestinal gastric cancer?

A

Antrum and lesser curvature

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24
Q

Which areas of the stomach are usually involved in diffuse gastric cancer?

A

All parts of the stomach but esp cardia

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25
Q

Which of the two gastric cancers has the worse prognosis?

A

Diffuse

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26
Q

Which of the two gastric cancers is most common?

A

Intestinal

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27
Q

RF of Intestinal gastric cancer

A

Male
Older age
H. Pylori infection
Chronic/atrophic gastritis

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28
Q

RF of diffuse gastric cancer

A

Female
Younger age < 50 years
Blood type A
Genetics
H. Pylori infection

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29
Q

What is the 5-year survival rate of Diffuse gastric cancer?

A

3-10%

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30
Q

Pathophysiology of intestinal gastric cancer

A

Occurs after inflammation of stomach
Chronic gastritis -> atrophic gastritis -> intestinal metaplasia and dysplasia

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31
Q

Describe the appearance of intestinal gastric cancer tumours

A

Polypoid or ulcerating lesions
w/ heaped, rolled-up edges

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32
Q

Pathophysiology of diffuse gastric cancer

A

Development of linitis plastica (leather bottle stomach)

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33
Q

Key presentation of Gastric cancer

A

Epigastric pain - constant and severe

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34
Q

Other signs/symptoms of Gastric cancer

A

Virchow’s node - left supraclavicular
N+V
Haematemesis/melaena
Anaemia - from occult blood loss

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35
Q

When would you do a 2-week endoscopy referral?

A

Dysphagia
OR
≥ 55 years WITH weight loss AND 1 of following:
Upper abdo pain
Reflux
Dyspepsia

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36
Q

When might vomiting be severe with Gastric cancer?

A

If tumour encroaches on pylorus

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37
Q

In a Px with gastric cancer, what might cause their dysphagia?

A

Tumour in fundus

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38
Q

Ix Gastric cancer

A

GS: Gastroscopy and biopsy - a neg biopsy doesn’t rule out diagnosis, usually 8-10 biopsies are taken

Endoscopic ultrasound - to see depth of invasion
CT/MRI of chest and abdomen (Staging)
PET scan - to see metastases

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39
Q

Tx Gastric cancer

A

Surgery (partial/total gastrectomy)

+ adjuvant combination chemo (ECF)
Epirubicin
Cisplatin
5-Fluorouracil

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40
Q

Name the two types of oesophageal cancer

A

Squamous cell carcinoma and Adenocarcinomas

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41
Q

In what region, where are Oesophageal cancer adenocarcinomas usually prevalent?

A

Western countries (HICs)

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42
Q

In what region, where are Oesophageal cancer squamous cell carcinomas usually prevalent?

A

Ethiopia, China S & E Africa (LICs)

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43
Q

Where are adenocarcinomas found in oesophageal cancer?

A

Lower 1/3 of oesophagus

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44
Q

Where are squamous cell carcinomas found in oesophageal cancer?

A

Upper 2/3 of oesophagus

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45
Q

RF for Adenocarcinomas in Oesophageal cancer

A

Barrett’s Oesophagus !!
GORD
Obesity
Smoking
Hernias
Males
Older age

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46
Q

RF for Squamous cell carcinoma (SCC)

A

Smoking
Alcohol
Older age
Males
BAME
Achalasia
Plummer-Vinson syndrome
Hot food and beverages

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47
Q

Progressive dysphagia suggests what?

A

CANCER!
If sudden dysphagia, suggests Achalasia or benign Oesopheageal cancer

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48
Q

Key presentation of Oesophageal cancer

A

Usually when disease presents itself, already at advanced stages

Progressive dysphagia (solids, then liquids)
Weight loss, anorexia etc
Hoarse voice
Odynophagia

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49
Q

Ix Oesophageal cancer

A

Upper GI endoscopy (Oesophagoscopy) w/ biopsy
CT/MRI of chest and abdomen (staging)
PET scan (metastases)

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50
Q

Differentials for Oesophageal cancer

A

Achalasia
Strictures
Barrett’s Oesophagus

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51
Q

Tx Oesophageal cancer

A

Surgical resection
Chemo and/or radiotherapy
Palliative care

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52
Q

What considerations should you consider for surgical resection for someone with cancer

A

Patient medically fit?
Age?
Co-morbidities?
Severity of cancer?
Is it resectable?

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53
Q

What is the prognosis of oesophageal cancer?

A

5 year prognosis is 25%
Generally poor because symptoms arise so late

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54
Q

When can Plummer-Vinson syndrome occur? How does it normally present?

A

In people with chronic IDA
Presents w/ dysphagia due to small growths of tissue that block the oesophagus

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55
Q

Tx GORD

A

Lifestyle - smaller meals, stop smoking, lose weight, avoid eating a few hours before sleep

Antacids - Gaviscon
PPI - lanzoprazole
H2 receptor antagonists - cimetidine, ranitidine

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56
Q

How do PPIs work?

A

Inhibit gastric secretion by blocking H+/K+ ATPase in parietal cells

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57
Q

Ix GORD

A

FBC - anaemia
24 hour pH monitoring (if pH < 4 for more than 4% of the time = abnormal)

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58
Q

What can cause swallowing difficulties?

A

Achalasia
Oesophageal cancer
Zenker’s diverticulum (Pharyngeal pouch)
Strictures
Scleroderma (systemic sclerosis)

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59
Q

Who does achalasia occur in?

A

Mostly elderly

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60
Q

Pathophysiology of Achalasia

A

Degen of ganglions in Auerbach’s/myenteric plexus
i.e. nerves in LOS don’t work! ∴ cannot relax ∴ obstruction!

61
Q

Key presentation of Achalasia

A

Unable to swallow BOTH food and liquid suddenly
Heartburn
Food regurg - can lead to aspiration pneumonia

62
Q

Ix Achalasia

A
  1. Endoscopy
  2. Barium swallow - “bird’s beak” sign
  3. GS : MANOMETRY

also : CXR - shows dilated oesophagus

63
Q

Tx Achalasia

A

No cure ∴ management of symptoms

Lifestyle - smaller meals
Medicine to relax LOS - nifedipine, nitrates, sildenafil
Botox to relax LOS - effects will wear off

Surgery (cardiomyotomy) - could lead to GORD

64
Q

In cases of bleeds/dysphasia, what investigation should you use?

65
Q

Complications of Achalasia

A

Aspiration pneumonia

66
Q

RF GORD

A

Obesity
Anything that ↑ abdo pressure e.g. pregnancy
Hiatus hernia
Smoking
Male!
NSAIDs, caffeine, alcohol

67
Q

Pathophysiology of GORD

A

↑ Transient LOS relaxations
∴ reflux of gastric acid and duodenal contents into oesophagus

68
Q

Key presentation of GORD

A

Heartburn
Regurg - worse when supine
Dysphagia/Odynophagia
Epigastric pain
Dyspepsia

Extra-oesophageal - cough, asthma, dental erosion

69
Q

Emergency (2 week) endoscopy referral
When?

A

Dysphagia!!!!
OR
≥ 55 years WITH weight loss PLUS one of following:
Upper abdo pain
Reflux
Dyspepsia

70
Q

Describe the histology of Barrett’s oesophagus

A

Stratified squamous to simple columnar epithelium

71
Q

Barret’s oesophagus is a premalignant for what?

A

Oesophageal cancer - adenocarcinoma

72
Q

Barret’s oesopagus is more common in which group?

A

Middle-age Caucasian male

73
Q

Define Barrett’s oesophagus

A

Metaplasia ≥1cm above the gastric-oesophageal junction

74
Q

Ix Barrett’s oesophagus

A

Upper GI endoscopy + biopsy

75
Q

What is gastritis?

A

Inflammation of stomach mucosal lining

76
Q

Causes of gastritis

A

Helicobacter pylori !!!!!!!!!
Autoimmune gastritis
Viruses e.g. CMV, HSV

77
Q

How does autoimmune gastritis cause gastritis?

A

Parietal cell antibodies and intrinsic factor antibodies
reduces vit B12 absorption in terminal ileum
∴ pernicious anaemia

??

78
Q

How do NSAIDs cause gastritis?

A

COxi inhibits prostaglandin synthesis
∴ less mucus secretion

79
Q

Key presentation of Gastritis

A

Epigastric pain
Dyspepsia

Anorexia
N+V
Haematemesis
Abdo bloating

80
Q

Ix Gastritis

A

H. Pylori infection - before testing, stop PPI for at least 2 weeks and Abx for 4 weeks
Urea breath test
Stool antigen test

Endoscopy - gastric mucosal inflammation / atrophy

Autoimmune - low B12, parietal cell antibodies, intrinsic factor antibodies

81
Q

Tx Gastritis

A

Stop NSAIDs, alcohol etc

H.Pylori - CAP !!!
clarithromycin 500mg + amoxicillin 1g + PPI
if penicillin allergy - metronidazole 400mg instead of amoxicillin

Autoimmune - IM vit B12 (cyanocobalamin)

H2 antagonists - ranitidine, cimetidine

82
Q

Complications of Gastritis

A

Peptic ulcers
Bleeding and anaemia
MALT lymphoma
Gastric cancer

83
Q

Types of Peptic ulcers
Where are they commonly situated?

A

Gastric - lesser curve of stomach
*Duodenal - duodenal cap

84
Q

What age group are Peptic ulcers more commonly found?

85
Q

What regions are peptic ulcers more commonly found?

A

LICs - due to H.Pylori

86
Q

Causes of Peptic Ulcers

A

Anything that ↓ Mucosal production / ↑ Acid production e.g.
H.Pylori
Gastritis
NSAIDs
Bile reflux
etc

87
Q

Describe the disease pathway starting with gastritis

A

Gastritis -> Peptic ulcer -> Gastric adenocarcinoma!

88
Q

Key presentation of Peptic ulcer

A

Recurrent burning epigastric pain

Dyspepsia
Haematemesis/melena
N+V
Anorexia

89
Q

Difference in presentation between duodenal and gastric ulcers

A

Duodenal - pain occurs when patient is hungry or eating, better after eating! Classically pain at night, ~ weight loss

Gastric - pain occurs several hours after eating! relieved by eating, ~ weight gain

90
Q

Ix Peptic ulcer

A

H. Pylori tests - stool antigen test, urea breath test

GS : ENDOSCOPY

91
Q

What can be found in blood test in a patient with peptic ulcers?

A

IgG antibodies
can be + for a year after

92
Q

Tx Peptic ulcer

A

Treat underlying cause - stop NSAIDs, treat H. Pylori, H2 antagonists etc
Reduce smoking, alcohol, stress etc

93
Q

What artery might be perforated with gastric and duodenal ulcers?

A

Duodenal - Left gastric artery
Gastric - gastroduodenal artery

94
Q

Difference in biopsy of Tropical Sprue and Coeliac

A

Complete villous atrophy - Coeliac
Incomplete villous atrophy - Tropical Sprue

95
Q

Stool markers of UC

A

pANCE
Faecal calprotein

96
Q

Stool markers of Crohn’s

A

Faecal calprotein

97
Q

Stool markers of Coelaic

A

IgA
tTG (tissue transglutaminase)
EMA (Anti-Endomysial antibody)

98
Q

UC associated with what other disease?

A

Primary sclerosing cholangitis

99
Q

Colonoscopy/Biopsy results UC

A

Continuous submucosal ulceration
Pseudopolyps
↓ Goblet cells

100
Q

Colonoscopy/Biopsy results Crohn’s

A

Transmural ulceration
Skip lesions
Fissures in lining
Cobblestone appearance
↑ Goblet cells

101
Q

Colonscopy/Biopsy results Coealiac

A

Complete villous atrophy
Crypt hyperplasia
Lymphocyte infiltration

102
Q

Presentation of IBS

A

ABC

Abdo pain - improves defecation
Bloating
Change in bowel habits

Symptoms worse after eating

103
Q

Tx IBS

A

Education + reassurance
Low

104
Q

Tx IBS

A

Education + reassurance
Low FODMAP diet
Avoid caffeine and alcohol

Diarrhoea - loperamide
Constipation - laxatives (ispaghula husk), increase fluid intake
Antispasmodics - buscopan
Tricyclic antidepressants
CBT

105
Q

RF IBS

A

Female
20 - 30
Anxiety
Depression
Stress
Prev GI infection

106
Q

Key Presentation UC

A

Abdo pain, L lower quadrant
Blood/mucus in stool
Bloody diarrhoea! (more common than in Crohn’s)

107
Q

What can decrease the risk of UC?

108
Q

IBD Extra-intestinal signs

A

A PIE SAC

Ankylosing spondylitis
Pyoderma gangrenosum
Iritis (ant. uveitis)
Erythema nodosum
Sclerosing cholangitis
Apthous ulcers/amyloidosis
Clubbing

109
Q

UC - just the rectum
What is it called?

110
Q

UC - rectum + L colon
What is it called?

A

Left sided colitis

111
Q

UC - entire colon up to ileocaecal valve
What is it called?

A

Pancolitis / Extensive colitis

112
Q

Ix UC

A

Bloods -
↑ CRP/ESR, ↑ WBC
iron/folate/vit B deficiency

pANCE
Faecal calprotein stool test (FIT test)

GS : COLONOSCOPY W BIOPSY

113
Q

Tx UC

A

MILD :
Aminosalicylate (5-ASAs) e.g. mesalazine (PO/PR)
+ Steroids e.g. prednisolone

MOD/SEVERE :
Fluid resus (if req)
IV steroids - hydrocortisone
+ TNF-a inhibitor - infliximab

GS :
Colectomy!!

REMISSION :
To maintain, azathioprine

114
Q

RF Crohn’s

A

Smoking !!!
NSAIDs
Chronic stress
Depression

115
Q

Key presentation of Crohn’s

A

Abdo pain - R lower quadrant
Changes in bowel habit
Malabsorption

116
Q

What can Crohn’s cause during healing process?

A

Fistulas
Adhesions

117
Q

Tx Crohn’s

A

Steroids - prednisolone (if mild), IV hydrocortisone (if severe)
*? 5ASA, methotrexate is 2nd line
If no improvement, infliximab

REMISSION :
Azathioprine
If CI, then methotrexate

SURGERY :
but will not fully cure patient

118
Q

UC vs Crohn’s : Granulomas?

A

UC = NO
Crohn’s = YES

119
Q

Ix Tropical Sprue

A

*GS :** Jejunal tissue biopsy!!

120
Q

Patient from tropical country + chronic GI and malabsorptive symptoms

A

= SUSPECT TROPICAL SPRUE

121
Q

Tx Tropical Sprue

A

Drink treated water + tetracycline for 6 months

122
Q

What type of hypersensitivity reaction is coeliac disease?

123
Q

RF Coeliac

A

HLA-DQ2
Autoimmune conditions
IgA def
Familial link

124
Q

Key presentation of Haemorrhoids

A

Bright red bleeding - not mixed w stool
Pruritus ani ! itching
Constipation
Straining
Lump around/inside anus

125
Q

Ix Haemorrhoids

A

External exam
DRE
Protoscopy

126
Q

Tx Haemorrhoids

A

Treat constipation

1ST AND 2ND DEGREE :
Rubber band ligation
Infrared coagulation
Injection scleropathy
Bipolar diathermy

3RD AND 4TH DEGREE :
Haemorrhoidectomy
Stapled haemorrhoidectomy
Haemorroidal artery ligation

127
Q

Tx Clostridium difficile

A

Metronidazole

128
Q

What can doxycycline cause?

A

Photosensitivity
Teratogenic

129
Q

What antibiotic may cause C. difficile toxins?

A

Clindamycin

130
Q

Ix Coeliac disease

A
  1. ↑ anti-tTG
  2. ↑ anti-EMA
  3. GS : ENDOSCOPY W DUODENAL BIOPSY
131
Q

Presentation of Coeliac disease

A

Diarrhoea
Weight loss
Steatorrhoea
Dermatitis herpetiformis
Bloating
Failure to thrive
Anaemia
Mouth ulcers
Angular stomatitis

132
Q

Where are iron, folate and B12 absorbed?

A

Dude Is Just Feeling Ill Bro

Duodenum - iron
Jejunum - folate
Ileum - B12

133
Q

Which bowel obstruction is the most common?

134
Q

Causes of SBO

A

Adhesions!! from prev surgeries
Crohn’s - strictures
Malignancy

135
Q

Key presentation of SBO

A

Colicky abdo pain - higher up
Abdo distension (not as severe as LBO)
Vomiting first (bilious)! then constipation
“Tinkling” bowel sounds

136
Q

Ix SBO

A

1st line - Abdo XR
dilation of small bowel > 3cm, coiled-spring appearance

GS : CT W CONTRAST, abdo and pelvis

137
Q

Tx SBO (conservative - stable Pxs)

A

Drip and suck
Insert IV cannula - resus w IV fluids
Nil by mouth!
Inset nasogastric tube to decompress stomach
Catheter - to monitor urine output

Analgesia, antiemetics, ABx

138
Q

Tx SBO (surgical - unstable Pxs)

A

Treat according to cause :
Laparotomy - to remove obstruction
Adhesiolysis - adhesions
Hernia repair
Tumour resection
Bowel resection

139
Q

Causes LBO

A

*Malignancy!
Sigmoid volvulus
Diverticulitis
Intussusception

140
Q

Key presentation LBO

A

Continuous abdo pain
Severe abdo distension
Constipation first, then vomiting! (V = bilious first then faecal)
Absent bowel sounds

141
Q

Ix LBO

A

1st line : Abdo XR - coffee bean appearance
dilation of large bowel > 6cm
dilation of caecum > 9cm

GS : CT W/ CONTRAST, abdo and pelvis

142
Q

LBO Tx

A

same as SBO

143
Q

What is Psuedo-obstruction also known as?

A

Ogilvie syndrome

144
Q

Ix Pseudo-obstruction

A

1st line - Abdo XR
megacolon - dilation > 10cm

GS : CT W/ CONTRAST, abdo and pelvis
NO transition zone!

145
Q

Pathophysiology Pseudo-obstruction

A

Parasymp nerve dysfunction
∴ absent smooth muscle

Colonic dilation in absence of mechanical obstruction

146
Q

Cause of Pseudo-obstruction

A

Post-op
Medications - opioids, CCB, antidepressants
Neurological - Parkinson’s, MS
etc

147
Q

Tx Pseudo-obstruction

A

Drip and suck
IV neostigmine
Surgical decomp for unstable

148
Q

Key presentation of diverticular disease

A

BBL
Bowel habit changed
Bloating
Left lower quadrant pain (guarding)

Phase 2 (24 decks)

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