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
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)
3
Q
Types of polyps in colorectal cancer
A
Adenomatous (APC mutation, cells appear normal)
& Serrated (mutations in DNA repair gene, saw-tooth appearance)
4
Q
Where does colorectal cancer metastasise to mostly?
A
Liver and lungs
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
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
7
Q
Presentation of descending and sigmoid colon carcinoma
A
Change in bowel habits
Blood/mucus in stool
Alternating constipation and diarrhoea
Thinner stools
8
Q
Presentation of rectal carcinoma
A
Rectal bleeding and mucus
If cancer grows, thinner stools and tensmus
9
Q
Emergency of colorectal cancer! - Complete obstruction
A
Absolute constipation
Colicky abd pain
Abd distention
Vomiting (faeculent)
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
11
Q
Epidemiology of Colorectal cancer
A
M > F
> 60 years
More in common in Western countries
4th most cancer common in world
12
Q
Where is Colorectal cancer mostly found?
A
Rectum! Sigmoid colon
13
Q
RF Colorectal cancer
A
IBD
Obesity
DM
Smoking
Alcohol
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!
15
Q
Pathophysiology of Colorectal cancer
A
Normal epithelium -> Adenoma -> Colorectal adenocarcinoma
Nearly all are adenocarcinomas
16
Q
4 cardinal signs of obstruction
A
- Absolute constipation
- Colicky abdominal pain
- Abdominal distention
- Vomiting (faeculent)
17
Q
Bowel cancer screening test
A
Faecal Immunochemical test (FIT)
60 - 74 years, every 2 years
18
Q
Tx Colorectal cancer
A
Surgical resection
Radiotherapy
Chemotherapy
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
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
21
Q
Name the two types of gastric cancer
A
Intestinal & Diffuse
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
23
Q
Which areas of the stomach are usually involved in intestinal gastric cancer?
A
Antrum and lesser curvature
24
Q
Which areas of the stomach are usually involved in diffuse gastric cancer?
A
All parts of the stomach but esp cardia
25
Which of the two gastric cancers has the worse prognosis?
Diffuse
26
Which of the two gastric cancers is most common?
Intestinal
27
RF of Intestinal gastric cancer
Male
Older age
H. Pylori infection
Chronic/atrophic gastritis
28
RF of diffuse gastric cancer
Female
Younger age < 50 years
Blood type A
Genetics
H. Pylori infection
29
What is the 5-year survival rate of Diffuse gastric cancer?
3-10%
30
Pathophysiology of intestinal gastric cancer
Occurs after inflammation of stomach
Chronic gastritis -> atrophic gastritis -> intestinal metaplasia and dysplasia
31
Describe the appearance of intestinal gastric cancer tumours
Polypoid or ulcerating lesions
w/ heaped, rolled-up edges
32
Pathophysiology of diffuse gastric cancer
Development of linitis plastica (leather bottle stomach)
33
Key presentation of Gastric cancer
Epigastric pain - constant and severe
34
Other signs/symptoms of Gastric cancer
**Virchow's node** - left supraclavicular
N+V
Haematemesis/melaena
Anaemia - from occult blood loss
35
When would you do a 2-week endoscopy referral?
Dysphagia
OR
≥ 55 years WITH weight loss AND 1 of following:
Upper abdo pain
Reflux
Dyspepsia
36
When might vomiting be severe with Gastric cancer?
If tumour encroaches on pylorus
37
In a Px with gastric cancer, what might cause their dysphagia?
Tumour in fundus
38
Ix Gastric cancer
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
39
Tx Gastric cancer
Surgery (partial/total gastrectomy)
+ adjuvant combination chemo (**ECF**)
**E**pirubicin
**C**isplatin
5-**F**luorouracil
40
Name the two types of oesophageal cancer
Squamous cell carcinoma and Adenocarcinomas
41
In what region, where are Oesophageal cancer adenocarcinomas usually prevalent?
Western countries (HICs)
42
In what region, where are Oesophageal cancer squamous cell carcinomas usually prevalent?
Ethiopia, China S & E Africa (LICs)
43
Where are adenocarcinomas found in oesophageal cancer?
Lower 1/3 of oesophagus
44
Where are squamous cell carcinomas found in oesophageal cancer?
Upper 2/3 of oesophagus
45
RF for Adenocarcinomas in Oesophageal cancer
Barrett's Oesophagus !!
GORD
Obesity
Smoking
Hernias
Males
Older age
46
RF for Squamous cell carcinoma (SCC)
Smoking
Alcohol
Older age
Males
BAME
Achalasia
Plummer-Vinson syndrome
Hot food and beverages
47
Progressive dysphagia suggests what?
CANCER!
If sudden dysphagia, suggests Achalasia or benign Oesopheageal cancer
48
Key presentation of Oesophageal cancer
Usually when disease presents itself, already at advanced stages
Progressive dysphagia (solids, then liquids)
Weight loss, anorexia etc
Hoarse voice
Odynophagia
49
Ix Oesophageal cancer
Upper GI endoscopy (**Oesophagoscopy**) w/ biopsy
CT/MRI of chest and abdomen (staging)
PET scan (metastases)
50
Differentials for Oesophageal cancer
Achalasia
Strictures
Barrett's Oesophagus
51
Tx Oesophageal cancer
Surgical resection
Chemo and/or radiotherapy
Palliative care
52
What considerations should you consider for surgical resection for someone with cancer
Patient medically fit?
Age?
Co-morbidities?
Severity of cancer?
Is it resectable?
53
What is the prognosis of oesophageal cancer?
5 year prognosis is 25%
Generally poor because symptoms arise so late
54
When can Plummer-Vinson syndrome occur? How does it normally present?
In people with chronic IDA
Presents w/ dysphagia due to small growths of tissue that block the oesophagus
55
Tx GORD
Lifestyle - smaller meals, stop smoking, lose weight, avoid eating a few hours before sleep
Antacids - Gaviscon
PPI - lanzoprazole
H2 receptor antagonists - cimetidine, ranitidine
56
How do PPIs work?
Inhibit gastric secretion by blocking H+/K+ ATPase in parietal cells
57
Ix GORD
FBC - anaemia
24 hour pH monitoring (if pH < 4 for more than 4% of the time = abnormal)
58
What can cause swallowing difficulties?
Achalasia
Oesophageal cancer
Zenker's diverticulum (Pharyngeal pouch)
Strictures
Scleroderma (systemic sclerosis)
59
Who does achalasia occur in?
Mostly elderly
60
Pathophysiology of Achalasia
Degen of ganglions in Auerbach's/myenteric plexus
i.e. nerves in LOS don't work! ∴ cannot relax ∴ obstruction!
61
Key presentation of Achalasia
Unable to swallow BOTH food and liquid suddenly
Heartburn
Food regurg - can lead to aspiration pneumonia
62
Ix Achalasia
1. Endoscopy
2. Barium swallow - "bird's beak" sign
3. **GS :** MANOMETRY
also : CXR - shows dilated oesophagus
63
Tx Achalasia
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
In cases of bleeds/dysphasia, what investigation should you use?
Endoscopy
65
Complications of Achalasia
Aspiration pneumonia
66
RF GORD
Obesity
Anything that ↑ abdo pressure e.g. pregnancy
Hiatus hernia
Smoking
Male!
NSAIDs, caffeine, alcohol
67
Pathophysiology of GORD
↑ Transient LOS relaxations
∴ reflux of gastric acid and duodenal contents into oesophagus
68
Key presentation of GORD
Heartburn
Regurg - worse when supine
Dysphagia/Odynophagia
Epigastric pain
Dyspepsia
Extra-oesophageal - cough, asthma, dental erosion
69
Emergency (2 week) endoscopy referral
When?
Dysphagia!!!!
**OR**
≥ 55 years _WITH_ weight loss _PLUS_ one of following:
Upper abdo pain
Reflux
Dyspepsia
70
Describe the histology of Barrett's oesophagus
**Stratified squamous** to **simple columnar epithelium**
71
Barret's oesophagus is a premalignant for what?
Oesophageal cancer - adenocarcinoma
72
Barret's oesopagus is more common in which group?
Middle-age Caucasian male
73
Define Barrett's oesophagus
Metaplasia ≥ 1cm above the gastric-oesophageal junction
74
Ix Barrett's oesophagus
Upper GI endoscopy + biopsy
75
What is gastritis?
Inflammation of stomach mucosal lining
76
Causes of gastritis
Helicobacter pylori !!!!!!!!!
Autoimmune gastritis
Viruses e.g. CMV, HSV
77
How does autoimmune gastritis cause gastritis?
Parietal cell antibodies and intrinsic factor antibodies
reduces vit B12 absorption in terminal ileum
∴ pernicious anaemia
??
78
How do NSAIDs cause gastritis?
COxi inhibits prostaglandin synthesis
∴ less mucus secretion
79
Key presentation of Gastritis
Epigastric pain
Dyspepsia
Anorexia
N+V
Haematemesis
Abdo bloating
80
Ix Gastritis
**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
Tx Gastritis
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
Complications of Gastritis
Peptic ulcers
Bleeding and anaemia
MALT lymphoma
Gastric cancer
83
Types of Peptic ulcers
Where are they commonly situated?
Gastric - lesser curve of stomach
*Duodenal - duodenal cap
84
What age group are Peptic ulcers more commonly found?
Elderly
85
What regions are peptic ulcers more commonly found?
LICs - due to H.Pylori
86
Causes of Peptic Ulcers
Anything that ↓ Mucosal production / ↑ Acid production e.g.
**H.Pylori**
Gastritis
NSAIDs
Bile reflux
etc
87
Describe the disease pathway starting with gastritis
Gastritis -> Peptic ulcer -> Gastric adenocarcinoma!
88
Key presentation of Peptic ulcer
Recurrent burning epigastric pain
Dyspepsia
Haematemesis/melena
N+V
Anorexia
89
Difference in presentation between duodenal and gastric ulcers
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
Ix Peptic ulcer
H. Pylori tests - stool antigen test, urea breath test
**GS :** ENDOSCOPY
91
What can be found in blood test in a patient with peptic ulcers?
IgG antibodies
can be + for a year after
92
Tx Peptic ulcer
Treat underlying cause - stop NSAIDs, treat H. Pylori, H2 antagonists etc
Reduce smoking, alcohol, stress etc
93
What artery might be perforated with gastric and duodenal ulcers?
Duodenal - Left gastric artery
Gastric - gastroduodenal artery
94
Difference in biopsy of Tropical Sprue and Coeliac
Complete villous atrophy - Coeliac
Incomplete villous atrophy - Tropical Sprue
95
Stool markers of UC
pANCE
Faecal calprotein
96
Stool markers of Crohn's
Faecal calprotein
97
Stool markers of Coelaic
IgA
tTG (tissue transglutaminase)
EMA (Anti-Endomysial antibody)
98
UC associated with what other disease?
Primary sclerosing cholangitis
99
Colonoscopy/Biopsy results UC
Continuous submucosal ulceration
Pseudopolyps
↓ Goblet cells
100
Colonoscopy/Biopsy results Crohn's
Transmural ulceration
Skip lesions
Fissures in lining
Cobblestone appearance
↑ Goblet cells
101
Colonscopy/Biopsy results Coealiac
Complete villous atrophy
Crypt hyperplasia
Lymphocyte infiltration
102
Presentation of IBS
**ABC**
Abdo pain - improves defecation
Bloating
Change in bowel habits
Symptoms worse after eating
103
Tx IBS
Education + reassurance
Low
104
Tx IBS
Education + reassurance
Low FODMAP diet
Avoid caffeine and alcohol
Diarrhoea - loperamide
Constipation - laxatives (ispaghula husk), increase fluid intake
Antispasmodics - buscopan
Tricyclic antidepressants
CBT
105
RF IBS
Female
20 - 30
Anxiety
Depression
Stress
Prev GI infection
106
Key Presentation UC
Abdo pain, L lower quadrant
Blood/mucus in stool
Bloody diarrhoea! (more common than in Crohn's)
107
What can decrease the risk of UC?
Smoking
108
IBD Extra-intestinal signs
**A PIE SAC**
**A**nkylosing spondylitis
**P**yoderma gangrenosum
**I**ritis (ant. uveitis)
**E**rythema nodosum
**S**clerosing cholangitis
**A**pthous ulcers/amyloidosis
**C**lubbing
109
UC - just the rectum
What is it called?
Proctitis
110
UC - rectum + L colon
What is it called?
Left sided colitis
111
UC - entire colon up to ileocaecal valve
What is it called?
Pancolitis / Extensive colitis
112
Ix UC
Bloods -
↑ CRP/ESR, ↑ WBC
iron/folate/vit B deficiency
pANCE
Faecal calprotein stool test (FIT test)
**GS :** COLONOSCOPY W BIOPSY
113
Tx UC
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
RF Crohn's
Smoking !!!
NSAIDs
Chronic stress
Depression
115
Key presentation of Crohn's
Abdo pain - R lower quadrant
Changes in bowel habit
Malabsorption
116
What can Crohn's cause during healing process?
Fistulas
Adhesions
117
Tx Crohn's
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
UC vs Crohn's : Granulomas?
UC = NO
Crohn's = YES
119
Ix Tropical Sprue
*GS :** Jejunal tissue biopsy!!
120
Patient from tropical country + chronic GI and malabsorptive symptoms
= SUSPECT TROPICAL SPRUE
121
Tx Tropical Sprue
Drink treated water + tetracycline for 6 months
122
What type of hypersensitivity reaction is coeliac disease?
Type 4 !
123
RF Coeliac
HLA-DQ2
Autoimmune conditions
IgA def
Familial link
124
Key presentation of Haemorrhoids
**Bright red bleeding** - not mixed w stool
Pruritus ani ! itching
Constipation
Straining
Lump around/inside anus
125
Ix Haemorrhoids
External exam
DRE
Protoscopy
126
Tx Haemorrhoids
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
Tx Clostridium difficile
Metronidazole
128
What can doxycycline cause?
Photosensitivity
Teratogenic
129
What antibiotic may cause C. difficile toxins?
Clindamycin
130
Ix Coeliac disease
1. ↑ anti-tTG
2. ↑ anti-EMA
3. **GS :** ENDOSCOPY W DUODENAL BIOPSY
131
Presentation of Coeliac disease
Diarrhoea
Weight loss
Steatorrhoea
Dermatitis herpetiformis
Bloating
Failure to thrive
Anaemia
Mouth ulcers
Angular stomatitis
132
Where are iron, folate and B12 absorbed?
**D**ude **I**s **J**ust **F**eeling **I**ll **B**ro
Duodenum - iron
Jejunum - folate
Ileum - B12
133
Which bowel obstruction is the most common?
SBO
134
Causes of SBO
Adhesions!! from prev surgeries
Crohn's - strictures
Malignancy
135
Key presentation of SBO
Colicky abdo pain - higher up
Abdo distension (not as severe as LBO)
Vomiting first (bilious)! then constipation
"Tinkling" bowel sounds
136
Ix SBO
1st line - Abdo XR
dilation of small bowel > 3cm, coiled-spring appearance
**GS :** CT W CONTRAST, abdo and pelvis
137
Tx SBO (conservative - stable Pxs)
**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
Tx SBO (surgical - unstable Pxs)
Treat according to cause :
Laparotomy - to remove obstruction
Adhesiolysis - adhesions
Hernia repair
Tumour resection
Bowel resection
139
Causes LBO
*Malignancy!
Sigmoid volvulus
Diverticulitis
Intussusception
140
Key presentation LBO
Continuous abdo pain
Severe abdo distension
Constipation first, then vomiting! (V = bilious first then faecal)
Absent bowel sounds
141
Ix LBO
1st line : Abdo XR - _coffee bean appearance_
dilation of large bowel > 6cm
dilation of caecum > 9cm
**GS :** CT W/ CONTRAST, abdo and pelvis
142
LBO Tx
same as SBO
143
What is Psuedo-obstruction also known as?
Ogilvie syndrome
144
Ix Pseudo-obstruction
1st line - Abdo XR
megacolon - dilation > 10cm
**GS :** CT W/ CONTRAST, abdo and pelvis
NO transition zone!
145
Pathophysiology Pseudo-obstruction
Parasymp nerve dysfunction
∴ absent smooth muscle
Colonic dilation in absence of mechanical obstruction
146
Cause of Pseudo-obstruction
Post-op
Medications - opioids, CCB, antidepressants
Neurological - Parkinson's, MS
etc
147
Tx Pseudo-obstruction
Drip and suck
IV neostigmine
Surgical decomp for unstable
148
Key presentation of diverticular disease
**BBL**
Bowel habit changed
Bloating
Left lower quadrant pain (guarding)
