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ESA 3 - Gastrointestinal System > GI Malignancies and Investigation of the GI Tract > Flashcards

GI Malignancies and Investigation of the GI Tract Flashcards

1
Q

What are the common GI malignancies?

A

Cancers of the;

  • Oesophagus
  • Stomach
  • Large intestine
  • Pancreas
  • Liver
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2
Q

What is the geographical epidemiology of oesophageal carcinoma?

A

Wide geographical variation, with incidence low in USA, and high around Caspian sea and parts of China

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3
Q

What % of malignancies in the UK does oesophageal carcinoma constitute?

A

2%

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4
Q

Is oesophageal carcinoma more prevalent in males or females?

A

Males

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5
Q

What are the clinical features of oesophageal carcinoma?

A
  • Dysphagia
  • Weight loss
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6
Q

What happens to the clinical features as an oesophageal carcinoma grows?

A

It occludes the lumen and causes the progessive worsening of the dysphagia

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7
Q

What investigations are conducted when an oesophageal carcinoma is suspected?

A
  • Endoscopy
  • Biopsy
  • Barium
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8
Q

What is the most common type of oesophageal carcinoma?

A

Squamous cell carcinoma

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9
Q

Where does squamous cell carcinoma of the oesophagus occur?

A

May occur at any level

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10
Q

What is an uncommon type of oesophageal carcinoma?

A

Adenocarcinoma

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11
Q

Where does adenocarcinoma of the oesphagus occur?

A

Lower third

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12
Q

What is adenocarcinoma of the oesophagus associated with?

A

Barrett’s oesophagus

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13
Q

At what stage is oesophageal carcinoma at presentation?

A

Advanced in most cases

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14
Q

How does oesophageal carcinoma spread?

A

Direct spread through the oesophageal wall

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15
Q

What % of oesophageal carcinomas are resectable?

A

40%

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16
Q

What is the prognosis of oesophageal carcinoma?

A

5% five year survival

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17
Q

What is the second most common GI malignancy?

A

Gastric cancer

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18
Q

How many new cases of gastric cancer are there in England and Wales each year?

A

11,000

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19
Q

How common is gastric cancer?

A

Common

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20
Q

What % of cancer deaths worldwide are accounted for by gastric cancer?

A

15%

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21
Q

Is gastric cancer more common in men or women?

A

Men

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22
Q

What is the geographical epidemiology of gastric cancer?

A

Geographical variation, common in Japan, Columbia, and Finland

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23
Q

What is gastric cancer associated with?

A

Gastritis

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24
Q

What blood group is gastric cancer commoner in?

A

A

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25
Q

What is the problem with diagnosing gastric cancer?

A

Symptoms are often vague

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26
Q

What are the clinical features of gastric cancer?

A
  • Epigastric pain
  • Vomiting
  • Weight loss
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27
Q

What investigations are used in the diagnosis of gastric cancer?

A
  • Endoscopy
  • Biopsy
  • Barium
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28
Q

What are the macroscopic features of gastric cancer?

A
  • Fungating
  • Ulcerating
  • Infiltrative
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29
Q

What kind of gastric cancer shows infiltration macroscopically?

A

Linitis plastica

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30
Q

What are the intestinal microscopic features of gastric cancer?

A

Variable degree of gland formation

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31
Q

What are the diffuse microscopic features of gastric cancer?

A

Single cells and small groups, signet ring cells

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32
Q

How far has early gastric cancer spread?

A

Confined to mucosa and sub-mucosa

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33
Q

What is the prognosis of early gastric cancer?

A

Good

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34
Q

How far has advanced gastric cancer spread?

A

Further spread

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35
Q

Where is advanced gastric cancer common?

A

UK

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36
Q

What is the 5 year survival rate for advanced gastric cancer?

A

~10%

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37
Q

How does gastric cancer spread?

A
  • Direct
  • Lymph nodes
  • Liver
  • Trans-coelomic
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38
Q

Where does gastric cancer spread directly?

A

Through the gastric wall into duodenum, transverse colon, and pancreas

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39
Q

Where does gastric cancer spread trans-coelomically?

A
  • Peritoneum
  • Ovaries
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40
Q

Describe the development of advanced gastric cancer from normal gastric mucosa

A
  1. Normal gastric mucosa
  2. H. Pylori infection
  3. Acute gastritis
  4. Chronic active gastritis
  5. Atrophic gastritis
  6. Intestinal metaplasia
  7. Dysplasia
  8. Advanced gastric cancer
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41
Q

What is cancer generally associated with?

A

Chronic inflammation

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42
Q

Where is gastric cancer common?

A

Countries with high H. Pylori prevalence

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43
Q

Give an example of a country where gastric cancer is common due to high H. Pylori prevalence

A

Columbia

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44
Q

What supports the association between H. Pylori and gastric cancer?

A

Serological and epidemiological evidence

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45
Q

What is the most common GI lymphoma?

A

Gastric lymphoma

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46
Q

What does gastric lymphoma start as?

A

A low-grade lesion

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47
Q

What is gastric lymphoma strongly associated with?

A

H. Pylori

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48
Q

What may eradication of H. Pylori lead to in gastric lymphoma?

A

Regression of tumour

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49
Q

How does the prognosis of gastric lymphoma differ from that of gastric cancer?

A

It is much better for gastric lymphoma

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50
Q

How common are gastrointestinal stromal tumours?

A

Uncommon

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51
Q

What are gastrointestinal stromal tumours derived from?

A

Interstitial cells of Cajal

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52
Q

What is the causative mutation in gastrointestinal stromal tumours?

A

C-kit (CD117)

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53
Q

What is the result of the CD117 mutation in gastrointestinal stomal tumours?

A

It makes it vulnerable to targeted treatment

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54
Q

What behaviour do gastrointestinal stromal tumours display?

A

Unpredictable;

  • Pleomorphism
  • Mitoses
  • Necrosis
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55
Q

What are the types of tumours of the large intestine?

A
  • Adenomas
  • Adenocarcinomas
  • Polyps
  • Anal carcinoma
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56
Q

What are the types of large intestine adenomas?

A
  • Dysplasia
  • Familial Adenomatous Polyposis (FAP)
  • Gardner’s Syndrome
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57
Q

What is large intestinal dysplasia?

A

Benign, neoplastic lesions in the large bowel

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58
Q

What are the macroscopic features of large intestinal dysplasia?

A

Sessile or pendunculated

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59
Q

What are the microscopic features of large intestinal dysplasia?

A

Variable degree of dysplasia

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60
Q

What is the clinical relevance of large intestinal dysplasia?

A

Malignant potential

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61
Q

What happens to incidence of large intestinal dysplasia in western populations?

A

It increases with age

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62
Q

What kind of syndromes are large intestinal dysplasia?

A

Genetic

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63
Q

What is the inheritance pattern of familial adenomatous polyposis (FAP)?

A

Autosomal dominant condition

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64
Q

Where is the FAP mutation?

A

Chromosome 5

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65
Q

What happens in a patient with FAP by the time they are 20?

A

There are 1000’s of adenomas in the large intestine, giving a high risk of cancer

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66
Q

What is Gardner’s syndrome?

A

A similar condition to FAP, with bone and soft tissue tumours

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67
Q

What is the most common GI malignancy?

A

Colorectal cancer

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68
Q

How many new cases of colorectal cancer are reported each year in England and Wales?

A

~25,000

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69
Q

What are the macroscopic features of colorectal cancer?

A

60-70% cases are rectosigmoid fungating/stenotic

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70
Q

What are the microscopic changes seen in colorectal cancer?

A
  • Mucinous
  • Signet ring cell type
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71
Q

How do the microscopic changes differ between different colorectal adenocarcinomas?

A

They are moderately different

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72
Q

How does colorectal cancer spread?

A
  • Direct through bowel wall to adjacent organs (e.g. bladder)
  • Via lymphatics to mesenteric lymph nodes
  • Via portal venous system to liver
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73
Q

What staging systems are used for colorectal cancer?

A
  • Dukes
  • TMN
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74
Q

What are the stages in Duke’s staging?

A
  • A - Confined to bowel wall
  • B - Through wall, but lymph nodes clear
  • C - Lymph node involvement
    • C1 - Highest node clear
    • C2 - Highest node involved
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75
Q

What are the mutations found in colorectal cancer?

A
  • Chromosome 5 (in FAP related colorectal cancer)
  • Ras mutations
  • p53 loss/inactivation
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76
Q

At what age does incidence of colorectal cancer peak?

A

60-70

77
Q

What is the geographical epidemiology of colorectal cancer?

A
  • High in UK and USA
  • Low in Japan
78
Q

What conditions increase the incidence of colorectal cancer?

A
  • Polyposis syndromes
  • UC and Crohns
79
Q

What is the aetiology of colorectal cancer?

A
  • Low residue diet
  • Slow transit time
  • High fat intake
  • Genetic predisposition
80
Q

What is the outcome of colorectal cancer?

A

Survival time reduces with increasing Duke’s staging

81
Q

Where does colorectal cancer frequently metastasise to in its advanced stages?

A

Liver

82
Q

Other than adenomas, what are the types of large intestine tumours?

A
  • Carcinoid tumour
  • Lymphoma
  • Smooth muscle/stromal tumours
83
Q

What kind of tumours are carcinoid tumours of the large intestine?

A

Neuro-endocrine tumours

84
Q

What kind of behaviour do large intestinal carcinoid tumours display?

A

Unpredictable

85
Q

How common are large intestinal carcinoid tumours?

A

Rare

86
Q

Where do lymphomas of the large intestines originate from?

A

May be primary, or spread from elsewhere

87
Q

How common are lymphomas of the large intestine?

A

Rare

88
Q

How common are large intestinal smooth muscle/stromal tumours?

A

Rare

89
Q

What behaviour do large intestinal smooth muscle/stromal tumours display?

A

Unpredictable

90
Q

What proportion of pancreas carcinomas are found in the head?

A

2/3

91
Q

What is the morphology of pancreatic carcinomas?

A

Firm pale mass with a necrotic centre

92
Q

Where may pancreatic carcinomas infiltrate?

A

Adjacent structures, e.g. the spleen

93
Q

What is the most common carcinoma of the pancreas?

A

Ductal adenocarcinomas

94
Q

What % of pancreatic carcinomas are ductal adenocarcinomas?

A

80%

95
Q

How do pancreatic carcinomas appear histologically?

A

Well formed glands

96
Q

What do some pancreatic acinar tumours have histologically?

A

Zymogen granules

97
Q

What is the prognosis for pancreatic carcinomas?

A

Poor

98
Q

What hapens in carcinoma of the Ampulla of Vater?

A

The bile duct is blocked with only a small tumour

99
Q

What does carcinoma of the Ampulla of Vater lead to?

A

Jaundice

100
Q

What is the prognosis for carcinoma of the Ampulla of Vater?

A

Good, because blockage leads to early presentation when the tumour is still treatable

101
Q

How common are islet cell tumours?

A

Rare

102
Q

What are the types of islet cell tumours?

A
  • Insulinoma
  • Glycagonoma
  • Vasoactive Intestinal Peptideoma (VIPoma)
  • Gastrinoma
103
Q

What does an insulinoma lead to?

A

Hypoglycaemia

104
Q

What does glycagonoma lead to?

A

Characteristic skin rash

105
Q

What does vasoactive intestinal peptideoma lead to?

A

Werner Morrison syndrome

106
Q

What does gastrinoma lead to?

A

Zollinger-Ellison syndrome

107
Q

Give 3 benign tumours of the liver

A
  • Hepatic adenoma
  • Bile duct adenoma/hamartoma
  • Haemangioma
108
Q

How common are benign tumours of the liver?

A

Fairly rare

109
Q

Give 3 malignant tumours of the liver

A
  • Hepatocellular carcinoma
  • Cholangiocarcinoma
  • Hepatoblastoma
110
Q

How many new cases of colorectal cancer are there in England and Wales per year?

A

25,000

111
Q

How many new cases of stomach cancer are there in England and Wales per year?

A

11,000

112
Q

How many new cases of pancreatic cancer are there in England and Wales per year?

A

5,500

113
Q

What investigations are used to investigate the abdomen?

A
  • Plain x-rays
  • Contrast studies
  • Ultrasound
  • Cross-setional imaging
  • Angiography
114
Q

What type of x-rays are used to investigate the abdomen?

A
  • Abdominal x-ray (AXR)
  • Erect chest x-ray (CXR)
115
Q

What kind of contrast studies are used to investigate the abdomen?

A
  • Barium swallow
  • Barium enema
  • Barium meal/follow through
  • Water soluble contrast studies
116
Q

What kind of cross-sectional imaging techniques are used to investigate the abdomen?

A
  • Computed tomography (CT)
  • Magnetic resonance imaging (MRI)
117
Q

How big is the dose of radiation given by the techniques used to investigate the abdomen?

A

Varies considerably

118
Q

Which techniques for investigation of the abdomen don’t use any radiation?

A
  • Ultrasound
  • MRI
119
Q

Which technique used to investigate the abdomen can deliver a high dose of radiation?

A

CT scan

120
Q

How does the radiation dosage given during a CT scan differ from that of an abdominal x-ray?

A

Can be up to 15x the dose

121
Q

What are the potential risks of radiation?

A
  • Carcinogenesis
  • Genetic
  • Developmental risk to foetus
122
Q

What are contrast studies used to define?

A

Hollow viscera

123
Q

What contrast is used in studies?

A
  • Barium
  • Water soluble contrast (typically containing iodine)
124
Q

What are the common types of GI contast studies?

A
  • Swallow
  • Meal
  • Follow through
  • Enema
125
Q

What is a barium enema?

A

A barium study where the contrast medium is inserted rectally

126
Q

What does a barium enema enable?

A

The colon to be visualised

127
Q

What does ultrasound utilise to generate images?

A

Sound waves

128
Q

What frequency sound waves are used in ultrasound?

A

Usually 2-18MHz

129
Q

What are the advantages of ultrasound?

A
  • Cheap compared to CT and MRI
  • Portable
130
Q

What is the disadvantage of ultrasound?

A

It is highly user dependant

131
Q

What can an abdominal ultrasound be used to do?

A
  • Determine if the patient has gallstones, or if the common bile duct is dilated
  • Can view liver and portal vein, even the appendix
132
Q

What is the dilation of the common bile duct an indicator of?

A

That there is an impacted gallstone in the duct

133
Q

What is the problem with abdominal ultrasounds with the aim to view the liver and portal vein?

A

The scans are often difficult to interpret, and the usefulness of a scan is often down to who is doing and interpreting the scan

134
Q

What technique is used to visualise the blood supply to the GI tract?

A

GI angiography

135
Q

When is being able to visualise the blood supply to the GI tract very useful?

A

For bleeding and ishchaemia

136
Q

How is GI angiography conducted?

A

By injecting a radio-opaque contrast agent intravenously, and then using various modalities to capture the images

137
Q

What is shown in this GI angiogram?

A

The aorta, with the coelic trunk, and superior mesenteric arteries and its branches. The inferior mesenteric artery and it’s branches are harder to see

138
Q

What structures are visable in an abdominal x-ray?

A
  • Stomach
  • Small and large bowel
  • Soft tissues
    • Liver
    • Spleen
    • Kidneys
    • Psoas muscles
    • Bladder
    • Lung bases
  • Bones
139
Q

When is a part of a hollow tube visible on an x-ray?

A

If it is filled with gas

140
Q

Why are parts of a hollow tube filled with gas visible on an x-ray?

A

Low density gas acts as contrast

141
Q

When are lumens not visible on abdominal x-rays?

A

When they are fully fluid filled

142
Q

When is the ability to visualise gas filled areas on an abdominal x-ray useful?

A

Can be used to visualise the stomach (if gas filled), but more commonly used to visualise the small bowel

143
Q

What are the common reasons for requesting a plain abdominal radiograph?

A
  • Acute abdominal pain
  • Small or large bowel obstruction
  • Acute exacerbation of IBD
  • Renal colic
144
Q

What abnormalities can be shown on an abdominal x-ray?

A
  • Small bowel obstruction
  • Large bowel obstruction
  • Volvulus
  • Chronic pancreatitis
  • Aneurysms with calcification
  • Nodes
  • Bones
  • Artifacts
  • Foreign bodies
  • Kidney stones
145
Q

What position does the small bowel usually occupy on the abdominal x-ray?

A

Central position

146
Q

What can the small bowel display on an x-ray?

A

‘Circular folds’, or valvulae conniventes

147
Q

How do valvulae conniventes appear on x-rays?

A

As lines that appear to cross the whole of the bowel lumen

148
Q

What is this x-ray image showing?

A

The large bowel

149
Q

What position does the large bowel usually occupy on an x-ray?

A

A more peripheral position

150
Q

What is it often possible to see on an x-ray of the larg bowel?

A
  • Haustra
  • Faeces
151
Q

How do haustra appear on an abdominal x-ray?

A

As incomplete lines going across the lumen

152
Q

How do faeces appear on an abdominal x-ray of the large bowel?

A

Like clouds in the lumen

153
Q

What rule do small and large bowel obstructions follow?

A

3/6/9

154
Q

What is the 3/6/9 rule?

A
  • A small bowel is said to be dilated when it is greater than 3cm diameter
  • The large bowel is said to be dilated when its greater than 6cm diameter
    • The caecum (when the ileoceacal valve is working) is said to be dialted when it is greater than 9cm diameter
155
Q

What is it important to check when applying the 3/6/9 rule?

A

That the x-ray is shown to scale

156
Q

What is this image showing?

A

A small bowel obstruction

157
Q

How does a small bowel obstruction usually present?

A
  • Vomiting (early)
  • Mild distention
  • Absolute constipation (late feature)
  • Colicky pain that presents every 2-3 minutes
158
Q

What is meant by absoloute constipation?

A

Not passing anything per rectum, even flatus

159
Q

Why do you vomit early, and experience constipation late, with a small bowel obstruction?

A

Because the obstruction is nearer the mouth than a large bowel obstruction

160
Q

What can cause a small bowel obstruction?

A
  • Adhesions
  • Hernias
  • Tumours
  • Inflammation
161
Q

What kind of hernias can cause a small bowel obstruction?

A
  • Inguinal
  • Femoral
  • Incisional
162
Q

What is this image showing?

A

A large bowel obstruction

163
Q

How does a large bowel obstruction appear on an abdominal x-ray?

A
  • More at the periphery of the x-ray
  • Lines going across the lumen (haustra) are incomplete
164
Q

How does a large bowel obstruction present?

A
  • Abdominal pain
  • Distention
  • Constipation (early feature)
  • Colicky pain
  • Vomiting (late feature)
165
Q

How does the colicky pain present with a large bowel obstruction differ from that with a small bowel obstruction?

A

It is not as frequent, being experienced every 10-15 minutes

166
Q

What is a feature of vomiting in large bowel obstructions?

A

Can be faeculant

167
Q

What are the causes of a large bowel obstruction?

A
  • Colorectal carcinoma
  • Diverticular stricture
  • Hernia
  • Volvulus
  • Psuedo-obstruction
168
Q

What is a volvulus?

A

When a viscera twists around itself, or more commonly when it twists around its mesentery

169
Q

What is the most common volvulus?

A

Sigmoid volvulus

170
Q

What is a more rare type of volvulus?

A

Caecal volvulus

171
Q

What is the consequence of twisting in a volvulus?

A

The enclosed loop of bowel dilates, and is at risk of perforating or cutting of its blood supply (which runs in the mesentery)

172
Q

What is this arrow showing?

A

Chronic pancreatitis

173
Q

When can an erect chest x-ray be useful?

A

In diagnosing a perforated bowel

174
Q

What can cause a perforated bowel?

A
  • Peptic ulcer
  • Diverticular disease
  • Tumour
  • Obstruction
  • Trauma
  • Iatrogenic
175
Q

Why does the CXR need to be erect when trying to diagnose a perforated bowel

A

Because you are looking for the diaphragm to be elevated away from any other viscera (the liver on the by the presence of air/gas in the peritoneal cavity. The air/gas will rise to the top of the cavity and so the patient needs to be sat up for 10 minutes prior to the x-ray to ensure this happens

176
Q

Why is a raised diaphragm indicative of a perforated bowel?

A

The peritoneal cavity normally only contains a small amount of fluid, so the presence of air/gas is abnormal and could be the result of a perforated bowel

177
Q

What does an x-ray of a raised diaphragm look like?

A
178
Q

What does an abdominal CT use?

A
  • High dose radiation
  • IV or oral/rectal contrast
179
Q

How does the resolution of an abdominal CT differ from that of a MRI?

A
  • Good spatial resolution
  • Poor contrast resolution
180
Q

Draw a diagram illustrating the planes of view that can be acheived by an abdominal CT

A
181
Q

Label this transverse abdominal CT

A
  • A - Liver
  • B - Stomach
  • C - Oesophagus
  • D - Spleen
182
Q

Label this coronal abdominal CT

A
  • A - Right crus
  • B - Oesophagus
  • C - Stomach (fundus)
  • Aorta
183
Q

Label this sagittal abdominal CT

A
  • A - Right crus of diaphragm
  • B - Celiac artery
  • C - Superior mesenteric artery
  • D - Oesophagus
  • E - Aorta
184
Q

Does MRI imaging use radiation?

A

No

185
Q

What is the advantage of MRI imaging?

A

Good spatial and contrast resolution

186
Q

What is the disadvantage of MRI imaging?

A

Time consuming

187
Q

What is a magnetic resonance cholangio-pancreatogram (MRCP)?

A

A MRI scan that can visualise the gallbladder and bilary tree

188
Q

Label this diagram

A
  • A - Gall bladder
  • B - Stone in gall bladder
  • C - Stone in bile duct
  • D - Bile duct

ESA 3 - Gastrointestinal System (12 decks)

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