GI / Nutritional Part 5 (Pancreatic carcinoma - Toxic Megacolon)

Question 1

MC location of pancreatic cancer and MC cancer-type

Answer 1

Location = head of pancreas (90%)
Type = adenocarcinoma (ductal)

islet cell is the other type, but not as common

Question 2

What is the #1 RF for pancreatic carcinoma and some others

Answer 2

Smoking

age > 55yo
chronic pancreatitis
DM
Males
Obesity
AA

Question 3

Classic symptom of pancreatic cancer

Answer 3

Painless jaundice (d/t CBD obstruction)

also weight loss is seen, similar s/s of pancreatitis, new onset DM, depression, pruritis (from bile salt deposition in skin)

Question 4

Your patient has a carcinoma at the head of the pancreas which has caused CBD obstruction, what PE sign might you observe

Answer 4

Courvoisier’s sign: palpable, nontender, distended gallbladder due to common bile duct obstruction (esp. if head of pancreas is involved)

Question 5

Your elderly patient has new onset DM and painless jaundice with weight loss. You suspect pancreatic cancer.

What imaging is first line?
What tumor marker will you follow after treatment?

Answer 5

CT scan
CA 19-9

CEA can be followed as well

Question 6

Your patient with pancreatic cancer is a candidate for surgery - what surgery will a surgeon likely perform?

chemo/radiation after?

Answer 6

Whipple procedure (pancreaticoduodenectomy) if confined to the head or duodenal area;
tail (distal resection);
post-op chemo (5-FU, gemcitabine) or radiotherapy

only 20% resectable at time of dx; overall 5yr survival rate is 5-15% :(

Question 7

Unfortunately, your patient with pancreatic cancer is not a candidate for surgery. What is your management and why?

Answer 7

ERCP w/ stent placement palliative for intractable itching

minimizes bile salt deposition?

Question 8

What is a pancreatic pseudocyst comprised of?

Answer 8

Cystic collection of tissue, fluid, and necrotic debris surrounding the pancreas

NO true epithelial lining in the capsule

Associated with:
*acute or chronic pancreatitis
*trauma to chest

Question 9

Your patient comes in with abdominal pain and an abdominal mass.

What is the study of choice for diagnosing a pancreatic pseudocyst?

Answer 9

CT Scan

US is an option

Question 10

You decide to do a FNA of a pancreatic pseudocyst. What do you expect to find?

Answer 10

*elevated amylase
*low CEA
*low fluid viscosity

Question 11

Your patient’s abdominal pain and pancreatic pseudocyst mass persists for 4-6 weeks.

How do you manage this and why?

Answer 11

-percutaneous drainage
-surgical decompression
(pancreaticogastrostomy)
-drain into stomach or bowel

Apart from helping symptoms, untreated pancreatic psedocysts can lead to peritonitis and other infections

Question 12

MCC of UGI bleed

Answer 12

PUD

Question 13

MC location of ulcers for PUD

Answer 13

Duodenum

duodenal ulcers are usually benign
4% of gastric ulcers are associated with gastric carcinoma - gastric ulcers also are not protected by mucous/bicarb as they are IN the stomach

Question 14

What layer of the intestine is their often a defect in for PUD?

Answer 14

defect in the mucosa that extends to the muscularis mucosa

Question 15

MCC of PUD

Answer 15

H pylori

NSAIDs/ASA – 2nd MC cause (GU – PG inhibition)

Question 16

Classic presentation of PUD and how this varies whether it is a duodenal vs gastric ulcer

Answer 16

Dyspepsia (burning, gnawing, epigastric pain) hallmark; N/V

DU: dyspepsia classically relieved w/ food
GU: sxs worsened w/ food

DU = duodenal ulcers
GU = gastric ulcers

Question 17

Your patient has a history of PUD and had an ulcer rupture. What are the expected s/s?

Answer 17

Severe abd pain that may radiate to the shoulder
Peritonitis

peritonitis = rebound tenderness, guarding, rigidity

Question 18

How do you diagnose PUD? What if you are sus of H pylori (and gold standard)?

Answer 18

Upper endoscopy w/ bx

H. pylori testing:
*endoscopy w/ bx – gold standard
*urea breath test (H. pylori converts labeled urea 🡪 labeled CO2; breathing out labeled urea = +)

Question 19

Managment of H Pylori (+) PUD

Answer 19

Tripple or quad therapy

Question 20

Managment of H Pylori (-) PUD

Answer 20

PPI

also H2 blocker and others

Question 21

What is the suffix for PPI vs H2 blockers?

Answer 21

PPI = -prazole
H2 blockers = -tidines

Question 22

MOA of a PPI

Answer 22

block H/K ATPase (proton pump) of parietal cell, reducing acid secretion

Question 23

What ADR is omeprazole associated with

Answer 23

C diff

also a P 450 inhibitor:
increases levels of theophylline, warfarin, phenytoin

Question 24

Which H2 blocker is associated with QT prolongation?

Answer 24

Famotidine

careful in cardio patients

Question 25

Which H2 blocker is associated with P450 inhibition?

Answer 25

Cimetidine ## Footnote like omeprazole, increases levels of theophylline, warfarin, phenytoin

Question 26

What are the main SEs of H2 blockers based on?

Answer 26

CNS effects ## Footnote often leads to confusion and other s/s

Question 27

Apart from PPIs and H2 blockers, what meds/classes are often used in the management of PUD?

Answer 27

Misoprostol Antacids Bismuth (pepto/kaopectate) Sucralfate

Question 28

MOA of misoprostol ## Footnote used sometimes in PUD

Answer 28

**PG E1 analog** that increases bicarbonate & mucus secretion, & reduces acid production

Question 29

When might a patient use misoprostol for PUD?

Answer 29

good for preventing NSAID-induced ulcers but not for healing already existing ulcers

Question 30

MOA of antacids ## Footnote Tums

Answer 30

neutralize acid, prevents conversion of pepsinogen to pepsin (active form)

Question 31

Which drug class for treatment of PUD sometimes results in darkening of tongue/stools

Answer 31

Bismuth compounds ## Footnote Pepto-Bismol Kaopecate

Question 32

MOA of bismuth compounds ## Footnote Pepto-Bismol Kaopecate

Answer 32

MOA: antibacterial & cytoprotective that inhibits peptic activity ## Footnote limited use = used in quadruple therapy in H. pylori management)

Question 33

Like bismuth compounds, sucralfate has limited use in PUD. What is it's indication?

Answer 33

MC used as **ulcer prophylactic** measurement than for tx

Question 34

MOA of Sucralfate

Answer 34

**cytoprotective** (forms viscous adhesive ulcer coating that promotes healing, protects the stomach mucosa)

Question 35

Why is Sucralfate often not used for PUD treatment?

Answer 35

may reduce bioavailability of H2RAs, PPIs when given simultaneously ## Footnote also tastes like metal and there can be nausea/constipation

Question 36

What is the MCC of intestinal obstruction in infancy?

Answer 36

Pyloric stenosis

Question 37

What is the pathophys of pyloric stenosis?

Answer 37

**Hypertrophy** & **hyperplasia** of the **pyloric muscles**, causing a functional gastric outlet obstruction (**preventing gastric emptying into the duodenum**)

Question 38

What patient demographic would be MC for pyloric stenosis? 1) age 2) med use 3) ethnicity 4) gender

Answer 38

1) age = 3-12 weeks 2) med use = erythromycin 3) ethnicity = caucasian 4) gender = male ## Footnote also first born

Question 39

Classic presentation of pyloric stenosis

Answer 39

Infant with **projectile vomitting** post-food | may have s/s of FTT ## Footnote PE: *palpable pylorus: “**olive shaped**” nontender, mobile hard mass to the right of the epigastrium

Question 40

Dx of choice for pyloric stenosis

Answer 40

US ## Footnote showing an elongated, thickened pylorus

Question 41

What is the characteristic finding found upon a GI series of pyloric stenosis?

Answer 41

**string sign** (thin column of barium through a narrowed pyloric channel) ## Footnote also maybe **railroad track sign**: excess mucosa in the pyloric lumen resulting in 2 columns of barium

Question 42

What might be the acid/base lab findings associated with pyloric stenosis?

Answer 42

hypokalemia, hypochloremic metabolic alkalosis

Question 43

Initial and definitive treatment of pyloric stenosis

Answer 43

Initial: rehydration (IV fluids) & potassium replacement Definitive: pyloromyotomy

Question 44

Most common cancer type and location of small bowel carcinoma

Answer 44

Adenocarcinoma of the duodenum ## Footnote rare overall

Question 45

RF of small bowel carcinoma (3)

Answer 45

*hereditary cancer syndromes: hereditary nonpolyposis colorectal cancer (HNPCC) *cystic fibrosis *Crohn’s disease | also alcohol and western diet ## Footnote remember, unlike UC - crohn's can effect the small bowel/intestine

Question 46

MC presenting symptom of small bowel carcinoma

Answer 46

Abdominal pain | typically intermittent & crampy in nature ## Footnote others include: *N/V *anemia *GI bleeding *jaundice *weight loss *obstruction, perforation

Question 47

What diagnostics might you use beside biopsy for small bowel carcinoma?

Answer 47

CT endoscopies

Question 48

What tumor marker might you follow during management of small bowel carcinoma?

Answer 48

CEA

Question 49

What is the management of small ball carcinoma? Chemo/radiation?

Answer 49

wide segmental surgical resection ## Footnote adjuvant chemo in pts w/ LN +

Question 50

T/F: Toxic Megacolon is an obstructive disease?

Answer 50

False ## Footnote just a huge diameter colon

Question 51

Apart from N/V, pain, distension, and systemic symptoms - this symptom is classic for toxic megacolon

Answer 51

PROFOUND bloody diarrhea

Question 52

What diameter must the colon be to make the diagnosis of toxic megacolon and what imaging is used to evaluate this?

Answer 52

**> 6 cm** as shown on **abd xray**

Question 53

What PE/ labs makes the diagnosis of toxic megacolon? ## Footnote in addition to > 6 cm colon

Answer 53

3 or more of the following: *fever >38C *pulse >120 *neutrophilic leukocytosis >10,500/microL *anemia PLUS 1 of the following: *hypotension *dehydration *electrolyte abnormalities *AMS

Question 54

What is the supportive treatment associated with toxic megacolon?

Answer 54

bowel rest, bowel decompression w/ NG tube, broad spectrum abx, fluid & electrolyte replacement ## Footnote also management of underlying cause

Question 55

What are the broad spectrum abx used in toxic megacolon?

Answer 55

Rocephin + Metro

Question 56

When might you consider steroids for supportive treatment in toxic megacolon?

Answer 56

If the patient has associated ulcerative colitis (UC)