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Surgery EOR > GI / Nutritional Part 5 (Pancreatic carcinoma - Toxic Megacolon) > Flashcards

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

1
Q

MC location of pancreatic cancer and MC cancer-type

A

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

islet cell is the other type, but not as common

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2
Q

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

A

Smoking

age > 55yo
chronic pancreatitis
DM
Males
Obesity
AA

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3
Q

Classic symptom of pancreatic cancer

A

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)

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4
Q

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

A

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

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5
Q

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?

A

CT scan
CA 19-9

CEA can be followed as well

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6
Q

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

chemo/radiation after?

A

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% :(

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7
Q

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

A

ERCP w/ stent placement palliative for intractable itching

minimizes bile salt deposition?

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8
Q

What is a pancreatic pseudocyst comprised of?

A

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

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9
Q

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

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

A

CT Scan

US is an option

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10
Q

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

A

*elevated amylase
*low CEA
*low fluid viscosity

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11
Q

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

How do you manage this and why?

A

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

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

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12
Q

MCC of UGI bleed

A

PUD

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13
Q

MC location of ulcers for PUD

A

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

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14
Q

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

A

defect in the mucosa that extends to the muscularis mucosa

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15
Q

MCC of PUD

A

H pylori

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

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16
Q

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

A

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

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17
Q

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

A

Severe abd pain that may radiate to the shoulder
Peritonitis

peritonitis = rebound tenderness, guarding, rigidity

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18
Q

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

A

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 = +)

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19
Q

Managment of H Pylori (+) PUD

A

Tripple or quad therapy

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20
Q

Managment of H Pylori (-) PUD

A

PPI

also H2 blocker and others

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21
Q

What is the suffix for PPI vs H2 blockers?

A

PPI = -prazole
H2 blockers = -tidines

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22
Q

MOA of a PPI

A

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

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23
Q

What ADR is omeprazole associated with

A

C diff

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

24
Q

Which H2 blocker is associated with QT prolongation?

A

Famotidine

careful in cardio patients

25
Q

Which H2 blocker is associated with P450 inhibition?

A

Cimetidine

like omeprazole, increases levels of theophylline, warfarin, phenytoin

26
Q

What are the main SEs of H2 blockers based on?

A

CNS effects

often leads to confusion and other s/s

27
Q

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

A

Misoprostol
Antacids
Bismuth (pepto/kaopectate)
Sucralfate

28
Q

MOA of misoprostol

used sometimes in PUD

A

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

29
Q

When might a patient use misoprostol for PUD?

A

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

30
Q

MOA of antacids

Tums

A

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

31
Q

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

A

Bismuth compounds

Pepto-Bismol
Kaopecate

32
Q

MOA of bismuth compounds

Pepto-Bismol
Kaopecate

A

MOA: antibacterial & cytoprotective that inhibits peptic activity

limited use = used in quadruple therapy in H. pylori management)

33
Q

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

A

MC used as ulcer prophylactic measurement than for tx

34
Q

MOA of Sucralfate

A

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

35
Q

Why is Sucralfate often not used for PUD treatment?

A

may reduce bioavailability of H2RAs, PPIs when given simultaneously

also tastes like metal and there can be nausea/constipation

36
Q

What is the MCC of intestinal obstruction in infancy?

A

Pyloric stenosis

37
Q

What is the pathophys of pyloric stenosis?

A

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

38
Q

What patient demographic would be MC for pyloric stenosis?

1) age
2) med use
3) ethnicity
4) gender

A

1) age = 3-12 weeks
2) med use = erythromycin
3) ethnicity = caucasian
4) gender = male

also first born

39
Q

Classic presentation of pyloric stenosis

A

Infant with projectile vomitting post-food

may have s/s of FTT

PE:
*palpable pylorus: “olive shaped” nontender, mobile hard mass to the right of the epigastrium

40
Q

Dx of choice for pyloric stenosis

A

US

showing an elongated, thickened pylorus

41
Q

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

A

string sign (thin column of barium through a narrowed pyloric channel)

also maybe railroad track sign: excess mucosa in the pyloric lumen resulting in 2 columns of barium

42
Q

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

A

hypokalemia, hypochloremic metabolic alkalosis

43
Q

Initial and definitive treatment of pyloric stenosis

A

Initial: rehydration (IV fluids) & potassium replacement

Definitive: pyloromyotomy

44
Q

Most common cancer type and location of small bowel carcinoma

A

Adenocarcinoma of the duodenum

rare overall

45
Q

RF of small bowel carcinoma (3)

A

*hereditary cancer syndromes: hereditary nonpolyposis colorectal cancer (HNPCC)
*cystic fibrosis
*Crohn’s disease

also alcohol and western diet

remember, unlike UC - crohn’s can effect the small bowel/intestine

46
Q

MC presenting symptom of small bowel carcinoma

A

Abdominal pain

typically intermittent & crampy in nature

others include:
*N/V
*anemia
*GI bleeding
*jaundice
*weight loss
*obstruction, perforation

47
Q

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

A

CT
endoscopies

48
Q

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

A

CEA

49
Q

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

A

wide segmental surgical resection

adjuvant chemo in pts w/ LN +

50
Q

T/F: Toxic Megacolon is an obstructive disease?

A

False

just a huge diameter colon

51
Q

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

A

PROFOUND bloody diarrhea

52
Q

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

A

> 6 cm as shown on abd xray

53
Q

What PE/ labs makes the diagnosis of toxic megacolon?

in addition to > 6 cm colon

A

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

54
Q

What is the supportive treatment associated with toxic megacolon?

A

bowel rest, bowel decompression w/ NG tube, broad spectrum abx, fluid & electrolyte replacement

also management of underlying cause

55
Q

What are the broad spectrum abx used in toxic megacolon?

A

Rocephin + Metro

56
Q

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

A

If the patient has associated ulcerative colitis (UC)

Surgery EOR (17 decks)

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