GI / Nutritional Part 5 (Pancreatic carcinoma - Toxic Megacolon) Flashcards
MC location of pancreatic cancer and MC cancer-type
Location = head of pancreas (90%)
Type = adenocarcinoma (ductal)
islet cell is the other type, but not as common
What is the #1 RF for pancreatic carcinoma and some others
Smoking
age > 55yo
chronic pancreatitis
DM
Males
Obesity
AA
Classic symptom of pancreatic cancer
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)
Your patient has a carcinoma at the head of the pancreas which has caused CBD obstruction, what PE sign might you observe
Courvoisier’s sign: palpable, nontender, distended gallbladder due to common bile duct obstruction (esp. if head of pancreas is involved)
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?
CT scan
CA 19-9
CEA can be followed as well
Your patient with pancreatic cancer is a candidate for surgery - what surgery will a surgeon likely perform?
chemo/radiation after?
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% :(
Unfortunately, your patient with pancreatic cancer is not a candidate for surgery. What is your management and why?
ERCP w/ stent placement palliative for intractable itching
minimizes bile salt deposition?
What is a pancreatic pseudocyst comprised of?
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
Your patient comes in with abdominal pain and an abdominal mass.
What is the study of choice for diagnosing a pancreatic pseudocyst?
CT Scan
US is an option
You decide to do a FNA of a pancreatic pseudocyst. What do you expect to find?
*elevated amylase
*low CEA
*low fluid viscosity
Your patient’s abdominal pain and pancreatic pseudocyst mass persists for 4-6 weeks.
How do you manage this and why?
-percutaneous drainage
-surgical decompression
(pancreaticogastrostomy)
-drain into stomach or bowel
Apart from helping symptoms, untreated pancreatic psedocysts can lead to peritonitis and other infections
MCC of UGI bleed
PUD
MC location of ulcers for PUD
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
What layer of the intestine is their often a defect in for PUD?
defect in the mucosa that extends to the muscularis mucosa
MCC of PUD
H pylori
NSAIDs/ASA – 2nd MC cause (GU – PG inhibition)
Classic presentation of PUD and how this varies whether it is a duodenal vs gastric ulcer
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
Your patient has a history of PUD and had an ulcer rupture. What are the expected s/s?
Severe abd pain that may radiate to the shoulder
Peritonitis
peritonitis = rebound tenderness, guarding, rigidity
How do you diagnose PUD? What if you are sus of H pylori (and gold standard)?
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 = +)
Managment of H Pylori (+) PUD
Tripple or quad therapy
Managment of H Pylori (-) PUD
PPI
also H2 blocker and others
What is the suffix for PPI vs H2 blockers?
PPI = -prazole
H2 blockers = -tidines
MOA of a PPI
block H/K ATPase (proton pump) of parietal cell, reducing acid secretion
What ADR is omeprazole associated with
C diff
also a P 450 inhibitor:
increases levels of theophylline, warfarin, phenytoin
Which H2 blocker is associated with QT prolongation?
Famotidine
careful in cardio patients
Which H2 blocker is associated with P450 inhibition?
Cimetidine
like omeprazole, increases levels of theophylline, warfarin, phenytoin
What are the main SEs of H2 blockers based on?
CNS effects
often leads to confusion and other s/s
Apart from PPIs and H2 blockers, what meds/classes are often used in the management of PUD?
Misoprostol
Antacids
Bismuth (pepto/kaopectate)
Sucralfate
MOA of misoprostol
used sometimes in PUD
PG E1 analog that increases bicarbonate & mucus secretion, & reduces acid production
When might a patient use misoprostol for PUD?
good for preventing NSAID-induced ulcers but not for healing already existing ulcers
MOA of antacids
Tums
neutralize acid, prevents conversion of pepsinogen to pepsin (active form)
Which drug class for treatment of PUD sometimes results in darkening of tongue/stools
Bismuth compounds
Pepto-Bismol
Kaopecate
MOA of bismuth compounds
Pepto-Bismol
Kaopecate
MOA: antibacterial & cytoprotective that inhibits peptic activity
limited use = used in quadruple therapy in H. pylori management)
Like bismuth compounds, sucralfate has limited use in PUD. What is it’s indication?
MC used as ulcer prophylactic measurement than for tx
MOA of Sucralfate
cytoprotective (forms viscous adhesive ulcer coating that promotes healing, protects the stomach mucosa)
Why is Sucralfate often not used for PUD treatment?
may reduce bioavailability of H2RAs, PPIs when given simultaneously
also tastes like metal and there can be nausea/constipation
What is the MCC of intestinal obstruction in infancy?
Pyloric stenosis
What is the pathophys of pyloric stenosis?
Hypertrophy & hyperplasia of the pyloric muscles, causing a functional gastric outlet obstruction (preventing gastric emptying into the duodenum)
What patient demographic would be MC for pyloric stenosis?
1) age
2) med use
3) ethnicity
4) gender
1) age = 3-12 weeks
2) med use = erythromycin
3) ethnicity = caucasian
4) gender = male
also first born
Classic presentation of pyloric stenosis
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
Dx of choice for pyloric stenosis
US
showing an elongated, thickened pylorus
What is the characteristic finding found upon a GI series of pyloric stenosis?
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
What might be the acid/base lab findings associated with pyloric stenosis?
hypokalemia, hypochloremic metabolic alkalosis
Initial and definitive treatment of pyloric stenosis
Initial: rehydration (IV fluids) & potassium replacement
Definitive: pyloromyotomy
Most common cancer type and location of small bowel carcinoma
Adenocarcinoma of the duodenum
rare overall
RF of small bowel carcinoma (3)
*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
MC presenting symptom of small bowel carcinoma
Abdominal pain
typically intermittent & crampy in nature
others include:
*N/V
*anemia
*GI bleeding
*jaundice
*weight loss
*obstruction, perforation
What diagnostics might you use beside biopsy for small bowel carcinoma?
CT
endoscopies
What tumor marker might you follow during management of small bowel carcinoma?
CEA
What is the management of small ball carcinoma? Chemo/radiation?
wide segmental surgical resection
adjuvant chemo in pts w/ LN +
T/F: Toxic Megacolon is an obstructive disease?
False
just a huge diameter colon
Apart from N/V, pain, distension, and systemic symptoms - this symptom is classic for toxic megacolon
PROFOUND bloody diarrhea
What diameter must the colon be to make the diagnosis of toxic megacolon and what imaging is used to evaluate this?
> 6 cm as shown on abd xray
What PE/ labs makes the diagnosis of toxic megacolon?
in addition to > 6 cm colon
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
What is the supportive treatment associated with toxic megacolon?
bowel rest, bowel decompression w/ NG tube, broad spectrum abx, fluid & electrolyte replacement
also management of underlying cause
What are the broad spectrum abx used in toxic megacolon?
Rocephin + Metro
When might you consider steroids for supportive treatment in toxic megacolon?
If the patient has associated ulcerative colitis (UC)
