GI Surgery - Cancer and Surgery Flashcards
Overview of GI cancer
Oesophageal (+Barrett's) Stomach cancer Pancreatic cancer Liver cancer Cholangiocarcinoma Colorectal cancer
A 74 ♂ presents to his GP with a 3mo history of weight loss, fatigue and loose stools. His maternal grandmother was diagnosed with bowel cancer in her 60s. O/E, you discover bright red blood PR.
What tumour marker is associated with your feared diagnoses?
Pancreatic cancer Oesophageal cancer Left-sided colorectal cancer Hepatocellular carcinoma Barrett’s oesophagus Cholangiocarcinoma α-fetoprotein CA19-9 CEA Stomach cancer
CEA
Carcinoembryonic antigen
Colorectal cancer tumour marker
A 60♀ presents complaining of vague abdominal pain and a feeling of nausea for the past 4mo. She denies any vomiting. On further questioning you find she has lost a significant amount of weight over the past 6mo or so, largely unintentionally. O/E, you discover a firm, rubbery lump in the left, supraclavicular fossa.
What is the most likely Dx?
Pancreatic cancer Oesophageal cancer Left-sided colorectal cancer Hepatocellular carcinoma Barrett’s oesophagus Cholangiocarcinoma α-fetoprotein CA19-9 CEA Stomach cancer
Stomach Cancer
A 45 ♂ with a background of IBD presents complaining of pruritus. He denies any further symptoms, but on direct questioning remarks that his stools have perhaps been slightly more pale of late. Physical examination is largely unremarkable, aside from a mild jaundice noted in his sclera. You order a series of investigations, which reveal a negative CA19-9.
What is the most likely diagnosis?
Pancreatic cancer Oesophageal cancer Left-sided colorectal cancer Hepatocellular carcinoma Barrett’s oesophagus Cholangiocarcinoma α-fetoprotein CA19-9 CEA Stomach cancer
Cholangiocarcinoma
An obese 56♂ with a PMH of chronic GORD presents complaining of a
worsening, burning pain in his chest, and of feeling a lump in his throat when eating. He describes himself as a ‘non-smoker’, having given up yesterday evening following a 40+yr history of smoking 30 a day.
What is the most likely diagnosis?
Pancreatic cancer Oesophageal cancer Left-sided colorectal cancer Hepatocellular carcinoma Barrett’s oesophagus Cholangiocarcinoma α-fetoprotein CA19-9 CEA Stomach cancer
Oesophageal Cancer
A 56 ♀ presents with a 2 week history of increasing jaundice and pruritis. Direct questioning reveals that over the past few months she has lost about 10kg in weight. An ultrasound scan shows dilated bile ducts but no evidence of gallstones.
What is the most likely diagnosis?
Pancreatic cancer Oesophageal cancer Left-sided colorectal cancer Hepatocellular carcinoma Barrett’s oesophagus Cholangiocarcinoma α-fetoprotein CA19-9 CEA Stomach cancer
Pancreatic cancer
Types of Oesophageal Cancer
Adenocarcinoma (commonest)
Squamous cell
Oesophageal Adenocarcinoma
Location, RF, Barrett’s?
Lower Third of Oesophagus
RF: Smoking, Obesity
Does arise from Barrett’s
Oesophageal Squamous cell cancer
Location, RF, Barrett’s
Middle third of oesophagus
RF: Smoking, Alcohol
Doesn’t arise from Barrett’s
Chronic Presentation of Oesophageal Cancer
Progressive dysphagia, solids –> liquids
Chest pain (burning)
Wt loss
Oesophageal Cancer Ix
Dx: OGD
Staging: CT
Barrett’s Oesophagus
Definition, Cause, Complications
“Columnar lined oesophagus [CLO]”
Metaplasia of the oesophagus, replacing normal squamous epithelium with columnar epithelium.
Caused by acid reflux (GORD)
Complications: Increased risk of adenocarcinoma of the oesophagus
Stomach Cancer Risk Factors
Smoking, H. Pylori infection, Chronic gastritis
Stomach Cancer Presentation
Epigastric Pain Nausea Vomiting +/- blood Anorexia, Dysphagia Wt Loss
Commonest Type of Stomach Cancer
Adenocarcinoma
Stomach Cancer O/E
Virchow’s Node/ Troisier’s sign: Lymphadenopathy in left supraclavicular fossa
Sister Mary Joesph node: Metastatic nodule on umbilicus
Palpable epigastric mass
Stomach Cancer Ix
OGD
Biopsy
Courvoisier’s Law
Painless jaundice + Palpable Gallbladder is unlikely to be due to gallstone’s
(Likely malignancy of gallbladder or pancreas)
Pancreatic Cancer RF
Smoking
Increased BMI
Chronic pancreatitis
Diabetes
Pancreatic Cancer Genetics
K-ras mutation (95%)
Pancreatic Cancer Presentation
Painless jaundice
Obstructive jaundice picture - pale stools/dark urine
Pancreatic Cancer O/E
Courvoisier’s Law
Painless jaundice/palpable gallbladder
Pancreatic Cancer Commonest type
Ductal carcinoma
Pancreatic Cancer Commonest location
Head > Body > Tail > Diffuse
Pancreatic Cancer Tumour marker
Ca 19-9
Pancreatic Cancer Ix
LFTs : Raised ALP
USS: Dilated biliary tree +/- pancreatic mass
Biopsy
Commonest cause of liver cancer
Metastasis
Liver Cancer RF
Cirrhosis: Infection - Viral hepatitis Inflammation - PSC, PBC Metabolic - NASH [Non-alcoholic steatohepatitis] Toxins - Alcohol, Drugs
Liver Cancer Presentation
Constitutional symptoms: FLAWS
+/- Ascites
+/- Abdo pain
Liver Cancer Commonest Type
- Secondary - Metastasis
2. Primary - Hepatocellular carcinoma
Liver Cancer Tumour marker
α-fetoprotein
Liver cancer Ix
USS
Biopsy
Cholangiocarcinoma
RF, Presentation, O/E
NB Presentation is similar to pancreatic cancer
RF: Primary sclerosing cholangitis (UC)
Presentation: Obstructive jaundice picture; Constitutional symptoms
O/E: ? Courvoisier’s law
Colorectal cancer
RF, Commonest Type, Tumour marker, Ix
RF:
Age
FHx
Diet (Meat in diet; Fat in diet; Low fibre)
Commonest: Adenocarcinoma
TM: CEA
Ix:
FBC - Microcytic anaemia
Colonoscopy + Biopsy
Colorectal cancer Presentation
R sided:
Iron deficiency anaemia
+/- Dark blood mixed in with stool
+/- RIF mass
L sided (Commonest): Change in bowel habits Rectal bleeding Bright red blood coating stool \+/-mucus
Rectal:
+Tenesmus
+ Worm like stool
Anal:
Pain
+/- Pruritis ani
+/- Mass
Duke’s Staging System
Used for colorectal cancers
A/B1/B2/C1/C2/D
A - Limited to mucosa
B1 - Extending into muscularis propria; No lymph node involvement
B2 - Transmural invasion; No lymph node involvement
C1 - Extending into muscularis propria; + Lymph node involvement
C2 - Transmural invasion; + Lymph node involvement
D - Distant metastasis
Progressions before colorectal cancer
Familial adenomatous polyposis [FAP]
Hereditary non-polyposis colorectal cancer [HNPCC]
FAP
Inheritance, Genetics, Characteristics, Lifetime risk of CRC without treatment
Autosomal dominant
Gene: APC
Characteristics: >1,000 polyps
Risk: 100%
HNPCC
Inheritance, Genetics, Characteristics, Lifetime risk of CRC without treatment
AKA lynch syndrome Autosomal dominant Genes: Mismatch repair genes Characteristics: Multiple CRCs and extra-colonic cancers Risk: 60%
A trauma Pt is rushed to AandE following a stab wound to the abdomen. On initial assessment, the Pt is septic, and it quickly becomes clear that the wound has perforated his bowel.
Which is the most appropriate procedure to perform?
Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz
Hartmann’s
A patient is known to have symptomatic Familial Adenomatous Polyposis, and is recommended surgery due to avoid his otherwise inevitable progression to colorectal cancer.
Which is the most appropriate procedure to perform?
Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz
Proctocolectomy
A ♀ swimsuit model requires and appendectomy. She is however refusing to sign the consent form as she is concerned about the cosmetic implications.
Which is the most appropriate procedure to perform?
Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz
Lanz
A Pt with Crohn’s disease has undergone a right hemicolostomy. The surgeon is, however, concerned about the integrity of the anastamosis in the short-term, given the status of the Pt.
Which is the most appropriate procedure to perform?
Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz
Loop ileostomy
Catherine Middleton, Duchess of Cambridge has been admitted to the Lindo Wing at St Mary’s, as she will imminently give birth to a future heir to the throne. She has requested a C-section.
BUT – as the surgeon scrubs in, he momentarily forgets which surgical procedure he should perform. He turn’s to the 3rd year Imperial medical student who is assisting and asks:
Which is the most appropriate procedure to perform?
Hartmann’s Gridiron Pfannestiel Abdominoperineal resection Lower abdominal resection Proctocolectomy Loop ileostomy Kocher’s Rutherford-Morrison Lanz
Pfannestiel
Hemicolectomy
Description and Indications
Removal of either the right or the left side of the bowel
Indications
R: Crohn’s Disease involving terminal ileum; Right sided CRC
L: Left sided CRC; Diverticular disease
Hartmann’s Procedure
Description and Indications
Emergency procedure:
Resection of the recto-sigmoid colon
Formation of an end colostomy stoma
Indications: Obstruction Perforation Abscess Trauma
“Reversal of Hartmann’s”
Description and Indications
Anastomosis of bowel and removal of stoma
If pt well enough - 3 months after Hartmann’s
Proctocolectomy
Description and Indications
Removal of the entire colon and rectum. Results in either:
Ileo-anal pouch anastomosis (“J pouch”)
End ileostomy
Indications: UC Crohn's FAP Pts with > 1 bowel cancer
Ileo-anal pouch anastomosis (J Pouch)
Formation of a new rectum - the pouch - out of loops of small bowel following proctocolectomy
Abdominoperineal resection
Description and Indications
Removal of the entire rectum and anus. Formation of an end colostomy.
Indications:
Lower rectal cancer
Anal cancer
Anterior resection of rectum - Lower anterior resection
Description and Indications
Removal of part or all of the rectum. Anastomosis of free ends.
Indications:
Upper rectal cancer
Diverticular disease
Scars - Indications
Kocher’s =Right subcostal Mercedes-Benz Midline laparotomy Loin McBurney’s =Gridiron Lanz Rutherford-Morrison = Hockey-Stick Pfannestiel Inguinal
Kocher’s =Right subcostal
Open cholecystectomy
Mercedes-Benz
Liver transplant
Midline laparotomy
Numerous
Major GI/abdo surgery
Loin
Nephrectomy
McBurney’s =Gridiron
Appendicectomy
Lanz
Appendicectomy
(+ improved cosmetic outcome)
Rutherford-Morrison = Hockey-Stick
Renal transplant
Pfannestiel
Gynaecological procedure
Eg C-Section
Inguinal
Hernia repair
Vascular access
Stoma
A conduit between the skin and a hollow viscus to divert faeces or urine outside the body to where it can be collected in a bag.
Ileostomy
Bowel, Appearance, Location, Faeces
Small bowel
Spouted (sticking out)
RIF
Green, Liquid
Colostomy
Bowel, Appearance, Location, Faeces
Large bowel
Flush
LIF
Formed
Loop ileostomy/colostomy
Temporary procedure:
A loop of bowel is brought to the surface and half divided, allowing faecal matter to drain into a stoma bag without reaching the distal bowel. It is then later reversed once the distal anastamosis has recovered.
