Oesophago-Gastric-Duodenal Pathology Flashcards
what are the 2 main types of cancer within the oesophagus?
which is most common
adenocarcinoma (most common)
squamous cell carcinoma
what is the cause of oesophageal adenocarcinomas?
recurrent gastric reflux
squamous epithelium metaplasia into columnar epithelium (which can handle the acid)
what is the cause of oesophageal squamous cell carcinoma?
stress (due to smoking or alcohol) turn cells dysplastic
what are the 3 main types of gastric cancer?
adenocarcinoma (most common)
Gastrointestinal Stromal Tumours (GIST)
Lymphomas
where do gastrointestinal stromal tumours develop?
in the wall of the GI tract and not the epithelium like 90% of GI cancers
what gastric cancer are H.pylori associated with?
adenocarcinomas
what are the 3 types of gastro-oesophageal junction cancer?
type 1: oesophageal (just above junction growing distally)
type 2: true junctions
type 3: gastric (occus in cardia and grow proximally)
what type of carcinomas are gastro-oesophageal junction cancers?
adenocarcinoma
what is the difference between dysphagia and odynophagia?
dysphagia= hard to swallow odynophagia= pain on swallowing
what is dysphonia?
change in speech
why might an oesophageal cancer cause dysphonia?
if it effects the recurrent laryngeal nerve
why might an oeosphageal cancer cause regurgitation?
food has been swallowed and stored in oesophagus because it can’t get through
what is dyspepsia?
epigastric pain/discomfort
what lymph nodes are likely to be metastasised from oesophageal cancers?
supraclavicular
how do you diagnose an oesophageal or gastric cancer?
upper GI endoscopy+ biopsy barium meal CT scan of chest and abdomen PET scan bronchscopies
why are fitness studies needed to be under taken before an operation of the oeosphagus can take place?
operation is severe and only fit patients can undertake it
what are the 7 alarm features which might suggest oesophageal/gastric cancer?
>55 years of age dysphagia GI blood loss persistent vomiting unexplained weight loss upper abdominal mass anaemia
what excludes you from having surgery on an oeosphageal cancer?
metastases
what location of oesophageal cancer tends to respond best to radical radiotherapy?
cervical oesophagus
what palliative mechanisms for oesophageal cancer are there?
radiotherapy intubation/stentes canalisation (ie for laser/alcohol) photodynamic therapy terminal care
what are the 3 main contraindications of having surgery to remove a gastric cancer?
widely metastatic disease
malignant ascites
brief life expectency
what is malignant ascites?
malignant cells found in fluid in peritoneal cavity
what are the 2 types of surgery used for gastric cancer?
total gastrectomy
partial gastrectomy
what type of lesions is a total gastrectomy used for?
proximal lesions
what type of surgery is a partial gastrectomy usef for?
distal lesions
why is being very young an adverse prognostic feature in gastric cancer? (in addition to being very old)
because gastric cancer is very aggressive in the young
young females who develop gastric cancer below 40 all die within a year whether they have surgery or not- tumour is very aggressive and feeds off female hormones
what are oesophageal varices?
high pressure veins that bulge into your oesophagus due to portal hypertension
what is angiodysplasia?
chaotic abnormal blood vessels growing on the surface of the gut
what is Barretts oeosphagus?
a premalignant metaplastic change of the squamous cells to columnar cells due to chronic reflux
what is haematemesis?
vomiting blood
what is malaena?
black tarry stools associated with upper GI bleeding
what techniques can be used to stop varices bleeding or ulcers bleeding?
band ligation sclerosant glue heater (cautery) probe injection with vasoconstrictors clip ligation
what is the function of sclerosant?
injected into the bleeding blood vessel and causes intense inflammation which stops the bleeding
what are strictures?
narrowings that occur throughout the GI tract
how are strictures managed?
balloon dilatation
metal/biodegradable stents
what is a polypectomy?
band ligation of a polyp
what does acute gastritis tend to be a complication of?
major trauma
which is more common- acute or chronic gastritis?
chronic gastritis
what are the 3 main types of chronic gastritis?
autoimmune
bacterial
chemical
what antibodies are produced in autoimmune chronic gastritis?
anti-parietal and anti-intrinsic factor antibodies
what is the result of the autoantibodies produced in autoimmune chronic gastrities?
atrophy and intestinal metaplasia
macrocytic pernicious anaemia
increased risk of malignancy
what causes macrocytic pernicious anaemia in autoimmune gastritis?
intrinsivc factor autoantibodies result in reduced b12 being absorbed
compare macrocytic anaemia with microcytic anaemia with respect to their causes?
macrocytic anaemia is to with a problem with the production of RBCs (eg vit B12 deficiency)
microcytic anamia is to do with a problem with the production of haemoglobin (eg iron deficiency)
what supplement must you give to a patient with autoimmune chronis gastritis?
vitB12 supplements
which bacteria is most associated with chronic gastritis?
H. pylori
where is H. pylori’s niche in the stomach?
between epithelial cell surface and mucous barrier
why does H. pylori cause chronic gastrits?
excites acute inflammatory repsonse, if not cleared this results in chronic active inflammation
what 4 conditions does H. pylori gastritis increase risk of?
duodenal ulcer
gastric ulcer
gastric carcinoma
gastric lymphoma
how do you test for H. pylori infection?
C13 urea breath test
faecal antigen testing
what are the 3 main causes of chemical gastritis?
NSAIDs
alcohol
bile reflux
why does bile reflux cause gastritis?
because bile starts to emulsify the lipid bilayer and thus it becomes broken down
how do peptic ulcers form?
acid and enzymatic (pepsi) attack on the gastrointestinal mucosa causing a breach
what is the difference between an intestinal type and diffuse type gastric adenocarcinomas?
intestinal type: polypoid mass
diffuse type- infiltrates stomach wall
which type- intestinal or diffuse- gastric adenocarcinoma has a greater chance of resection?
intestinal gastric adenocarcinoma
what happens to the stomach wall in a diffuse type gastric adenocarcinoma?
thick, rigid wall that lacks distendability is developed
the imbalance of what 2 things predisposes to ulcers?
- acid + enzymatic attack
2. mucosal barrier
what are the 2 subtypes of oesophagitis?
acute (rare)
chronic (common)
what are the 2 main causes of acute oesophagitis?
- corrosive esophagitis following chemical ingestion
- infective oesophagitis in immunocompromised patients
what is the main cause of chronic oesophagitis?
reflux oesophagitis
what is reflux oesophagitis?
inflammation of oesophagus doe to refluxed low pH gastric content
why can obesity and pregnancy cause a defective LOS resulting in reflux oesophagitis?
they both increase intra-abdominal pressure which puts strain on the sphincter
what are the 3 main complications of chronic reflux?
ulceration
stricture
barrets oesophagus
what is allergic oeosphagitis?
a rare chronic condition where allergic causes causes chronic inflammation of the oesophagus- eosinophil mediated
what is the treatment for allergic oesophagitis?
steroids
chromoglycate
montelukast
what is the only benign oesophageal tumour?
squamous papilloma (rare)
where is an adenocarcinoma of the oeosphagus most common?
lower 1/3
this is the area reflux occurs
what is the pathogenesis of an adenocarcinoma of the oesophagus?
- reflux disease
- chronic reflux oesophagitis
- Barretts Oesophgus
- low grade dysplasia
- high grade dysplasia
- adenocarcinoma
what is the Rome III criteria of dyspepsia?
- epigastric pain or burning
- postprandial fullness
- early satiety
what category do postprandial fullness and early satiety fall under?
postprandial distress syndrome
what are the structures of the foregut?
oesophagus stomach duodenum (1/2) pancreas (1/2) gallbladder
what are the 4 main causes of dyspepsia?
peptic ulcer disease
drugs (NSAIDs)
gastric cancer
idiopathic (‘functional’)
what are the examination findings of non-complicated dyspepsia?
epigastric tenderness only
what are the examination findings of complicated dyspepsia?
- weight loss
- abdominal mass
- evidence of gastric -outflow obstruction
- peritonism
what are the signs of gastric outflow obstruction on exmination?
distension
succusion splash on auscultation
what are the alarm features that need to be checked in a patient who present with dyspepsia?
dysphagia evidence of GI blood loss persistent vomiting unexplained weight loss upper abdominal mass
what is the management of a patient who presents with dyspepsia has no alarm symptoms?
‘test and treat’ strategy
check H. pylori status:
-if positive, eradicate + confirm
-if negative, acid inhibition (eg PPI)
what is the management of a patient who presents with dyspepsia and has alarm symptoms?
refer to hospital specialist
what type of dyspepsia do peptic ulcers cause?
pain rather than post prandial distress syndrome
what are the main 2 causes of peptic ulcer disease?
H. pylori
NSAIDs
how does H. pylori spread?
faecal-oral/-oral oral spread
when do G cells secrete gastrin?
high pH in stomach
what is the pathogenesis of H.pylori causing gastric cancer?
- H. pylori reduces number of parietal cells and therefore reduces HCl
- G cells are stimulated to produce gastrin
- hypergastraemia occurs- more gastrin released than parietal cell receptors present
- this causes atrophy
- dysplasia
(LOW ACID)
what is the pathogenesis of H. pylori causing duodenal ulcers?
- H. pylori inhibits somatostatin
- increased gastric secretion
- increased HCl secretion
- this is released into the duodenum causing ulcers
(HIGH ACID)
what happens to the stomach mucosa in an atrophic state?
loss of folds, stomach becomes smooth and featureless
why must you give PPI’s only after testing for H. pylori?
PPIs can give false negatives
what enzyme to H. Pylori make which cleaves urea into ammonium bicarbonate?
urease
what is the treatment for peptic ulcer disease?
‘test and treat’ for H pylori
if positive, eradicate and confirm
if negative, antisecretory therapy (PPIs)
withdraw NSAIDs
what is the therapy for eradication of H pylori infection?
triple therapy for 1 week
PPI + amoxicillin 1g bd + clarithromycin 500mg bd
OR
PPI _ metronidazole 400mg bd + clarithromycin 250mg bg
what are the common side effects of triple therapy for H. pylori eradication?
nausea diarrhoea
after triple therapy for eradication of H pylori what do you do if patient is still symptomatic?
retest
what are the 4 main complications of peptic ulcer disease?
anaemia
bleeding
perforation
gastric outlet/duodenal obstruction
what is the post therapy follow up for a duodenal ulcer?
uncomplicated duodenal ulcer requires no follow up apart from confirmation of clearance
if symptoms persist then follow up
what is the post therapy follow up for a gastric ulcer?
follow up endoscopy at 6-8 weeks regardless of clearance of symptoms
what determines whether H. pylori is going to cause acid hyposecretion (by reducing number of parietal cells) or acid hypersecretion (by inhibiting somatostatin)?
pro-inflammatory host genotype (host response)
IL-1B genotype is more likely to go onto acid hyposecretion (gastric cancer causing)
no IL-1b genotype is more likely to go onto acid hypersecretion (duodenal ulcer causing)
what are the 3 main reasons for gastro-oesophageal reflux disease?
incompetent LOS
poor oesophageal clearnace (decreased peristalsis)
visceral sensitivity
what are the investgations used for GORD suspicion?
endoscopy
barium swallow
oeeophageal manometry and pH studies
nuclea studies
what are the lifestyle modifications to prevent GORD?
stop smoking
lose weight (if obese)
prop up the bed head
avoid provoking factors (alcohol and fatty food etc)
what is the management of oeosophageal dysplasia? (pre-malignant)
more frequent surveillance optimise PPI dose endoscopic mucosal resection radiofreq ablation (halo) argon
what is gastroparesis?
delayed gastric emptying but with no physical obstruction
what are the symptoms of gastroparesis?
post-prandial fullnes bloating nausea vomiting weight loss upper abdominal pain
what illicit drug is associated with gastroparesis?
cannabis
what medication is associated with gastroparesis?
opiates, anticholinergics
how do you investigate suspected gastroparesis?
gastric emptying studies
what is the management of gastroparesis?
removal of precipitating factors eg drugs liquid diet eat little and often promotility agents gastric pacemaker
what is achalasia?
a disorder of the oeosphagus which prevents peristalasis from functioning properly
