OSCE Cases Flashcards
What are the most common histological types of oesophageal cancer?
Squamous cell carcinoma of the upper oesophagus
Adenocarcinoma of the distal oesophagus - junction of the oesophagus and stomach
What are the risk factors for SCC of the oesophageal?
Low socioeconomic groups
Smoking
Alcohol
Males
Age +60
HPV infection
What are the risk factors for adenocarcinoma of the oesophagus?
Smoking
Barrett’s oesophagus
GERD
Obesity
History of Breast Ca
What are the symptoms of oesophageal cancer?
Dysphagia
Pain
Hoarseness
Cough with swallowing - oesophageal-tracheal fistula
Weight loss
Neck mass
What are the signs of oesophageal cancer?
Cervical lymph nodes
Hypercalcaemia - parathyroid hormone production
Dehydration, weight loss and muscle wasting
How is oesophageal cancer diagnosed?
History - Risk factors, symptoms
Examination - signs
Barium swallow
Endoscopy - direct visualization
FNA our Biopsy - histology
CT scan - Staging of disease
What are the findings on barium swallow for oesophageal Ca?
Irregular concentric narrowing - Stricture formation
Typical shouldering at the upper end of the lesion
Why is endoscopy performed for oesophageal Ca?
Direct visualisation of lesion
Biopsy of lesion for histology
What is the management of oesophageal cancer?
Surgical resection - oesophagectomy
- If lesion is limited to the oesophagus
- Done via transhiatal or thoracotomy
Neoadjuvant Chemotherapy with/without neoadjuvant Radiotherapy
* For downstaging of locally advanced tumours
Expandable stents insertions
- For lesions that cannot be resected
- With neoadjuvant chemo-/radiotherapy
Laser / cryotherapy
- For intraluminal lesions that cannot be resected
- Restores patency of oesophagus
How is oesophageal cancer staged?
TNM Staging…
Barium swallow
- Position
- length/size
- oesophageal tracheal fistula
- axis deviation and angulation
Endoscopic ultrasound
CT scan
What are the contraindications for surgery in oesophageal cancer?
Metastasis
Invasion of adjacent structures
Severe associated co-morbid diseases
What are the risk factors for gastric cancer?
Diet - low fat, low protein, high salt, alcohol
Environmental - poor food prep and drinking water, smoking
Poor socioeconomic status
Genetic predisposition
H. Pylori infection
Prior gastric surgery
Gastric ulcer
Atrophic gastritis
Polyps
Males
Describe the Borrmann classification of the endoscopic finding of a gastric adenocarcinoma
Type 1: Polypoid or fungating lesion
Type 2: Ulcerating lesions surrounded by an elevated border
Type 3: Ulcerating lesion with infiltration into the gastric wall
Type 4: Diffusely infiltrating lesion
Type 5: Lesions that do not fit any of the above
Describe Lauren’s classification for intestinal gastric adenocarcinoma
Ulcerative
Usually in the Antrum of the stomach
Pre-existing gastric atrophy and intestinal metaplasia
Any blood type
More common in males
Older age
Gland formation
Haematogenous spread
Better prognosis
Describe Lauren’s classification for diffuse gastric cancer
No gastric atrophy or intestinal metaplasia usually
Blood group A
More common in females
Younger
Poorly differentiated, signet ring cells
Transmural or lymphatic spread
Poor prognosis
How would a patient with a gastric adenocarcinoma present?
Dyspepsia - GERD
Epigastric discomfort / indigestion
Weight loss, vomiting, anorexia
Dysphasia
Gastric outlet obstruction
Early satiety
Anaemia
What are the signs of advanced gastric adenocarcinoma?
Palpable abdominal mass
Palpable supraclavicular lymph-node’s (virchows LN / troisiers sign)
Sister Mary Joseph nodule
Irregular hepatomegaly
Ascites
How is gastric adenocarcinoma diagnosed?
FBC
* Aneamia due to bleeding cancer
U&E
* Lookiing for electrolyte abnormalities due to weight loss, vomiting and anorexia
LFTs - To assess liver function in case of mets
CEA tumour marker
Blood gas
- If the patient has gastric outlet obstruction
- To rule out metabolic acidosis
Gastroscopy with biopsy for histological classification
CXR
* To look for/rule out lung and liver mets
CT scan
* * To look for/rule out metastases
How do you stage a gastric adenocarcinoma?
TNM staging
What is the management of a gastric carcinoma?
Subtotal gastrectomy- distal third tumors
Total gastrectomy - middle and proximal third tumors
Lymph nodes in close proximity are always removed
What are the complications of a gastrectomy?
Bleeding
Anastomoses leakage
Obstruction
Ulcer recurrence
Gastro-jejuno-colic fistula
Alkaline reflux gastritis
Dumping syndrome
Chronic gastroparesis
Malabsorption - anaemia
Describe the pathophysiology of bowel obstruction
- Complete obstruction
- Intestine proximal to obstruction contracts vigorously trying to overcome obstruction
- colicky pain + increased bowel sounds
- abdominal distension
- proliferation of gas producing bacteria
- Further abdominal distension
- vomiting (feaculant oudor)
- dehydration
- constipation/obstipation
What are the causes of large bowel obstruction?
Colorectal Cancer
Faecal Impaction
Sigmoid Volvulus
Diverticular stricture
Adhesions
Foreign body
Hernia
What are the four cardinal features of mechanical intestinal obstruction?
Pain
Abdominal distension
Vomiting
Constipation/Obstipation
How would you diagnose bowel obstruction?
History - Previous surgery, symptoms
Examination- especial abdominal and rectal examination
Bloods - FBC, U&E
AXR - supine or erect
Single contrast barium enema
List the risk factors / pre-malignant factors for colorectal carcinoma
Western diet - high fat, low fiber
Genetic factors:
- Family history
- FAP
- Lynch syndrome type I/II
Ulcerative colitis
Previous irradiation
Implantation of ureters in colon
Colorectal schistosomiasis
How did you diagnose colorectal carcinoma?
History and examination - NB PR Exam
Sigmoidoscopy
Barium enema of colonoscopy
CT abdo
Discuss a fungating colorectal adenocarcinoma
Usually in the right colon
Few symptoms
Early: peri umbilical/epigastric discomfort 30mins after a meal
Discuss a annular stenosing colorectal adenocarcinoma
Typically left colon/sigmoid
GERD
Increasing Constipation or alternating episodes of constipation and diarrhea
Discuss a malignant ulcer colorectal adenocarcinoma
Typically in the rectum
Blood/Mucus per rectum
Tenesmus
Spurious diarrhea
Do NOT diagnose this radiologically
Discuss your approach to a patient with colorectal carcinoma
History - suggestive symptoms
Examination - all especially PR exam; looking for signs
Special investigations - Colonoscopy/Sigmoidoscopy and biopsy Barium enema Tumour markers CEA FBC for Fe anaemia CT abdo
Staging TNM CXR LFTs Abdo US
Surgical resection - colectomy/hemicolectomy with removal of regional lymph nodes
Adjuvant Chemo/radiotherapy
6 monthly follow-ups - Exam, LFTs, CXR, US abdo, CEA levels
2 yearly colonoscopies
Discuss your special investigation findings of colorectal carcinoma
Colonoscopy/Sigmoidoscopy and biopsy
*
Barium enema
*
Tumour markers CEA
*
FBC
* Fe deficiency anaemia - occult bleeding per rectum
CT abdo
* Staging and metastases
List the 2 most common causes of obstructive jaundice
Gallstones
Head of pancreas carcinoma
Provide a DDx for obstructive jaundice due to luminal obstruction
Gallstones
Parasites
- Ascaris Lumbricoides
- Daughter cyst of Enchinococcus cyst
What are the signs of obstructive jaundice?
Yellow skin and sclera
Dark Urine
Pale stools
Itching
RUQ pain and tenderness
How would you investigate Obstructive jaundice?
Urine dipstick
- bilirubin
- urobilinogen
FBC
* Increased WCC with cholangitis
LFTs
- Low albumin
- Increased Alkaline phosphate and GGT
Ultrasound
- Visualization of obstruction - cystic/solid
- Billiary Dilatation above the obstruction
- Level of obstruction
- Hyperechoic mass > gallstone
- Distended gallbladder + thickened wall > acute cholecystitis
AXR
* Radio-opaque gallstones (10-20%) - Brown and black stones coz’ it contains calcium
ERCP
* Filling defect
What are the consequences of gallstones in the gallbladder?
Mostly asymptomatic
Gallstone dyspepsia
- Upper abdominal discomfort
- Aversion of fatty foods
- Flatulence
Biliary colic
- Colic-like pain in RUQ - radiates to right scapula
- Nausea and vomiting
- Tenderness over gallbladder
Acute cholocystitis
Carcinoma of the gallbladder
What is the management of symptomatic gallstones?
Laproscopic cholecystectomy
Open cholecystectomy if…
- Evidence of severe/perforated acute cholecystitis
- Exploration of bile duct required
What are the symptoms and signs of acute cholecystitis?
BIliary colic > constant pain in RUQ
Pyrexia
Murphy’s sign (+)
Raised WCC
Paralytic ileus
*Constipation
How is Acute cholecystitis diagnosed?
Ultrasound
- Distended gallbladder
- Thickened gallbladder wall
- Sonographic Murphy’s sign - Localised tenderness
Tc-99m HIDA scintigram
- Done under sonar
- Isotope reaches bowel but no activity seen in gallbladder
How would you manage acute cholecystitis due to gallstones?
Admit
IV fluids
NPO
Analgesia - Pethidine
Broad spectrum antibiotics - Cephzol / Amoxicillin + Gentamicin
Cholecystectomy within 3-4 days
What are the clinical features of an adenocarcinoma of the pancreas?
Painless obstructive jaundice
* Preceded by vague, deep-seated abdominal pain + bachache (poor prognostic indicator)
Anorexia, weight loss
Palpable gallbladder
Liver palpable - congestion
How would you diagnose a tumour of the pancreas?
LFTs
* Total bilirubin >10x normal favours malignant obstructive jaundice
Tumour Markers
* Elevated CA19-9
Ultrasound
- Biliary/pancreatic duct dilatation
- Cystic neoplasn
Abdominal CT scan
- Visualize tumour
- Biliary/pancreatic duct dilatation
- Local infiltration
- LN/Liver metastases
ERCP
- Site and form of biliary obstruction
- Displacement/obstruction of pancreas
What is the treatment for pancreatic tumours?
Surgical resection (whenever possible)
Islet cell tumours / cystadenoma
* Simple enucleation
Head of pancreas / peri-ampullary tumors
* Whipple operation (Pancreaticduodectomy)
Body/tail pancreatic tumour
* Distal pancreaticduodectomy + excision of spleen and splenic vessels
Unresectable tumour
* Palliative - Gallbladder/bileduct anastomosis to small bowel
What is the prognosis of adenocarcinoma of the pancreas?
Poor :(
Without resection 1 year survival <10%
With resection 1 year survival ± 12%
When would you perform surgery for portal hypertension?
(When there’s complications)
Bleeding Oesophageal Varices
- Who failed other treatment modalities
- Good operative risk
Ascites
Hypersplenism
What are the endoscopic treatment interventions for oesophageal varices?
Sclerotherapy
Rubber band ligation
What are the invasive radiological treatment procedures for oesophageal varices?
Embolisation
Transjugular intrahepatic portosystemic shunt (TIPSS)