Peptic Disease and GI Cancer Flashcards
What is GORD (gastro-oesophageal reflex disorder)?
these are symptoms or complications resulting from the reflux of gastric contents into the oesophagus or beyond, into the oral cavity (including the larynx) or lung.
_____% of all westerners are affected by GORD
10-20
What is the pathological cause of GORD?
relaxation of the lower oesophageal sphincter which causes the reflux of gastric contents into the oesophagus
What are the presentations of GORD?
dyspepsia (heartburn)
acid regurgitation
laryngitis
globus
enamel erosion
halitosis
What can exacerbate symptoms of dyspepsia?
worse on lying or bending over
worse after meals
worse at night
What does globus refer to ?
the feeling that something is blocking your throat (oesophagus)
it is the perceived ability to swallow
What are the risk factors for GORD?
Obesity
Hiatus hernia
genetic component
alcohol
smoking
stress
pregnancy- due to increased pressure on abdominal contents
coffee
fatty foods
Calcium channel blockers
What is a hiatus hernia?
this is when the actual top of the stomach herniates up into the chest cavity
What is the first line management of GORD?
trial of proton pump inhibitors- completely blocks all acid production
lifestyle changes
What is the MOA of proton pump inhibitors?
they essentially function to block/stop the secretion of gastric acid (HCl) by the parietal cells
they do this by binding and blocking the action of the H+/K+ ATPase on the luminal surface of the parietal cells
Thus inhibiting secretion of gastric acid.
What investigations can you carry our for a GORD diagnosis?
Oseophagogastrodueodenoscopy (OGD)- using a telescope
Amulatory pH monitoring
Barium swallow to see any narrowing, scarring or blockage
What management can be considered for ongoing symptoms of GORD?
Surgery (fundoplication)
H2 antagonist
What is a Nissen Fundoplication and how is it useful in managing GORD?
a fundoplication is the narrowing of the oesophagus, the top end of the stomach (fundus) is wrapped around the bottom end of the oesophagus to create a narrowing and replace the (failed) oesophageal sphincter
What is an adjunct of the Nissen Fundoplication?
H2 antagonist
What is the MOA of H2 antagonists?
the bind to and block histamine H2 receptors located on gastric parietal cells.
Histamine is one of the mechanisms through which gastric acid is secreted from parietal cells. Binding of histamine can stimulate the action of H+/K+ ATPase (this increasing acid production)
What are the complications of GORD?
oesophageal cancer
haemorrhage
perforation
oesophageal stricture
Barretts oesophagus
adenocarcinoma of oesophagus
What is an adenocarcinoma?
malignancy associated with glandular cells
What is metaplasia?
changes of a normal oral flora into pre-malignant tissues
What is dysplasia?
a bad growth
What is barretts oesophagus?
this is a change in the squamous epithelium of the oesophagus to columnar epithelium (metaplasia)
What is barretts oesophagus associated with?
GORD
How is barretts oesophagus diagnosed?
diagnosis is histological
histology would demonstrate intestinal columnar lined epithelium with or without goblet cells
((columnar cells with goblet cells are endogenous to intestine))
There is an increased risk of adenocarcinoma with barretts oesophagus. True or false
true
Briefly state the stages of development of an adenocarcinoma of the oesophagus
((remember adenocarcinoma of the oesophagus would indicate that there has been a change to glandular as opposed to previous squamous epithelial tissue)
Squamous epithelium
Inflammation
Ulceration
Healing
Barretts columnar epitheliym
low dysplasia
high dysplasia
cancer
What is a peptic ulcer?
this is a break in the epithelial mucosal lining of the stomach or duodenum (25cm) of more than 5mm in diameter with depth of the submucosa.
Does not extend into muscularis
What factors offer cytoprotection to the cells in the GI tract/promote mucosal defence?
((cytoprotection is why we do not feel the effects of the acid))
Prostaglandins
Mucous
Mucosal blood flow
bicarbonate
Ulcers occur as a result of the reduction in cytoprotection. True or false
True
not a result of increased acid production
What factors promote mucosal damage and loss of cytoprotection?
gastric acid
pepsin
H pylori
NSAIDs - reduce prostaglandin production
What is the presentation of peptic ulcers?
abdominal pain
“pointing sign”- showing site of pain with one finger
epigastric tenderness
nausea and vomiting
weight loss
haematemesis (blood in vomit)
malaena (bleeding in faeces)
perforation
Haematemesis is often an indication of what kind of bleeding in peptic ulcers ?
faster bleeding
Malanea is often an indication of what kind of bleeding in peptic ulcers?
slower bleeding
What is the management of an actively bleeding ulcer?
ABCD resuscitation
2x wide bore cannulas (fluid delivery)
Blood resuscitation
Endoscopy
proton pump inhibitors (IV)- helps stop the bleeding- stops acid production, protects cells, stops bleeding
What is the management of peptic ulcers with no bleeding that are also H. Pylori negative?
treat underlying cause of the peptic ulcer
avoid using NSAIDs
PPI
H2 antagonist (prevents stimulation of acid production)
What is the management of peptic ulcers with no bleeding but H.pylori positive?
treat underlying cause of peptic ulcer
avoid NSAIDs
H. Pylori eradication therapy
How does H. pylori damage encourage development of peptic ulcers?
they damage mucous protection (against acid)
What type of bacterium is helicobacter pylori?
a gram negative microaerophilic bacterium
___% of individuals affected with H. pylori are asymptomatic
80
What is the MOA of H. pylori in damaging mucosa?
it penetrates the mucoid lining of the stomach to find less acidic region
urease of bacteria breaks down urea into CO2 and ammonia which is toxic to cells.
immune response is triggered to the presence of the bacteria which in response increased acid production. More acid is present in the duodenum
There is an increased prevalence of oesophageal cancer in what regions of the world?
afro-carribean and far eastern populations
Adenocarcinoma is a disease of _________ countries
developed
There is a _________ dominance for oesophageal cancer (gender)
male
Squamous cell carcinoma is a disease of __________ countries
developing
risk increases with smoking and alcohol
What are the main types of oesophageal cancer?
squamous cell carcinoma
adenocarcinoma
What are the risk factors for oesophageal cancers?
alcohol
GORD
smoking
barrets oesophagus - associated with adenocarcinoma oesophageal cancers
Where are squamous cell oesophageal cancers usually located?
usually halfway down the oesophagus
Where are adenocarcinoma oesophageal cancers usually located?
tend to be at the bottom end of the oesophagus where acid is refluxing
Ulcers then lead to barretts oesophagus which is associated with adenocarcinomas of the oesophagus
What is the presentation of oesophageal cancers?
weight loss- due to pain on swallowing
cachexia- weakness/wasting
progressive dysphagia (solids >fluids)
odynophagia (painful sensation in relation to swallowing)
hoarse voice
What is the survival rate for oesophageal cancers according to cancer research UK?
5 year survival rate in 15% of cases
What investigations can be carried out to diagnose oesophageal cancers?
OGD (oesophagogastroduodenoscopy)
CT thorax, abdominal
MRI thorax abdominal
Ultrasound (can include ultrasound of liver for metastatic stread)
What is the metastatic spread of oesophageal cancer (common sites of metastasis)?
lymph nodes
liver
lungs
bone
What is the management of low grade oesophageal cancer?
endoscopic resection +/- ablation (removal)
MI (minimally invasive) oesophagectomy
What is the management of middle grade oesophageal cancer?
surgical resection (if surgical candidate)
Chemo or radio monotherapy (one or the other)
What is the management of advanced oesophageal cancer?
chemo AND radiotherapy
palliative stent to ease swallowing
What is the most common type of stomach cancer?
adenocarcinomas
What are the other types of stomach cancer?
Lymphoma (lympoid tissue, MALT?)
Leiomyosarcoma
NETs (neuroendocrine tumours)
squamous cell carcinoma
There is a higher incidence of stomach cancer in what part of the world?
East Asia
Eastern Europe
South America
What is the usual age of onset for stomach cancer?
50-70 years
What are the risk factors of stomach cancer?
Pernicious anaemia
H. Pylori
Cured meats (N- nitrosos compounds)-nitrosamines are keratogenic
Smoking (evidence is not strong)
What is pernicious anaemia?
autoimmune condition that affects the stomach. Involves gastritis, atrophy of body and fundus of the stomach which leads to loss of normal gastric glands, mucosal architecture, and parietal and chief cells (pepsinogen).
disease in red blood cells that occurs when intestines are unable to absorb B12
usually due to lack of intrinsic factor (IF)
leads to macrocytic anaemia
What are some causes of pernicious anaemia?
genetic susceptibility
H. pylori
What are the symptoms of pernicious anaemia ?
peripheral sensory neuropathy
yellow-blue blindness
depression
paranoi
dementioa
hearth failure
multiple infections
Pernicious anaemia is often described as a disease of the _________.
elderly
What are the presentations of stomach cancer?
abdominal pain
weight loss
lymphadenopathy
GI bleed (uncommon)
Virchows node- lymphatic drainage from abdominal cavity
Sister Mary Joseph nodule- transperitoneal spread (metastatic spread)
What is the prognosis of stomach cancer in the UK according to Cancer Research UK
5 year survival in 19 % of cases
What is the management of low grade stomach cancer?
surgical resection
peri-or post operative chemo
What is the management of middle grade stomach cancer?
chemoradiation
What is the management of advanced stomach cancer?
chemoradiation
palliative gastrectomy
What is the metastatic spread of stomach cancer?
lymph nodes
liver
lungs
bone
peritoneum
Majority of colorectal cancers are ___________. (type of cancer)
adenocarcinomas
What percentage of colorectal cancers occur in the colon?
71%
What percentage of colorectal cancers occurs in the rectum?
29%
What is the greatest risk factor for colorectal cancers?
age
99% of colorectal cancer cases occur in what age group ?
> 40 years
What are the genetic components of colorectal cancers?
familial adenopolyposis
hereditary non-polpyosis colorectal cancer (polyps not present)
What are the environmental risk factors for colorectal cancers?
age
obesity
red meat consumption
low fibre diet
What is the pattern of inheritance for familial adenopolyposis (FAP)?
autosomal dominant
only one copy of the gene required for phenotype/disease to be expressed
What is the gene affected in FAP?
APC
What is the characteristic presentation of FAP?
multiple benign polyps of the large intestine
What is the pattern of inheritance for Hereditary Non-polyposis colorectal cancer (HNPCC)?
Autosomal dominant
What gene is affected in HNPCC?
MSH gene
HNPCC can affect what areas?
endometrial
ovary
stomach
What does the 2 hit hypothesis refer to (colorectal cancer) ?
meets epigenetics
There is usually a familial genetic disposition (mutation in tumour suppressor genes) as well as a sporadic mutation in the other allele
What is the pathophysiology of colorectal cancer?
normal epithelium
early adenoma
intermediate adenoma
late adenoma
carcinoma
What is the presentation of colorectal cancer?
rectal bleeding
change in bowel habit
tenesmus (feeling that you need to pass stool even though your bowels are empty)
abdominal mass
anaemia
weight loss
What is the metastatic spread of colorectal cancer?
lymph nodes
liver
lungs
bone
brain
How is colorectal cancer screened for?
Faecal occult blood test
Every 2 years
for 60-74 years
>75 screening test is available on request
What is the next step after a faecal occult blood test with an abnormal result?
colonoscopy
There ware many variations of bowel cancer management. What are these variations dependent on ?
stage
patient suitability
Give some examples of bowel cancer management strategies
surgical resection
stending
chemotherapy
radiotherapy (adjuvant and neoadjuvant)
What are the oral complications of cancer treatment ?
oral mucositis
infection
xerostomia/salivary gland dysfunction
functional disabilities
taste alterations
nutritional compromise
abnormal dental development
What are oral complications of chemotherapy specifically?
neurotoxicity- can mimic tooth ache
bleeding
What are oral complications of radiotherapy specifically?
osteonecrosis
trismus (lockjaw, spasms of muscles of mastication) / tissue fibrosis
radiation caries- tooth decay as as a result of radiation induced dry mouth
What is metastasis ?
development of secondary malignant growth distant from primary site of cancer
What are the routes of cancer metastasis?
direct
haematogenous (via blood)
lymphatic (via lymph)
transcolemic e.g. via peritoneal cavity
What are the common metastatic sites of breast cancer?
bone
lung
lymph node
liver
brain
What are the common metastatic sites of prostate cancer?
bone
lymph node
lung
brain
liver
What are the common metastatic sites of colorectal cancer?
liver
lung
bone
brain
What are the common metastatic sites of lung cancer?
lung
adrenal gland
bone
brain
liver
TNM staging; T refers to …
size of tumour
graded 1-4
TNM staging; N refer to …
node (lymph node presence)
0-3
TNM staging; M refer to …
Metastasis
0-1
What does the number staging for cancer refer to?
stage 0- carcinoma in situ, early
stage I- localised
stage II- early locally advanced
stage III- late locally advanced
Stage IV- metastasised
What are the types of cancer staging ?
TNM staging
Number staging (1-5)
Specific staging
Give examples of specific staging
Duke’s staging in colorectal cancer
Breslow staging in melanoma
What cancer staging method is most commonly used to stage cancers?
TNM system
