S4C1 Flashcards
What is a Statement of intent?
a document that allows a medical practitioner to complete a Medical Certificate of Death for a patient in the community who is expected to die.
The GP must have seen the patient within the previous 14 days before death.
If a hospital medical practitioner completes the Statement of Intent for Salford it will be valid until 5pm the next working day.
What is a DNA CPR forms?
Do Not Attempt Cardiopulmonary Resuscitation - this policy refers solely to cardiopulmonary resuscitation (CPR) in the event of a cardio respiratory arrest
How to assess swallowing?
To check swallowing:
- Give 3oz water
- Drink sequentially until all is gone
- Hand on throat to feel when swallowing
- Check voice after
- Is any water sticking?
- Check for coughing, tickling, voice change
Red flags of checking swallowing?
Coughing
Choking
Wet vocal quality
Signs of struggle
What cells line the buccal cavity?
What do they produce?
Lined by oral mucosa
thick stratified squamous epithelium that is resistant to abrasion
Produces defensins to inhibit bacterial growth
What is Saliva made up of?
99% water lingual lipases and alpha-amylase Mucoproteins - act as lubricant Lysozymes Immunoglobulins - esp. IgA Electrolytes Calcium Phosphate
What controls Saliva secretion?
secreted continuously
salivation is controlled by salivatory nuclei in medulla and pons of the brain stem
Mechanorecptors and chemoreceptors in the mouth stimulate production of saliva with a high water content
Input from higher brain centres and lower GI can induce salivation
Describe the Oesophagus
Pharynx to stomach (~25cm)
Normally closed
Highly folded mucosa
Submucosa contains:
Blood vessels
Lymphatics
Nerves
Lymphoid tissue
Mucus glands
Lined by stratified squamous epithelium to resist abrasion
Muscularis layer
Skeletal in first third - voluntary
Mixed in middle third
Smooth in last third - involuntary
Outer layer is mostly adventitia
Fixed to adjacent structures by connective tissue
Last part beyond diaphragm covered with serosaWhat lining changes are present at the Gastro-oesophageal junction?
changes from squamous to columnar epithelium (glandular)
What are the cranial nerve involved in swallowing?
Multiple cranial nerves transmit afferent and efferent control of swallowing.
Nerves V, IX and X provide sensory information
Nerves V, VII, IX, X, XII proved motor innervation to different areas
What are the types of dysphagia?
Oropharyngeal
Abnormal bolus transfer to the oesophagus
Difficulty initiating a swallow
Only one manifestation of the primary disease
Oesophageal
Abnormal bolus transport through the oesophagus
Food stops after initiation of swallow
Location of the primary disease
Describe the epidemiology of Dysphagia.
Community - 8-16% of older people have symptoms of dysphagia
Old age/ frailty - 33% of >80s have dysphagia
Hospital - Up to 47% of older patients in hospital have dysphagia
Nursing home - 50% in nursing homes have dysphagia, 80% of dementia patients have dysphagia
What are the causes of dysphagia?
Neurological
Diseases
Injuries
Abnormalities of CNS, Anterior horn cell, PNS and neuromuscular junction
Physical -Related to head and neck impairments
Respiratory disease - COPD
Psychological
Describe Dysphagia after a stroke.
50% of all stroke victims have dysphagia Usually oropharyngeal 30% increased risk of mortality Aspiration most important complication Recovery in majority
What is achlasia?
The failure of a ring of muscle fibres, such as a sphincter of the oesophagus, to relax.
What are the causes of achalasia?
Associated with HLA-DQw1
Circulating antibodies to enteric neurons suggest that achalasia many be an autoimmune disorder
Potentially result from chronic infections with herpes zoster or measles viruses
Describe the epidemiology of Achlasia.
1 per 100,000 per year
Onset before adolescence
Diagnosed between 25-60
Long term risk - 13% 15 year mortality
Describe Voluntary passive euthanasia
To allow the patient to die by omission by withdrawing (removing treatment to allow natural progression) or withholding (not performing) treatment
Describe Voluntary active euthanasia
A person directly and deliberately causes the patients death
Some people believe this is morally better than passive
Describe Non-voluntary euthanasia
The person is unconscious or otherwise unable to make a meaningful choice between living and dying, so an appropriate person takes the decision on their behalf
Describe involuntary euthanasia
When the person chooses life but dies anyway
What treatments are available for oropharyngeal dysphagia?
Swallowing therapy - SALT Swallowing exercises Dietary changes Healthy balanced diet Softer foods Thickened fluids Support at meal times
Feeding tubes
Provides nutrition
Given if at risk of malnutrition and dehydration
What are the 2 types of feeding tubes?
Nasogastric tube - passed through nose and down into stomach
Short term
Replaced into other nostril after ~ 1 month
Percutaneous endoscopic gastrostomy (PEG) - directly implanted into your stomach
Long term
Several months before replacing
Major complications are infection and internal bleeding
What treatments are available for Oesophageal dysphagia?
Medications - PPIs
Botox - treats achalasia
6 months
Surgery
Endoscopic dilation
Stent insertionWhat are the 3 integrated phases of swallowing?
Phase - muscle involved - neural control - voluntary control
- Oral - Striated - Cortex/medulla - Full
- Pharyngeal - Striated - Medulla - Some
- Oesophageal - Striated/Smooth - Medulla / ENS - None
What is the self-regulation model?
- Stimuli are presented (i.e., something happens that provokes a reaction, whether that’s a thought, something another person said, getting significant news, etc.)
- The individual makes sense of the stimuli, cognitively (understanding it) and emotionally (feeling it)
- The sense-making leads to the individual choosing coping responses (i.e., what the person does to influence their feelings about the stimuli or the actions they take to address the stimuli)
- The sense-making and coping responses determine the outcomes (i.e., the individual’s overall response and how they choose to behave)
- The individual evaluates his coping responses in light of these outcomes and determines whether to continue using the same coping responses or alter their formula
What are the two main types of oesophageal cancer?
Squamous cell carcinoma (more common in the developing world) typically occurring in the middle and upper thirds of the oesophagus
-Strongly associated with smoking and excessive alcohol consumption, as well as chronic achalasia, low vitamin A levels and, rarely, iron deficiency
Adenocarcinoma (more common in the developed world) typically occurring in the lower third of the oesophagus
- Arises as a consequence of metaplastic epithelium (termed Barrett’s oesophagus) which progresses to dysplasia, to eventually become malignant - Risk factors for this subtype are long-standing GORD, obesity, and high dietary fat intake
What are the clinical features of oesophageal cancer?
Dysphagia - characteristically progressive
-Any patient with dysphagia should be assumed to have cancer until proven otherwise
Significant weight loss - due to both dysphagia and cancer-related anorexia
What are the red flag symptoms of oesophageal cancer?
>55 yrs with weight loss Upper abdominal pain Dyspepsia Reflux Dysphagia
What is the management of Oesophageal cancer?
70% of patients are treated palliatively as many patients present with advanced disease
Surgery - major as both abdo and chest must be opened
Stent - help with swallowing
Radiotherapy/chemo - reduce tumour size and bleeding
Photodynamic therapy - kills nearby cells using light
What is Barrett’s Oesophagus?
Metaplasia of the oesophageal epithelial lining, whereby normal stratified squamous epithelium are replaced by simple columnar epithelium.
What is the pathophysiology of Barrett’s?
The vast majority of cases are caused by chronic gastro-oesophageal reflux disease.
The epithelium of the oesophagus becomes damaged by the reflux of gastric contents, resulting in a metaplastic transformation. This in turn increases the risk of developing dysplastic and neoplastic changes.
What part of the oesophagus is most affected in Barrett’s?
What does the endoscopy look like?
The distal oesophagus is most commonly affected.
On endoscopy, the oesophagus appears red and velvety, with some preserved pale squamous islands. Diagnosis relies on biopsy demonstrating the presence of simple columnar epithelium within the oesophagus
What are the risk factors for Barrett’s Oesophagus?
Caucasian Male >50 Smoker Obesity Hiatus Hernia Family History
What are the clinical features for Barrett’s Oesophagus?
History of GORD Retrosternal chest pain Excessive belching Odynophagia - painful swallowing Chronic cough Hoarseness
What are the red flag symptoms for malignancy in Barrett’s Oesophagus?
Dysphagia Weight loss Early satiety - feeling full Malaise Loss of appetite
How do you manage Barrett’s Oesophagus?
Given a proton-pump inhibitor (typically high dose and twice daily).
Any medication that affects stomach defences (such as NSAIDs) should be stopped.
The patient should be provided with lifestyle advice to reduce the acidic stimulus on the squamous cells (the driver of the metaplastic change.
What surrounds the salivary glands?
Surrounded by a Connective tissue capsule with septa that divide the gland into lobules
What type is the salivary glands and what do they produce?
Compound tubuloacinar glands
- branching duct system
Produces serous, mucous or mixed secretions
What are the different types of excretory ducts? (from small to big)
Intercalated ducts - small, tiny lumen, simple low cuboidal epithelium
Striated ducts - formed by merging intercalated ducts, simple columnar epithelium
Intralobular ducts - formed by merging striated ducts, gradually increase in size and become surrounded by CT
Interlobular ducts - epithelium may be pseudostratified, may possess cilia, eventually convey saliva into oral cavity
What are the major salivary glands and the type of secretion they produce?
Parotid gland - serous
Submandibular - seromucous (Mainly serous)
Sublingual gland - seromucous (Mainly mucous)
