Week 3 - E - Gastric cancer (lymphoma, adenocarcinoma, H.E.R2), Upper GI Bleeding (Blatchford/Rockall, peptic ulcers/varices)

Question 1

What are the main types of malignant gastric tumours?

Answer 1

Gastric carcinoma - adenocarcinoma
Gastric B-cell lymphoma \
* MALT lymphoma (Mucosa associated lymphoid tissue lymphoma) \
* Diffuse large B-cell lymphoma of the stomach

Question 2

Let’s quickly discuss gastric lymphoma What is the difference in treatment of Maltoma (MALT lymphoma) * Diffuse large B cell lymphoma

Answer 2

Maltoma - associated with H. pylori infection in 95% of cases good prognosis \
* if low grade then 80% respond to H. pylori eradication \
* Radiation can be used if H.pylori negative

Diffuse large B-cell lymphomas of the stomach are primarily treated with chemotherapy with CHOP (cyclophosphamide+doxorubicine+vincristine+prednisone) with or without rituximab being a usual first choice

Question 3

Now we’ll discuss gastric carcinoma - adenocarcinoma
What are the risk factors for gastricadenocarcinoma - conditions and lifestyle? (6)

Answer 3

H.Pylori infection
Blood group A
Pernicious anaemia
Atrophic gastritis
Smoking
Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome

Question 4

Gastric cancer symtoms often present late What are the symptoms of gastric cancer? What is often the first sign seen which shows metastases - known as Troisier’s sign?

Answer 4

Often non-specific \
* Dyspepsia (age >/=55 with treatment refractory symptoms demands invesitgation) \
* Anaemia, Loss of weight, Anorexia, Recent onset / progressive symptoms, Malaena, Swallowing difficulty - dysphagia
Troisier’s sign is where there is a large left supraclavicular fossa node (Virchow’s node) - shows metastases and may be first clinical sign

Question 5

Where in the stomach are the gastric adenocarcinomas more common?

Answer 5

Gastric adenocarcinomas
Incidence at the gastrooesophageal junction / cardia of stomach is increasing
Incidence of distal and gastric body carcinoma is decreasing

Question 6

How is gastric cancer diagnosed? How is staging of gastric cancer performed?

Answer 6

DIagnosis is made through endoscopy with biopsy - aim to biopsy all gastric ulcers
Staging is carried out by Endoscopic ultrasound or CT scan of abdomen and chest

Question 7

Staging of gastric cancer uses the TNM staging classification - it is the same as the oesophagus Describe the staging

Answer 7

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Question 8

What are the two type of gastric adenocarcinoma?

Answer 8

Intestinal type - has a slightly better prognosis
Diffuse type

Question 9

What is diffuse gastric cancer also known as? What is seen on histology of a biopsy in a patient with diffuse gastric cancer?

Answer 9

Diffuse gastric cancer is also known as linitis plastica
On biopsy, you can see Signet Ring cells
This is because the tumour cells produce mucous
If the mucus remains inside the tumour cell, it pushes the nucleus to the periphery

Question 10

How can gastric cancers spread? What is it known as when it metastasies to the ovary?

Answer 10

Gastric cancers can spread \
* Locally - into other organs and into peritoneal cavity and ovaries \
* malignancy in the ovary that metastasized from a primary site, classically the GI tract is known as Kruckenberg tumour - gastric adenocarcinomas is the most common source
Lymphatics
Haematogenous - eg to the liver

Question 11

What is the treatment of gastric adenocarcinoma?

Answer 11

If no metastases then surgery with curative intent with pre and/or post operative chemotherapy
If metastases, then palliative chemotherapy is normally adviced eg cisplatin

Question 12

Offer HER2, immunohistochemistry testing to people with metastatic oesophago-gastric adenocarcinoma HER2 is an oncogene that when over-expressed has been shown to play an important role in different cancers What can be given to aid with chemotherapy treatment in patients who are HER2 positive?

Answer 12

HER2 is the target of the monoclonal antibody trastuzumab (marketed as Herceptin).
Trastuzumab is effective only in cancers where HER2 is over-expressed.

Question 13

There are many different causes of upper gastrointestinal bleeding These cards will focus on the treatment of bleeding - peptic ulcers and oesophageal varices List various aetiology of upper GI bleeds? Which is the most common cause?

Answer 13

Duodenal ulcer - posterior situated duodenal ulcer- most common cause
Gastric erosions
Gastric ulcer
Oesophageal varices
Mallory-Weiss tear
Oesophagitis
Duodenitis
Malignancy

Question 14

What are the presenting symptoms of an Upper GI bleed?

Answer 14

Patients may present with the following:
Haematemesis and/ or malaena
Epigastric discomfort
Sudden collapse
Haemochezia (passage of fresh blood through the anus), may also be caused by an Upper GI bleed

Question 15

In patients who present with an Upper GI bleed it is important to take a full history (if possible) What is asked?

Answer 15

Ask about past GI bleeds, dyspepsia/known ulcers, known liver disease or oesophageal varices, drugs (aspirin, steroids, thrombolytics, anticoagulants) is there serious comorbidity

Question 16

In patients presenting with an upper GI bleed, what is it important to carry out in the acute management?

Answer 16

Acute management - ABCDE Airway protection - oxygen if needed
Breathing
Circulation - IV access via large bore cannulas - take bloods and give fluids
Bloods for FBC, U&Es, Group and Save (in case transfusion is required), coagulation factors Also insert urinary catheter to montior hourly output

Question 17

It is important to assess the severity of the haemorrhage in patients presenting with a bleed What is the 100Rule? - indicates a poor prognostic group What other factors indicate a poor prognosis?

Answer 17

* BP dropping 100/min \
* Hb

Age>60
Comorbid disease
Postural drop in BP

Question 18

What is the scoring system used in Tayside that assesses the need for intervention?

Answer 18

The Glasgow Blatchford score assesses the need for intervention in the management of Upper GI bleeds
Score of 0-1 > no clinical concern
Score of >1 - intermediate/high risk concern and intervention required

Question 19

What investigation is carried out in patients presenting with upper GI bleeding? What score does this allow you to calculate?

Answer 19

In patients presenting with upper GI bleeding, carry out an upper GI endoscopy
Allows for calculation of Rockall score (provides an indicator of GI bleed mortality
* pre-endoscopy from history/examination
* and post-endoscopy is added to this score to provide mortality rate after endoscopy)

Question 20

What are the three main purposes of the oesophagogastroduodenal endoscopy? (upper GI endoscopy)

Answer 20

To identify the cause of the bleed
Apply therapeutic manoeuvres
Assess risk of rebleeding

Question 21

The complete Rockall Score is calculated based on clinical bleeding AND endoscopy results. What are all the factors going into a complete Rockall score?

Answer 21

Age, pulse, SBP, co-morbidity
Diagnosis on endoscopy
Stigmata - signs of recent haemorrhage on endoscopy

Question 22

If suspecting massive bleeding, what should be started?

Answer 22

If suspecting massive bleeding, start Major Haemorrhage protocol (repro notes)

Question 23

If after calculating the Blatchford score for pre-endoscopic risk of requiring intervention, and you witness a bleed, what should be given? What should be given if you suspect/known liver disease in the patient? How do these drugs work to help stop the bleed?

Answer 23

If witnessed bleeding in the patient, IV omeprazole infusion should be prescribed
* Omeprazole appears to help stop bleeding in gastric ulcers because a neutral pH facilitates platelet aggregation
If suspect /known liver disease due to examination findings/history - give IV terlipressin
* Terlipressin acts on type 1 vasopressin receptors to cause vascular smooth muscle contraction

Question 24

BLEEDING PEPTIC ULCERS When endoscopically examining the patients upper GI bleed and diagnosis of peptic ulcer bleed is confirmed, need to identify whether it is a high risk or low risk for bleed What is the difference between the two? What is the difference in management?

Answer 24

High risk peptic ulcer - shows active bleeding, adherent clot, non-bleeding visible vessel (2 points on Rockall score) - aim for endoscopic haemostasis
Low risk peptic ulcer - flat, pigmented spot or clean base (0 points on Rockall score) - no need for endoscopic haemostasis, discharge with tests for Hpylori and discharge with oral PPI

Question 25

What is the initial management of high risk peptic ulcers (active bleed, adherent clot, non-bleeding visible vessel)?

Answer 25

Achieve endoscopic haemostasis by giving endoscopic adrenaline injection around bleeding point plus one of:
* Endoscopic clipping
* Endoscopic cautery - thermoregulation
* fibrin or thrombin
Also give IV omeprazole after treatment for bleeding

Question 26

If the initial endoscopic treatment (2 of adrenaline injection/clips/cautery) fails to work, what is needed to be carried out?

Answer 26

Interventional radiology or surgery is then carried out
Interventional radiologists use minimally invasive, image-guided procedures to diagnose and treat disease.

Question 27

Acute Variceal Bleeding What causes oeseophageal varices? Why may bleeding be very brisk here? Pic shows oesophageal varices on endoscopy

Answer 27

Oesophageal varices is the submucosal venous dilatation secondary to increased portal venous pressures -
Bleeding may be very brisk especially if underlying coagulopathy secondary to loss of hepatic synthesis of clotting factors

Question 28

If the patient does not have documented chronic liver disease, what could make you suspect that varices are the cause of the bleeding?

Answer 28

History
Chronic alcohol excess
Chronic viral hepatitis
Metabolic or autoimmune liver disease
O/E - Stigmata of chronic liver disease eg
* Palmar erythema * Leuconychia * Clubbing * Spider naevia * Ascites * Jaundice

Question 29

Aims of management of a patient with acute variceal bleeding * Resusciation * Haemostasis * Prevent complications of bleeding * Prevent deterioration of liver function * Prevent early re-bleeding How are oesophageal varices initially managed?

Answer 29

ABC, prophylactic Abx, correct clotting
Patient receives terlipressin prior to endoscopy - used to cause vascular smooth muscle contraction (vasopressin 1 receptors on smooth muscle)
Then endoscopic variceal ligation (endoscopic banding) is 1st line
Sclerotherapy is carried out if EVL cannot

Question 30

2016 NICE guidelines: ‘Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding.’ What is given as prophylactic antibiotic in oesophageal variceal bleed? What is given to correct the clotting factors?

Answer 30

Quinolones are typically used eg ciprofloxacin
To correct the clotting factors, give vitamin K and fresh frozen plasma

Question 31

What is sclerotherapy?

Answer 31

Sclerotherapy for esophageal varices, also called endoscopic sclerotherapy, is a treatment for esophageal bleeding that involves the use of an endoscope and the injection of a sclerosing solution into veins.

Question 32

What is carried out if vasoactive drug and endoscopic variceal bleeding fails to cause endoscopic haemostasis?

Answer 32

If terlipressin + EVL fails, patient should recieve a Sengsten Blakemore tube
This should be done with care; gastric balloon should be inflated first and oesophageal balloon second.
Remember the balloon with need deflating after 12 hours (ideally sooner) to prevent necrosis.

Question 33

If bleeding continues after Sengsten-Blakemore tube placement, what is carried out?

Answer 33

Transjugular intrahepatic portosystemic shunt (TIPS or TIPSS) is an artificial channel within the liver that establishes communication between the inflow portal vein and the outflow hepatic vein

Question 34

For patients in whom an early trans-jugular intrahepatic porto-systemic shunt is not performed, once the bleeding has stopped the vasoactive drug should be continued (unsure for how many days) What is given once the vasoactive drug (terlipressin usually) is stopped?

Answer 34

Give a non-selective BBlocker eg propranolol
Non-selective β-blockers (but not cardioselective β-blockers like atenolol) are preferred because they decrease both cardiac output by β1 blockade and splanchnic blood flow by blocking vasodilating β2 receptors at splanchnic vasculature