Week Ten - Case One Flashcards
what is the second most common cancer worldwide
gastric adenocarcinoma
what is the male to female ratio of gastric adenocarcinoma
2:!
what is the cause of gastric adenocarcinoma thought to be
the combination of genetic factors and nitrates in the diet, with increased risk on smokers and those with h pylori infection
what is diagnosis usually a combination of
usually a combination of an endoscopy and CT +/- USS
what is staging of gastric adenocarcinoma done using
the TNM scale
what are gastric tumours almost always
almost always an adenocarcinoma of the mucous secreting cells of gastric pits. the most common mutation is that of tumour suppressor gene p53
what is the 5 year syrivival rate of stomach cancer
about 10%
what are the two other types of tumours that affect the stomach
Gastric lymphoma (MALT) – accounts for 1-2% of gastric carcinomas.
H pylori is again a large precipitating factor. Presentation often similar to gastric adenina carcinoma and thus may be difficult to differentiate from GORD or gastric ulcer
Oesophageal carcinoma – almost always occurs in the presence of Barrett’s oesophagus, and is basically just an adenocarcinoma of the new columnar epithelium – i.e. it is similar historically to gastric carcinoma. Likely to present with dysphagia
what sort of diets can predispose you to gastric adenocarcinoma
smoked fish, pickled foods, salt and nitrates
what foods have a beneficial benefit
fresh fruit and vegetables, particular those containing vitamin C and A
what is thought to be responsible for 60-70% of gastric adenocarcinoma s
h pylori
you are at greater risk of you get the infection when you are young, and if you are one of the people who goes hypocholorohydric when they get it
H pylori will often cause inflammation, leading to gastritis, leading to gastric atrophy, which leads to gastric carcinoma
what are the other risks for developing gastric adenocarcinoma
Smoking
Gastric polyps
FAP (familial adenomatous polyposis)
Genetic factors – e.g. HDC-1 mutations
Resection of the stomach
what are the symptoms of gastric adenocarcinoma
History of recent dyspepsia.(50%) This pain will be very similar to that of peptic ulcer disease, and can often be relieved by antacids.
Loss of appetite / anorexia (35%)
Bloating / fullness
Weight loss (72%)
Vomiting/nausea (40%)
Iron-deficiency anaemia due to occult bleeding
Dysphagia (22%)
Melaena (20%)
Mass (17%)
Haematemesis is unusual
what are the red flag symptoms
patients of any age, with dyspepsia, AND
- chronic GI bleeding
- dysphagia
- progressive wright loss
- iron deficiency anaemia
- perisitent vomtiing
- epigastric mass
- suspicious barium meal result
OR
patients > 55
- with sudden onset dyspepsia
what are the tests done to confirm gastric adenocarcinoma
essentially all you need to do is a gastroscopy and routine FBC, and LFTs
what is the most common genetic factor for gastric adenocarcinoma
loss of the TSG p53 which occurs in about 70% of gastric cancersw
where are early gastric cancers confined to
the mucosa and the submucosa, whilst more advanced cancers can penetrate the muscular proproria, and may become ulcerating
what is the prognosis for early gastric cancer
90%
how can the cancers be described
as either intestinal or diffuse
intestinal ones have histology representative of internal epithelium, whilst diffuse ones arise form normal gastric mucosa
who do diffuse cancers tend to occur in
younger patients
what is the pattern of the disease
initially there will be chronic gastritis leading to atrophy, then onto metaplasia, and premalignant dysplasia, finally ending up at malignancy
where can gastric cancer spread lymphatic ally to
the Virchow’s node, and can spread via venous blood to the liver and ovaries
what are Krukenburg tumours
spread of cancer via the venous blood to the liver and ovaries
what will a CT show
liver metastasis, but not lymph node involvement. will also show gastric wall thickening
what will an endoscopic ultrasound show
how far the tumour has progressed through the gastric wall and lymph node involvement
what is the other way to stage gastric tumours apart from TNM
UICC score
what is the best form of treatment
surgery is the best form of treatment
what does this surgery involve
a partial or total resection of the stomach, and removal of varying amounts of surrounding lymph nodes
what are the only treatments available for those who surgery is not available to
only palliative care, pain relief and counselling are available
what are the early complications of surgery
usually respiratory, cardiac and wound complications
leakage at the point of anastomosis, particularly if it was a total gastrectomy, and the oesophagus is joint straight onto the jejunum
fluid collection and accesses around areas of lymph node dissection
acute pancreatitis if lymph nodes form this region have been removed
nasogastric drainage if the jejunum doesn’t drain well after the operation
what are the features of late complications of surgery usually
these are normally due to physiological changes in the upper GI tract. most of these will appear within a few months of surgery, but then disappear within a year
what are the actual late complications of surgery
Reflux gastritis due to loss of the pyloris and reflux of biliary contents into the stomach. Most patients who have surgery will have endoscopic evidence of gastritis, but only a small percentage will have significant symptoms.
Dumping – is a term used to refer to many symptoms that are attributed to rapid gastric emptying. These symptoms include:
Fullness
Pain
Nausea
Diarrhoea
Vomiting
Vasomotor symptoms – i.e. the symptoms affecting the level of dilatation of the blood vessels. These are due to rapid fluid shifts into the bowel lumen, and are similar to the symptoms of hypovolaemia. Hypovolaemia is a decreased blood volume.
Late dumping – this is due to an insulin surge soon after a meal followed by reactive hypoglycaemia.
Dumping is treated by controlling the diet. Patient’s should eat lots of small meals, keep dry food and liquids separate, and avoid simple sugars. The symptoms of dumping will lessen over time.
Weight loss – Patients who have a total gastrectomy will lose about 10% of their body weight, whilst those who have a partial gastrectomy will only lose about 5%. This is due to a combination of factors, including, symptoms of dumping, change in diet, gastritis, and possibly due to continuing cancer progression.
Anaemia – very common as a result of loss of intrinsic factor due to the fact you have removed the parietal cells in the stomach! Another factor will also be that iron remains in its insoluble ferric form, as there may not be enough acid to convert it to ferrous. After a total gastrectomy, patients have to have vitamin B12 injections.
Increased risk of osteoporosis and osteomalacia – it is not entirely clear why this is the case, but it is possibly to do with reduced calcium / vitamin D absorption
what is one of the most common indications for palliative care
gastric outlet obstruction from a stenosing distal gastric cancer, but there are many others
what is the median life expectancy for somebody just diagnosed with incurable gastric cancer
4-6 months
it is very important that a palliative plan is put in place as soon as possible after diagnosis
what percentage of all gastric neoplasms does gastric lymphoma account for
2-5%
where do gastric lymphomas occur
in the mucosa associated lymphoid tissue (MALT)
this type of tissue appears in the stomach as a result of chronic inflammation, which is thought to be a result of h pylori infection
is MALT tissue normally present in the stomach
NO
the lymphomas are normally ? cell derived?
normally B cell derived although T cell ones do sometimes occur
how can these gastric lymphomas be classified
as high or low grade
low grade tumours are treated with H pylori eradication treatment, and this’ll also result in healing of the tumour in 70-100% of cases
high grade tumours are treated with chemoradiotherapy
what is Murphy’s sign
this is pain in the right upper quadrant from local peritoneum from acute cholecysitits
what is a paraumbilical hernia
a paraumbilical hernia should present with a lump around the umbilicus. there may be skin changes over this lump if there are incarcerated contents within the hernia
what is Cullens sign
this is periumbilical ecchymosis
what is Caput Medusae
these are periumbilical varies that branch out from the umbilicus that occurs with portal hypertension from liver cirrhosis
what is Rovsing’s sign
this is pain felt in the right iliac fossa on palpation in the left iliac fossa from local peritoneum from acute appendicitis
what is Grey-Turner’s sign
ecchymosis in either flank
what do Cullen’s and Grey-Turner’s sign both indicate
internal haemorrhage which can present in acute pancreatitis, splenic rupture or perforatied peptic ulcer disease
when these signs result from acute haemorrhagic pancreatitis, this can indicate severe disease and higher mortality
what is acute pancreatitis
is an inflammation of the pancreas caused by an activation of pancreatic enzymes and autodigestion
it can often cause a SIRS which in turn can cause organ failure such as AKI, and respiratory failure
how is acute pancreatitis diagnosed
a diagnosis requires at least 2 of the following 3 features;
- abdominal pain
- serum lipase/amylase levels greater than 3 times the upper limit of normal
- radiological evidence of pancreatitis
what is more sensitive, lipase or amylase
lipase
Amylase rises rapidly within 2 hours of the onset of acute pancreatitis, and peaks between 12 and 72 hours. It is then excreted rapidly by the kidneys, with levels returning to normal as soon as 3 days. Lipase, however, peaks at 24 hours and can remain elevated for between 8 and 14 days as it is reabsorbed by the renal tubules back into the circulation. This biochemical profile makes lipase a much better clinical test for acute pancreatitis.
what is the description of mild acute pancreatitis
no organ failure or local/systemic complications
what is the description of moderate severe acute pancreatitis
transient organ failure such as AKI, resolving within 48 hours
may have local complication
what is the description of severe acute pancreatitis
persistent organ failure or multi organ failure
what are the two types of acute pancreatitis
interstitial oedematous pancreatitis and necrotising pancreatitis
what is the most common type of pancreatitis
interstitial oedematous pancreatitis
pancreatic parenchyma is inflamed or oedematous
what does interstitial oedematous pancreatitis lead to
acute peripancreatic fluid collection (APFC)
occurs within 4 weeks, the fluid is extra pancreatic in location
if not resolved within 4 weeks, it may organise and become a pseudocyst
what is a pseudocyst
a homogenous fluid filled collection with a cyst wall
can compress on surrounding structures, such as the stomach
what is necrotising pancreatitis
necrosis of the pancreatic parenchyma and or peripancreatic tissue
may become infected
what does necrotising pancreatitis lead to
acute necrotic collection (ANC)
occurs within 4 weeks. the fluid is intra or extra pancreatic in location
inhomogeneous collection of fluid and solid components
no wall
what is walled off necrosis (WON)
occurs after 4 weeks of onset of pain
what are the causes for acute pancreatitis
ERCP
alcohol
gallstone disease
autoimmune diswase
family history
idiopathic
high serum triglyceride levels
what criteria is used to diagnose acute pancreatitis
Atlanta criteria
what does the Atlanta criteria state
that the patent should have two of the following to diagnose acute pancreatitis ;
- epigastric pain
- raised lipase/amylase
- radiological evidence of acute pancreatitis
once diagnosis has been established, what is the next most appropriate investigation in patients pathway of acre
ultrasound of the abdomen
Investigations should focus firstly on establishing the diagnosis. If the diagnosis at admission is at all unclear, then a CT scan would be warranted to rule out any other pathology. A CT for acute pancreatitis within the first week correlates very poorly with clinical severity, as is its sensitivity for diagnosing necrotising pancreatitis within the first few days. CT imaging is most useful 5-7 days after hospital admission, as this is the timeframe for when local complications may develop.
An US Abdo is therefore the next appropriate investigation for the patient. Although he has a clear risk factor (i.e., high alcohol intake), gallstone disease accounts for over 50% of acute pancreatitis cases and needs to be ruled out as a cause. An US is the investigation of choice for this.
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