Week Ten - Case Three Flashcards
what is the criteria for a direct access upper GI endoscopy?
1.3 Referral guidance for Endoscopy links to NICE guidelines on suspected cancer: recognition and referral (1.2.7. endoscopy for people with dysphagia or aged > 55 with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia).
what is the most common histological type of gastric cancer
adenocarcinomas
what is it called when an adenocarcinoma spreads primarily through the musculature of the stomach wall
the thickening is called linitis plastica
what is the 5 year survival for stage 4 cancer
less than 1%
what are the risk factors for gastric adenocarcinoma
Age (75 years and over)
Male (2:1 – 12:1)
H.pylori infection
Familial adenomatous polyposis (FAP)
Ethnicity (Black, Hispanic and Asian)
Smoking and alcohol
Diet
Obesity – more so in men
what are the 5 investigations carried out for suspected gastric adenocarcinomas
- upper GI endoscopy
- minimum of 6 biopsies
- initial staging CT t,a,p
- discussion at MDT
- staging laparoscopy
what is a peptic ulcer
a break in the mucosal lining of the stomach (gastric ulcer) or duodenum. (duodenal ulcer)
where does the disruption usually extend into
the submucosa or the muscularis propria
usually more than 5mm in diameter
what are the risk factors for peptic ulcer disease
alcohol
smoking
blood group O
naproxen
h pylori
what kind of pain is typical of peptic ulcer pain
epigastric pain that is constant, radiates into the back usually when hungry
what are the typical symptoms of peptic ulcer disease
epigastric pain, early satiety, reflux symptoms, and nausea
what is the relationship between H pylori and stomach acid
h pylori is protected from stomach acid as it uses its flagella to migrate into the mucous lining from the stomach wall to bind to epithelial cells. it also produces urease to neutralise stomach acid into CO2 and ammonia
can patients with h pylori be asymptomatic
yes
how its H pylori transmitted
can be transmitted by the oral to oral route, or faecal oral route
h pylori has been isolated from saliva and faeces in infected people
what can an ulcer lead to if untreated
can erode through the entire stomach wall leading to perforation If untreated
how do patients present with a perforation
a rigid abdomen which is indicative of generalised peritonitis secondary to florid bowel contents in the peritoneal cavity. there is usually a sudden onset of epigastric pain before becoming more generalised in nature
what is the A and E management of a patient with perforation
NBM
antibiotics
general surgery team
analgesia
antiemetics
VTE prophylaxis
fluid balance
what are the most common postoperative complications from a laparotomy
intra-abdominal collection
LRT infection
urinary tract infection
ongoing leak form the site of the perforation
DVT
postoperative ileus
what do peptic ulcers involve
ulceration of the mucosa of the stomach or the proximal duodenum
what type of ulcer is the most common
duodenal ulcers are the most common
what are the risk factors for peptic ulcers
helicobacter pylori
NSAIDs
what are the key risk factors that increase stomach acid
stress
alcohol
caffeine
smoking
spicy foods
what is the risk of bleeding from a peptic ulcer increased with the use of
NSAIDs
aspirin
DOACs
steroids
SRRI antidepressants
how do peptic ulcers present
Epigastric discomfort or pain
Nausea and vomiting
Dyspepsia
what are the signs of upper GI bleeding
Haematemesis (vomiting blood)
Coffee ground vomiting
Melaena (black, tarry stools)
Fall in haemoglobin on a full blood count
what can chronic microscopic bleeding lead to
iron deficiency anaemia, with low haemoglobin, low mean cell volume and low ferritin
what typically worsens the pain of gastric ulcers
eating
what typically improves the pain associated with duodenal ulcers
the pain of duodenal ulcers tends to improve immediately after eating, followed by pain 2-3 hours later.
in MCQ’s, how do we differentiate between gastric and peptic, apart from the pain
patients with gastric ulcers tend to lose weight due to fear of pain on eating, whereas with duodenal ulcers, the weight is stable or increases
what are the 3 core aspects of treating peptic ulcers
stopping NSAIDs
treating h pylori infections
PPIs
what may be performed at 4-8 weeks to ensure the ulcer heals
repeat endoscopy
what are the three complications of peptic ulcers
bleeding
perforation
scarring and strictures
what does perforation result in
acute abdominal pain and peritonitis, requiring urgent surgical repair, which is usually done laparoscopically
what can scarring and strictures lead to
narrowing of the exit of the stomach, causing difficulty emptying the stomach contents
how does gastric outlet obstruction present
with early fullness after eating, swell as upper abdominal discomfort, abdominal distention and vomiting, particularly after eating
how is gastric outlet obstruction treated
with balloon dilatation during an endoscopy or surgery
what are the vast majority of pancreatic cancers
adenocarcinomas and occur in the head of the pancreas as opposed to the body or tail
what can the tumour result in
jaundice
once the tumour in the head of the pancreas grows large enough, it can compress the bile ducts, resulting in obstructive jaundice
where does pancreatic cancer spread and what is the average survival
pancreatic cancers tend to spread and metastasis early, particularly to the liver, then to the peritoneum, lungs and bones.
the average survival when diagnosed with advanced disease is around 6 months
what is the survival rate when it is caught early
When caught early, the cancer is isolated to the pancreas and surgery is possible, the 5-year survival is still around 25% or less.
what is the key presenting features that should make you immediately consider pancreatic cancer and what is the key differential
painless obstructive jaundice is the key presenting features and the key differential is cholangiocarcinoma
what does painless obstructive jaundice present with
presents with:
Yellow skin and sclera
Pale stools
Dark urine
Generalised itching
what are the other vague presenting features for pancreatic cancer
Non-specific upper abdominal or back pain
Unintentional weight loss
Palpable mass in the epigastric region
Change in bowel habit
Nausea or vomiting
New-onset diabetes or worsening of type 2 diabetes
in relation to diabetes, what can be a sign of pancreatic cancer
a new onset of diabetes, or a rapid worsening of glycemic control type 2 diabetes
what are the NICE guidelines for referring suspected pancreatic cancer
- over 40 with jaundice - referred on a 2 week wait referral
- over 60 with weight loss plus an additional symptom - referred for a direct accesss CT abdomen
what are the additional symptoms for those over 60
Diarrhoea
Back pain
Abdominal pain
Nausea
Vomiting
Constipation
New-onset diabetes
what is the only scenario where GPs can refer directly for a CT scan
suspected pancreatic cancer
Whenever guidelines and clinical practice have notable exceptions like this it is worth taking note of, as these make good facts for examiners to test your knowledge on.
what is Courvoisier’s Law
states that a palpable gallbladder along with jaundice is unlikely to be gallstones
the cause is usually cholangiocarcinoma or pancreatic cancer
what does Trousseau’s sign of malignancy refer to
refers to migratory thrombophlebitis as a sign of malignancy, particularly pancreatic adenocarcinoma
what is thrombophlebitis
where blood vessels become inflamed with an associated blood clot (thrombus) in that area. migratory refers to the thrombophlebitis recurring in different location over time
what is diagnosis of pancreatic cancer usually based on
imaging (CT scan) plus histology from the biopsy
what does a staging CT scan involve
Staging CT scan involves a full CT thorax, abdomen and pelvis (CT TAP). This is used to look for metastasis and other cancers.
what is the tumour marker that may be raised in pancreatic cancer
CA 19-9 (carbohydrate antigen) is a tumour marker that may be raised in pancreatic cancer. It is also raised in cholangiocarcinoma and a number of other malignant and non-malignant conditions.
what may be used to access the biliary system in detail to assess the obstruction
Magnetic resonance cholangio-pancreatography (MRCP) may be used to assess the biliary system in detail to assess the obstruction.
what can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour
Endoscopic retrograde cholangio-pancreatography (ERCP) can be used to put a stent in and relieve the obstruction, and also obtain a biopsy from the tumour.
what are the four types of surgery used in the management of pancreatic cancer
Total pancreatectomy
Distal pancreatectomy
Pylorus-preserving
pancreaticoduodenectomy (PPPD) (modified Whipple procedure)
Radical pancreaticoduodenectomy (Whipple procedure)
what is a Whipple procedure
A Whipple procedure (pancreaticoduodenectomy) is a surgical operation to remove a tumour of the head of the pancreas that has not spread. A Whipple procedure is a massive operation so patients need to be in good baseline health. It involves the removal of the:
Head of the pancreas
Pylorus of the stomach
Duodenum
Gallbladder
Bile duct
Relevant lymph nodes
what is a modified Whipple procedure
involves leaving the pylorus in place. it is also known as a pylorus-preserving pancreaticoduodenectomy (PPPD)
what is cholangiocarcinoma
a type of cancer that originates in the bile ducts. the majority are adenocarcinomas
where may cholangiocarcinoma affect
the bile ducts in the liver (intrahepatic ducts) or outside the liver (extrahepatic ducts).
where is the most common site of cholangiocarcinoma
in the perihilar region, where the right and left hepatic duct have joined to become the common hepatic duct, just after leaving the liver
what are the key risk factors for cholangiocarcinoma
primary sclerosing cholangitis
liver flukes (a parasitic infection)
patients with ulcerative colitis are at risk of developing what
primary sclerosing cholagitis
what is the presentation of cholangiocarcinoma
obstructive jaundice is the key presenting feature to remember.
what is obstructive jaundice also associated with
pale stools
dark urine
generalised itching
what are the other non-specific signs and symptoms of cholangiocarcinoma
Unexplained weight loss
Right upper quadrant pain
Palpable gallbladder (swelling due to an obstruction in the duct distal to the gallbladder)
Hepatomegaly
how to differentiate between causes of painless jaundice in your exams
pancreatic cancer is more common than cholangiocarcinoma, so therefore this is the likely answer in your exams
what is diagnosis based on
imaging (CT scan) and histology from a biopsy
what tumour marker is raised in cholangiocarcinoma
CA 19-9
it is also raised in pancreatic cancer
what is the management of cholangiocarcinoma
curative surgery may be possible however, palliative treatment involves
Stents inserted to relieve the biliary obstruction
Surgery to improve symptoms (e.g., bypassing the biliary obstruction)
Palliative chemotherapy
Palliative radiotherapy
End of life care with symptom control
