oesophageal cancer
- risk factors for adenocarcinoma? 3
- risk factors for squamous cell carcinoma? 4
- risk factors for both? 3
adenocarcinoma:
- barretts oesophagus
- GORD
- obese
squamous cell
- alcohol
- very hot drinks
- poor diet
- chewing tobacco
both
- smoking tobacco
- increased age (over 50)
- male
nb
- adenocarcinoma more common in west and lower 3rd of oesophagus
- squamous cell more common in east and upper 3rd
oesophageal cancer:
- symptoms/signs? 4
- investigations? 1
- treatments? 2
- dysphagia
- weight loss
- retrosternal chest pain
- neck swelling
(- haematemesis)
(- cervical lymphadenopathy)
(- horners syndrome)
if in proximal 3rd:
- hoarseness
- cough
- endoscopy with biopsy (occassionally barium swallow)
- most commonly palliative chemo or radio
- if small: radical resection surgery (preceeded by chemo or radio)
nb
- radio used more for squamous cell
- chemo used more for adenocarcinoma
gastric carcinoma:
- types of cancer? 4
- risk factors for commonest type? 4
- age + gender affected?
- adenocarcinoma (commonest)
- leiomyomas
- carcinoid
- MALT/lymphomas
- diet high in nitrosamines (smoked or fresh fish, pickled fruit)
- chronic atrophic gastritis
- blood group A
- chronic gastric ulceration related to H pylori
- norm >50
- men 3x more likely
gastric carcinoma:
- symptoms? 6
- signs? 3
- persistent indigestion + heartburn
- epigastric pain
- trapped wind/frequent burping
- anaemia (iron deficient)
- lethargy
- weight loss +/- anorexia
signs:
- weight loss
- palpable epigastric mass
- palpable supraclavicular lymph node (Troisiers sign) suggests disseminated disease
nb occasionally presents as upper GI bleeding
nb dysphaguia uncommon unless involving proximal fundus + gastro-oesophageal junction
gastric carcinoma:
- investigations? 2
- treatment?
- diagnosis norm by gastroscopy
- use US or CT for staging
vast majority present late so are unresectable but some may be suitable for surgery
treatment mainly directed at symptom control + palliation
pancreatic carcinoma:
- most common type?
- risk factors? 8
ductal denocarcinoma (90%)
- chronic pancreatitis
- exposure to naphthalene + benzidine
- smoking
- alcohol abuse
- overweight/high fat diet
- male
- increasing age (norm >60)
- FH
nb incidence of this is rising rapidly
pancreatic carcinoma:
- presentation of tumour in head of pancreas? (65%) 4
- presentation of tumour inn body or tail? (35%) 2
- signs/symptoms common to both? 8
head:
- obstructive jaundice
- pruritis
- palpable (often painless) gallbladder
- vague pain (70%) radiating to back
body/tail:
(- asymptomatic in early stages)
- epigastric pain, raditing to back (relieved on sitting forward)
- palpable epigastric mass
both:
- anorexia
- weight loss
- acute pancreatitis
- diabetes
- hepatomegaly (dt mets)
- lymphadenopathy
- splenomegaly
- thrombophlebitis migrans (10%)***
pancreatic carcinoma:
- bloods? 4
- other investigations? 2
- treatment? 3
- FBCs
- LFTs
- blood sugar
- serum CA19.9
- ultrasound
- CT
95% are not suitable for surgical resection on presentation
very poor prognosis
- pain relief (morphine)
- relieve jaundice via ERCP
- adjunctive chemo or surgery if poss
colorectal carcinoma:
- most common type?
- modifiable risk factors?
- non-modifiable risk factors?
- usually adenocarcinoma
- diet poor in fruit + veg
- diet high in red + processed meat
- smoking
- high alcohol intake
- familial syndrome (FAP, HNPCC, juvenile polyposis)
- strong FH
- PMH of polyps or cancer anywhere
- chronic UC or crohn’s
nb about 20% are due to a familial syndrome
clinical presentation of colorectal carcinoma:
- Right/ascending colon? 4
- Left/descending colon? 4
- rectum? 4
- emergency presentation? 3
right/ascending: - iron-deficient anaemia - weight loss - abdo pain - palpable mass (- obstruction less likely)
left/descending: - PR bleeding (dark red mixed w stool) - change in bowel habit (increase freq) - bloating + flatulence - palpable mass (- obstruction more likely)
rectum:
- PR bleeding (dark red on stool surface)
- change in bowel habit (difficulty defecating)
- tenesmus (painful + sensation of incomplete defecation)
- mass palpable on PR
emergency (40% picked up this way):
- large bowel obstruction
- perforation w peritonitis
- acute OR bleeding
colorectal carcinoma:
- investigations?
- treatment?
- FBC (for anaemia)
- faecal blood
- colonoscopy (or using CT)
- if no mets, surgical removal with pre-operative chemo
nb chemo can also be used palliatively
chronic liver failure:
- 2 most common causes?
- other groups of causes? 4
most common:
- chronic alcohol abuse
- chronic hep B or C infection
genetic conditions:
- haemochromatosis
- a1-antitrypsin deficiency
- wilson’s disease
non-alcoholic steatohepatitis (NASH)
autoimmune:
- primary biliary cholangitis
- primary sclerosing cholangitis
- autoimmune hepatitis
drugs
- amiodarone
- methyldopa
- methotrexate
chronic liver failure:
- symptoms? 5
- peripheral signs? 5
- more central signs? 7
- fatigue
- pruritis
- URQ pain
- nausea
- disorientation/confusion
peripheral:
- leuconycia (low albumin)
- clubbing
- dupytens contracture
- palmar erythema
- liver flap
- jaundice (sclera + skin)
central:
- spider naevi
- scratches from itching
- ascites (shifting dullness)
- caputs medusa
- gynaeomastia
- atrophic testes
- hepatomegaly (small if late)
chronic liver failure:
- blood tests? 4
- other investigations? 4
- LFTs
- INR
- FBC
- U+Es
- ultrasound
- MRI
- ascitic tap
- liver biopsy (definitive)
chronic liver failure:
- non-pharm management? 2
- drugs to avoid? 3
- pharm management?
- surgical treatment? 1
- good nutrition
- alcohol abstinence
avoid:
- NSAIDs
- sedatives
- opiates
symptomatic treatment
- colestyramine (for pruritis)
treat underlying cause (eg hep C or PBC)
fluid restrict + low salt if got ascites
- liver transplant is only definitve treatment
nb consider spontaneous bacterial peritonitis (SBP) in any patient w ascites who deteriorates rapidly!
nb monitor kidney function
ascites:
- most common cause of transudate?
- other causes of transudate?
- causes of exudate?
liver cirrhosis
transudate:
- portal hypertension
- hepatic outflow obstuction
- budd-chiari syndrome
- hepatic veno-occlusive disease
- cardiac failure
- tricuspid regurg
- constrictive pericarditis
- meig’s syndrome
exudate:
- peritoneal carcinomatosis
- peritoneal TB
- pancreatitis
- nephrotic syndrome
- lymphatic ostruction
nb can get ascites with any advanced/malignant cancers
nb budd-chiari syndrome is occlusion of hepatic veins -> liver enlargement, ascites + abdo pain
nb meig’s syndrome is triad of ovarian fibroma, ascites + pleural effusion
ascites:
- clinical presentation?
- investigation?
- treatment?
fullness in the flank w shifting dullness
tense ascites is uncomfortable + produces respiratory distress
a pleural effusion (nor R sided) + peripheral oedema may be present
- diagnostic aspiration of 20ml of ascetic fluid in all patients
- high conc of albumin indicates a transudate. Neutrophil count, gram stain + culture, cytology for malignant cells + amylase to exclude pancreatic ascites
treat underlying cause
diuretics
- restrict sodium
- oral spiralactone
(- furosemide sometimes added)
monitor weight to see progress
paracentesis is used if ascites is tense or are resistant to standard medical therapy
Protein-energy malnutrition:
- causes due to reduce intake?
- causes due to malabsorption?
- causes due to high metabolic rate?
- dementia
- anorexia nervosa
- coeliac disease
- pancreatitis
- crohns
- carcinomas
- prolonged infection or inflammation
vit c deficiency
- name?
- risk factors? 3
- groups of symptoms/signs? 5
scurvy
- pregnant
- poor
- unusual diet
1) listlessness (no interest in things)/anorexia/cachexia
2) gingivitis/loose teeth/halitosis
3) bleeding from gums/nose/hair follicles/into joints/bladder/gut
4) muscle pain/weakness
5) oedema
vit B1 deficiency
- other name of vitamin?
- name of two conditions? and signs/symptoms (3 each)
- who at risk? 3
thiamine
Beriberi
- heart failure
- general oedema
- neuropathy
Wernicke’s encephalopathy
- confusion
- ataxia
- opthalplegia (nystagmus nerve palsies)
nb can progress to korsakoffs psychosis if untreated
- chronic alcoholics
- prolonged vomiting (e.g. chemo,morning sickness)
- anyone malnourished/eating disorder
coeliac disease:
- risk factors? 3
- pathophysiology?
- female
- FH
- PMH autoimmune conditions
T-cell infiltration and subsequent inflammation in the mucosa of the small bowel leading to malabsorption
coeliac disease
- GI symptoms? 5
- other symptoms? 6
- diarrhoea (esp smelly)
- bloating & flatulence
- constipation
- indigestion
- abdo pain
- fatigue (can be due to malnutrition or iron or B12 deficiency more specifically)
- weight loss
- itchy rash (dermatitis herpetiformis)
- ataxia or neuropathy
- depressions
- inability to get pregnant
coeliac disease:
- blood tests? 2
- other investigation?
- management?
- FBC and blood smear (iron deficiency anaemia is commonest presentation of coeliac in adults)
- IgAtTG test
nb if suspected dermatitis herpetiformis is present then can take samples from this rash
- endoscopy with biopsy
- gluten-free diet
