Year 5 Core Conditions > Gastrointestinal - Level 2 > Flashcards

Gastrointestinal - Level 2 Flashcards

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1
Q

Definition of malnutrition?

A

o Nutrient deficient state of protein, energy or micronutrients

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2
Q

Definition and symptoms of Kwashikor?

A 
o	Inadequate protein intake
o	Moon facies, swollen abdomen (pot belly)
o	Hepatomegaly
o	Pitting oedema
o	Dry, dark skin which splits
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3
Q

Definition and symptoms of marasmus?

A 
o	Inadequate energy and protein intake
o	Loss of weight and reduction in muscle mass
o	Thin, atrophic skin
o	Alopecia, brittle hair
o	Lanugo hair
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4
Q

Symptoms and management of iodine deficiency?

A

 Symptoms - Goitre, hypothyroidism, growth restriction

 Management - Iodine supplements, seafood

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5
Q

Symptoms and management of vitamin A deficiency?

A

 Symptoms - Night blindness, oval Bitot’s spots, cloudy corneas, immune dysfunction, increased illnesses
 Management – dark green leafy vegetables, animal products, vitamin Asupplements

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6
Q

Symptoms and management of vitamin C deficiency?

A

 Symptoms – listlessness, anorexia, bleeding gums, gingivitis, loose teeth, halitosis, muscle pain
 Management – increase vitamin C, supplements (Ascorbic Acid PO)

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7
Q

Symptoms and management of Vitamin B1 (thiamine) deficiency?

A

 Symptoms – beri beri – heart failure with oedema, neuropathy
 Management – Thiamine urgently

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8
Q

Symptoms of vitamin B2 (riboflavin) deficiency?

A

 Symptoms – angular stomatitis, cheilitis

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9
Q

Symptoms of Vitamin B6 (pyridoxine) deficiency?

A

 Symptoms – polyneuropathy

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10
Q

Symptoms of Vitamin E deficiency?

A

 Symptoms – haemolysis, neurological deficit

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11
Q

Symptoms of Vitamin K deficiency?

A

 Symptoms – bleeding disorders

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12
Q

Symptoms and management nicotinic acid deficiency?

A

 Symptoms – Pellegra – diarrhoea, dementia, dermatitis (Casal’s necklace)
 Rx – Nicotinamide PO

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13
Q

Risk factors for malnutrition?

A 
o	Young age
o	Neglect
o	Poverty 
o	Living alone
o	Severe learning difficulties or mental health problems
o	Gastric surgery
o	Malabsorption ~(CF, Crohn’s disease, Coeliac disease, chronic pancreatitis)
o	Stroke
o	Cancer
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14
Q

Symptoms of malnutrition?

A
  • BMI <18.5
  • Increasing fatigue
  • Non-healing wounds
  • Slowed growth
  • Reduced muscle mass
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15
Q

Definition of dyspepsia?

A
  • Dyspepsia – upper abdominal pain, heartburn, acid reflux, nausea and/or vomiting, typically >4 weeks
    o Most common cause of dyspepsia – GORD, PUD, functional dyspepsia, upper GI malignancy
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16
Q

Pathology of GORD?

A

 Reflux of gastric contents (acid, bile and pepsin) into oesophagus causing heartburn
 Due to transient relaxation (reduced tone) of LOS, increased intra-abdominal pressure, delayed gastric emptying and impaired oesophageal clearance of acid

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17
Q

Epidemiology of dyspepsia?

A
  • Dyspepsia occurs in 40% each year
    o At endoscopy 40% have GORD
  • Higher prevalence in Northern Europe
  • Increases with age and more common in women
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18
Q

Risk factors of GORD?

A 
o	Stress/Anxiety
o	Smoking
o	Alcohol
o	Foods – coffee, chocolate, fatty foods
o	Obesity
o	Drugs – alpha-blockers, anticholinergics, benzodiazepines, BB, bisphosphonates, CCB, corticosteroids, NSAIDs, nitrates, theophylline, TCA
o	Pregnancy
o	Hiatus hernia
o	FHx
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19
Q

Causes of dyspepsia?

A

o Oesophagitis

o Endoscopy-negative

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20
Q

Risk factors for Barrett’s oesophagus?

A

o Male, long duration/severe of GORD, previous oesophagitis/hiatus hernia/ulcers

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21
Q

Symptoms of GORD?

A

Heartburn
 Burning epigastric/retrosternal pain
 Worse on bending, lying down, with hot drinks, alcohol
 Relieved by antacids

Regurgitation

Belching

Odynophagia (pain on swallowing)

Increased salivation (waterbrash)

Nocturnal cough/asthma

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22
Q

Atypical symptoms of GORD?

A

hoarseness, cough, asthma, dental erosions

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23
Q

Investigations to perform in dyspepsia?

A

o FBC (low Hb, raised platelets)

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24
Q

Referral to endoscopy within 2-weeks under what criteria?

A

 With dysphagia or

 Aged 55 and over with weight loss and any of the following:
• Upper abdominal pain
• Reflux
• Dyspepsia

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25
Referral to endoscopy non-urgently under what criteria?
 Treatment-resistant dyspepsia or  Upper abdominal pain with low haemoglobin levels or ```  Raised platelet count with any of the following: • Nausea • Vomiting • Weight loss • Reflux • Dyspepsia • Upper abdominal pain, or ``` ```  Nausea or vomiting with any of the following: • Weight loss • Reflux • Dyspepsia • Upper abdominal pain ```
26
Management of dyspepsia with unknown cause - lifestyle advice?
Lose weight, avoid triggers (coffee, chocolate, tomatoes, fatty/spicy foods) Eat smaller meals, eat in evening 3-4 hours before going to bed Stop smoking Reduce alcohol Sleep with head of bed raised Antacids - OTC Review medications
27
Management of dyspepsia with unknown cause -if persistent symptoms?
o If persistent symptoms – FBC (check for anaemia or high platelets)
28
Management of dyspepsia with unknown cause - initial drug treatment?
 PPI for 1 month | • Lansoprazole 30mg, Omeprazole 20-40mg, esomeprazole 20mg
29
Management of dyspepsia with unknown cause - initial testing and eradication?
 H.pylori test – if positive then eradication therapy • Carbon-13 urea breath test or stool antigen test (no PPI in last 2w, no Abx in last 4w) • Eradication 7-days triple therapy - Omeprazole 20mg BD/Lansoprazole 30mg BD, amoxicillin 1g BD + clarithromycin 500mg BD (or metronidazole 400mg BDS)  If persists then switch
30
Management of dyspepsia with unknown cause - recurrent/refractory symptoms?
 H2-receptor antagonists  Re-test H.pylori only if – poor compliance, NSAIDs indicated, FHx of gastric malignancy, severe symptoms or patient request
31
Management of dyspepsia with unknown cause - when to refer to endoscopy?
 Refractory or recurrent symptoms |  Treatment with 2nd line H.pylori unsuccessful
32
Management of endoscopically proven GORD - lifestyle measures?
 Lose weight, avoid triggers (coffee, chocolate, tomatoes, fatty/spicy foods)  Eat smaller meals, eat in evening 3-4 hours before going to bed  Stop smoking  Reduce alcohol  Sleep with head of bed raised
33
Management of endoscopically proven GORD -if proven GORD?
 PPI for 4-8 weeks • Lansoprazole 30mg, omeprazole 20-40mg, esomeprazole 20mg, pantoprazole 40mg, rabeprazole 20mg  If symptoms recur: • Offer PPI at lowest dose possible to control symptoms • H2RA therapy if inadequate response to PPIs
34
Management of endoscopically proven GORD - if proven severe oesophagitis?
 PPI for 8 weeks • If treatment fails – switch to another PPI • Maintenance treatment – Full-dose PPI long-term  If symptoms recur: • Further 1 month PPI course • Double dose of PPI • H2RA therapy if inadequate response to PPIs
35
Management of endoscopically proven GORD - when to consider endoscopy?
o Consider endoscopy to diagnose Barrett’s oesophagus if long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia
36
Referral to GI or upper GI surgeon - when?
* Refractory, persistent or unexplained * Controlled on PPI but does not want to continue or PPI not tolerated * RF of Barrett’s oesophagus – upper GI endoscopy
37
Referral to GI or upper GI surgeon - specialist investigations?
* Oesophageal manometry * Ambulatory 24-hour oesophageal pH monitoring (exclude achalasia, hypomotility) * Barium swallow (exclude structural disorders – hiatus hernia, achalasia)
38
Referral to GI or upper GI surgeon - specialist management?
• Laparoscopic Nissen fundoplication o Confirmed diagnosis of acid reflux and adequate symptom control but does not want to continue on long-term PPI or cannot tolerate PPI • Endoscopic radiofrequency ablation • Laparoscopic insertion of magnetic bead band • Endoscopic infection of bulking agent
39
Complications of GORD?
``` o Oesophageal ulcers/haemorrhages/strictures o Anaemia o Aspiration pneumonia o Barrett’s oesophagus o Dental erosions, gingivitis, halitosis ```
40
What is Barrett's oesophagus?
 Columnar metaplasia of distal oesophagus, malignant potential and risk of adenocarcinoma  Endoscopy surveillance needed
41
Prognosis of GORD?
o Recurrence is 80% o 10-15% of people with GORD symptoms will develop Barrett’s oesophagus, of these 1-10% will develop oesophageal adenocarcinoma over 10-20 years
42
Risk factors for GORD in children?
o Fluid diet, horizontal stature and short intra-abdominal length of oesophagus o Cerebral palsy o Preterm infants o Following surgery for oesophageal atresia or diaphragmatic hernia
43
Symptoms of GORD in children?
- Recurrent regurgitation/vomiting - Possetting - May contain some blood - Increased salivations - Chronic cough - Normal weight and otherwise well
44
when to investigated GORD in children?
o Upper GI contrast with Hx of bile stained vomiting or Hx of GORD o Specialist assessment for endoscopy with biopsies if:  Haematemesis, melaena, dysphagia, no improvement after 1 year old, faltering growth, distress, feeding aversion, iron-deficiency anaemia o Oesophageal pH study – recurrent aspiration pneumonia, unexplained apnoea/seizure-like events/upper airway inflammation, frequent otitis media
45
Management of GORD in infants?
* Position at 30o head-up prone position after feeds * Dietary: Thickened milk feeds (Carobel), small frequent meals, avoid food before sleep, avoid fatty foods, caffeine, citrus juices, alcohol, smoking • Drugs:  1-2 weeks Gaviscon added to feeds (antacid and alginate forms viscous layer)  4 week trial H2 receptor antagonists (ranitidine) or PPI (omeprazole) - If unexplained feeding difficulty, distressed, faltering growth • Surgery if failed medical therapy  Upper GI endoscopy  Fundoplication – fundus of stomach wrapped around intra-abdominal oesophagus
46
Management of GORD in children?
• Lifestyle management • Drugs  Consider if regurgitation + feeding difficulty/distressed/faltering growth  4-week PPI/H2 – persistent heartburn - If not resolving – endoscopy • Enteral Feeding  If faltering growth and no other explanation • Surgery  Endoscopy and biopsies prior to surgery  Fundoplication if intractable, medical therapy unsuccessful
47
Complications of GORD in children?
- Failure to thrive - Oesophagitis – haematemesis and iron deficiency anaemia - Recurrent pulmonary aspiration – pneumonia, wheeze - Dystonic neck posturing (Sandifer syndrome – extension and lateral turning of head)
48
Pathology of oesophageal carcinoma?
o SCC – usually middle 1/3, incidence decreasing, men 2:1 | o Adenocarcinoma – arises from Barrett’s oesophagus, lower 1/3 of oesophagus
49
Types of oesophageal carcinoma?
``` o Adenocarcinoma – most common  Smoking  Obesity  GORD  Barrett’s oesophagus  Radiotherapy for breast cancer ``` ``` o SCC – high in China/Japan  Smoking  High salt diet  Achalasia  Coeliac disease  Very hot food  Plummer Vinson syndrome ```
50
Symptoms of oesophageal carcinoma?
``` o Progressive dysphagia (initially solids then liquids) o Weight loss o Retrosternal chest pain o Hoarseness o Cough (if upper 1/3) ```
51
When to offer urgent 2-week upper GI endoscopy of oesophageal carcinoma?
- Offer urgent upper GI endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in people: o with dysphagia or o aged 55 and over with weight loss and any of the following:  upper abdominal pain  reflux  dyspepsia
52
When to offer non-urgent upper GI endoscopy of oesophageal carcinoma?
o Treatment-resistant dyspepsia or o Upper abdominal pain with low haemoglobin levels or ``` o Raised platelet count with any of the following:  Nausea  Vomiting  Weight loss  Reflux  Dyspepsia  Upper abdominal pain, or ``` ``` o Nausea or vomiting with any of the following:  Weight loss  Reflux  Dyspepsia  Upper abdominal pain ```
53
Staging tests of oesophageal carcinoma?
o PET-CT whole body o TNM staging o Her2 testing in metastatic oesophageal adenocarcinoma
54
Management of oesophageal carcinoma - radical treatment?
 Radical oesophagectomy o T1N0 (Endoscopic mucosal resection or oesophagectomy) • +/- lymph node dissection  Neoadjuvant chemradiotherapy
55
Management of oesophageal carcinoma - follow up?
o Give advice on symptoms of recurrence and advise to contact MDT if symptoms present
56
Management of oesophageal carcinoma - palliative management - if non-metastatic but not fit for surgery?
 Chemoradiotherapy |  OR chemo + stenting, palliative radio
57
Management of oesophageal carcinoma - palliative management - if locally advanced or metastatic?
 Palliative Chemotherapy (trastuzumab + cisplatin + 5-FU)  If outflow obstruction: • Palliative surgery • Stenting o Self-expanding if needed to help with dysphagia • Radiotherapy
58
Definition of hiatus hernia?
- Protrusion of intra-abdominal contents through enlarged oesophageal hiatus of diaphragm - Most commonly contains portion of stomach - Displacement of GOJ above diaphragm reduces LOS pressure and predispose to GORD
59
Types of hiatus hernia?
o Sliding (Type 1) (80%) – protrusion of GOJ followed by body of stomach above diaphragm o Type 2 (20%) – Pure para-oesophageal hernia/rolling hernia – herniation of fundus or body with GOJ below o Type 3 – mixed o Type 4 – Giant – any type of hernia with herniation of organs
60
Epidemiology of hiatus hernia?
- Many people asymptomatic | - 95% Type 1
61
Risk factors of hiatus hernia?
o Obesity o Previous gastro-oesophageal procedure o Elevated intra-abdominal pressure – pregnancy, ascites o Age
62
Symptoms of hiatus hernia?
``` o Heartburn  Typically, after meals, on bending/lying down  Retrosternal burning sensation o Regurgitation  Sour/metallic taste in mouth, particularly when lying flat o Dysphagia o Nausea & vomiting o Hiccups ```
63
Investigations of hiatus hernia?
``` - CXR o Soft tissue opacity o Retrocardial air-fluid level diagnostic of para-oesophageal hiatus hernia - Barium studies - Endoscopy - Oesophageal manometry ```
64
Management of hiatus hernia - general measures?
o Avoid factors which increase intra-abdominal pressure o Elevate bed to relieve nocturnal symptoms o Weight loss o Small meals and avoid eating just before bed o Avoid food trigger for GORD – alcohol, acidic foods
65
Management of hiatus hernia - drug therapy?
o If symptomatic GORD |  PPIs - omeprazole
66
Management of hiatus hernia - surgical management - when to offer?
 Drug or general measures failed  Complications of reflux  Symptomatic para-oesophageal hernia
67
Management of hiatus hernia - surgical management - what?
o Laparoscopic fundoplication (can be open)  Nissen’s – complete wrapping of fundus around oesophagus or modified – partial  Gastropexy can be used
68
Prognosis of hiatus hernia?
o If sliding – most symptoms relieved by medical treatment
69
Complications of hiatus hernia?
o Bloating o Volvulus o Obstruction o Recurrence of hernia post-repair
70
Pathology of peptic ulcer disease?
o Breakdown of epithelial cells to muscularis mucosa | o Acid breaks down wall
71
Epidemiology of peptic ulcer disease?
- Duodenal 4x more common - Men 4:1 Women - Elderly more susceptible - Developing countries due to H.pylori
72
Aetiology of peptic ulcer disease?
``` o H.pylori (80-90%) o NSAIDs and aspirin (gastric) o Smoking o Alcohol o Zollinger-Ellison Syndrome o Duodenal reflux o Crohn’s ```
73
Symptoms of gastric peptic ulcer disease?
 Epigastric pain (burning)  Worse at meal times, relieved by antacids  Weight loss and nausea common
74
Symptoms of duodenal peptic ulcer disease?
 Epigastric pain (burning)  Worse when hungry or at night – relieved by eating/milk  Nausea, flatulence common  Relieved by antacids
75
Red flag symptoms of gastric malignancy?
``` o Anaemia (iron def) o Loss of weight o Anorexia o Recent onset/Progressing o Melaena/Haematemesis o Swallowing difficulties ```
76
Management of peptic ulcer disease- lifestyle advice?
o Weight loss o Avoid trigger foods – coffee, chocolate, tomatoes, fatty or spicy foods o Eat smaller meals and eat evening meals 3-4 hours before going to bed o Stop smoking o Reduce alcohol o Raising head of bed
77
Management of peptic ulcer disease- medication review?
o Stop NSAIDs | o Reduce or stop – aspirin, bisphosphonates, corticosteroids, potassium supplements, SSRIs
78
Management of peptic ulcer disease- when to refer to endoscopy within 2 weeks?
```  With dysphagia or  Aged 55 and over with weight loss and any of the following: • Upper abdominal pain • Reflux • Dyspepsia ```
79
Management of peptic ulcer disease- when to refer to endoscopy non-urgently?
 Treatment-resistant dyspepsia or  Upper abdominal pain with low haemoglobin levels or ```  Raised platelet count with any of the following: • Nausea • Vomiting • Weight loss • Reflux • Dyspepsia • Upper abdominal pain, or ``` ```  Nausea or vomiting with any of the following: • Weight loss • Reflux • Dyspepsia • Upper abdominal pain ```
80
Management of proven peptic ulcer disease- initial testing?
Test for H.pylori infection (if not known)  Initial detection – Carbon-13 urea breath test or stool antigen test  Ensure no PPI in past 2 weeks, or antibiotics in last 4 week
81
Management of proven peptic ulcer disease- if person positive for H.pylori with PU?
Associated with NSAID use – full-dose PPI therapy for 8 weeks, then eradication therapy after completion of PPI therapy • PPI = lansoprazole 30mg, omeprazole 20-40mg, esomeprazole 20mg, pantoprazole 40mg, rabeprazole 20mg • Eradication 7 day = PPI BD + amoxicillin 1g BD + clarithromycin 500mg BD (or metronidazole 400mg BD) Not associated with NSAID use – eradication therapy • Eradication 7 day = PPI BD + amoxicillin 1g BD + clarithromycin 500mg BD (or metronidazole 400mg BD)
82
Management of proven peptic ulcer disease- if person negative for H.pylori with PU?
Full-dose PPI therapy for 4-8 weeks • PPI = lansoprazole 30mg, omeprazole 20-40mg, esomeprazole 20mg, pantoprazole 40mg, rabeprazole 20mg
83
Management of proven peptic ulcer disease- follow up?
o Repeat endoscopy 6-8 weeks after starting eradication therapy o H.pylori retesting 6-8 weeks after starting eradication, with carbon-13 urea breath test  If H.pylori positive – offer second line eradication • 2nd line eradication = offer PPI, amoxicillin and the other drug not given o If healed – offer PPI if needed, reduce dose of NSAIDs, switch aspirin  Lowest dose effective with PPI and consider PRN prescription
84
Management of proven peptic ulcer disease- review in primary care?
o Annual review
85
Management of proven peptic ulcer disease- when to refer to GI?
o Refractory or recurrent symptoms despite optimal management o Treatment with 2nd line eradication unsuccessful o Limited antibiotics options o Proven gastric ulcer has not healed on repeat endoscopy o Zollinger-Ellison syndrome
86
Complications of Peptic ulcer disease?
o Haemorrhage o Perforation o Gastric outlet obstruction o Gastric malignancy
87
Prognosis of peptic ulcer disease?
o Mortality rate 6-8% o 1 in 10 with bleeding ulcer will die o 1 in 4 with perforated ulcer will die
88
Causes of bowel perforation - chemical, infection & ischaemia?
Chemical  Peptic ulcer disease  Foreign Body (battery) Infection  Diverticulitis  Cholecystitis  Meckel’s diverticulum Ischaemia  Mesenteric ischaemia  Cancer  Obstruction
89
Causes of bowel perforation - colitis, iatrogenic and direct rupture?
Colitis  Toxic megacolon (C.diff/UC) Iatrogenic  Surgery, endoscopy  Trauma Direct rupture  Excessive vomiting leading to oesophageal perforation (Boerhaave syndrome)
90
Symptoms of bowel perforation?
o Severely painful sudden event o Sudden localised epigastric pain spread to remainder of abdomen  Worse on coughing or moving and may radiate to shoulder tip o Vomiting, lethargy
91
Signs of bowel perforation?
o Patient lies still, may writhe in agony | o Absent bowel sounds, generalised peritonitis and fever
92
Investigations in bowel perforation?
AXR o Rigler’s sign (both sides of bowel seen, due to free abdominal air ``` Erect CXR (free gas under diaphragm) o Contrast CT scan when CXR not definitive ``` ``` Bloods o FBC (raised WCC), U&Es, LFTs, CRP, glucose, amylase, clotting, Ca, Group and save ``` Pregnancy test if woman Urinalysis ECG/Troponin
93
Initial management of bowel perforation?
o Oxygen o IV analgesia (morphine) and antiemetic (IV metoclopramide 10mg) o IV fluid resuscitation (0.9% saline) o NBM and NG tube o IV Abx (co-amoxiclav 1.2g TDS and metronidazole 500mg TDS and stat gent if septic) o Refer to surgeon
94
Surgical management of bowel perforation?
o Laparotomy and repair:  Peptic ulcer – omental patch  Perforated diverticulae – Hartmann’s procedure
95
Conservative management of bowel perforation?
o If mild disease and only localised peritonitis on CT or elderly patients
96
Most common location and type of gastric cancer?
- Most commonly found in antrum | - Mostly adenocarcinoma
97
Types of gastric cancer?
- Type 1 (intestinal) o Localised ulcerated lesions with rolled edges, distal stomach - Type 2 (diffuse) o Extensive submucosal spread, mostly cardia
98
Spread of gastric cancer?
- Spread via local, lymph, blood, transecoelomic
99
Other tumour types of gastric cancer?
o GIST – stromal or mesenchymal tumours in stomach or proximal SI  Have malignant potential  Usually asymptomatic and incidental finding • Can ulcerate and bleeding o MALToma – B-cell lymphomas
100
What are the types of gastric polyps?
o Asymptomatic, usually removed endoscopically o Hyperplastic – most common, <2cm and not malignant o Adenomatous – solitary in antrum, rare, premalignant o Cystic Gland – microcysts lined by chief/parietal cells, fundus and body
101
Epidemiology of gastric cancer?
- 4th most common cancer - More common in Japan, China, Eastern Europe - Men 2:1 Women
102
Aetiology of gastric cancer?
``` o H.pylori o Chronic Gastritis o Smoking o Diet (low in fruit & veg, high in salted & smoked foods) o Pernicious anaemia o FHx o Nitrosamines ```
103
Symptoms of gastric cancer?
``` o Epigastric pain  Like peptic ulcer  Relieved by food/antacids o Loss of appetite o Weight loss o Vomiting o Dysphagia ```
104
Signs of gastric cancer?
``` o Anaemia o Palpable Virchows node o Mass in epigastrium o Hepatomegaly, ascites – metastases o Acanthosis Nigricans o Dermatomyositis ```
105
Management of gastric cancer - when to refer on 2-week pathway?
APPOINTMENT Upper abdominal mass consistent with stomach cancer ``` UPPER GI ENDOSCOPY  with dysphagia or  aged 55 and over with weight loss and any of the following: • upper abdominal pain • reflux • dyspepsia. ```
106
Management of gastric cancer - when to refer non-urgently?
 Haematemesis OR ```  People aged 55 or over with: • Treatment-resistant dyspepsia or • Upper abdominal pain with low haemoglobin levels or • Raised platelet count with any of the following: o nausea o vomiting o weight loss o reflux o dyspepsia o Upper abdominal pain, or • Nausea or vomiting with any of the following: o weight loss o reflux o dyspepsia o upper abdominal pain ```
107
Management of gastric cancer - secondary care investigations?
o Endoscopy and biopsies taken o CT  TNM staging o Staging laparoscopy if potentially curable o EUS to determine depth if help o PET scan if metastatic disease suspected o Her2 testing in metastatic gastric adenocarcinoma
108
Management of gastric cancer - radical treatment?
Nutritional assessment by specialist dietician Gastrectomy (radical surgical resection)  Neo-adjuvant chemotherapy  D2 lymph node dissection
109
Management of gastric cancer - palliative treatment?
Specialist cancer-specific dietician Palliative Chemotherapy (trastuzumab (HER2 positive) + cisplatin + 5-FU) If outflow obstruction:  Palliative surgery  Stenting - Self-expanding if needed to help with dysphagia  Radiotherapy
110
Prognosis of gastric cancer?
o 5-year survival 20% | o Surgery improves survival
111
Most common pancreatic cancer?
- Mostly ductal adenocarcinoma, metastasise early and present late
112
Epidemiology of pancreatic cancer?
- 5th most common cause of cancer death in UK - Men < Women - Incidence increases with age
113
Types of pancreatic cancer?
Adenocarcinomas (96%)  Head 60%, Body 25%, tail 15% Others – ampullary tumour, pancreatic islet cells (insulinoma, gastrinoma, glucagonoma, somatostatinoma)
114
Aetiology of pancreatic cancer?
``` o Smoking o Petrol o Obesity o High fat/Red meat diet o Alcohol o Diabetes o Chronic pancreatitis ```
115
Symptoms pancreatic cancer - if head or ampulla?
``` o Painless obstructive jaundice o Blocks CBD o Weight loss o Distended gall bladder o May be mass palpable ```
116
Symptoms pancreatic cancer - if body or tail?
o Abdominal pain – back, dull  Relieved by sitting forwards o Weight loss o Anorexia
117
Signs of pancreatic cancer?
``` o Jaundice o Palpable gallbladder o Epigastric mass o Hepatomegaly o Splenomegaly o Ascites ```
118
Bloods in pancreatic cancer?
o Cholestatic jaundice (rise in ALP and GGT) | o Ca19-9 raised
119
When to offer surveillance for pancreatic cancer?
o hereditary pancreatitis and a PRSS1 mutation o BRCA1, BRCA2, PALB2, or CDKN2A (p16) mutations, and one or more first-degree relatives with pancreatic cancer o Peutz-Jeghers syndrome
120
Referral for 2-week appointment in pancreatic cancer?
Aged >40 and jaundice
121
Consider direct access CT scan within 2 weeks in pancreatic cancer?
``` Consider an urgent direct access CT scan within 2 weeks, or an urgent ultrasound scan if CT is not available, if aged >60 with weight loss and any of the following: o diarrhoea o back pain o abdominal pain o nausea o vomiting o constipation o new-onset diabetes ```
122
Secondary care diagnosis of pancreatic cancer?
o Pancreatic protocol CT scan (chest, abdomen, pelvis) | o If unclear – PET/CT or EUS tissue sampling (FNA)
123
Staging of pancreatic cancer?
o If localised disease and having treatment – PET/CT | o MRI if liver metastases suspected
124
Management of pancreatic cancer - general measures?
o Nutrition  Enteric-coated pancreatin if unresectable or after resection of cancer o Pain Management  Opiates  If uncontrolled, opioid adverse effects: EUS-guided percutaneous neurolytic coeliac plexus block o Biliary Obstruction  Offer resectional surgery if possible  If unresectable – endoscopically placed self-expanding metal stent
125
Management of pancreatic cancer - resectable disease?
 Surgical excision (pancreaticoduodenectomy – Whipple’s) + lymphadenectomy
126
Management of pancreatic cancer - locally advanced?
 Chemotherapy |  Chemoradiotherapy
127
Management of pancreatic cancer - metastatic cancer?
 Chemotherapy • FOLFIRINOX • Gemcitabine  Stent insertion
128
Prognosis of pancreatic cancer?
o Mean survival 6 months
129
Definition of coeliac disease?
- T-cell mediated autoimmune disease of small bowel which glutens/prolamin (in wheat, barley, rye, oats) intolerance causes villous atrophy and malnutrition - Gliadin toxic part which leads to villous atrophy, crypt hyperplasia and increased intraepithelial lymphocytes - Mucosa improves when gluten removed - Called gluten-sensitive enteropathy
130
Epidemiology of coeliac disease?
- Incidence increasing with 1 in 300 people - Peaks in infancy, 50-60 but can occur at any age - Women 2>1 Male
131
Risk factors of coeliac disease?
``` o Genetic  HLA DQ2/8 o Familial o Autoimmune Disease  DM1, Thyroid disease, Addison’s ```
132
Symptoms of coeliac disease?
``` o Diarrhoea o Weight loss o Abdominal pain o Bloating o Nausea, vomiting o Foul-smelling stools o Steatorrhea o Malaise/Fatigue ```
133
Signs of coeliac disease?
o Anaemia (iron or B12) o Aphthous mouth ulcers o Angular stomatitis o Dermatitis herpatiformis
134
When to offer serological testing in coeliac disease?
o Persistent unexplained abdominal or GI symptoms o Faltering growth o Prolonged fatigue o Unexpected weight loss o Severe or persistent mouth ulcers o Unexplained iron, vitamin B12 or folate deficiency o T1DM o Autoimmune thyroid disease at diagnosis o IBS o 1st degree relatives with coeliac disease
135
what serological testing to perform in suspected coeliac disease?
Before testing, confirm patient eaten gluten at least 2x/day for last 6 weeks Antibodies  IgA tTGA (tissue transglutamase) • IgA EMA (endomysial) – 2nd line if IgA tTG weakly positive  Total IgA Bloods  FBC • Decreased Hb, ferritin, B12
136
When to refer patient suspected of coeliac disease?
Refer anyone with positive serological test result to GI specialist (or negative test but clinical suspicion) for: o Duodenal Endoscopy & Biopsy  Villous atrophy, Increased WBC, Crypt hyperplasia  Reverses upon cessation of gluten
137
Management of coeliac disease - annual review?
o Adherence to gluten-free diet o Measure BMI o Risk of osteoporosis o Consider FBC, coeliac screen, TFT, LFT, Vit D/B12, U&Es
138
Management of coeliac disease - management?
Lifelong gluten-free diet - IMPORTANT o Avoid food based on wheat, barley and rye  Bread, flour, cakes, pastries, biscuits  Foods-contained gluten (sausages, ready meals, soups, sauces) o Read food labels to check products suitable o Can prescribe gluten-free biscuits, flour, bread, pasta o Provide information – Coeliac UK
139
Management of coeliac disease - supplements?
o High-dose folic acid for women who are pregnant | o If deficient, folic acid, calcium, Vit D
140
Management of coeliac disease - Vaccines?
- Pneumococcal vaccine if hyposplenic
141
Management of coeliac disease - if refractory disease?
- If refractory coeliac disease – refer to specialist centre for treatment with prednisolone
142
Complications of coeliac disease?
``` o Anaemia o Lactose-intolerance o T-Cell lymphoma o Malignancy o Osteoporosis ```
143
Pathology of acute pancreatitis?
o Inappropriate activation of trysinogen into trypsin by lysosomal enzymes (cathepsin) o Activation leads to further activation and inflammation, oedema and necrosis o Damage causes by TNF-a and IL-1 o Neutrophil recruitment and inflammatory process leads to capillary permeability, ARDS, DIC, renal failure
144
Definitions of acute pancreatitis?
o Mild – Absence of complications or organ dysfunction o Moderate – Local complications and organ dysfunction resolved <48 hours o Severe – Persistent organ dysfunction often leading to necrosis and abscess/cysts
145
Epidemiology of acute pancreatitis?
- Increasing incidence | - 20% mortality, 80% mild
146
Causes of acute pancreatitis?
``` o Idiopathic o Gallstones o Ethanol o Trauma o Steroids o Mumps o Autoimmune o Scorpion bites o Hypercalcaemia, hyperlipidaemia o ERCP o Drugs – Oestrogens, azathioprin ```
147
Symptoms of acute pancreatitis?
o Severe, constant epigastric pain radiating to centre of back  Relieved by sitting forward o Nausea and vomit in
148
Signs of acute pancreatitis?
o Epigastric tenderness, guarding, rigidity o Tachycardia, fever, jaundice, shock, ileus o Cullen’s signs – periumbilical bruising o Grey Turner’s signs – flank bruising, retroperitoneal haemorrhage
149
Investigations of acute pancreatitis?
Check blood glucose and SpO2 Bloods o FBC (raised WCC), CRP, U&E, LFTs, Ca, glucose o Lipase – grossly raised >5x upper limit o Coagulation screen o Lactate if unwell o ABG Imaging o CXR o Contrast spiral CT scan to identify necrosis o ECG
150
Management of acute pancreatitis - severity assessment?
```  Glasgow modified criteria for severity  3 or more detected within 48h suggests severe disease and prompts transfer to ITU/HDU • PaO2 (<8kPa) • Age (>55) • Neutrophilia (>15x109/L) • Ca (<2mmol/L) • Renal function (Urea >16mmol/L) • Enzymes (LDH>600iu/L, AST>200iu/L) • Albumin (<32g/L) • Sugar (glucose>10mmol/L) ```
151
Management of acute pancreatitis - initial management?
 O2  IV access and IV fluids  IV analgesia (pethidine) and antiemetic (cyclizine 50mg)  IV Abx (Tazocin 4.5g IV)  NG if vomiting  If able to take oral intake, encourage - Enteral nutrition if moderate/severe acute pancreatitis  Urinary catheter and monitor UO  Consider insertion of central venous line  Contact HDU/ICU  May need endoscopic surgical debridement
152
Complications of acute pancreatitis?
o Early complications  Shock, ARDS, Renal failure, DIC, Sepsis, hypocalcaemia, high glucose o Late Complications  Pancreatic necrosis, pseudocyst, abscesses, bleeding, thrombosis, fistulae
153
Pathology of peritonitis? | Definition of peritonitis - primary?
o Omentum attempts to confine area by wrapping around infection o Adjacent bowel and fibrinous adhesions involved o If fails, generalised peritonitis occurs o Primary = inflammation occurs in peritoneum itself rather than as a result of pathology arising in another organ (SBP)
154
Definition of peritonitis -secondary?
o Secondary = Pathological process adjacent to peritoneum causes inflammation (perforated viscus)
155
Definition of peritonitis - localised?
o Localised = inflammation in limited area, such as adjacent to inflamed appendix/diverticulum
156
Definition of peritonitis - generalised?
o Generalised = Widespread inflammation
157
Definition of peritonitis - intra-abdominal sepsis?
o Intra-abdominal sepsis = intra-abdominal infection and encompasses localised and generalised peritonitis
158
Aetiology of peritonitis?
Upper GI - Malignancy, trauma, perforated peptic ulcer, iatrogenic (endoscopy) Lower GI - Ischaemic bowel, diverticulitis, hernia, obstruction, IBD, appendicitis, trauma Biliary - Cholecystitis, pancreatitis, endocarditis, malignancy GU - PID, malignancy
159
Symptoms of peritonitis?
``` o Abdominal pain  Poorly, localised initially  Worsening and more localised when infection spreads o Anorexia o Nausea and vomiting ```
160
Signs of peritonitis?
o Prostration (lying down stretched out) o Shock – hypotension, fever, hypothermia, tachycardia o Lying still o Tenderness (+/- rebound/percussion pain) o Board-like abdominal rigidity o Guarding o No bowel sounds
161
Investigations to perform in peritonitis?
Bloods o FBC, U&E, LFT, CRP, amylase and lipase, clotting, Ca o Cultures o Crossmatch/Group and Save ABG ECG + troponin if cardiac suspected Urinalysis + PREGNANCY TEST
162
Imaging to perform in peritonitis?
o Erect CXR o AXR o USS o CT scan if no delay
163
Initial management of peritonitis?
Bed Rest + NBM Treat Shock  IV 0.9% NaCl 500ml bolus NG Tube if severe vomiting, signs of obstruction or unwell and risk of aspiration Antibiotics  IV co-amoxiclav + metronidazole Analgesia  Morphine + Ondansetron/cyclizine Urgent surgical/gynaecological review
164
Further management of peritonitis?
- Laparoscopy/Laparotomy
Year 5 Core Conditions
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