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35 Cards in this Set
- Front
- Back
What is the fourth leading cause of cancer related deaths in the US?
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Pancreatic cancer
85% are adenocarcinomas arising from ductal epithelium Mortality rates closely follow incidence rates |
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What are risk factors for pancreatic cancer?
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Genetics
Diabetes mellitus Cigarette smoking Obesity Alcohol/diet/aspirin/NSAIDS??? |
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What is the patient presentation for pancreatic cancer?
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Abdominal pain - upper abdomen, radiates to back, made worse with eating
Weight loss - associated with anorexia, early satiety, steatorrhea Jaundice - painful or painless, pruritus, alcoholic stools, dark urine |
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How can symptoms help determine location in pancreatic cancer?
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Body or tail - pain and weight loss
Head - steatorrhea, weight loss, jaundice |
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What is seen on physical exam for pancreatic cancer?
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Ascites
An abdominal mass Nontender but palpable gallbladder (Courvoisier's sign) Left supraclavicular lymphadenopathy (Virchow's node) |
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How is pancreatic cancer diagnosed?
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1. CA 19-9 (not as initial test; monitors cancer progress)
2. Helical CT scan with contrast - preferred for diagnosis, assess resectability, and staging 3. Endoscopic ultrasound (EUS) - dilated bile ducts or presence of mass in head of pancreas; biopsy 4. Endoscopic retrograde cholangiopancreatography (ERCP) - stricture or obstruction of common bile and pancreatic duct "double duct) sign; biopsy 5. MR cholangiopancreatography (MRCP) - anatomy of biliary tree and pancreatic duct, evaluate above and below a stricture, identify intrahepatic mass lesions |
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How is pancreatic cancer treated?
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Surgery - only 15-20% pts are candidates; Whipple procedure
Palliation: chemotherapy, radiation, chemoradiotherapy stent placement (to keep biliary ducts open; reduce jaundice) pain control, depression, nutrition If a pt is having steatorrhea, 90% of pancreas is not working |
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What are causes of upper GI bleed?
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Peptic ulcer disease (>50%) - gastric more common than duodenal
Esophageal varices 90% of upper GI bleeds undergo endoscopy within 24 hrs of hospitalization for direct visualization |
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What is the patient presentation for upper GI bleed?
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Hematemesis (red blood or coffee-ground) - bleeding proximal to ligament of Treitz
Melena (dark tarry stool) - bleeding proximal to ligament of Treitz PMH - liver disease, peptic ulcer disease, alcohol abuse Medications - aspirin, NSAIDS |
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In an upper GI bleed, the patient may present as bleeding with...(5)? What does each indicate?
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Epigastric or RUQ pain - peptic ulcer
Odynophagia, GERD, dysphagia - esophageal ulcer Emesis, retching, or coughing prior - Mallory-Weiss tear Jaundice, weakness, fatigue, anorexia, abdominal distention - esophageal varices Dysphagia, early satiety, involuntary weight loss, cachexia - malignancy |
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What is seen on physical exam of upper GI bleed?
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Abdominal pain with rebound and guarding
Rectal exam - stool color and guaiac testing Hemodynamic stability: mild to moderate hypovolemia - resting tachycardia blood volume loss at least 15% - orthostatic hypotension blood volume loss at least 40% - supine hypotension |
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How is an upper GI bleed triaged?
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1. Fluid resuscitation - 2 large bore IV lines with rapid infusion of saline
2. Blood transfusion - hemoglobin around 7-8g/dL; packed RBCs or FFP; initial hematocrit does not accurately reflect degree of blood loss 3. Medications - PPI: significantly reduces rebleeding risk 4. Consultation - gastroenterologist; surgeon 5. Nasogastric tube - get contents out of stomach, also tells how much they are bleeding 6. Oxygen 7. Admit to ICU |
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How is an upper GI bleed diagnosed?
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Upper endoscopy - contraindicated in uncooperative pt or pt with suspected perforation
Angiography Technetium-99m sulfur colloid scans - tagged red blood scan Upper GI barium studies contraindicated |
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When are esophageal varices seen?
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Develops as a consequence of portal hypertension - alcoholic liver disease; chronic active hepatitis
1/4 - 1/3 of all pts with cirrhosis will have variceal hemorrhage at least once in lifetime |
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How are esophageal varices treated?
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Active bleeding:
1. Medications - vasopressin and terlipressin; somatostatin and octreotide 2. Endoscopy (definitive treatment of choice) - sclerotherapy; variceal band ligation 3. Balloon tamponade 4. Surgery - pts with well preserved liver function, failed endoscopy (portacaval shunt, splenorenal shunt, TIPS) Prophylactic: Medications to decrease hypertension (propanolol, nadolol) |
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What are causes of lower GI bleed?
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Anatomic - diverticulosis
Vascular - angiodysplasia, ischemic, radiation-induced Inflammatory - infectious or inflammatory colitis Neoplastic |
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What is the patient presentation for lower GI bleed?
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Painless
Hematochezia - passage of maroon (rt colon), bright red blood (lt colon), or blood clots per rectum Rapid transit of blood can appear bright red Originates from site distal to ligament of Treitz |
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How is a lower GI bleed triaged?
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1. Fluid resuscitation - 2 large bore IV lines with rapid infusion of saline (18 gauge or larger)
2. Blood transfusion |
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How is a lower GI bleed diagnosed?
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Guaiac testing (hemoccult)
Nasogastric lavage - exclude upper GI cause Colonoscopy - localize site, collect specimens, therapeutic intervention Angiography Technetium-99m sulfur colloid scans Barium studies have no role |
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What is the most common cause of lower GI bleed?
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Diverticular bleed
Located in colonic wall at sites of penetration of vessels Artery ruptures into diverticular sac Faucet "on and off" bleed |
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What is the most frequent congenital anomaly of the GI tract?
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Meckel's Diverticulum
Typically occurs in childhood |
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What is the rule of twos for Meckels?
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Occurs in 2% of pop
2:1 Male to female ratio Found within 2 feet of ileocecal valve 2 inches long 2% develop complication over course of life |
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What is the pt presentation, diagnosis, and treatment for Meckels?
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Presentation: asymptomatic, painless bleeding
Diagnosis: Meckel scan (nuclear study) - improved results with administration of H2 blocker 24-48hrs before test Treatment: excision |
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What are the non-neoplastic polyps:
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Hyperplastic (most common) - histologically have serrated pattern; proximal lesions can progress to cancer
Mucosal Inflammatory Submucosal (lipomas, leiomyomas, hemangiomas, fibromas) - lipoma most common; yellow color and softness "pillow sign" |
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What are the neoplastic polyps?
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Serrated - hyperplastic, sessile, serrated adenomas
Hamartomatous - juvenile, Peutz-Jeghers Adenomatous - very similar appearance to hyperplastic; >1cm have higher risk of malignancy, about 2/3 of all colonic polyps, 7-10 yrs to progress to cancer |
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What is the pt presentation and detection/treatment of colonic polyps?
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Presentation: asymptomatic, small polyps (>1cm) typically don't bleed
Detection/treatment: colonoscopy (up to 27% miss rate); polypectomy (biopsy forceps, snare excision, piecemeal excision, dissection, resection) |
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What are the guidelines for surveillance of colonic polyps?
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Hyperplastic polyps - considered to have normal colonoscopy, repeat in 10 yrs
1-2 small adenomas (including low-grade dysplasia) - repeat in 5-10 yrs 3-10 adenomas, adenoma >1cm, adenoma with villous features or high grade dysplasia - repeat in 3 yrs |
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What is the third most common cause of cancer in the US?
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Colon cancer
Incidence increases with age (>40) Gradual shift toward right-sided or proximal colon cancers (improvement in diagnosis and screening of left-sided) |
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What are sites of metastasis for colon cancer?
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Regional lymph nodes
Bone Brain Liver Lungs Peritoneum |
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What are risk factors for colon cancer?
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Hereditary - FAP, Lynch Syndrome
Family history IBD - UC, CD Ethnicity and gender - African Am. 20%, men 25% Diabetes mellitus and insulin resistance Alcohol use and cigarettes Obesity Red meat consumption Bacterial infection (Strep. bovis) Vitamin D deficiency |
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What are protective factors for colon cancer?
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Physical activity
Diet - high in fruits and vegetables Fiber Folate, Vitamin B6, Calcium Garlic consumption Omega 3 fatty acids Aspirin and NSAIDS |
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What is the pt presentation for colon cancer?
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Symptoms usually mean advanced disease
Hematochezia or melena Change in bowel habits (more common for left-sided) Abdominal pain Abdominal distention Weight loss Nausea and vomiting |
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What is the pathology and diagnosis for colon cancer?
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Path = adenocarcinomas
Colonoscopy Air contrast barium enema w/ flexible sigmoidoscopy Double contrast barium enema CT colonography Capsule colonoscopy |
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What is the treatment for colon cancer?
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Surgical resection
Sentinel node mapping Regional lymphadenectomy (at least 12 nodes) Chemotherapy Radiation therapy Chemoradiotherapy |
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What are the guidelines of surveillance for colon and rectal cancer?
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Colonoscopy 3-6 months after resection for clearance of synchronous disease
Colonoscopy at 1 yr post-resection or 1 yr post clearance If normal at 1 yr, repeat in 3 yrs If normal at 3 yrs, repeat in 5 yrs |