GI Malignancies and Investigation of the GI Tract Flashcards Preview

ESA 3 - Gastrointestinal System > GI Malignancies and Investigation of the GI Tract > Flashcards

Flashcards in GI Malignancies and Investigation of the GI Tract Deck (188)
1

What are the common GI malignancies? 

Cancers of the;

  • Oesophagus
  • Stomach
  • Large intestine
  • Pancreas
  • Liver

 

2

What is the geographical epidemiology of oesophageal carcinoma? 

Wide geographical variation, with incidence low in USA, and high around Caspian sea and parts of China

3

What % of malignancies in the UK does oesophageal carcinoma constitute? 

2%

4

Is oesophageal carcinoma more prevalent in males or females? 

Males 

5

What are the clinical features of oesophageal carcinoma? 

  • Dysphagia 
  • Weight loss

 

6

What happens to the clinical features as an oesophageal carcinoma grows? 

It occludes the lumen and causes the progessive worsening of the dysphagia 

7

What investigations are conducted when an oesophageal carcinoma is suspected? 

  • Endoscopy 
  • Biopsy 
  • Barium

 

8

What is the most common type of oesophageal carcinoma? 

Squamous cell carcinoma 

9

Where does squamous cell carcinoma of the oesophagus occur? 

May occur at any level 

10

What is an uncommon type of oesophageal carcinoma?

Adenocarcinoma 

11

Where does adenocarcinoma of the oesphagus occur? 

Lower third

12

What is adenocarcinoma of the oesophagus associated with? 

  Barrett's oesophagus 

13

At what stage is oesophageal carcinoma at presentation? 

Advanced in most cases 

14

How does oesophageal carcinoma spread? 

Direct spread through the oesophageal wall 

15

What % of oesophageal carcinomas are resectable? 

40%

16

What is the prognosis of oesophageal carcinoma?

5% five year survival 

17

What is the second most common GI malignancy? 

Gastric cancer

18

How many new cases of gastric cancer are there in England and Wales each year? 

11,000

19

How common is gastric cancer? 

Common

20

What % of cancer deaths worldwide are accounted for by gastric cancer? 

15%

21

Is gastric cancer more common in men or women? 

Men 

22

What is the geographical epidemiology of gastric cancer?

Geographical variation, common in Japan, Columbia, and Finland 

23

What is gastric cancer associated with? 

Gastritis 

24

What blood group is gastric cancer commoner in? 

A

25

What is the problem with diagnosing gastric cancer? 

Symptoms are often vague 

26

What are the clinical features of gastric cancer? 

  • Epigastric pain 
  • Vomiting
  • Weight loss

 

27

What investigations are used in the diagnosis of gastric cancer? 

  • Endoscopy
  • Biopsy
  • Barium

 

28

What are the macroscopic features of gastric cancer? 

  • Fungating
  • Ulcerating
  • Infiltrative

29

What kind of gastric cancer shows infiltration macroscopically? 

Linitis plastica 

30

What are the intestinal microscopic features of gastric cancer? 

Variable degree of gland formation

31

What are the diffuse microscopic features of gastric cancer? 

Single cells and small groups, signet ring cells 

32

How far has early gastric cancer spread?

Confined to mucosa and sub-mucosa

33

What is the prognosis of early gastric cancer? 

Good

34

How far has advanced gastric cancer spread? 

Further spread

35

Where is advanced gastric cancer common?

UK

36

What is the 5 year survival rate for advanced gastric cancer? 

~10%

37

How does gastric cancer spread?

  • Direct
  • Lymph nodes 
  • Liver
  • Trans-coelomic

 

38

Where does gastric cancer spread directly? 

Through the gastric wall into duodenum, transverse colon, and pancreas

39

Where does gastric cancer spread trans-coelomically? 

  • Peritoneum
  • Ovaries

40

Describe the development of advanced gastric cancer from normal gastric mucosa

  1. Normal gastric mucosa
  2. H. Pylori infection 
  3. Acute gastritis 
  4. Chronic active gastritis 
  5. Atrophic gastritis 
  6. Intestinal metaplasia 
  7. Dysplasia 
  8. Advanced gastric cancer 

 

41

What is cancer generally associated with? 

Chronic inflammation

42

Where is gastric cancer common? 

Countries with high H. Pylori prevalence 

43

Give an example of a country where gastric cancer is common due to high H. Pylori prevalence

Columbia

44

What supports the association between H. Pylori and gastric cancer? 

Serological and epidemiological evidence 

45

What is the most common GI lymphoma? 

Gastric lymphoma 

46

What does gastric lymphoma start as? 

A low-grade lesion

47

What is gastric lymphoma strongly associated with? 

H. Pylori

48

What may eradication of H. Pylori lead to in gastric lymphoma? 

Regression of tumour

49

How does the prognosis of gastric lymphoma differ from that of gastric cancer? 

It is much better for gastric lymphoma 

50

How common are gastrointestinal stromal tumours? 

Uncommon

51

What are gastrointestinal stromal tumours derived from? 

Interstitial cells of Cajal

52

What is the causative mutation in gastrointestinal stromal tumours? 

C-kit (CD117)

53

What is the result of the CD117 mutation in gastrointestinal stomal tumours? 

It makes it vulnerable to targeted treatment 

 

54

What behaviour do gastrointestinal stromal tumours display? 

Unpredictable; 

  • Pleomorphism
  • Mitoses
  • Necrosis

55

What are the types of tumours of the large intestine? 

  • Adenomas
  • Adenocarcinomas
  • Polyps
  • Anal carcinoma

56

What are the types of large intestine adenomas? 

  • Dysplasia 
  • Familial Adenomatous Polyposis (FAP)
  • Gardner's Syndrome

 

57

What is large intestinal dysplasia? 

Benign, neoplastic lesions in the large bowel

58

What are the macroscopic features of large intestinal dysplasia? 

Sessile or pendunculated 

59

What are the microscopic features of large intestinal dysplasia? 

Variable degree of dysplasia 

60

What is the clinical relevance of large intestinal dysplasia? 

Malignant potential 

61

What happens to incidence of large intestinal dysplasia in western populations? 

It increases with age 

62

What kind of syndromes are large intestinal dysplasia? 

Genetic

63

What is the inheritance pattern of familial adenomatous polyposis (FAP)? 

Autosomal dominant condition 

64

Where is the FAP mutation? 

Chromosome 5

65

What happens in a patient with FAP by the time they are 20? 

There are 1000's of adenomas in the large intestine, giving a high risk of cancer 

66

What is Gardner's syndrome? 

A similar condition to FAP, with bone and soft tissue tumours 

67

What is the most common GI malignancy? 

Colorectal cancer 

68

How many new cases of colorectal cancer are reported each year in England and Wales? 

~25,000 

69

What are the macroscopic features of colorectal cancer?

60-70% cases are rectosigmoid fungating/stenotic 

70

What are the microscopic changes seen in colorectal cancer? 

  • Mucinous
  • Signet ring cell type 

71

How do the microscopic changes differ between different colorectal adenocarcinomas? 

They are moderately different 

72

How does colorectal cancer spread? 

  • Direct through bowel wall to adjacent organs (e.g. bladder)
  • Via lymphatics to mesenteric lymph nodes 
  • Via portal venous system to liver 

 

73

What staging systems are used for colorectal cancer? 

  • Dukes
  • TMN

 

74

What are the stages in Duke's staging? 

  • A - Confined to bowel wall 
  • B - Through wall, but lymph nodes clear 
  • C - Lymph node involvement 
    • C1 - Highest node clear 
    • C2 - Highest node involved 

 

75

What are the mutations found in colorectal cancer? 

  • Chromosome 5 (in FAP related colorectal cancer) 
  • Ras mutations
  • p53 loss/inactivation

 

76

At what age does incidence of colorectal cancer peak? 

60-70

77

What is the geographical epidemiology of colorectal cancer? 

  • High in UK and USA
  • Low in Japan

 

78

What conditions increase the incidence of colorectal cancer? 

  • Polyposis syndromes
  • UC and Crohns

 

79

What is the aetiology of colorectal cancer?

  • Low residue diet
  • Slow transit time
  • High fat intake
  • Genetic predisposition 

 

80

What is the outcome of colorectal cancer?

Survival time reduces with increasing Duke's staging

81

Where does colorectal cancer frequently metastasise to in its advanced stages? 

Liver

82

Other than adenomas, what are the types of large intestine tumours? 

  • Carcinoid tumour 
  • Lymphoma
  • Smooth muscle/stromal tumours 

83

What kind of tumours are carcinoid tumours of the large intestine? 

Neuro-endocrine tumours

84

What kind of behaviour do large intestinal carcinoid tumours display? 

Unpredictable 

85

How common are large intestinal carcinoid tumours? 

Rare

86

Where do lymphomas of the large intestines originate from? 

May be primary, or spread from elsewhere

87

How common are lymphomas of the large intestine? 

Rare

88

How common are large intestinal smooth muscle/stromal tumours? 

Rare

89

What behaviour do large intestinal smooth muscle/stromal tumours display? 

Unpredictable 

90

What proportion of pancreas carcinomas are found in the head? 

2/3 

91

What is the morphology of pancreatic carcinomas? 

Firm pale mass with a necrotic centre 

92

Where may pancreatic carcinomas infiltrate?

Adjacent structures, e.g. the spleen

93

What is the most common carcinoma of the pancreas? 

Ductal adenocarcinomas

94

What % of pancreatic carcinomas are ductal adenocarcinomas?

80%

95

How do pancreatic carcinomas appear histologically? 

Well formed glands 

96

What do some pancreatic acinar tumours have histologically? 

Zymogen granules 

97

What is the prognosis for pancreatic carcinomas? 

Poor 

98

What hapens in carcinoma of the Ampulla of Vater? 

The bile duct is blocked with only a small tumour

99

What does carcinoma of the Ampulla of Vater lead to? 

Jaundice

100

What is the prognosis for carcinoma of the Ampulla of Vater?

Good, because blockage leads to early presentation when the tumour is still treatable

101

How common are islet cell tumours? 

Rare

102

What are the types of islet cell tumours? 

  • Insulinoma
  • Glycagonoma
  • Vasoactive Intestinal Peptideoma (VIPoma)
  • Gastrinoma

 

103

What does an insulinoma lead to? 

Hypoglycaemia 

104

What does glycagonoma lead to? 

Characteristic skin rash

105

What does vasoactive intestinal peptideoma lead to? 

Werner Morrison syndrome

106

What does gastrinoma lead to? 

Zollinger-Ellison syndrome

107

Give 3 benign tumours of the liver

  • Hepatic adenoma
  • Bile duct adenoma/hamartoma
  • Haemangioma

 

108

How common are benign tumours of the liver? 

Fairly rare 

109

Give 3 malignant tumours of the liver

  • Hepatocellular carcinoma
  • Cholangiocarcinoma
  • Hepatoblastoma

 

110

How many new cases of colorectal cancer are there in England and Wales per year? 

25,000

111

How many new cases of stomach cancer are there in England and Wales per year? 

11,000

112

How many new cases of pancreatic cancer are there in England and Wales per year?

5,500

113

What investigations are used to investigate the abdomen?

  • Plain x-rays
  • Contrast studies
  • Ultrasound
  • Cross-setional imaging
  • Angiography 

114

What type of x-rays are used to investigate the abdomen? 

  • Abdominal x-ray (AXR)
  • Erect chest x-ray (CXR) 

 

115

What kind of contrast studies are used to investigate the abdomen? 

  • Barium swallow
  • Barium enema
  • Barium meal/follow through
  • Water soluble contrast studies 

 

116

What kind of cross-sectional imaging techniques are used to investigate the abdomen? 

  • Computed tomography (CT) 
  • Magnetic resonance imaging (MRI)

 

117

How big is the dose of radiation given by the techniques used to investigate the abdomen?

Varies considerably

118

Which techniques for investigation of the abdomen don't use any radiation? 

  • Ultrasound
  • MRI

 

119

Which technique used to investigate the abdomen can deliver a high dose of radiation? 

CT scan

120

How does the radiation dosage given during a CT scan differ from that of an abdominal x-ray? 

Can be up to 15x the dose 

121

What are the potential risks of radiation? 

  • Carcinogenesis
  • Genetic
  • Developmental risk to foetus 

 

122

What are contrast studies used to define? 

Hollow viscera

123

What contrast is used in studies? 

  • Barium
  • Water soluble contrast (typically containing iodine) 

 

124

What are the common types of GI contast studies? 

  • Swallow
  • Meal 
  • Follow through 
  • Enema 

 

125

What is a barium enema? 

A barium study where the contrast medium is inserted rectally 

126

What does a barium enema enable?

The colon to be visualised 

127

What does ultrasound utilise to generate images? 

Sound waves 

128

What frequency sound waves are used in ultrasound? 

Usually 2-18MHz

129

What are the advantages of ultrasound? 

  • Cheap compared to CT and MRI
  • Portable 

 

130

What is the disadvantage of ultrasound?

It is highly user dependant 

131

What can an abdominal ultrasound be used to do?

  • Determine if the patient has gallstones, or if the common bile duct is dilated 
  • Can view liver and portal vein, even the appendix

132

What is the dilation of the common bile duct an indicator of? 

That there is an impacted gallstone in the duct 

133

What is the problem with abdominal ultrasounds with the aim to view the liver and portal vein? 

The scans are often difficult to interpret, and the usefulness of a scan is often down to who is doing and interpreting the scan 

 

134

What technique is used to visualise the blood supply to the GI tract? 

GI angiography

135

When is being able to visualise the blood supply to the GI tract very useful? 

For bleeding and ishchaemia 

 

136

How is GI angiography conducted? 

By injecting a radio-opaque contrast agent intravenously, and then using various modalities to capture the images 

137

What is shown in this GI angiogram?

The aorta, with the coelic trunk, and superior mesenteric arteries and its branches. The inferior mesenteric artery and it's branches are harder to see 

138

What structures are visable in an abdominal x-ray? 

  • Stomach
  • Small and large bowel 
  • Soft tissues 
    • Liver
    • Spleen
    • Kidneys
    • Psoas muscles
    • Bladder
    • Lung bases
  • Bones 

 

139

When is a part of a hollow tube visible on an x-ray? 

If it is filled with gas 

140

Why are parts of a hollow tube filled with gas visible on an x-ray? 

Low density gas acts as contrast 

141

When are lumens not visible on abdominal x-rays? 

When they are fully fluid filled 

142

When is the ability to visualise gas filled areas on an abdominal x-ray useful? 

Can be used to visualise the stomach (if gas filled), but more commonly used to visualise the small bowel 

143

What are the common reasons for requesting a plain abdominal radiograph? 

  • Acute abdominal pain 
  • Small or large bowel obstruction 
  • Acute exacerbation of IBD
  • Renal colic

144

What abnormalities can be shown on an abdominal x-ray? 

  • Small bowel obstruction 
  • Large bowel obstruction 
  • Volvulus 
  • Chronic pancreatitis 
  • Aneurysms with calcification 
  • Nodes 
  • Bones 
  • Artifacts 
  • Foreign bodies 
  • Kidney stones 

 

145

What position does the small bowel usually occupy on the abdominal x-ray? 

Central position 

146

What can the small bowel display on an x-ray? 

'Circular folds', or valvulae conniventes 

147

How do valvulae conniventes appear on x-rays? 

As lines that appear to cross the whole of the bowel lumen

 

148

What is this x-ray image showing? 

 

The large bowel

149

What position does the large bowel usually occupy on an x-ray? 

A more peripheral position 

150

What is it often possible to see on an x-ray of the larg bowel? 

  • Haustra 
  • Faeces

 

151

How do haustra appear on an abdominal x-ray? 

As incomplete lines going across the lumen

152

How do faeces appear on an abdominal x-ray of the large bowel? 

Like clouds in the lumen 

153

What rule do small and large bowel obstructions follow? 

3/6/9

154

What is the 3/6/9 rule? 

  • A small bowel is said to be dilated when it is greater than 3cm diameter 
  • The large bowel is said to be dilated when its greater than 6cm diameter 
    • The caecum (when the ileoceacal valve is working) is said to be dialted when it is greater than 9cm diameter 

155

What is it important to check when applying the 3/6/9 rule? 

That the x-ray is shown to scale 

156

What is this image showing? 

 

A small bowel obstruction 

157

How does a small bowel obstruction usually present? 

  • Vomiting (early)
  • Mild distention 
  • Absolute constipation (late feature)
  • Colicky pain that presents every 2-3 minutes 

 

158

What is meant by absoloute constipation? 

Not passing anything per rectum, even flatus 

159

Why do you vomit early, and experience constipation late, with a small bowel obstruction? 

Because the obstruction is nearer the mouth than a large bowel obstruction 

160

What can cause a small bowel obstruction? 

  • Adhesions 
  • Hernias 
  • Tumours 
  • Inflammation 

 

161

What kind of hernias can cause a small bowel obstruction? 

  • Inguinal 
  • Femoral 
  • Incisional 

 

162

What is this image showing? 

 

A large bowel obstruction 

163

How does a large bowel obstruction appear on an abdominal x-ray? 

  • More at the periphery of the x-ray
  • Lines going across the lumen (haustra) are incomplete 

 

164

How does a large bowel obstruction present? 

  • Abdominal pain
  • Distention
  • Constipation (early feature) 
  • Colicky pain 
  • Vomiting (late feature)

165

How does the colicky pain present with a large bowel obstruction differ from that with a small bowel obstruction? 

It is not as frequent, being experienced every 10-15 minutes 

166

What is a feature of vomiting in large bowel obstructions? 

Can be faeculant 

167

What are the causes of a large bowel obstruction? 

  • Colorectal carcinoma 
  • Diverticular stricture 
  • Hernia 
  • Volvulus 
  • Psuedo-obstruction 

 

168

What is a volvulus? 

When a viscera twists around itself, or more commonly when it twists around its mesentery 

169

What is the most common volvulus? 

Sigmoid volvulus 

170

What is a more rare type of volvulus? 

Caecal volvulus 

171

What is the consequence of twisting in a volvulus? 

The enclosed loop of bowel dilates, and is at risk of perforating or cutting of its blood supply (which runs in the mesentery) 

172

What is this arrow showing? 

 

Chronic pancreatitis 

173

When can an erect chest x-ray be useful? 

In diagnosing a perforated bowel 

174

What can cause a perforated bowel? 

  • Peptic ulcer 
  • Diverticular disease 
  • Tumour 
  • Obstruction 
  • Trauma 
  • Iatrogenic 

 

175

Why does the CXR need to be erect when trying to diagnose a perforated bowel 

Because you are looking for the diaphragm to be elevated away from any other viscera (the liver on the by the presence of air/gas in the peritoneal cavity. The air/gas will rise to the top of the cavity and so the patient needs to be sat up for 10 minutes prior to the x-ray to ensure this happens 

176

Why is a raised diaphragm indicative of a perforated bowel? 

The peritoneal cavity normally only contains a small amount of fluid, so the presence of air/gas is abnormal and could be the result of a perforated bowel 

177

What does an x-ray of a raised diaphragm look like? 

178

What does an abdominal CT use? 

  • High dose radiation 
  • IV or oral/rectal contrast 

 

179

How does the resolution of an abdominal CT differ from that of a MRI? 

  • Good spatial resolution
  • Poor contrast resolution 

 

180

Draw a diagram illustrating the planes of view that can be acheived by an abdominal CT

181

Label this transverse abdominal CT

 

  • A - Liver 
  • B - Stomach 
  • C - Oesophagus 
  • D - Spleen

 

182

Label this coronal abdominal CT

 

  • A - Right crus 
  • B - Oesophagus 
  • C - Stomach (fundus)
  • Aorta 

 

183

Label this sagittal abdominal CT

 

  • A - Right crus of diaphragm 
  • B - Celiac artery 
  • C - Superior mesenteric artery 
  • D - Oesophagus 
  • E - Aorta 

184

Does MRI imaging use radiation? 

No 

185

What is the advantage of MRI imaging? 

Good spatial and contrast resolution 

186

What is the disadvantage of MRI imaging? 

Time consuming 

187

What is a magnetic resonance cholangio-pancreatogram (MRCP)?

A MRI scan that can visualise the gallbladder and bilary tree 

188

Label this diagram

 

  • A - Gall bladder
  • B - Stone in gall bladder 
  • C - Stone in bile duct 
  • D - Bile duct