Clinical Considerations In Patient With Abdominal Pain Ii

Front 1

What is the fourth leading cause of cancer related deaths in the US?

Back 1

Pancreatic cancer
85% are adenocarcinomas arising from ductal epithelium
Mortality rates closely follow incidence rates

Front 2

What are risk factors for pancreatic cancer?

Back 2

Genetics
Diabetes mellitus
Cigarette smoking
Obesity
Alcohol/diet/aspirin/NSAIDS???

Front 3

What is the patient presentation for pancreatic cancer?

Back 3

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

Front 4

How can symptoms help determine location in pancreatic cancer?

Back 4

Body or tail - pain and weight loss
Head - steatorrhea, weight loss, jaundice

Front 5

What is seen on physical exam for pancreatic cancer?

Back 5

Ascites
An abdominal mass
Nontender but palpable gallbladder (Courvoisier's sign)
Left supraclavicular lymphadenopathy (Virchow's node)

Front 6

How is pancreatic cancer diagnosed?

Back 6

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

Front 7

How is pancreatic cancer treated?

Back 7

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

Front 8

What are causes of upper GI bleed?

Back 8

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

Front 9

What is the patient presentation for upper GI bleed?

Back 9

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

Front 10

In an upper GI bleed, the patient may present as bleeding with...(5)? What does each indicate?

Back 10

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

Front 11

What is seen on physical exam of upper GI bleed?

Back 11

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

Front 12

How is an upper GI bleed triaged?

Back 12

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

Front 13

How is an upper GI bleed diagnosed?

Back 13

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

Front 14

When are esophageal varices seen?

Back 14

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

Front 15

How are esophageal varices treated?

Back 15

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)

Front 16

What are causes of lower GI bleed?

Back 16

Anatomic - diverticulosis
Vascular - angiodysplasia, ischemic, radiation-induced
Inflammatory - infectious or inflammatory colitis
Neoplastic

Front 17

What is the patient presentation for lower GI bleed?

Back 17

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

Front 18

How is a lower GI bleed triaged?

Back 18

1. Fluid resuscitation - 2 large bore IV lines with rapid infusion of saline (18 gauge or larger)
2. Blood transfusion

Front 19

How is a lower GI bleed diagnosed?

Back 19

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

Front 20

What is the most common cause of lower GI bleed?

Back 20

Diverticular bleed
Located in colonic wall at sites of penetration of vessels
Artery ruptures into diverticular sac
Faucet "on and off" bleed

Front 21

What is the most frequent congenital anomaly of the GI tract?

Back 21

Meckel's Diverticulum
Typically occurs in childhood

Front 22

What is the rule of twos for Meckels?

Back 22

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

Front 23

What is the pt presentation, diagnosis, and treatment for Meckels?

Back 23

Presentation: asymptomatic, painless bleeding
Diagnosis: Meckel scan (nuclear study) - improved results with administration of H2 blocker 24-48hrs before test
Treatment: excision

Front 24

What are the non-neoplastic polyps:

Back 24

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"

Front 25

What are the neoplastic polyps?

Back 25

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

Front 26

What is the pt presentation and detection/treatment of colonic polyps?

Back 26

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)

Front 27

What are the guidelines for surveillance of colonic polyps?

Back 27

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

Front 28

What is the third most common cause of cancer in the US?

Back 28

Colon cancer
Incidence increases with age (>40)
Gradual shift toward right-sided or proximal colon cancers (improvement in diagnosis and screening of left-sided)

Front 29

What are sites of metastasis for colon cancer?

Back 29

Regional lymph nodes
Bone
Brain
Liver
Lungs
Peritoneum

Front 30

What are risk factors for colon cancer?

Back 30

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

Front 31

What are protective factors for colon cancer?

Back 31

Physical activity
Diet - high in fruits and vegetables
Fiber
Folate, Vitamin B6, Calcium
Garlic consumption
Omega 3 fatty acids
Aspirin and NSAIDS

Front 32

What is the pt presentation for colon cancer?

Back 32

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

Front 33

What is the pathology and diagnosis for colon cancer?

Back 33

Path = adenocarcinomas
Colonoscopy
Air contrast barium enema w/ flexible sigmoidoscopy
Double contrast barium enema
CT colonography
Capsule colonoscopy

Front 34

What is the treatment for colon cancer?

Back 34

Surgical resection
Sentinel node mapping
Regional lymphadenectomy (at least 12 nodes)
Chemotherapy
Radiation therapy
Chemoradiotherapy

Front 35

What are the guidelines of surveillance for colon and rectal cancer?

Back 35

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