Medicine GI

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jstaylor
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235028
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Medicine GI
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2013-10-26 18:01:34
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Medicine GI
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  1. Colorectal Cancer
    -epidemiology
    • EPIDEMIOLOGY:
    • -third most common CA in USA in men and women
    • -majority are adenocarcinomas (other rare types include carcinoid, lymphoma, kaposi's sarcoma)
  2. Colorectal cancer
    SCREENING:
    • 1. FOBT (poor SN and SP, PPV 20%)
    • 2. DRE (only 10% palpable rectally)
    • 3. Colonoscopy (most SN and SP!)
    • 4. Flex Sig (60cm scope, reach 50-70% of polyps)
    • 5. Barium Enema (entire colon, need colonoscopy for any abnl finding)
    • 6. CEA (not useful for screening, prognostic)
  3. Colorectal Cancer
    RISK FACTORS:
    • -Age >50y
    • -Adenomatous polyps (premalignant lesions, most do not develop into CA, villous > tubular)
    • -IBD (UC>CD)
    • -FHx
    • -Diet (high fat, low fiber)
    • -Major Polyposis syndromes
  4. Colorectal Cancer
    -detailed screening guidelines
    • AVERAGE RISK:
    • -FOBT yearly after 50
    • -Flex sig or BE q3-5y after 50
    • -Colonoscopy q10y after 50

    • INCREASED RISK (FAP):
    • -Flex sig q1y after puberty

    • HNPCC:
    • -colonoscopy q1-2y after 8 yrs of disease (after 15 yrs if only L-sided colitis)

    • 1st DEGREE RELATIVE W/ CRC:
    • -same as average risk but begin at age 40 or 10y before family member presented

    • HISTORY OF ADENOMATOUS POLYP:
    • -colonoscopy in 1-3y if multiple or advanced
    • -colonoscopy in 5y if small (<1cm)
  5. Colorectal Cancer
    -pathogenesis
    -pattern of spread
    -clinical features
    • PATHOGENESIS:
    • -virtually all arise from adenomas
    • -most are endoluminal adenocarcinomas that arise from the mucosa
    • -villous polyps more commonly transform than tubular polyps
    • -red meat and animal fat promote bacterial strains that produce carcinogens (vit A, C, E may inactivate, broccoli, turnips and cauliflower induce benzpyrene hydroxylase which also inactivates)

    • PATTERN OF SPREAD:
    • 1. Hematogenous
    •      -portal circulation to Liver
    •      -LV most common site of distant spread
    •      -lumbar/vertebral veins to lungs
    • 2. Lymphatic
    • 3. Transperitoneal and intraluminal

    • CLINICAL FEATURES:
    • -sxs usually only with advanced disease
    • -hematochezia/iron deficiency anemia
    • -change in bowel habits
    • -abdominal pain (most common presenting sx, caused by obstruction or peritoneal dissemination)
    • -weight loss
  6. Colorectal Cancer:
    -Right Sided Tumor Symptoms
    • COMMON:
    • -occult blood in stool
    • -iron deficiency anemia
    • -melena

    • UNCOMMON:
    • -change in bowel habits
    • -obstruction unusual (larger luminal diameter)

    • TRIAD:
    • 1. anemia
    • 2. weakness
    • 3. RLQ mass
    • **only occasionally all present
  7. Colorectal Cancer:
    -Left Sided Tumor Symptoms
    • COMMON:
    • -more ostruction (smaller lumen)
    • -common changes in bowel habits (constipation/diarrhea, narrow stool caliber)
    • -hematochezia
  8. Colorectal Cancer:
    -Rectal Cancer Symptoms
    20-30% of CRC

    • -Hematochezia (most common sx)
    • -Tenesmus
    • -Rectal mass, feeling of incomplete stool
  9. Colorectal Cancer
    -Staging and Prognosis
    • -obtained via CT scan and CXR
    • -90% of recurrences occur within 3y of surgery

    • STAGE A:
    • -confined to mucosa and submucosa (leads to stage I: T1-2, N0, M0)
    • -5ys = >80%

    • STAGE B:
    • -Invasion of muscularis propria (leads to stage II: T3-4, N0, M0)
    • -5ys = 60% (70%)

    • STAGE C:
    • -Local node involvement (leads to stage III: T any, N1-N3, N0)
    • -5ys = 20% (40%)

    • STAGE D:
    • -distant metastases (leads to stage IV: M1)
    • -5ys = 3% (5%)
  10. Colorectal Cancer
    -treatment
    • -only curative tx = surgery (bowel + lymphatics)
    • -CEA level used as prognostic factor (obtain before surgery)

    • SURGERY:
    • *stage A and B (50% cured)
    • -partial colectomy
    • -only cures 35-40% LN positive CRC (add chemo 5-FU)

    • RADIATION:
    • *only in rectal
    • -colon cancer: adjuvant rad with chemo commonly offered in T4 cases
    • -rectal cancer: adjuvant rad + chemo enhances cure rates in transumural or LN positive

    • CHEMOTHERAPY:
    • *5FU and levimasole for B at high risk and all C and D
    • -5-FU +/- leucovorin
    • -irinotecan
    • -oxaliplatin
    • -controversial in LN negative
    • -palliative chemo in metastatic disease (5-FU)

    • FOLLOW-UP:
    • -stool guaiac
    • -annual CT and CXR x 5yrs
    • -Colonoscopy at 1y, then q3y
    • -CEA levels every 3-6mo
  11. Colorectal Cancer
    -CEA
    CEA levels are not useful for diagnosis but are useful for prognosis

    Increase in CEA after surgery is a sensitive marker of recurrence

    Very high CEA elevation suggest liver involvement
  12. Benign Tumors of the Colon (Polyps)
    -epidemiology
    -histologic types
    -clinical features
    • EPIDEMIOLOGY:
    • -5-10% of ppl >40y
    • -most non-malignant

    • HISTOLOGIC TYPES:
    • 1. Adenomatous
    •      -precursor to adenocarcinoma
    •      -risk increases when >2cm
    •      -risk increases with villous vs tubular
    •      -risk increases with sessile vs pedunculated
    • 2. Hyperplastic
    •      -non-malignant
    •      -mostly left sided (rectosigmoid)
    • 3. Juvenile
    •      -typically children <10y
    •      -highly vascular, common
    •      -should be removed
    • 4. Inflammatory polyps (pseudopolyps)
    •      -associated with UC

    • CLINICAL FEATURES:
    • -rectal bleeding
    • -incomplete obstruction (crampy pain)
  13. Benign Tumors of the Colon (polyps)
    -diagnosis
    -treatment
    • DIAGNOSIS:
    • -air contrast barium enema
    • -colonoscopy

    • TREATMENT:
    • -Hyperplastic: no specific therapy required, commonly removed if can't distinguish from adenomatous
    • -Pedunculated: colonoscopic removal
    • -Sesile: may require surgical excision
  14. Benign Tumors of the Colon (polyps)
    -hereditary polyposis syndromes
    • -Familial Adenomatous Polyposis
    • -Gardner's Syndrome
    • -Turcot's Syndrome
    • -Peutz-Jeghers
    • -Familial Juvenile Polyposis Coli
    • -Hereditary nonpolyposis CRC
    • -Cowden's Disease
    • -Cronkhite-Canada Syndrome
  15. Familial Adenomatous Polyposis
    • EPIDEMIOLOGY/PATHOPHYS:
    • -autosomal dominant
    • -delection of APC gene
    • -formation of 100s of adenomatous polyps in the intestine
    • -duodenum involved in 90%
    • -polyps may also form in stomach, jejunum and ileum

    • PROGNOSIS:
    • -80-90% develop colon malignancy by age 40

    • TREATMENT:
    • -subtotal resection of colon with observation by 30 years
    • -sulindac therapy may lead to regression of polyps
  16. Gardner's Syndrome
    • CLINICAL PRESENTATION:
    • -FAP + osteomas or soft tissue tumors
    • -lipomas, fibromas, dermoid tumors, sebaceous cysts
  17. Turcot's Syndrome
    • PATHOPHYSIOLOGY:
    • -autosomal dominant

    • CLINICAL PRESENTATION:
    • -FAP + malignant CNS tumor
    • -glioblastoma multiforme, medulloblastoma
    • -high risk of malignancy
  18. Peutz Jegher's Syndrome
    • EPIDEMIOLOGY:
    • -autosomal dominant

    • CLINICAL PRESENTATION:
    • -single or multiple hamartomas spread through whole GI tract
    • -low risk for malignancy
    • -may have recurrent GI bleeding
    • -pigmented spots around lips, oral mucosa, face, genitalia and palmar surfaces
  19. Familial Juvenile Polyposis Coli
    • EPIDEMIOLOGY:
    • -rare
    • -presents in childhood
    • -autosomal dominant

    • CLINICAL PRESENTATION:
    • -more than 10, up to hundreds of juvenile polyps in colon, SI and stomach
    • -GI bleeding

    • PROGNOSIS:
    • -slight increase in malignancy later in life
  20. Hereditary nonpolyposis CRC
    "Lynch syndrome"

    • I: "Site specific CRC"
    • -early onset CRC, absence of antecedent multiple polyposis

    • II: "cancer family syndrome"
    • -Lynch I + increased incidence and early occurance of other cancers
  21. Cowden's Disease
    • EPIDEMIOLOGY:
    • -rare
    • -autosomal dominant

    • CLINICAL PRESENTATION:
    • -multiple hamartomas of face, skin (acral keratoses) and mouth
    • -breast lesions in 50%
    • -thyroid abnormalities in 10-15%
    • -no increased cancer risk associated with GI hamartomatous polyps
  22. Cronkhite-Canada Syndrome
    • CLINICAL PRESENTATION:
    • -intestinal polyps
    • -alopecia
    • -hyperpigmentation
    • -lack of fingernails
  23. Drugs that cause pancreatitis
    • Diuretics: furosemide, thiazides
    • IBD drugs: sulfasalzine, 5-ASA
    • Immunosuppressive  agents: azothioprine, L-asparaginase
    • Valproic acid
    • Drugs used by AIDS patients: didanosine, pentamidine
    • Antibiotics: metronidazole, tetracycline
  24. Serum ascites albumin gradient
    SAAG
    • transudative vs exudative
    • SAAG = serum [albumin] - ascites [albumin]
    • >1.1g/dL: 95% transudative process (i.e. portal hypertension)

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