GI exam 1

Symptoms of esophageal cancer

-Dysphagia
-Iron deficiency anemia (bleeding)
-Anorexia, weight loss
-Tracheoesophageal fistula

What is Barrett's esophagus? What is it a risk factor for?

Chronic GERD, acid damage to esophagus (metaplasia of esophageal tissue)

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RF for esophageal adenocarcinoma

Risk factor for esophageal adenocarcinomas

**Caucasians**

**men**

**Western countries**

**Barrett’s esophagus**

**GERD**

**obesity**

**smoking**

possible H. pylori eradication

Patient with Barrett's esophagus - how often should they be screened for cancer?

Upper endoscopy every 2-5yr, more frequent if dysplasia found

Major risk factors for esophageal SCC?

\-Tobacco/alcohol
\-Black men
\-Urban areas
\-Low SES
\-Possible HPV association

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also diet **(N-nitroso compounds)**, achalasia, diet, injury

Treatments unique to esophageal cancer?

**-Endoscopic mucosal resection
-Esophageal stent**

Incidence of gastric cancer parallels....

rate of H. pylori

H. pylori infection is a risk factor for....

gastric cancer

Early satiety is the key symptom of cancer in what location?

gastric

Tumor markers of gastric cancer

CEA, CA-19, CA 125

What is Virchow's Node? What does it indicate?

Left supraclavicular adenopathy

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Metastatic disease

What is Sister Mary Joseph Nodule? What does it indicate?

Periumbilical node

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Metastatic disease

What rare cancer makes up 3% of all GI tract malignancies?

Small bowel

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EXTREMELY RARE

What is the most common GI malignancy in the US?

Colorectal cancer

Major risk factors for colorectal cancer?

__***Family history***__

__***Inflammatory bowel disease***__

* Chronic inflammation may cause metaplasia, which may erode and become cancerous

Abdominal radiation

Diabetes mellitus

Obesity

Older age

Colonic polyp with the highest malignant potential

**Villous** **adenomatous** polyp

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How does colorectal cancer usually present?

**MANY ARE ASYMPTOMATIC**

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\-Iron deficiency anemia

\-Change in bowel habits

\-Rectal bleeding

\-Weight loss

\-Intestinal obstruction

\-Abd pain

When should colonoscopy screenings start and how often should they be done?

45yr, every 10yr

Most common benign lesion of the liver?

Hepatic cyst

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especially in women

Most common benign solid tumor of the liver?

Hepatic hemangioma

diagnose with U/S, CT contrast, or MRI T2

When should hepatocellular carcinoma be suspected?

Patients with ***previously compensated cirrhosis*** who develop ascites, varices, encephalopathy

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**Hepatitis B**

Hepatitis B/C is a risk factor for....

HCC

How should patients be screened for HCC?

US every 6mo +/- AFP

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AFP alone not recommended CT not recommended

What lesion is associated with anabolic steroids and/or oral contraceptives?

Hepatic adenoma (benign lesion)

5 year survival rate for pancreatic adenocarcinoma?

Tumor marker for pancreatic adenocarcinoma?

CA 19-9

CA 19-9 is the tumor marker for....

Gastric cancer

Cholangiocarcinoma

Pancreatic adenocarcinoma

CEA is the tumor marker for....

Gastric cancer

Cholangiocarcinoma

CA 125 is the tumor marker for.....

Gastric cancer

What is the only hepatitis virus that is encoded in DNA?

Hepatitis B

What is the only cure for liver cirrhosis?

liver transplant

What colon disease is strongly associated with primary sclerosing cholangitis?

ulcerative colitis

What does ulcerative colitis increase your risk for?

colon cancer

What lab titer will be positive in patients immunized against hep B?

anti HBS (surface antibody)

What is the most likely diagnosis?

(beads on a string)

sclerosis cholangitis

What stage of hepatic encephalopathy includes cerebral edema?

stage 4

What lab test will be most elevated in choleastatic jaundice?

alkaline phosphatase (due to bile canaliculus ripping apart and releasing anchored proteins)

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(if

What generation is at highest risk for occult hep C?

baby boomers (prior to hep c vax)

What is the serum marker for primary biliary cholangitis?

AMA (anti-mitochondrial antibody)

Eating smoked meats increases your risk of what type of cancer?

gastric

What hepatitis treatment has severe side effects?

pegylated interferon alpha

(not commonly prescribed)

What disease is likely in patients with cirrhosis that present with abdominal pain and fever?

spontaneous bacterial peritonitis (SBP)

What is the protein that is highly saturated in hereditary hemochromatosis?

transferrin (normally

What is the mechanism that causes viral hepatitis to injure the liver?

host inflammatory response (cytokine storm)

How often should patients with a family history of colon cancer get a colonoscopy?

every 5 years (may start sooner the 45 depending on hx)

How often should a patient get a colonoscopy without a family history of colon cancer?

every 10 years (starting at 45)

What is the first phase of hepatitis infection? What is another name for it related to viral activity?

incubation period, viral replication

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genetic PCR is positive

What scoring system is used to determine treatment course for alcoholic hepatitis? What score indicates the use of steroids?

"Maddrey's discriminant function; over 32" (higher risk of mortality)

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What phase of infection never happens in hepatitis A?

chronic

What lab remains elevated in hepatitis B carriers?

surface antigen

What lab remains elevated in chronic active hepatitis B patients?

envelope antigen

What is the route of transmission of hepatitis E? Hep A?

fecal oral (both)

Dysphagia may indicate what type of cancer?

esophageal

What syndrome is associated with renal failure in patients with liver failure?

hepatorenal syndrome

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***diagnosis of exclusion***

What is the best treatment for hepatitis A infection?

supportive care; self-limiting 3-4 weeks

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severe: hospitalize, possible transplant

What is the first-line medication for treating hepatic encephalopathy?

lactulose

What is the preferred screening method for non-alcoholic fatty liver disease (NAFLD)?

abdominal ultrasound (1st line)

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CT/MRI more sensitive

What is the primary treatment for early non-alcoholic fatty liver disease (NAFLD)?

low fat and carb diet with exercise

**reduce obesity and triglycerides!!!**

What is the most likely diagnosis? Kyser Fleischer finding

"Wilson's disease;

(d/t accumulation of copper in the retina)"

Alpha 1 antitrypsin is produced in what organ?

liver

What finding is most concerning for a poor outcome in patients with known alcoholic liver disease?

encephalopathy (presents as AMS)

What medication is preferred in the treatment of alcoholic hepatitis?

prednisolone (bioactive metabolite of prednisone)

What is the most common cause of chronic liver disease?

viral hepatitis

How much time should you wait before checking acetaminophen levels after an acute overdose?

4 hours after ingestion

What AST/ALT ratio is most concerning for alcoholic hepatitis?

2:1

What scoring system is used to predict complications in patients with cirrhosis?

Child-Pugh score

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Class A compensated (score 5-6)

Class C complications (score 10-15)

A MELD score of what predicts a 30-day survival rate of less than 50% in patients with liver failure?

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5\.7 survival rate?

greater than 20

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score

"What lab test can inform you about the progression of a patient's condition with hepatic encephalopathy?"

"ammonia (big change \= worse condition, don't use absolute levels)"

What procedure is indicated in patients with active alcoholic cirrhosis who also have either repeated bleeding or transfusion of multiple units of blood?

TIPS procedure

"What Maddrey's discriminant function score indicates a very poor prognosis?"

greater than 32 (treat with steroids!!)

if ~new cases \> ~death rate, what does that indicate about screening methods?

screening is sufficient

screening methods may be insufficient as indicated by \________ and \___________

high cases and many deaths

Incidence of Esophageal Squamous Cell Carcinoma (trend)

decreasing

how to diagnose esophageal SCC

endoscopy
CT may be incidentally find

prognosis esophageal SCCa?

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Screening?

good if caught early

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no screening

location of esophageal SCCa vs adenocarcinoma

middle esophagus (SCC)

distal esophagus (adenocarcinoma)

incidence of esophageal adenocarcinoma

INCREASING

what is Barrett’s esophagus?

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causes?

Metaplasia\* of esophageal tissue

* Replacement of normal squamous epithelium with metaplastic columnar epithelium with Goblet cells

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due to chronic GERD

symptoms of esophageal adenocarcinoma

* ***Dysphagia***
* ***Weight loss***
* ***Anorexia***
* ***Iron deficiency anemia***
* ***Tracheoesophageal fistula***

diagnosis of esophageal adenocarcinoma

* Barium study - swallow barium to visualize GI tract
* CT scan
* __**Endoscopy**__
* __**Biopsy needed to confirm diagnosis**__

signs of metastatic disease

* palpable liver,
* palpable abdominal mass,
* Virchow’s Node
* Sister Mary Joseph Node (terminal finding)

gastric cancer endoscopically may mimic

gastric ulcer

**biopsy to confirm**

sign of gastric cancer in barium/radiographicaly/ct

apple core lesion

incidence of colorectal cancers is ____ (US vs world)

**decreasing in USA**

increasing worldwide

colonic polyps are (benign or malignant)?

benign!!! but some may have risk of malignancy

types of adenomatous polyps

tubular, tubulovillous, villous

risk of malignancy due to hyperplastic polyps

0%

hamartomatous polyps are

non-cancerous but not truly benign

pseudopolyps are (describe)

inflammatory

treatment of colonic polyps

resect if adenomatous

Familial Adenomatous Polyposis (FAP)

autosomal dominant

mutation in APC gene

93% risk by gae 50 of malignancy

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hemachezia possible

lifelong polyp formation

NSAIDs may slow formation

lynch syndrome

related to

Familial ==Adenomatous== Polyposis (FAP)

hereditary non-polyposis colon cancer risk

Peutz-Jeghers Syndrome

hereditary disease with higher risk of GI cancer

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autosomal dominant

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features:

* hamartomatous polyps (jejunum, stomach, colon)
* mucocutaneous pigmentation - melanin spots (lips, palms, skin)
* increased risk of non-GI cancer
* **intussusception**

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***Cancer screening – upper and lower endoscopy staring at age 8-10!***

incidence of colon cancers per region of colon

ascending > sigmoid > rectal

hepatic cysts are

asymptomatic, benign usually; singular and small (can be multiple)

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do not require treatment

Dx with US/CT/MRI

hepatic adenomas

often benign, asymptomatic unless large for abd pain

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resect if symptomatic or large

AFP screening

***Alpha-Fetoprotein Test***

* ***Elevated in pregnancy, gonadal tumors (e.g. testicular cancer) and other malignancies***
* ***May also be elevated in chronic hepatitis***
* poor sensitivity/specificity BY ITSELF
* does not correlate with size/stage

AFP elevations or decreases may indicate

* Open neural tube defects (ONTD), such as spina bifida
* Down syndrome
* Other chromosomal abnormalities
* Defects in the abdominal wall of the baby
* Twins (more than 1 baby is making the protein)
* A miscalculated due date, as the levels change during pregnancy

screening for HCC

NONE!

not cost effective if no chronic hep B and cirrhosis

* U/S q6months +/- AFP

Cholangiocarcinoma: risk factors

presentation:

diagnosis

treatment

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major risk factors: **Primary sclerosing cholangitis (**painless jaundice!)

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presentation: jaundice, abd pain, weight loss, fever, dark urine, clay colored stools, pruritus, **Klatskin tumor (left and right biliary ducts)**

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Dx: LFTs, CA-19, CEA, US, CT, MRCP/ERCP

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Treatment **SURGERY = only cure**