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98 Cards in this Set
- Front
- Back
what's leukoplakia
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mucous membrane disorder characterised by white patches
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which cancer makes up 95% of oral cancers
what sex, & age likely risk factors |
squamous cell carcinoma (SCC)
male 50+ smoking, UV, alcohol, immunosuppression, poor nutrition |
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presentation of oral cancer (signs)- SCC
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appearance: leukoplakia, red/velvety, speckled
granular irregular exophytic (protrudes) non-healing ulcer 3wks+ swollen mobile teeth lymphadenopathy |
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when would urgent referral for oral cancer suspicion be approriate (1)
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HOARSEness 3wks+
particularly in 50+ smokers/ heavy drinkers |
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oral manifestations of systemic diseases
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ULCERS: chron's, coeliac, infections
ANGULAR STOMATITIS: iron def GINGIVITIS: vit C def GLOSSITIS: iron/ folate/ B12 def THRUSH: DM, HIV.....loads |
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apart from systemic diseases, why else might someone have oral manifestations
- e.g. |
side effects of drugs:
- NICORANDIL (K-channel openr) for angina |
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screen for colorrectal ca
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FOBT
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what physiological mechanisms cause nausea
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LOS & stomach RELAX
upper s.int & pyloric sphincer contract move into body of stomach |
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wheres the vomiting centre
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medulla oblongata
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what symptoms precede vomiting
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nausea
sweating pale profuse salivation tachycardia |
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what's the major consequence of severe vomiting
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DEHYDRATION (lose gastric protons H+) & Cl-
→ METABOLIC ALKALOSIS - H+ accompanied by K+ excretion = hypokalaemia |
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which 4 areas can vomiting triggers signal to in the brain
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VC, Vestibular nucleus, NTS or CTZ
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vomiting triggers: sight, pain & smells signal to where in the brain
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direct to VC
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vomiting triggers: motion and vestibular disorders signal to where in the brain
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Vestibular nucleus
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vomiting triggers: pharyngeal/ gastric/ duodenal stimulation signal to where in the brain
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NTS (nucleus tractus solitarus) or CTZ (chemoreceptor trigger zone)
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how do drug & radiation chemotherapy induce emesis
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release 5-HT from ENTEROCHROMAFFIN cells lining gut → 5-HT receptors in gut → vagal afferent → signal to CTZ
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how does dopamine cause emesis (vomiting)
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D2 receptors prevalent in CTZ
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which receptors are prevalent in the CTZ for vomiting
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5-HT3 & D2 (receives dopamine)
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5 major classes of anti-emetic drugs (anti-vomiting)
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5-HT3 antagonists
muscarinic antagonists H1-antagonists Dopamine-receptor antagonists (D2) Cannabinoids |
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eg of 5-HT3 antagonists used in vomiting
uses SE's |
ONDANSTERON
chemo & radio-induced ✔ well tolerated x. constipation x. headaches |
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eg muscarinic antagonists use in vomiting
uses SE's |
HYOSINE/ SCOPOLAMINE
prophylaxis motion sickness x. burry vision x. urinary retention x. dry mouth x. sedation |
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eg H1-antagonists use in vomiting
uses SE's |
CYCLIZINE (also blocks M receptors)
motion sickness x. drowsy |
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eg dopamine antagonists use in vomiting
uses SE's |
DOMPERIDONE & metoproclamide
drug-induced vomiting, Gi disorders (e.g. GORD) x. reduced GI transit PENZOTHIAZINE used in severe vomiting |
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eg of a cannabinoid used last resort in chemo-induced vomiting unresponsive to other agents
SE's |
NABILONE--> opiate receptors
x. dry mouth x. drowsy x. dizzy x. mood changes |
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2 eg's acute inflam oesophagus
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infection (in immunocompromised)
corrosive after chemical indigestion |
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common cause of chronic oesophagus inflam
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GORD/ reflux oesophagitis
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3 causes of GORD
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defective sphincter mechanisms
abnormal oesophageal motility (achalasia, spasm, HTN peristalsis) increased intra-abdominal pressure |
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3 complications of GORD
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ulceration
stricture (fibosis & scarring = narrowing) Barret's oesophagus |
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what's the cell change (metaplasia) in Barret's oesophagus
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stratified squamous --> COLUMNAR epithelium
BENIGN...but... (increase risk developing dysplasia & carcinoma) |
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what's allergic oesophagitis characterised by and what does the oesophagus look like on endoscopy
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EOSINOPHILIA
corrugated, ridges assoc with asthma, young, M |
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3 drugs for treatment of allergic oesophagitis
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steroids, cromoglycate, ,montelukast
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what is the main type of benign oesophageal tumour
what virus is it related with |
squamous PAPILLOMA (wart-like growth)---HPV
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2 main types MALIGNANT oesophageal tumours
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SCC (epithelial layers)
ADENOCARDINOMA (glandular) |
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aetiology (causes) of SCC in oesophagus
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vit A/ zinc def
tannic acid/ strong tea smoking, alcohol HPV oesophagitis (GORD) genetic |
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epidemiology of oesophageal adenocarcinoma
aetiology - main BIG risk/ predisposition pathogenesis |
caucasians, M, obese
lower 1/3 oesophagus BARRET's --> dysplasia --> adenocarcinoma |
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3 mechanisms of cancer metastises
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local - direct invasion
lymphatic systemic - vascular- blood |
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symptoms of oesophgeal tumour/ cancer
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DYSPHAGIA, retrosternal chest pain
regurgitation anaemia, weight loss, fatigue, lymphadenopathy |
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what's the treatment of choice for oral cancers
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surgery +/- adjuvant therapy
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symptoms of oesophagitis GORD
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heart burn/ acid reflux/ chest pain
belching water brash (excessive salivation) odynophagia (painful swallow) weight loss hoarseness/ cough (upper 1/3) |
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risk factors for oesophagitis (GORD)
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ageing, obese, FH, smoking, alcohol, hiatus hernia, preg, big meals
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when does GORD/ oesophagitis require Ix
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ALARM symp's:
- gastroscopy OGD & biopsy - Ba swallow (hiatus hernia?) |
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management of oesophagitis (GORD)
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LIFESTYLE (weight loss, reg meals, raise bed, stop smoking, avoid fatty, hot drinks, alochol, eating late...)
DRUGS: antacids, PPIs |
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Gastropariesis can cause GORD or be a complication of it, what is it
causes symps |
DELAYED gastric EMPTYING (no physical obstruction:
DM, cannabis, meds, systemic disease - early satiety, nausea, vomiting, epigastric pain |
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Ix & management of gastropariesis
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IX: endoscopy & Ba swallow (exclude other causes)
gastric emptying studies Rx: remove precipitating factors, soft diet, low fat |
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4 ALARM features of oesophageal and gastric cancer
ALARM age to suspect it |
weight loss/ anorexia
HAEMATEMESIS DYSPHAGIA MASS >55yrs |
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aetiology / important cause of gastric cancer
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H.pylori infection
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Ix's for oesophageal cancers
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endoscopy + biopsy
bronchoscopy ?invasion imaging: Ba swallow, CT FITTNESS study--> potential surgery |
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4 types treatment for oesophageal cancer
prognosis |
SURGERY
RADIOtherapy INTUBATE/ stent RECANALISATION majority die <1yr |
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symptoms specific to gastric cancer
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dyspepsia
early satiety upper GI bleed abdo mas- ALARM general: weight loss, anaemia, >55yrs, fatigue |
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Ix's gastric ca
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gastroscopy + biopsy
imaging: Ba meal, CT |
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3 options for gastric cancer treatment
5 yr survival |
SURGERY
CHEMO INTUBATION 15% 5-yr survival |
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6 main causes upper GI bleed "haematemesis"
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peptic ulcer
GASTRIC EROSIONS duodenal ulcer varices Mallory-Weiss tear Oesophagitis |
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presentation upper GI bleed
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haematemesis (bright or coffee-ground)
malena (dark, dig upper GI blood) ↑HR , ↓BP dyspnoea collapse |
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what does the rockall score measure/ predict
what factors does it consider |
predict REBLEED & DEATH , triage- who to discharge...
- age - shock - cormobidity - Dx - sings of haemorrhage |
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which score to use to assess need for endoscopy / intervention
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BLATCHFORD score or Rockall
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initial management of upper GI bleed
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ABCDE & RESUSCITATION
O2 IV fluids! ?blood transfusion >30% loss asap endoscopy necessary? |
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management (after initial resuscitation) of non-variceal upper GI bleeding
- endoscopic - pharmacological |
1) ENDOSCOPIC therapy to ACTIVELY bleeding lesions/ visible vessels/ ulcers with adherent clot
- adrenaline, thermal , mechanical 2) DRUGS: - H.pylori eradication (if applicable- e.g. omeprazole+amox+met ) - IV PPI |
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clinical clues (S&Ss) to suspect VARICEAL upper GI bleed (as oppose to non-variceal bleed)
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portal HTN: ascites, caput medusa
CHRONIC LIVER DISEASE: palmar erythema, spider naevi, jaundice confused |
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management (after initial resuscitation) of VARICEAL bleed
- endoscopic - pharmacological - specifically for Chronic liver disease pt's |
TERLIPRESSIN (vasoactive)
BAND LIGATION CLD= Abx's |
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management of variceal re-bleed (2)
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TIPS (transjugular intrahepatic portosystemic shunt)- treats portal HTN
BALLOON TAMPONADE/ Sengstaken-Blakemore tube (temp) |
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causes of peptic ulcers (4)
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bacterial/ viral infections
H.pylori! IBS GB/ liver disease functional |
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6 causes of dyspepsia
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peptic ULCER
oesophagitis/ duodenitis/ gastritis gastric MALIGNANCY GORD |
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S&Ss peptic ulcer
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DYSPEPSIA
epigastric pain (assoc with food, nocturnal) bloating/ early satiety heartburn weight loss FH |
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structures which can cause epigastric pain
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heart (eg MI)
oesophagus, stomach, duodenum pancreas, liver, GB, CBD |
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pharmacological therapy for peptic ulcers (2)
H.pyroli specific eradication |
PPIs: omeprazole
H2-antagonists: ranitidine H.pylori= abxs: omeprazole+amox+met/ claryth STOP NSAIDs |
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what's produced by H.pylori to aid its survival
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UREASE
ammonium bicarb NEUTRALISES stomach pH |
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tests/ Ix's for dx of H pylori
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★UREA BREATH TEST★
or culture biopsy serology |
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how does H.pylori cause increased acidd (HCl) production
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H.pylori reduces somatostatin release from D cells
G cells → gastrin → parietal cells → HCl |
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when H.pylori colonises stomach, what disease ensues
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chronic gastritis
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how does chronic gastritis predispose to gastric cancer
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ATROPHY of mucosa
↓parietal = ↓acid H.pylori grows dysplasia --> gastric cancer |
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treatment for H.pylori (triple therapy)
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omeprazole + amox + metramidazole or clarythromycin
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if dyspepsia is H.pylori -ve, how to manage?
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PPI: omeprazole
or H2-antagonist: ranitidine |
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4 causes of ACUTE gastritis
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head injury
severe injury shock severe burns |
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4 causes of CHRONIC gastritis (ABCR)
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AUTOIMMUNE (atrophic)
BACTERIAL: H.PYLORI CHEMICAL: reflux, NSAIDs, alcohol RARE: lymphocytic, eosinophilic, granulomatous |
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3 chemical causes of chronic gastritis
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reflux bile
NSAIDs alcohol |
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what do lamina propria cells produce in response to infection with H.pylori
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anti-H.pylori IgA antibodies
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which type of peptic ulcer most common- pathogenesis
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DUODENAL
50% ↑acid secretion = gastric metaplasia, inflammation, epithlial damage |
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morphology of peptic ulcers
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clear edges "punched out"
2-10cm diam or microscopic layered floor of nectrotic fibropurulent debris base granulation tissue deep fibrotic scar neutrophils & exudate |
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3 complications of peptic ulcers
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perforation
haemorrhage stenosis |
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2 types of benign gastric tumours
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HYPERPLASTIC polyps
CYSTIC GLAND polyps |
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3 types MALIGNANT gastric tumours
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ADENOCARCINOMA (epithlial cells)- most common!
lymphoma GI Stromas Tumours (GISTs) |
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aetiology & asoociation of gastric adenocarcinomas
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H.pylori- chronic gastritis
atrophic gastritis (autoimmune) deprived SMOKING adenomatous POLYPS (e.g. genetic- FAP) HNPCC/ Lynch syndrome |
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2 subtypes of gastric adenocarcinomas
what's the difference: - loc - formation - prognosis |
1) INTESTINAL- exterior, gland formation, better prognosis
2) DIFFUSE (pic) - stomach wall, thickening & fibrosis, worse prognosis - linitis plastica, sclerosis, SIGNENT RING type |
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which type of malignant gastric tumour is derived from mucosal lymphoid tissue, shows clonal B-cell proliferation & lymphoid cells fill the stroma of stomach wall
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gastric lymphoma (MALToma)
|
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dysphagia (difficulty swallowing) can be due to what 2 broad categories of problems
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MECHANICAL BLOCK
MOTILITY disorder other: inflam |
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important Q-s to ask about dysphagia- why
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ONSET- gradual (mechanical- stricture), sudden (motility d.)
CONSTANT/ EPISODIC - stricture/ spasm DURATION- ca over long period PAIN- ca, inflam, spasm ASSOC SYMPs DYSPEPSIA |
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6 Common Ix's for dysphagia
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FBC (anaemia)
U&Es (hydration) CXR (mediatinum fluid, gastric bubble, aspiration) ★OGD +/- biopsy ★ Ba swallow ---normal?---> manometry |
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MECHANICAL causes of dysphagia
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food bolus
Schatzki ring (benign fibrous narrowing lower oesophagus) diverticulum extrinsic pressure (lung ca, LA enlargement, mediastinal nodes, AAA) |
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MOTILITY causes of dysphagia
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achalasia (LOS fails to relax)
diffuse spasm Bulber palsy Motor neurone disease Cerebrovascular disease |
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4 pathogens causing oesophageal infection
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candida
Herpes CMV EBV |
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what's the ROME III criteria for IBS
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1) RECURRENT abdo pain for 3+ days/ month, for 3months
2) + 2 of: - better with defaecation - change stool freq - change stool consistency |
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age and sex presentation for IBS
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20-40yrs F>M
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S&Ss IBS
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abdo pain (central/lower)- better with defaecation
abdo bloating altered bowel habit & freq tenesmus mucus PR CHRONIC- exacerbated with stress, menstruation, fibre, drugs |
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pathophysiological feature of IBS
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VISCERAL hypersensitivity
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IBS ALARM features!
|
>50 - ?colorectal ca
short duration woken at night- ?IBD BLOOD PR- ?IBD/ ca ↓weight- ?IBD/Ca anaemia FH colorectal ca-----> scope! recent abxs |
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Dx of IBS by Ix
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Dx of EXCLUSION
FBC, U&Es, LFTs, ESR, CRP, coeliac serology urinalysis Stool if ?infection Colonoscopy- if FH colorectal ca/ >50yrs |
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treatment/ management of IBS
|
Diet (reg, ↓fibre, ↓caffiene, hydrated)
Lifestyle (exercise, ↓stress) DRUGS: - laxatives- constipation - antimotility (loperamide)- diarrhoea - anti-spasmodics (mebeverine)- colic/bloating - anti-depressants (amitryptiline) PSYCHOLOGICAL therapies |
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main Ddx's for IBS (5)
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IBD
colorectal ca coeliac disease malabsorption gastroenteritis |