dr.ishara maduka m.b.b.s. (colombo). surgical conditions affecting upper gi tract oral cancer...
TRANSCRIPT
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Dr.Ishara Maduka M.B.B.S. (Colombo)
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Surgical conditions affecting upper GI tractOral cancerDysphagia and Oeasophageal cancerDyspepsia and GORDPeptic ulcerGastric carcinomaUpper GI bleeding
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Oral cancersOral cancer is the commonest cancer in males in Sri
LankaAccounts for 2-4 % of all malignant tumours in the
western worldParticularly common in some parts of Asia where
betel chewing is common.Associated with other tumours of the aerodigestive
tractIn particular carcinoma of the :
LarynxBronchusOesophagus
85% are squamous cell carcinomas
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Risk factors
Betel chewingSmokingAlcohol excessSyphilitic glossitisSideropenic dysphagia
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What is a premalignant lesionA Premalignant lesions is a morphologically altered tissue that has a greater risk than normal tissue for a malignancy to occur.
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What are the premalignant lesions in the oral cavityLeucoplakia
Erythroplakia
Chronic hyperplastic candidiasis
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Leucoplakia Erythroplakia
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Clinical features of oral cancerOral cancer produces symptoms earlyThis allows the potential for early diagnosis
and treatmentDiagnosis is usually clinicalCommonest sites with the mouth are
TongueFloor of the mouthGingiva and alveolar ridgeBuccal mucosaHard palate
Most tongue cancers occur on the lateral margin of the middle third of the tongue
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Clinical features Contd…Tumours in the floor of the mouth often have
early bone involvementPresent as exophytic growths or ulcersPain is a late symptom
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Investigation
Diagnosis can be confirmed by a biopsy under local anaesthetic
FNA of palpable nodes is useful to confirm lymphatic spread
CT is useful for assessing extent of nodal disease
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ManagementResectionReconstructionRadiotherapyChemotherapy
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Physiotherapists roleEstablish communication with the patientPreoperative assessmentPost operative careChest clearance exercisesShoulder and neck exercisesDonor flap site exerciseMobility
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What’s meant by dyspahgia?Dysphagia means difficulty in swallowing.
Orynophagia means pain when swallowing.
Phagophobia means fear of swallowing.
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What causes dysphagiaCauses can be divided anatomically into
mechanical and non mechanical causes
Mechanical causes Non mechanical causes
Oesophageal carcinoma
Achalasia cardia
Corrosive strictures Oesophageal spasms
Mediastinal tumours compressing oesophagus
Foreign bodies
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Clinically categorized according to presentationProgressive dysphagia
Non progressive dysphagia
Oesophageal carcinoma
Achalsia cardia
Corrosive stricture
Foreign body
Mediastinal tumour compressing oesophagus
Oesophageal spasms
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Oesophageal carcinoma2nd commonest cancer in males in Sri Lanka90% are squamous cell carcinomasOccur in the upper or middle third of the
oesophagus8% are adenocarcinomasOccur in the lower third of the oesophagusOverall 5 year survival is very poor and is at
best 20%
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Risk factorsSquamous cell carcinoma
Alcohol / tobaccoDiet high in nitrosaminesTrace element deficiency - molybdenumVitamin deficiencies - vitamins A & CAchalasiaCoeliac DiseaseGenetic - TylosisHigh incidence in areas of Northern China and the
Caspian regionAdenocarcinoma
15% associated with Barrett's Oesophagus
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Premalignant lesions in the oes.Barrett's oesophagus
Consists of columnar-lined distal oesophagusDue intestinal metaplasia of distal oesophageal mucosaCan progress to dysplasia and adenocarcinomaIts is an acquired condition due to gastro-oesophageal
refluxBile reflux appears to be an important aetiological
factor10% of patients with GORD develop Barrett's
oesophagusApproximately 1% of patients with Barrett's
oesophagus per year progress to carcinomaBarrett's oesophagus increase the risk of cancer by x30
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Clinical features
Progressive dysphagia
Respiratory symptoms due to overspill or occasionally a trachea-oesophageal fistula
Weight loss
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InvestigationsDiagnosis confirmed by:
Endoscopy plus biopsy / cytology
Barium swallow
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TreatmentSurgicalResection and anastomosis
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What is dyspepsiacharacterized by chronic or recurrent pain in
the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating. It can be accompanied by bloating, belching, nausea, or heartburn.
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Conditions causing dyspepsiaGORD (gastro-oeasophageal reflux disease)Peptic ulcerCarcinoma of the stomachGall bladder stones
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GORD (gastro-oeasophageal reflux disease)Occurs due to reflux of gastric contents in to
oesophagus causing symptoms of dyspepsia.
Risk factors – High fat diet, obesity, pregnancy, increased acid secretion, alcohol, smoking.
Treatment – Advice to remain seated after eating, reduced amount of fatty food, weight control, antacid drugs.
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Peptic ulcer
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Peptic ulcerOccur due to increased acid secretion by
parietal cells.
Risk factors – NSAIDS, H. Pylori infection
Sites of peptic ulcerationStomachDuodenum
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SymptomsDyspeptic symptoms
Upper GI bleeding
Symptoms due to complications
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ComplicationsGastric ulcer Duodenal ulcer
BleedingGastric carcinoma
Duodenal rupture
Gastric outlet obstruction
Duodenal stricture
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Helicobacter pyloriH. pylori is gram-negative spiral
flagellated bacteriumProduces ureaseImportant in the aetiology of peptic ulcers
and gastric cancerFound in:
90% patients with duodenal ulceration70% patients with gastric ulceration60% patients with gastric cancer
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Treatment of peptic ulcerAvoid NSAIDS as much as possible
Eradicate H. pylori by antibiotics and proton pump inhibitors.
Truncal vagotomy and highly selective vagotomy done in the past to reduce acid secretion
Gastrectomy in untreatable gastric carcinoma
Treat complications
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Carcinoma of the stomachRisk factorsDiet low in Vitamin CBlood group APernicious anaemiaHypogammaglobulinaemiaPost gastrectomy
Precursor statesHelicobacter pylori infectionAtrophic gastritisIntestinal metaplasiaGastric dysplasiaGastric polyps
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Clinical featuresDyspeptic symptoms
Upper GI bleeding
Loss of appetite
Wasting/ cachexia
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ManagementSurgical – gastrectomyRadiotherapyChemotherapy
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Gall bladder stonesGallstones are found in 12% men and 24%
womenPrevalence increases with advancing age10-20% become symptomatic
PathophysiologyThree types of stones are recognised
Cholesterol stones (15%)Mixed stones (80%)Pigment stones (5%)
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Clinical presentation of gall stonesAcute cholecystitis
Biliary colic
Dyspepsia
Obstructive jaundice
Pancreatitis
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Acute cholecystitis90% cases result from obstruction to the
cystic duct by a stoneIncreased pressure within the gallbladder
results in an acute inflammatory responseSecondary bacterial infections occurs in 20%
of cases of acute cholecystitisMost common organisms are E. coli,
Klebsiella and strep. faecalis
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Clinical featuresConstant pain (usually greater than 12 hours
duration) in right upper quadrant
Fever, tachycardia
Tenderness in right upper quadrant
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InvestigationsUltrasound scan
Serum bilirubin
Serum amylase
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ManagementInitial management is usually conservativePatient is fasted, given intravenous fluids and
opiate analgesiaIntravenous antibiotics (e.g. second
generation cephalosporin) should be given to prevent secondary infection
80% patients improve with conservative treatment
Surgical treatment of choice is delayed cholecystectomy
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CholecystectomyOpen or closed
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Laparoscopic cholecystectomy is the gold standard
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Questions?